The Help Me Grow Blog
Dec 01, 2012
Reframing the Early Detection and Early Intervention Pathway
Since its inception in 1998, a fundamental premise of Help Me Grow is that developmental surveillance and screening, with early detection of at-risk children and their referral to community resources, enhances the capacity of the medical home to support families in raising healthy children. The National Center promotes Help Me Grow as an evidenced-based approach to early detection and intervention. Recently published research now offers further evidence of the validity and importance of our collective efforts.
A Summer 2012 brief from the PolicyLab of The Children’s Hospital of Philadelphia Research Institute advocates for a more coordinated approach to meeting children’s developmental needs and the adoption of the SERIES paradigm of developmental screening in which each step (Screening, Early Identification, Referral, Intake, Evaluation, and Services) is seen as an integral component of a single process. Their emphasis is concordant with our formulation of developmental surveillance and screening as a single process combining a longitudinal monitoring approach with the periodic administration of formal screening tools.
Indeed, too often surveillance and screening are viewed as separate activities, thereby minimizing the effectiveness and potential benefits of either. Furthermore, despite the clarity of the 2006 policy statement of the Council on Children with Disabilities of the American Academy of Pediatrics (AAP), the surveillance/screening interface may be inappropriately viewed as an “either/or” option. Yet surveillance without screening is likely to contribute to children eluding early detection, while the isolated use of screening tools is challenged by lofty expectations despite understandably modest psychometric properties and may result in over-or under-identification. Indeed, we have long been critical of the “relentless pursuit of the perfect screening tool,” since we do not believe that such tools should be used in isolation, but rather always within the context of all that is known of the child and family through longitudinal surveillance.
The PolicyLab brief draws upon their recent experience implementing developmental screening in four urban primary care practices as part of the Translating Evidence-Based Developmental Screening (TEDS) study. While the researchers deserve commendation for assessing the feasibility of implanting developmental screening into primary care, I am admittedly less enthusiastic about their comparison of the effectiveness of standardized screening (using the Ages and Stages Questionnaire) with that of “routine developmental surveillance.”
As already discussed, surveillance and screening represent a single process, not separate components amenable to comparison. I would criticize this analysis as a “straw man” argument that contradicts the AAP policy statement and is even incompatible with the views of certain screening advocates. My favorite example is the renaming of the revised and restandardized Denver Developmental Screening Test-Revised, the DDST-R, as the Denver II in 1992 by Bill Frankenburg and colleagues, who dropped “screening test” from the title and reframed the tool as an aid to surveillance (consider their analogy to a growth chart in monitoring physical growth).
Notwithstanding this concern, the researchers’ findings are important, if not surprising, and certainly compatible with our Help Me Grow experience in Connecticut and elsewhere. Despite implementation of screening (i.e., ASQ) during 73% of well-child visits, only two-thirds of children referred by their pediatrician received a successful early intervention intake and multidisciplinary evaluation and only 11% of those who failed developmental screening ever received intervention services. The investigators conclude that cross-system information exchange and intake processes must be strengthened to effectively meet the developmental needs of children.
Findings from this important study validate our Help Me Grow experience and the importance of ensuring that early detection leads to the linkage of at-risk children and their families to community-based programs and services. That multiple contacts are required to facilitate such linkage emphasizes the critical need for effective care coordination and the importance of facilitated access to programs and services through a single portal of entry. Cross-sector collaboration among child health, early care and education, and family support providers is integral to the Help Me Grow process. The authors of the brief acknowledge Help Me Grow among the successful strategies to enable the “spectrum of referral” approach.