Developmental Surveillance and Screening Algorithm Within a Pediatric Preventive Care Visit

The algorithm below is used in the developmental surveillance and screening policy statement. Its purpose is to guide providers through the delivery of developmental surveillance and screening. Click on an action/process and decision step for more information.

Printable Algorithm
Excerpted from: American Academy of Pediatrics; Council on Children With Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee and Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening. Pediatrics. 2006;118(1):405-420

1.) Pediatric Patient at Preventive Care Visit

Developmental concerns should be included as one of several health topics addressed at each pediatric preventive care visit throughout the first 5 years of life.
Additional Resources

2.) Perform Surveillance

Developmental Surveillance is a flexible, longitudinal, continuous, and cumulative process whereby knowledgeable healthcare professionals identify children who may have developmental problems. There are 5 components of development surveillance: eliciting and attending to the parents’ concerns about their child’s development, documenting and maintaining a developmental history, making accurate observations of the child, identifying the risk and protective factors, and maintaining an accurate record and documenting the process and findings. Additional Resources

3.) Does Surveillance Demonstrate Risk?

Yes | No--Schedule Next Routine Visit
The concerns of both parents and child health professionals should be included in determining whether surveillance suggests the child may be at risk of developmental delay. If either parents or the child health professional express concern about the child’s development, a developmental screening to address the concern specifically should be conducted.

4.) Is this a 9-, 18-, or 30-month visit?

Yes | No--Schedule Next Routine Visit
All children should receive developmental screening using a standardized test. In the absence of established risk factors or parental or provider concerns, a general developmental screen is recommended at the 9-, 18-, and 30-month* visits. Additionally, autism-specific screening is recommended for all children at the 18 and 24 month visits.
*Because the 30-month visit is not yet a part of the preventive care system and is often not reimbursable by third-party payers at this time, developmental screening can be performed at 24 months of age.

5a & 5b.) Administer Screening Tool

Developmental screening is the administration of a brief standardized tool aiding the identification of children at risk of a developmental disorder. Developmental screening that targets the area of concern is indicated whenever a problem is identified during developmental surveillance. Additional Resources

6a & 6b.) Are the Screening Tool Results Positive/Concerning?

Yes | No--Schedule Next Routine Visit
When the results of the periodic screening tool are normal, the child health professional can inform the parents and continue with other aspects of the preventive visit. When a screening tool is administered as a result of concerns about development, an early return visit to provide additional developmental surveillance should be scheduled, even if the screening tool results do not indicate a risk of delay.

7.) Make Referrals for: Developmental and Medical Evaluations & Early Developmental Intervention/Early Childhood Stories Additional Resources

8.) Developmental and Medical Evaluations

If screening results are concerning, the child should be scheduled for developmental and medical evaluations. Developmental evaluation is aimed at identifying the specific developmental disorder or disorders affecting the child. In addition to the developmental evaluation, a medical diagnostic evaluation to identify an underlying etiology should be undertaken. Early Developmental Intervention/Early Childhood Services can be particularly valuable when a child is first identified to be at high risk of delayed development, because these programs often provide evaluation services and can offer other services to the child and family even before an evaluation is complete. Establishing an effective and efficient partnership with early childhood professionals is an important component of successful care coordination for children. Additional Resources

9.) Is a Developmental Disorder Identified?

Yes | No-- Schedule Next Routine Visit
If a developmental disorder is identified, the child should be identified as a child with special health care needs and chronic condition management should be initiated (see No. 10 below). If a developmental disorder is not identified through medical and developmental evaluation, the child should be scheduled for an early return visit for further surveillance. More frequent visits, with particular attention paid to areas of concern, will allow the child to be promptly referred for further evaluation if any further evidence of delayed development or a specific disorder emerges.
Additional Resources
Center for Medical Home Improvement

10.) Identify as a Child with Special Health Care Needs: Initiate Chronic Condition Management

When a child is discovered to have a significant developmental disorder, that child becomes a child with special health care needs, even if that child does not have a specific disease etiology identified. Such a child should be identified by the medical home for appropriate chronic condition management and regular monitoring and entered into the practice’s children and youth with special health care needs registry.
Additional Resources
Center for Medical Home Improvement
The National Early Childhood Technical Assistance Center (NECTAC)