Implementation Minicases

These minicases address specific, common issues that arise prior to implementation.

Provider reluctance

  1. "I already ask these questions about development."
    1. We can’t ask all questions to all patients – we all have busy days and late patients – and the validated tool ensures we consistently ask all questions in the most effective way
    2. Subtle differences in word choice affect parent response rates: asking for concerns elicits more than asking for worries
    3. Parent surveys indicate that provider impressions of developmental surveillance do not match parental impressions about whether the child’s development was reviewed; parents are more satisfied with providers when they perceive development was reviewed
  2. "Anxious parents will over-report."
    1. Children whose parents endorse many predictive concerns but who screen out when formally assessed may still be at high risk, with lower academic performances and social skills
    2. Perhaps their anxiety is seeded in something different about their child – maybe not a true disability, but a weakness or vulnerability
    3. A validated tool may organize their concerns, which would be there anyway
  3. "Less educated, less experienced parents will under-report."
    1. This group of parents may not know when a child should meet a specific milestone, but can tell if their child is not speaking as well as same-aged cousins, is having behavior problems, or struggling with homework
    2. Asking these questions at repeat well child care visits may trigger parents to look more closely at their child’s skills
    3. Most of these tools were studied with parents of a range of educational levels and are written on a 5th grade level

Staff time limits

  1. "I don’t have time to add something new to my visit."
    1. Having parents answer questions before you enter the room may save time
    2. Scoring takes under 2 minutes (for the PEDS and ASQ)
    3. Surveys inquiring about parent concerns may prevent last minute questions, and later phone calls and emails
    4. Providers who have implemented routine screening do not complain of the time it takes after the initial few sessions of use
    5. Office systems can be arranged to minimize provider time
  2. "Parents who endorse many concerns will require too much time."
    1. These parents would have had these concerns regardless
    2. A standard algorithm to address the concerns can save time
  3. "I don’t have time to deal with all of the referrals this will generate."
    1. Most children will not have concerns endorsed
    2. Setting up systems ahead of time can minimize this
      1. Have photocopied or web-based handouts about Early Intervention, school-based evaluations, mental health resources
      2. Train other office staff to arrange referrals at the end of the visit, just as they address vaccinations, school and camp forms, etc
    3. Referring patients at a young age could minimize their needs in the future, which could require future efforts to address a bigger problem


  1. "Some screens cost money; I am already stretched very thin."
    1. Many private payors reimburse for developmental screening (code 96110)
    2. In some states, Medicaid reimbursements are also available
    3. Practices that train residents may ask residency programs to contribute to the effort of improving training by chipping in for the cost
    4. Private practices can ask parents to complete the tool online and have parents pay for the screening
  2. "I have a small practice but would like a better purchasing deal."
    1. Collaborate with nearby providers to purchase in bulk
    2. Telephone the publisher and explain your situation
    3. Contact your local AAP Chapter for ideas or partners
    4. Choose a tool that is financially manageable
    5. Track your reimbursement, which may cover the cost

Integrating with existing office systems

  1. "My front desk already has so much paperwork."
    1. Incorporate your front desk in creating a system that will work
    2. In lighter hours or seasons, attach surveys to other papers handed out at well child visits
    3. Ask adolescent patients to volunteer: attaching paperwork together, punching holes in the forms so they fit in your charts
  2. "I use an electronic medical record."
    1. Scan in parent surveys if you wish to keep them, or discard them after scoring is complete
    2. Purchase the electronic system of the screening tool
    3. Document concerns and algorithm decisions in your electronic template

Individual patient differences

  1. "My patients speak many languages. I don’t have time to translate a survey."
    1. Choose a tool already translated into the languages spoken in your community
    2. If no language-appropriate tool is available, use the survey questions as your developmental history
  2. "My population will not be able to read this, even at a 5th grade level."
    1. Many providers worry about this problem, but surveys written at very basic levels are accessible to most patients
    2. Some will need the survey questions integrated into the interview
    3. This may provide an opportunity to refer parents to adult literacy services
  3. "My population does not like to reveal developmental concerns, views developmental disabilities in a culturally specific manner, or is wary of outside services."
    1. Regular conversations about development open a dialog that continues over time for those who do not view developmental differences as an indication for referral at the time of identification
    2. Even for those who do not seek evaluation or intervention, your monitoring of development may help the family with interactions, developmentally appropriate expectations, and family-based support

Clinical Judgment

  1. "How can 10 questions do a better job than I do? Isn’t my job to assess and address these needs?"
    1. A survey does not replace you
      1. Parent endorsements will always have to be reviewed with a conversation
      2. A survey provides structure to the interview you are already doing
      3. A parent survey may strengthen your relationship with parents
        1. You are communicating your interest in their concerns
        2. Parents express higher satisfaction when pediatric providers address behavior and development
    2. Your clinical judgment is always necessary
      1. Children who are not developing typically in your estimation should be referred, regardless of parent survey answers
      2. Parent concerns about behavior, such as tantrums and toileting, are addressed with provider counseling per the referral algorithm on the PEDS, for example
      3. You are improving your clinical care with use of validated tools

Choosing a Tool

  1. "Which tools are available?"
    1. Review the most commonly used screening tools
    2. AAP Policy Statement includes a lengthy list of tools – see PEDIATRICS Vol. 118 No. 1 July 2006, pp. 405-420
  2. "Which tool is right for our practice?"
    1. Ask yourself and your staff the following questions:
      1. Will your patients want more in depth questions? Will they want to report on specific tasks a child does or does not do?
      2. What is the literacy level of your typical patient?
      3. Do you prefer an age specific tool or the same tool for all ages?
      4. Do you prefer parent report or do you want to observe the child’s skills?
    2. Try out the tool that best matches your practice operation and patient needs on a trial basis