Little is known about the current practices of primary care physicians regarding developmental surveillance and screening during pediatric preventive care visits. We conducted a mailed survey of a random national sample of pediatricians and family physicians to describe their practices and identify factors that predict use of developmental screening tools, an efficacious way of identifying children with developmental delays. Most physicians reviewed developmental milestones and prompted parents for developmental concerns at preventive care visits. Approximately half of the physicians used a formal developmental screening instrument. Female physician gender predicted higher rates of use of screening tools for family physicians, but not for pediatricians. Most physicians seemed committed to the early diagnosis of developmental delays. Substantial variability in surveillance and screening practices, barriers of time and reimbursement, and under-reliance on parent-completed questionnaires underscore areas for improvement.
Developmental disabilities affect an estimated 17% of children in the United States. 1 In young children, disabilities often present as less specific delays in the acquisition of expected developmental milestones in speech, cognitive, adaptive, fine motor, or gross motor development. Early identification coupled with early treatment to address delays can improve outcome, enhance function, and reduce the development of secondary behavioral problems. 2-4 Young children with developmental delays, however, seem to be under-identified and underserved. From 1999 to 2000, approximately 1.8% of children aged less than 3 years received early intervention services in the United States under the Individuals with Disabilities Education Act Part C, whereas an estimated 5% of preschoolers were served under Part B. 5 These data indicate that a substantial proportion of infants and toddlers with developmental delays are not identified or fail to receive early intervention services.
Primary care physicians, because they routinely see children less than 5 years of age for preventive care visits, can play a key role in the early identification of developmental delays. 6 Although the primary care physician's role emphasizes monitoring and screening of the development of young children, limited information is available about physicians' actual practices in this area. One of the few studies to examine the issue noted that although 63% of a sample of 121 pediatricians reported using a developmental screening test, only 15% to 20% of these physicians screened more than 10% of their patients. 7 In another study using clinical scenarios to describe young children with a variety of developmental concerns, only 19% of pediatricians reported that use of a standardized developmental screening instrument would be included in their approach to a young child with language delay, and 38% of pediatricians would use such an instrument if parents raised a concern about possible mental retardation in their 3-year-old child. 8 A study that updated these survey results 15 years later found that pediatricians reported higher rates of use of screening instruments (61% for the child with suspected mental retardation) and were more likely to refer the children described to be assessed by specialists. 9 These and other studies describing physician surveillance and screening behavior have been regional in scope and, in contrast with the current study, have focused on pediatricians to the exclusion of family physicians. 7-9
How might the identification of developmental delays in young children be improved? A recent survey of members of the American Academy of Pediatrics identified several relevant barriers to timely identification in primary care practice in general and to the use of validated screening tools in particular. 10 Barriers to the use of formal developmental screening instruments most frequently endorsed by physicians included insufficient time and reimbursement for this activity. 10 Many of the available provider-administered tools can consume the greater part of a preventive care visit if administered in a standardized fashion. Other important barriers to developmental screening identified in the survey included unfamiliarity with screening tools, the absence of nonphysician staff to participate in developmental screening, and unfamiliarity with billing codes related to this procedure. A minority of physicians were concerned about a lack of available developmental diagnostic and treatment services. 10
These barriers may be surmountable. Validated parent questionnaires have the potential to reduce the amount of provider time needed for developmental screening, thereby addressing one of the major identified barriers to this activity. 11-13 There is also evidence that parental concern about a child's development or behavior can be used as a reliable predictor of actual developmental delays. 14 The extent to which primary care physicians have adopted these newer methods for developmental surveillance and screening is not known.
To better understand how primary care physicians identify young children with developmental delays, we surveyed a national random sample of primary care pediatricians and family physicians. We gathered descriptive information regarding their self-reports of current developmental screening practices and tested several hypotheses regarding whether reported identification efforts varied depending on physician beliefs. First, we hypothesized that physicians who believed in the effectiveness of early intervention services would be more likely to report referral to these services in response to clinical vignettes describing young children with probable developmental delays. We predicted that physicians who reported that there are sufficient resources in their community to serve children with developmental delays would be more likely to provide referral for such services in response to clinical vignettes. Similarly, we predicted that physicians who report confidence in their ability to manage consultations and referrals for therapy would be more likely to make such referrals in response to the vignettes. Last, we predicted that there would be a negative association between physicians' belief in their ability to identify children with developmental delays on the basis of clinical expertise and the likelihood that physicians would report using a formal developmental screening tool in practice.
We also examined two associations identified by other investigators. Female physicians, compared with their male colleagues, exhibit higher rates of screening in adult medicine. 15-17 Among pediatricians in a recent survey, practitioners with more than 50% publicly insured patients or more than 40% non-white patients were more likely to report that they felt less confident in their ability to perform developmental assessments (self-efficacy) and that they had less time to perform such assessments. 10