Child Development

IMPROVING THE PRACTICE OF DEVELOPMENTAL PEDIATRICS IN PRIMARY CARE SETTINGS

Meeting Purpose:
The general objective was to determine how CDC can best contribute to the goal of promoting optimal child development within public and private health systems through creating a change in the way general pediatricians address and manage the developmental needs of children.

More specifically, we sought to discuss how to create a feasible method of practice that would allow for implementation of the recent developmental screening recommendations established by the American Academy of Pediatrics (AAP) Committees, through focusing on:

• current practice

• known barriers to implementing developmental screening nationally

• lessons learned from previous efforts

• potential opportunities for improvement

• inclusion of screening and counseling to encourage positive development along with identifying and treating potential developmental delays

Rationale for the meeting:

A plethora of neurobiological, behavioral, and social science research has significantly advanced our appreciation and understanding of the importance of early life experiences on early brain development and human behavior. The potential to improve developmental outcomes in children through planned interventions is now well established. Because nearly all children under 5 years-of-age participate in well-child care, the healthcare setting is an ideal place for assuring optimal development of children. Currently, however, the practice of developmental screening, and promotion of optimal development, in primary pediatric care practice varies tremendously and is less than optimal in most places.

Changing medical practice is challenging and will require a highly collaborative approach. The change has already begun with the issuance of AAP Committee statements, extensive work in the field, and the increasing recognition of the importance of early development on later behaviors and life outcomes. Furthering this work by developing a standard of practice that is feasible to conduct within the setting of well-child care, proving its effectiveness and cost effectiveness, making it available, providing support for its use, and monitoring outcomes is critical to advancing our goals.

It became clear, through discussions between CDC’s National Center on Birth Defects and Developmental Disabilities, AAP, and Center for Child Well-being, that there are a number of key stakeholders who need to be consulted and involved in the effort to promote developmental screening. In addition, we need more thorough discussion about what activities are already ongoing, and what gaps exist. To gather this information, we proposed to have a small meeting of 10-15 key stakeholders and experts in the field.

Location of meeting
Conference Center, Task Force for Child Survival and Development, Decatur, GA. The meeting was hosted by the Center for Child Well-being, a program of the Task Force.

Time of meeting
8/19/02 from 1:00-5:00 PM and 8/20/02 from 8:30 AM-12:30 PM

List of Attendees

Issues discussed:
Current State of Developmental Screening– Barry Zuckerman & Camille Smith

• History of Developmental Screening: Significant changes over the years were passage of PL 94-142 in 1976, Bright Futures, Early and Periodic Screening, Diagnosis, and Treatment, Healthy Steps, Early Head Start, pediatric training in child development, and the creation of psychometrically sound instruments

• Current Practice:

  • Models of Practice/Schedule of practice

    • Instruments – several instruments were mentioned such as the Parents' Evaluations of Developmental Status (PEDS), Ages and Stages, etc.

    • Referrals (further diagnostics and assessments, other services that are available to the child, Part C, Head Start, etc.)
       

  • In summary, even though there have been advances over the years, the limited amount of evidence available suggests that the delivery of developmental screening suffers from significant inadequacies including inconsistent delivery, failure to use validated assessment tools, lack of confidence in advising concerned parents, available resources, and inadequate training.

Barriers to Developmental Screening and Appropriate Follow-Up Care or Services – Frances Glascoe & Martha Rogers

• Training: Physicians feel that they are inadequately trained in child development and administration and interpretation of screening instruments. There needs to be more attention paid to clinical judgment.

• Cost/Reimbursement: Physicians feel that they are inadequately compensated for their time or that they cannot address developmental issues because they will not be reimbursed for it.

• Time: There is not enough time in the office for screening.

• Staff: Inadequately staffed.

• Lack of knowledge: Need to gain more knowledge in referrals and community program resources

• Lack of knowledge: Need to gain more knowledge about effective intervention/treatments after positive screen and improve communication between physician referral source (for example, physicians often don’t know what happens to the child that they referred).

In summary, there was much discussion about mechanisms of getting pediatricians to understand that developmental screening is an essential part of well-child care. Participants discussed the notion that systemic change is fundamentally important for the integration of developmental screening into current health practices.

DAY 2

Federal Partners Presentations

• Current Activities: Maternal and Child Health Bureau (MCHB), Office of Special Education Programs (OSEP), Part C Activities, Head Start

• Future Plans of each of these agencies were discussed

What can be done and how do we get there?

• Avoiding historical pitfalls: Instead of looking for one quick, inexpensive way of better service provision we need to examine the system of developmental services

  • What Do We Mean by Developmental Services

    • Universal: Anticipatory guidance and screening

    • Targeted: Developmental evaluation, counseling, and referral

    • Treatment: Secondary prevention and tertiary prevention

• Changes at the level of well-child care

  • Physician time and reimbursement

  • Develop efficient models of practice and of practice support

  • Make tested screening tools available

  • Prioritize, systematize, and rationalize the schedule and content of well-child care

• Training

  • Continuing medical education.

  • Train in adoption of specific clinical procedures including screening and parent education.

  • Science-based education in developmental disabilities.

  • Consultation and technical assistance.

  • Residency training programs.

    • Faculty training

    • Curricular materials
       

• Coordination of resources

  • Map referral resources

  • Develop standards for resource availability

  • Educate physicians about existing resources

  • Promote effective communication between community resources and physicians

  • Provide easily accessible, reliable care coordination
     

• Need for data

  • Evidence for clinical effectiveness of developmental services.

  • Benchmark and routinely collect data on children’s developmental status, outcomes of services, and parents’ needs for service.

  • Demonstrate cost effectiveness and cost benefit of good quality preventive and developmental care.
     

• Need for Systemic view

  • Strategies for Systemic Change

  • Promote adoption of new standards of care

  • Support the acquisition of requisite professional skills

  • Provide models and tools to restructure well-child care

  • Facilitate adequate reimbursement for services

  • Foster links between pediatricians and other community resources for families

  • Increase the demand for comprehensive, good quality care

Parents in the Middle: Process of Pediatric Care:

• Pediatric practices are in a unique position to identify children with and at risk for developmental problems, to evaluate their developmental status, and to initiate appropriate interventions. Additionally, pediatricians have the opportunity to recognize the manifestations of stressors in parenting, evaluate the risks involved, and determine the necessary interventions.

Pediatric care -> Parenting Behaviors -> Child outcomes

Concluding comments:
At the end of the meeting, each participant was asked to state his/her view on what CDC’s number one priority should be in promoting developmental screening in pediatric well-child care. These are summarized in the Potential Opportunities for CDC to Improve the Practice of Developmental Pediatrics in Primary Care.

Potential Opportunities for CDC to Improve the Practice of Developmental Pediatrics in Primary Care

Improving Practice at the Provider Level

• Design a model system of practice that includes cost effective screening for developmental problems and promotes optimal development that is integrated within the current system of well-child care.

• Work with a consortium of primary care practices to determine feasibility, costs, outcomes, and parent/provider satisfaction.

• Produce tool kit for technology transfer to other practices.

• Work with professional organizations to translate these lessons learned into best practices policy documents.

Improving Practice at the Community Level

• Develop state-wide, multidisciplinary resource centers that would provide a variety of services including training, increased awareness and advocacy, research, and coordination and linkage of intervention services.

Improving Pre-service Training

• Award grants to residency training programs to develop novel training curricula.

Addressing Reimbursement Issues

• Work with CMS to develop guidance to providers on coding and other billing issues.

Improve Likelihood of Incorporation into Managed Care Systems

• Conduct cost effectiveness studies and develop plan to disseminate to care systems

• Award grants to measurement groups to develop quality assurance measures that can be used by managed care systems

Improve Advocacy

• Convene parent and other groups that may be working toward improving the state of a particular developmental problem.

• Organize these groups into a consortium for greater effectiveness.

• Assist consortium in finding non-governmental support for advocacy issues.

Improve the Collection and Use of Data for Monitoring and Program Evaluation

• Compile list of existing data systems that collect elements of interest

• Develop mechanism for reporting compiled data (annual publication)

• Develop effective distribution plan for data

• Look at data issues from both national, state, and community perspectives

Increase Awareness

• Develop communication plan(s) for increasing education and awareness to the public, parents, professionals, and community organizations.

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National Center on Birth Defects and Developmental Disabilities

The National Center on Birth Defects and Developmental Disabilities (NCBDDD) promotes the health of babies, children, and adults, and enhances the potential for full, productive living.  Our work includes identifying the causes of birth defects and developmental disabilities, helping children to develop and reach their full potential, and promoting health and well-being among people of all ages with disabilities.