These minicases address specific, common issues that arise prior to implementation.
- "I already ask these questions about development."
- 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
- Subtle differences in word choice affect parent response rates: asking for concerns elicits more than asking for worries
- 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
- "Anxious parents will over-report."
- 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
- Perhaps their anxiety is seeded in something different about their child – maybe not a true disability, but a weakness or vulnerability
- A validated tool may organize their concerns, which would be there anyway
- "Less educated, less experienced parents will under-report."
- 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
- Asking these questions at repeat well child care visits may trigger parents to look more closely at their child’s skills
- 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
- "I don’t have time to add something new to my visit."
- Having parents answer questions before you enter the room may save time
- Scoring takes under 2 minutes (for the PEDS and ASQ)
- Surveys inquiring about parent concerns may prevent last minute questions, and later phone calls and emails
- Providers who have implemented routine screening do not complain of the time it takes after the initial few sessions of use
- Office systems can be arranged to minimize provider time
- "Parents who endorse many concerns will require too much time."
- These parents would have had these concerns regardless
- A standard algorithm to address the concerns can save time
- "I don’t have time to deal with all of the referrals this will generate."
- Most children will not have concerns endorsed
- Setting up systems ahead of time can minimize this
- Have photocopied or web-based handouts about Early Intervention, school-based evaluations, mental health resources
- Train other office staff to arrange referrals at the end of the visit, just as they address vaccinations, school and camp forms, etc
- Referring patients at a young age could minimize their needs in the future, which could require future efforts to address a bigger problem
- "Some screens cost money; I am already stretched very thin."
- Many private payors reimburse for developmental screening (code 96110)
- In some states, Medicaid reimbursements are also available
- Practices that train residents may ask residency programs to contribute to the effort of improving training by chipping in for the cost
- Private practices can ask parents to complete the tool online and have parents pay for the screening
- "I have a small practice but would like a better purchasing deal."
- Collaborate with nearby providers to purchase in bulk
- Telephone the publisher and explain your situation
- Contact your local AAP Chapter for ideas or partners
- Choose a tool that is financially manageable
- Track your reimbursement, which may cover the cost
Integrating with existing office systems
- "My front desk already has so much paperwork."
- Incorporate your front desk in creating a system that will work
- In lighter hours or seasons, attach surveys to other papers handed out at well child visits
- Ask adolescent patients to volunteer: attaching paperwork together, punching holes in the forms so they fit in your charts
- "I use an electronic medical record."
- Scan in parent surveys if you wish to keep them, or discard them after scoring is complete
- Purchase the electronic system of the screening tool
- Document concerns and algorithm decisions in your electronic template
Individual patient differences
- "My patients speak many languages. I don’t have time to translate a survey."
- Choose a tool already translated into the languages spoken in your community
- If no language-appropriate tool is available, use the survey questions as your developmental history
- "My population will not be able to read this, even at a 5th grade level."
- Many providers worry about this problem, but surveys written at very basic levels are accessible to most patients
- Some will need the survey questions integrated into the interview
- This may provide an opportunity to refer parents to adult literacy services
- "My population does not like to reveal developmental concerns, views developmental disabilities in a culturally specific manner, or is wary of outside services."
- 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
- 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
- "How can 10 questions do a better job than I do? Isn’t my job to assess and address these needs?"
- A survey does not replace you
- Parent endorsements will always have to be reviewed with a conversation
- A survey provides structure to the interview you are already doing
- A parent survey may strengthen your relationship with parents
- You are communicating your interest in their concerns
- Parents express higher satisfaction when pediatric providers address behavior and development
- Your clinical judgment is always necessary
- Children who are not developing typically in your estimation should be referred, regardless of parent survey answers
- Parent concerns about behavior, such as tantrums and toileting, are addressed with provider counseling per the referral algorithm on the PEDS, for example
- You are improving your clinical care with use of validated tools
Choosing a Tool
- "Which tools are available?"
- Review the most commonly used screening tools
- AAP Policy Statement includes a lengthy list of tools – see PEDIATRICS Vol. 118 No. 1 July 2006, pp. 405-420
- "Which tool is right for our practice?"
- Ask yourself and your staff the following questions:
- Will your patients want more in depth questions? Will they want to report on specific tasks a child does or does not do?
- What is the literacy level of your typical patient?
- Do you prefer an age specific tool or the same tool for all ages?
- Do you prefer parent report or do you want to observe the child’s skills?
- Try out the tool that best matches your practice operation and patient needs on a trial basis