CHILD DEVELOPMENT (Screening)

Evidence Statement Benefit Plan Language Other Information and Resources Author(s)

References


Updated 1/31/11

Evidence Statement

Clinical Preventive Service Recommendations

U.S. Preventive Services Task Force Recommendation
In 2006, the U.S. Preventive Services Task Force (USPSTF) found that evidence was "insufficient" to recommend for or against routine use of brief, formal screening instruments in primary care to detect speech and language delay in children up to 5 years of age.1

Evidence Rating: I (Insufficient Evidence)
The USPSTF was unable to find studies that addressed the overarching question of whether screening for speech and language delay with brief, formal instruments improves long-term speech, language, and other non-speech-and-language outcomes. However, the USPSTF did find fair evidence to suggest that interventions can improve the results of short-term assessments of speech and language skills. The USPSTF could not find studies that addressed the potential harms of screening or interventions for speech and language delays. The USPSTF could not determine the balance of benefits and harms of screening with brief, formal screening instruments.1

The USPSTF did not examine other aspects of developmental screening.

Evidence Rating:
Not Specified

Other professional organization such as the National Association of Pediatric Nurse Practitioners (NAPNAP)3 and the American Academy of Neurology4 recommend screening for developmental disorders.



Condition / Disease Specific Information

Epidemiology of Condition/Disease
A developmental delay, disorder, or disability refers to the presence of one or more of a diverse group of chronic conditions that hinders a child from developing age-appropriate cognitive, emotional, social, behavioral, psychological, or motor skills such as learning, communicating with adults, playing with other children, or walking. Developmental disabilities can begin at any time during childhood and, depending on the severity of the condition, can result in delayed learning (such as a speech impediment that can be overcome with speech therapy), a physical or mental impairment (such as dyslexia), or a permanent disability (such as cerebral palsy or mental retardation).

Examples of developmental disabilities include:
  • Attention deficit/Hyperactivity disorder (ADD/ADHD)
  • Autism spectrum disorders
  • Cerebral palsy
  • Depressive or anxiety disorders
  • Epilepsy
  • Hearing loss
  • Learning disorders such as dyslexia
  • Mental retardation
  • Muscular dystrophy
  • Speech disorder
  • Tourette syndrome and other tic disorders
  • Vision impairment
Approximately 6.6% of children (aged 5 to 17 years) in the United States have ADD, 3.6% have a developmental delay (DD), 8.2% have a learning disability (LD), and 13.6% have a mental health problem.5

Children with developmental disabilities have poorer health outcomes, a lower level of education attainment, and higher rates of delinquency and incarceration than do children without disabilities. Poor outcomes associated with developmental delays and disabilities include:

Reduced educational attainment
  • Poor school performance
  • Reduced school attendance
Poor overall health status
  • Increased rate of injuries
  • Increased rate of emergency room visits, doctor visits, and hospitalizations
  • Longer hospital stays
  • Higher rates of mental illness and behavioral problems
Social problems
  • Poor peer relationships
  • Increased risk of substance abuse
  • Increased risk of delinquency and violence in adolescence and adulthood
Condition/Disease Risk Factors
There are multiple risk-factors for developmental delays, disabilities, and disorders.6-8



The Value of Prevention

Economic Burden of Condition/Disease
The economic and social burden of developmental disabilities is great. The poor health and social outcomes of children with developmental disabilities result in excess medical, education, and criminal justice system costs for families, employers, and communities. The lifetime direct and indirect costs for persons born in 2000 with developmental disabilities were estimated to equal $51.2 billion for persons with mental retardation, $11.5 billion for persons with cerebral palsy, $2.1 billion for persons with hearing loss, and $2.5 billion for persons with vision impairment (all figures in year 2003 dollars).9 Indirect costs for the developmentally disabled person include the value of productivity losses in the workplace and household because of premature death, inability to work, or limitation in the amount and type of work that can be performed.

The excess medical costs associated with developmental disabilities are well-documented. For example, children with ADHD have higher health-related expenses than do children without developmental delays and disabilities. In fact, compared to children who develop normally, children with ADHD have 2.6 times as many medical claims and average nearly $1,000 per year in added medical costs (the average annual per patient cost for a child with ADHD in 1998 was $1,574 compared to $541 for a child without ADHD).10 Further, family members of children with ADHD have per-capita annual direct and indirect costs nearly twice that of the family members of children without ADHD ($2,728 compared to $1,440).10 Similarly, results from Washington State Medicaid claims data show that, compared to children who develop normally, children with developmental delays:
  • Are at least 5 times more likely to have chronic health conditions such as gastrointestinal disorders, central nervous system disorders, and conditions of the ear, nose, and throat;
  • Have 1.5 times as many physician visits during their first 5 years of life;
  • Have more hospitalizations during their first 5 years of life, even when factors such as health status are controlled; and
  • Have more than 10 times the number of visits to specialty practitioners such as physical and occupational therapists, speech therapists, and audiologists.11
This additional need for healthcare translates into added costs for employers.

Workplace Burden of Condition/Disease
While employers are not directly impacted by the societal costs of developmentally disabled children, the added cost to the healthcare system should be of major concern to employers. Further, children with developmental delays and disabilities are a source of indirect costs to employers due to the fact that affected children experience more health problems and therefore require more substantial parental caregiving than do children without developmental problems. The added time and stress associated with intensive caregiving may result in employees experiencing higher medical claims themselves (due to increased health problems or depression), and lower productivity, increased absenteeism, or an early exit from the workforce. For example, the mothers of children with disabling conditions are estimated to lose an average of approximately 5 hours of work per week equaling 250 hours per year.12 Assuming an hourly cost of $12 to $20 (including fringe benefits), that implies a lost productivity cost of $3,000 to $5,000 per child, per year.12

Economic Benefit of Preventive Intervention
Screening and early intervention services may reduce long-term societal costs. However, there is no direct evidence to support cost-savings associated with screening or early detection.13

Estimated Cost of Preventive Intervention
In 2004, the private-sector cost of a well-child visit that included developmental screening averaged $83; approximately 95% of all paid claims fell within the range of $30 to $127 dollars. The private-sector cost of a limited developmental screen (e.g., Developmental Screening Test II, Early Language Milestone Test) averaged $27 and 95% of all paid claims fell within the range of $0 to $95. The private-sector cost of an extended developmental test (i.e., assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized assessment instruments) averaged $144 and 95% of all paid claims fell within the range of $0 to $466.13

Estimated Cost of Treatment
The cost of treatment will vary widely depending on the type and severity of the condition.

Cost-Effectiveness and/or Cost-Benefit Analysis of Preventive Intervention
Screening and early intervention services may reduce long-term societal costs. However, there is no direct evidence to support cost-savings associated with screening or early detection.13



Preventive Intervention Information

Preventive Intervention: Purpose of Screening
Screening tools are designed to identify children who may have a delay or disability and thus need more intensive diagnostic assessment and possible intervention or treatment. The purpose of screening is to identify children affected by developmental delays and disabilities when they are still developmentally receptive and malleable and therefore most responsive to interventions.

Benefits and Risks of Intervention
Research has shown substantial benefits to early recognition and intervention, especially for certain conditions. For example, children with autism who are identified early in life and receive specialized interventions have significantly improved cognitive, language, and motor skills and attain a higher level of education than do autistic children who are identified later in life.14-15 Early intervention can also improve the cognitive developmental trajectories of children with developmental disabilities and decrease conduct problems at home and in the classroom (resulting in an increased rate of high school graduation and decreased juvenile and adult arrests).16-17

The risks of screening for developmental delays and disabilities include the possibility of a negative influence on the parent's perception of their child, the added time and costs associated with screening and—as with all screenings—the risk of false-positives which can produce anxiety and subject the child and parent to unneeded tests and evaluations. Research has found that false-positive rates can reach 15% to 30% for developmental screening.13 False-positive results can place an extraordinary burden on the healthcare system, erode trust in the system, and potentially influence parents' perception of their child.18 However, some research has found children with false-positives perform substantially lower than do children with true-negative scores on measures of intelligence, language, and academic achievement indicating that while these children do not have a developmental disability they may nonetheless benefit from further assessment and referral to services such as Head Start and specialized day care.18-19

The benefits of early recognition and the opportunity for early intervention are expected to outweigh the risks and costs associated with screening.

Initiation, Cessation, and Interval of Screening
Research is insufficient to determine the most efficacious age at which to screen for, diagnose, and treat specific developmental disorders. The AAP recommends screening all infants and young children due to the availability and importance of 1) early intervention services for children birth to 3 years of age, and 2) early childhood education services for children age 3 to 5 years.

Developmental concerns should be addressed among other health topics at each preventive care visit during the first 5 years of life. Developmental surveillance, asking for example, "Do you have any concern about your child's development, learning, or behavior?" is important at each visit.

Structured screening should occur at the 9, 18, and 30-month visits.2

Intervention Process
Developmental screening consists of a brief assessment conducted by a parent and/or health care provider that can include direct observation, patient (child) elicitation (i.e., asking the child to name three colors), interviewing parents of a child expressing usual behavior, and physical testing (e.g., measuring a child's ability to visually track objects). Screening tools help a clinician assess a child's attainment of developmental milestones—the physical, cognitive, and behavioral skills that are necessary components of a child's development. Developmental screening is best conducted by a primary care provider who has knowledge of the child's health and consistent contact with the child.

Treatment Information
Providers should refer children with development disabilities to Early Intervention (EI) services and other developmentally appropriate services, as medically indicated. Health benefits should include provisions for diagnostic follow-up and treatment services.



Strength of Evidence

The level of evidence supporting the recommendations contained in this section is described below.

Recommended Guidance:
American Academy of Pediatrics (AAP)
Strength of Evidence: Not Specified
  • The AAP recommends regular, universal developmental screening of infants and young children by primary pediatric healthcare providers at 9, 18, and 30 months, using standardized screening tools with high specificity and sensitivity, to identify children in need of further assessment and diagnosis, and appropriate referral for early intervention and education services, as indicated.2
Note: In 2006, the U.S. Preventive Services Task Force (USPSTF) found that evidence was "insufficient" to recommend for or against routine use of brief, formal screening instruments in primary care to detect speech and language delay in children up to 5 years of age.1 The USPSTF did not examine other aspects of developmental screening.20



Summary Plan Description

Covered Screening
Coverage is provided for developmental screening including the use of standardized instruments.

Initiation, Cessation, and Interval
Developmental screening services are covered for all children as a component of the 9, 18, and 30-month well-child care visits.



CPT Codes

Child Development (Screening)
96110 Developmental screening; limited with interpretation and report
96111 Developmental testing; extended with interpretation and report
99381 Initial comprehensive preventive medicine evaluation and management, infant (under 1 year), new patient
99382 Initial comprehensive preventive medicine evaluation and management, early childhood (ages 1 to 4), new patient
99391 Periodic comprehensive preventive medicine evaluation and management, infant (under 1 year), established patient
99392 Periodic comprehensive preventive medicine evaluation and management, early childhood (ages 1 to 4 ), established patient



Other Information and Resources

Business Group Resource(s)

CDC Resource



Author(s)

Campbell KP, Lollar D, Chattopadhyay S. Child development evidence-statement: screening. In: Campbell KP, Lanza A, Dixon R, Chattopadhyay S, Molinari N, Finch RA, editors. A Purchaser's Guide to Clinical Preventive Services: Moving Science into Coverage. Washington, DC: National Business Group on Health; 2006.



References

1 U.S. Preventive Services Task Force. Screening for speech and language delay in preschool ahildren: Recommendation statement. Pediatrics 2006;117(2):497-501.
2 American Academy of Pediatrics. 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.
3 Cole L. National Association of Pediatric Nurse Practioners input for Congressman Waxman regarding how to improve screening and treatment services for children with autistic spectrum disorders in the U.S. August, 2003.
4 Filipek PA, Accardo PJ, Ashwal S, Baranek GT, Cook EH, et al. Practice paramenter: Screening and diagnosis of autism. Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society. Neurology 2000;55: 468-474.
5 Center for Mental Health Services. Mental Health, United States, 2002. Manderscheid RW, Henderson MJ, eds. DHHS Publication No. (SMA) 3938. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2004. Chapter 9 pp109-119.
6 Cordero JF. A new look at behavioral outcomes and teratogens: A commentary. Birth Defects Res. Part A. Clin Mol Teratol 2003; 67:900-902.
7 Koger SM, Schettler T, and Weiss B. Environmental toxicants and developmental disabilities. Am Psychol. 2005; 60(3): 243-255.
8 Cordero JF, Lollar DJ. Environmental factors affecting learning and behavior performance: a commentary. School Psychology Quarterly 2006 (special issue: In press).
9 Honeycutt A, Dunlap L, Chen H, et al. Economic costs associated with mental retardation, cerebral palsy, hearing loss, and vision impairment - United States. MMWR 2004; 53(03):57-59.
10 Swensen AR, Birnbaum HG, Secnik K, Marynchenko M, Greenberg P, Claxton A. Attention-Deficit/Hyperactivity Disorder: increased costs for patients and their families. J Am Acad Child Adolesc Psychiatry 2003; 42(12):1415-23.
11 Gallaher MM. Christakis DA. Connell FA. Healthcare use by children diagnosed as having developmental delay. Arch Pediatr Adolesc Med 2002; 156(3): 246-251.
12 Powers ET. Children's health and maternal work activity: Estimates under alternative disability definitions. J Hum Resour 2003; 38(3):522-556.
13 Thomson Medstat. Marketscan. 2004.
14 National Research Council, Committee on Educational Interventions for Children with Autism, Division of Behavioral and Social Sciences and Education. Educating Children with Autism. Washington, DC: National Academy Press; 2001.
15 Rogers SJ. Brief report: intervention in Autism. J Autism Dev Disord 1996;26(2):243-246.
16 Reynolds AH, Ou S-R, Topitzes JW. Paths of effects of early childhood intervention on educational attainment and delinquency: a confirmatory analysis of the Chicago Child-Parent Centers. Child Dev 2004;75(5):1299-1328.
17 Webster-Stratton C and Taylor T. Nipping early risk factors in the bud: preventing substance abuse, delinquency, and violence in adolescence through interventions targeted at young children (0-8 years). Prev Sci 2001;2(3):165-192.
18 Kwon C and Farrell PM. The magnitude and challenge of false-positive newborn screening test results. Archives of Pediatric & Adolescent Medicine 2000;154:714-718.
19 Glascoe FP. Are overreferrals on developmental screening tests really a problem? Archives of Pediatrics & Adolescent Medicine 2001;155(1):54-59.
20 U.S. Preventive Services Task Force. Screening for Speech and Language Delay in Preschool Children: Recommendation Statement. Pediatrics 2006:117(2):497-501.