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PEDS uses parents’ concerns to identify risk level
Physicians have made great strides in preventing and detecting pediatric illness, but there is still one significant area that often remains overlooked. Only about 30% of children with serious developmental and behavioral problems are identified before they enter school, when they could benefit from early intervention.
With a new screening tool, clinicians are beginning to address that deficiency. The PEDS (parents’ evaluation of developmental status) is a short form that categorizes parents’ concerns and allows physicians to identify children who may be at risk for developmental or behavioral problems. In many cases, parents simply can be reassured that their child is developing normally. In other cases, the physician can conduct further screening or provide a referral.
"We’re dealing with the highest prevalence of all [problems] that affect children," says Frances Page Glascoe, PhD, associate professor of pediatrics at Vanderbilt School of Medicine in Nashville, TN, and the developer of the PEDS. Glascoe notes that about 18% of children have a developmental problem. "Yet physicians have not approached the detection of developmental problems with nearly the kind of rigor with which they’ve approached asthma or otitis," she says. "There’s every reason for them to want to do more than they’re doing."
Development moves into the spotlight
In fact, developmental issues are coming to the forefront in pediatric medicine.
"For a long time in pediatrics, the big problems were infectious diseases and injuries," says Jeff Brown, MD, MPH, a pediatrician and director of the general pediatrics division of Denver Health, a system of city and county hospitals and neighborhood clinics. "With vaccines and better antibiotics, we’ve been able to rein in a lot of those problems.
"There’s been a lot of talk about the new morbidities — learning problems, behavioral problems, developmental problems," he says. "As pediatricians, we’ve been trying to figure out how to identify those problems."
Denver Health used the PEDS in a pilot project and just began using them throughout the clinics. At a minimum, Denver Health expects pediatricians to administer the PEDS by the time a child is 2 and again between the ages of 2 and 4. Brown advocates using the PEDS at every well-child visit up to school age.
"It’s quick and easy," he says. "You don’t need any extensive testing devices — dolls, blocks, cubes, bells [as in other, child-oriented screening tests]."
The PEDS relies on parents’ reports of "concerns" about their child’s development. Scoring instructions alert physicians to items that relate to behavior (such as having tantrums or refusing to go to bed) and to development (such as difficulty being understood).
The PEDS is based on research that identified risk categories based on parents’ observations. That makes it far more accurate than off-the-cuff conversations in which physicians might incorrectly dismiss parents’ comments, says Glascoe.
Even the wording is crucial. "If physicians ask, Do you have worries about your child’s development?’ most parents will say no," she says. "Only 50% of parents know what the word development’ means."
PEDS asks about concerns about "your child’s learning, development, and behavior." (See sample questionnaire, inserted in this issue.) About 43% of all parents will list no concerns. Another 20% have nonsignificant concerns, mostly behavioral, such as comments about children who are willful, whiny, or aggressive. Only 5% and 7% of these children, respectively, have undetected disabilities, says Glascoe, although physicians may want to provide parent education resources. "If parents only have a behavioral concern and that’s it, there’s almost no chance that there’s have a developmental problem," she says.
Parents crave the reassurance that their child is developing normally, says Brown. "’Your baby is OK.’ What mother doesn’t want to hear that? It’s an incredible boost."
Almost one in four parents will have a single significant concern about their child’s development. These children are at moderate risk; 29% of them have detected disabilities. They need further screening, advises Glascoe.
"Pediatricians don’t have to do the screening on their own," says Glascoe, who notes that in conjunction with federal guidelines, states offer free screening for children ages 0 to 3. (For more information, see the Web site, www.nectas.nc.edu.) Public schools offer screening of children older than 3.
When parents have more than one significant concern, their children are at high risk. About 70% have either undetected disabilities or below-average skills in language, intelligence, or school achievement. Glascoe advises referring them for diagnostic testing such as speech-language evaluation, or psychological testing.
With early intervention, children with developmental problems are more likely to graduate from high school and less likely to have antisocial behavior, Glascoe says.
PEDS useful in performance assessment
The PEDS also has become a tool for population-based measurement and accountability. The Foundation for Accountability (FAACT) in Portland, OR, and the National Committee for Quality Assurance in Washington, DC, included the PEDS in the Child and Adolescent Health Measurement Initiative as a way of deter- mining whether health plans and providers are "Promoting Healthy Development." (For more information on the initiative, see related article, p. 114.)
The PEDS identifies risk levels, and patient-based surveys could determine whether physicians provided any follow-up, says Christina Bethell, PhD, FACCT’s director of research.
"Follow-up" could be as simple as asking patients to return in six months or scheduling a hearing check, she says. "This tool is designed to encourage health plans to move more into early detection of problems," says Bethell.
[Editor’s note: For more information or to order copies of the PEDS forms and the manual ($30 plus shipping and handling for manual plus 100 forms), contact Ellsworth & Vandermeer Press, 4405 Scenic Drive, Nashville, TN 37204. Telephone: (615) 386-0061. Fax: (615) 386-0346.]