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Implementing Developmental Screening and Referrals: Lessons Learned From a National Project
Abstract
OBJECTIVES: To assess the degree to which a national sample of pediatric practices could implement American Academy of Pediatrics (AAP) recommendations for developmental screening and referrals, and to identify factors that contributed to the successes and shortcomings of these efforts. BACKGROUND: In 2006, the AAP released a policy statement on developmental surveillance and screening that included an algorithm to aid practices in implementation. Simultaneously, the AAP launched a 9-month pilot project in which 17 diverse practices sought to implement the policy statement's recommendations. METHODS: Quantitative data from chart reviews were used to calculate rates of screening and referral. Qualitative data on practices' implementation efforts were collected through semistructured telephone interviews and inductively analyzed to generate key themes. RESULTS: Nearly all practices selected parent-completed screening instruments. Instrument selection was frequently driven by concerns regarding clinic flow. At the project's conclusion, practices reported screening more than 85% of patients presenting at recommended screening ages. They achieved this by dividing responsibilities among staff and actively monitoring implementation. Despite these efforts, many practices struggled during busy periods and times of staff turnover. Most practices were unable or unwilling to adhere to 3 specific AAP recommendations: to implement a 30-month visit; to administer a screen after surveillance suggested concern; and to submit simultaneous referrals both to medical subspecialists and local early-intervention programs. Overall, practices reported referring only 61% of children with failed screens. Many practices also struggled to track their referrals. Those that did found that many families did not follow through with recommended referrals. CONCLUSIONS: A diverse sample of practices successfully implemented developmental screening as recommended by the AAP. Practices were less successful in placing referrals and tracking those referrals. More attention needs to be paid to the referral process, and many practices may require separate implementation systems for screening and referrals.
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“In some settings, screening programs have been criticized for identifying children with high likelihood of developmental delays without being able to ensure timely follow-up evaluation and services (e.g., King et al., 2010).”
From Navigating the Challenges: A Commentary on Barriers to Autism Screening in Childcare Centers (2026) · cites this paper as King et al., 2010
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“Importantly, screening needs to be linked to psychoeducation and counseling, follow-up services and treatment (Grossman et al., 2010; King et al., 2010).”
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“EI can have societal economic benefits by reducing the economic strain of costly services later in life, though further research is needed to quantify potential or actual cost savings (Knapp et al., 2009; Motiwala et al., 2006; Piccininni et al., 2017).”
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“In a study examining outcomes of the AAP screening guidelines, King et al. (2010) found that more than one-third of children who failed the screen were not referred to specialty care.”
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“This is in contrast to the finding by Schonwald et al. (2009) and King et al. (2010), which showed the feasibility of implementing routine developmental screening in an urban community with diverse socioeconomic backgrounds.”
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“In a study of 17 sites nationwide, referrals after a positive developmental screen ranged from 48–78% depending on the clinic, which led the authors to conclude that screening and referrals each need their own workflow procedures [33].”
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“Such collaboration may be hindered because of policy differences between education, social service, and health agencies (Adams et al., 2013; Flynn & Harbin, 1987; T. King et al., 2010; Pedonti et al., 2019; Summers et al., 2001).”
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“Clinician judgment tends to override the results of a concerning screen, more noticeably for PEDS.75 In a national screening and surveillance implementation project (17 diverse practices in 15 states over 9 months), King et al found that practices referred only 61% (range = 78% in September, 48% in January) of childre…”
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Missed, Misused, or Mismanaged
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Godoy, L., Carter, A. S., Silver, R. B., Dickstein, S., & Seifer, R. (2014) · Journal of Developmental & Behavioral Pediatrics · doi:10.1097/dbp.0000000000000060 · Cited by 39
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“(6) When an EI/ECSE or community-based referral is indicated, systemwide care coordination is needed to ensure that further evaluation reliably occurs in a timely manner and that the most effective services are provided.(14,17,19,33,64) Systemwide care coordination, a clinician’s surveillance, and supplemental screeni…”
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BackgroundEarly developmental outcomes predicted by gestational age from 35 to 41 weeks
Dueker, G., Chen, J., Cowling, C., & Haskin, B. (2016) · Early Human Development · doi:10.1016/j.earlhumdev.2016.07.006 · Cited by 31
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“A larger number of studies has examined the barriers perceived by providers to making and pursuing a referral.(3,5,14-17) A lack of knowledge about the EI system was consistently identified as a barrier.”
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Developmental Screening in the Primary Care Setting: A Qualitative Integrative Review for Nurses
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“Practice-Wide Engagement Practice-wide changes were necessary to ensure successful implementation of developmental screening (Glascoe, 2015; King et al., 2010).”
BackgroundMethodInfluentialStill Left Behind: Fewer Black School-Aged Youth Receive ASD Diagnoses Compared to White Youth
Habayeb, S., Kenworthy, L. E., Torre, A. D. L., & Ratto, A. B. (2021) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-021-05118-1 · Cited by 25
Improving Child Development Screening: Implications for Professional Practice and Patient Equity
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Increasing the Delivery of Preventive Health Services in Public Education
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Assessment of Psychopathology in Young Children
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“Despite these challenges, universal mental health screening in primary care has been shown to be feasible and effective in improving rates of referral (King et al., 2010; Schonwald, Huntington, Chan, Risko, & Bridgemohan, 2009).”
Li, C., Zhu, G., Feng, J., Xu, Q., Zhou, Z., Zhou, B., Hu, C., Liu, C., Li, H., Wang, Y., et al. (2018) · Autism Research · doi:10.1002/aur.1984 · Cited by 27
“After this 3-year program, the proportion of caregivers able to identify the early signs of ASD increased from 37% to 52%, and the proportion of caregivers who were unaware of the optimal time for intervention was reduced from 57% to 42% [King et al., 2010].”
BackgroundYingling, M. E., & Bell, B. A. (2020) · Child Care Health and Development · doi:10.1111/cch.12790 · Cited by 26
Smith‐Nielsen, J., Lønfeldt, N. N., Guédeney, A., & Væver, M. S. (2017) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2017.11.005 · Cited by 23
Developmental Support for Infants With Genetic Disorders
Wojcik, M. H., Stewart, J. E., Waisbren, S. E., & Litt, J. S. (2020) · PEDIATRICS · doi:10.1542/peds.2019-0629 · Cited by 23
Berry, A. D., Garzon, D. L., Mack, P., Kanwischer, K., & Beck, D. G. (2014) · Journal of Pediatric Health Care · doi:10.1016/j.pedhc.2014.04.008 · Cited by 23
“However, developmental www.jpedhc.org screening with a validated screening tool has been found to increase accurate identification of these children (Rydz et al., 2005; King et al., 2010).”
BackgroundMethodInfluentialImproving Developmental Screening, Discussion, and Referral in Pediatric Practice
Bright, M. A., Zubler, J. M., Boothby, C., & Whitaker, T. M. (2019) · Clinical Pediatrics · doi:10.1177/0009922819841017 · Cited by 23
“Increases in screening and discussion are consistent with previous literature.(7,8,10) A novel and important finding of the current study, however, is the significant improvement observed with initiation of a referral in a timely manner after an abnormal screen.”
Rural and Racial/Ethnic Differences in Children Receiving Early Intervention Services
Barnard-Brak, L., Morales-Alemán, M. M., Tomeny, K. R., & Mcwilliam, R. (2021) · Family & Community Health · doi:10.1097/fch.0000000000000285 · Cited by 19
Boh, A., & Johnson, L. (2017) · Early Child Development and Care · doi:10.1080/03004430.2016.1278369 · Cited by 22
“…18, 24, and 30 months of age and that any child determined to be at risk for developmental delays be referred for the appropriate early intervention evaluation and service provision (Arunyanart et al., 2012; Bethell, Reuland, Schor, Abrahms, & Halfon, 2011; King et al., 2010; Radecki et al., 2011).”
BackgroundTelephone-based developmental screening and care coordination through 2-1-1: a randomized trial
Nelson, B. B., Thompson, L. R., Herrera, P., Biely, C., Arriola Zarate, D., Aceves, I., Estrada, I., Chan, V., Orantes, C., & Chung, P. J. (2019) · Pediatrics · doi:10.1542/peds.2018-1064 · Cited by 21
Autism Screening in Early Childhood: Discriminating Autism From Other Developmental Concerns
Brewer, N., Young, R. L., & Lucas, C. A. (2020) · Frontiers in Neurology · doi:10.3389/fneur.2020.594381 · Cited by 21
“That there may be practical constraints on screening implementation is indicated by findings that, despite recommendations from organizations such as the American Academy of Pediatrics that all children be screened at 18 and 24 months (12), reported rates of screening of children in this age range among pediatricians…”
BackgroundFactors influencing autism spectrum disorder screening by community paediatricians
Ip, A., Zwaigenbaum, L., Nicholas, D. B., & Sharon, R. (2015) · Paediatrics & Child Health · doi:10.1093/pch/20.5.e20 · Cited by 21
McCrae, J. S., Robinson, J. A., Spain, A. K., Byers, K. D., & Axelrod, J. L. (2021) · BMC Health Services Research · doi:10.1186/s12913-021-06057-4 · Cited by 19
Early Intervention and the Role of Pediatricians
Rose, L., Herzig, L., & Hussey-Gardner, B. T. (2014) · Pediatrics in Review · doi:10.1542/pir.35-1-e1 · Cited by 21
Moving From Research to Large-Scale Change in Child Health Care
Bergman, D. A., & Beck, A. L. (2011) · Academic Pediatrics · doi:10.1016/j.acap.2011.06.004 · Cited by 20
“The developmental screening process was then tailored to the existing screening process in offices and the needs of the community partners.(66,67) Full-scale implementation is a dynamic process demanding a constant reevaluation of an intervention in light of changing systems, patient populations, and external environm…”
MethodChando, S., Craig, J. C., Burgess, L., Sherriff, S., Purcell, A. A., Gunasekera, H., Banks, S., Smith, N., Banks, E., & Woolfenden, S. R. (2020) · BMC Pediatrics · doi:10.1186/s12887-019-1902-z · Cited by 20
“Reducing disparities in early childhood development has been hampered by the lack of robust, populationbased evidence to inform program development and implementation [5, 6].”
BackgroundInfluentialImproving Delivery of Bright Futures Preventive Services at the 9- and 24-Month Well Child Visit
Duncan, P. M., Pirretti, A. E., Earls, M. F., Stratbucker, W. B., Healy, J. A., Shaw, J. S., & Kairys, S. W. (2014) · PEDIATRICS · doi:10.1542/peds.2013-3119 · Cited by 19
Self-citationDevelopmental delay in infants and toddlers with sickle cell disease: a systematic review
Hoyt, C. R., Varughese, T. E., Erickson, J., Haffner, N., Luo, L., L’Hotta, A. J., Yaeger, L., & King, A. A. (2021) · Developmental Medicine & Child Neurology · doi:10.1111/dmcn.15048 · Cited by 19
Gaze-based classification of autism spectrum disorder
Fabiano, D., Canavan, S. J., Agazzi, H. C., Hinduja, S., & Goldgof, D. B. (2020) · Pattern Recognition Letters · doi:10.1016/j.patrec.2020.04.028 · Cited by 19
“The lengthy evaluation coupled with the need for a specialist operating in a clinical environment contributes toward delays in early identification, as these resources are not universally available and tend to cluster in urban areas [ 24 , 26 , 38 ].”
BackgroundDecker, K. B., Williams, E., Cook, G. A., & Fry, M. M. (2020) · Maternal and Child Health Journal · doi:10.1007/s10995-020-03067-2 · Cited by 17
Uchitel, J., Alden, E. R., Bhutta, Z. A., Cavallera, V., Lucas, J. E., Oberklaid, F., Patterson, J. C., Raghavan, C., Richter, L., Rikard, B. K., et al. (2022) · Journal of Developmental & Behavioral Pediatrics · doi:10.1097/dbp.0000000000001112 · Cited by 21
“supervision and counseling,(10) and in performing appropriate referrals.(11) In one study, the American Academy of Pediatrics (AAP) investigated the feasibility of implementing their screening algorithm across several primary care practices(11) and found that practitioners struggled to fulfill 3 key AAP recommendation…”
BackgroundEvolving Roles for Health Care in Supporting Healthy Child Development
Schickedanz, A. B., & Halfon, N. (2020) · The Future of Children · doi:10.1353/foc.2020.a807755 · Cited by 17
Silver, R. B., Newland, R. P., Hartz, K. A., Jandasek, B. N., Godoy, L., Lingras, K. A., Low, C. M., Dickstein, S., Campagna, K., Berger, B., et al. (2017) · Clinical Practice in Pediatric Psychology · doi:10.1037/cpp0000214 · Cited by 16
“In addition to supporting implementation science frameworks, our research corroborated many of the barriers and facilitators found in other qualitative research on screening (e.g., King et al., 2010; Schonwald et al., 2009).”
Research Collaboration with 2-1-1 to Eliminate Health Disparities
Linnan, L. A. (2012) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2012.09.025 · Cited by 16
Integrating a New Online Autism Screening Tool in Primary Care to Lower the Age of Referral
Schrader, E. A., Delehanty, A. D., Casler, A. G., Petrie, E., Rivera, A., Harrison, K., Paterniti, T. A., Sebastiany, L., Nottke, C., Sohl, K., et al. (2020) · Clinical Pediatrics · doi:10.1177/0009922819900947 · Cited by 15
Guttmann, A., Saunders, N. R., Kumar, M. M., Gandhi, S., Diong, C. C., MacCon, K., & Cairney, J. (2020) · The Journal of Pediatrics · doi:10.1016/j.jpeds.2020.03.016 · Cited by 15
Matheis, M., & Matson, J. L. (2015) · Journal of Developmental and Physical Disabilities · doi:10.1007/s10882-015-9449-x · Cited by 15
“2011), implementation of these practices has been problematic (AlQabandi et al. 2011; King et al. 2010; Matson and LoVullo 2009).”
BackgroundInfluentialBranson, D. M., & Bingham, A. (2016) · Infants & Young Children · doi:10.1097/iyc.0000000000000079 · Cited by 15
“More than 12 million or 61% of children in the United States younger than 5 years spend time in out-of-home child care (Laughlin, 2013).”
BackgroundInvestigating a “Wait and See” Mindset Among Pediatric Health Care Providers
Edwards, N. M., Kaiser, E., & Stapel‐Wax, J. L. (2021) · Infants & Young Children · doi:10.1097/iyc.0000000000000201 · Cited by 14
“King et al. (2010) also found that PCPs who were successful in implementing screenings were not similarly as successful in making and tracking referrals to EI services.”
Result(2018) · Archivos Argentinos de Pediatria · doi:10.5546/aap.2018.7 · Cited by 14
Colombo, P., Buo, N., Ceccarelli, S. B., & Molteni, M. (2022) · Brain Sciences · doi:10.3390/brainsci12020256 · Cited by 14
“Moreover, once a child has been identified as being at risk of ASD through screening, a direct referral to a specialist service speeds up the diagnostic process, reduces the time between the first concerns and the diagnosis, and improves family compliance with the evaluation process [19].”
Background
Metadata
- Authors
- King, T. M., Tandon, S. D., Macias, M. M., Healy, J. A., Duncan, P. M., Swigonski, N. L., Skipper, S. M., & Lipkin, P. H.
- Affiliations
- Johns Hopkins University (US)
- Medical University of South Carolina (US)
- American Academy of Pediatrics (US)
- University of Vermont (US)
- Indiana University Indianapolis (US)
- Kennedy Krieger Institute (US)
- Venue
- Pediatrics
- Publisher
- American Academy of Pediatrics (AAP)
- Published
- 2010-02-01
- Volume
- 125
- Issue
- 2
- Pages
- 350-360
- ISSN
- 0031-4005 (ISSN-L)
- 1098-4275
- OpenAlex
- W2067299533
- Cited by
- 251
- References
- 28
- Citations by year
- 2026: 9 · 2025: 6 · 2024: 7 · 2023: 9 · 2022: 13 · 2021: 19 · 2020: 30 · 2019: 23 · 2018: 17 · 2017: 16 · 2016: 23 · 2015: 10 · 2014: 21 · 2013: 11 · 2012: 16
- FWCI
- 25.56
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- PEDIATRICS (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Center for Research Resources (KL2RR025006, K12RR017627)
- Topics
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Child and Adolescent Health
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Adolescent and Pediatric Healthcare
- Keywords
- developmental screening, child development monitoring, pediatric practice, American Academy of Pediatrics policy statement, early intervention programs, referral tracking, implementation barriers, employee turnover
- MeSH terms
- Algorithms, Child Development, Developmental Disabilities, Child, Preschool, Humans, Infant, Infant, Newborn, Mass Screening, Pediatrics, Primary Health Care, Referral and Consultation, United States, Practice Guidelines as Topic, Guideline Adherence
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