Challenges To Early Detection in Primary Care
There are 8 major reasons why children with difficulties are not identified in primary care:
- The tendency to use informal milestones checklists. These lack criteria and items are not well- defined. For example, age-specific encounter forms typically used at well-child visits, may include an item such as “knows colors”. What does that mean? Must the child name colors? If so, how many? Does he or she have to point to colors when named? Or does he or she simply need to match them? The difference in skill levels required for each of these tasks ranges from about age 2 ½ to age 4 ½. Further, informal checklists lack psychometric scrutiny so we don’t have proof that asking about color knowledge is even a good predictor of developmental delays. In contrast quality screening tools use questions proven to predict developmental status and because such measures are standardized, the same task is presented the same way every time along with clear criteria for performance.
- Over-reliance on clinical observation without supporting measurement. Clinical judgment is helpful (e.g., for identifying pallor, clamminess, fussiness and other symptoms of illness) but development and developmental problems are usually far too subtle to simply observe. Most children with difficulties are not dysmorphic and so lack any visible physical differences from other children. Most walk and talk but how well they do these things requires careful measurement. We do not put a hand to a forehead to detect a fever. We measure. Development and behavior require measurement with quality instruments if we are to detect delays and disabilities
- Failing to measure at each well-visit. Development develops and developmental problems do to. A child may be normally developing at 9 months but will she be at 18 months if she is not using words? Or at 24 months if not combining words. We can’t predict outcomes very well (except when problems are severe). Repeated measurement and measurement with quality tools is essential.
- Difficulties communicating with families. Many parents don’t raise concerns about their children. Those with limited education often do not know that primary care providers are interested in development and behavior, child-rearing, etc. Many informal questions to parents do not work well. For example, “Do you have worries about your child’s development?” What is wrong with that question. The word “worries” is too strong and only about 50% of parents know what “development” means. Only about 2% of families will answer, even while the prevalence of problems in the 0 – 21 year age range is 16% - 18% (www.cdc.gov). In contrast, quality tools use questions proven to work and are far more likely to detect difficulties.
- Limited awareness of referral resources. Many children, even if administered a good screening tool, and found to have problematic results, are not referred? Why? Many primary care providers are unaware of referral resources in their communities. Why? Early interventionists have not consistently informed providers of their services. They many not respond like the ideal sub-specialist (e.g., calling back, informing about results, engaging in collaborative decision making about treatment, etc.). See www.DBPeds.org for links to referral resources.
- Failure to use a quality screening instrument. Unfortunately, the most famous and well known of screens, the Denver-II, lacks psychometric support. It under-identifies by about 50% or vastly over-refers depending on how questionable scores are handled. That it is also a hands-on measure taking longer to give than the usual 15 – 20 minute well-visit, means that most professionals use only selected items, and may thus further degrade what little accuracy there is. More accurate options and ones more workable for primary care in that they can be completed by parents in waiting or exam rooms, include Parents' Evaluation of Developmental Status (PEDS), Ages and Stages Questionnaire (ASQ) and PEDS:Developmental Milestones (PEDS:DM) with all three tools offering compliance with the tenants of both surveillance and screening. Practices with nurse practitions or developmental specialists, and early intervention intake services may have the time to administer accurate but lengthier measures that elicit skills directly from children (e.g., Brigance Screens (developed by Albert Brigance), Bayley Infant Neurodevelopmental Screener (BINS), or Battelle Developmental Inventory Screening Test (BDIST).
- Failing to monitor referral rates. Many providers are unaware of the prevalence of disabilities and delays and get little feedback when they’ve failed to identify a child with difficulties. Families often leave the practice or stop showing up for well-visits. So, there is an acute need to consider the prevalence of difficulties in light of personal referral rates: Overall about 1 in 6 children between 0 and 21 will need special assistance: about 4% of children 0 – 2, 8% of children 0 – 3, 12% of children 0 – 4, and 16% of children 0 – 8.
- Constraints of time and money. Many health care providers feel there is little time for screening during busy well visits. Generally this complaint reflects lack of awareness of screening measures that can be completed in waiting rooms (e.g., paper-pencil tools that families can self-administer independently, thus saving providers substantive time). Reimbursement for early detection has been notoriously poor. However in 2005 the Centers for Medicare and Medicaid Services enabled providers to add the -25 modifier to their preventive service code and to bill separately from the well-visit for 96110 (the developmental-behavioral screening code). Nationally, reimbursement now averages about $10. Some states have handled this mandate differently (e.g., North Carolina providers higher reimbursement for well care but does not allow screening to be unbundled from the well-visit for separate billing). Typically private payers honor Medicaid mandates and follow suit with billing and coding although this has not always occurred. The American Academy of Pediatrics has a Coding Hotline and advocates with private payers to provide reimbursement for screening.
Read more about this topic: Developmental-Behavioral Screening And Surveillance, So Do Developmental Surveillance and Screening Work?
Famous quotes containing the words care, primary, challenges and/or early:
“Self-determination has to mean that the leader is your individual gut, and heart, and mind or were talking about power, again, and its rather well-known impurities. Who is really going to care whether you live or die and who is going to know the most intimate motivation for your laughter and your tears is the only person to be trusted to speak for you and to decide what you will or will not do.”
—June Jordan (b. 1939)
“Parental attitudes have greater correlation with pupil achievement than material home circumstances or variations in school and classroom organization, instructional materials, and particular teaching practices.”
—Children and Their Primary Schools, vol. 1, ch. 3, Central Advisory Council for Education, London (1967)
“A powerful idea communicates some of its strength to him who challenges it.”
—Marcel Proust (18711922)
“We early arrive at the great discovery that there is one mind common to all individual men: that what is individual is less than what is universal ... that error, vice and disease have their seat in the superficial or individual nature.”
—Ralph Waldo Emerson (18031882)