Do we need developmental screenings during well visits?

It is not uncommon for a 2-year-old boy not to talk at his well-child visit.  One of my own grandsons was not using words and needed speech therapy to get his speech started. At 3-years-old you cannot get him to keep quiet, though he is still clearly somewhat uncomfortable with his speech.

My daughter and son-in-law who are very articulate lawyers, knew he was acting differently from other 2-year-olds, but would not have known he needed speech therapy if they had not brought it up with their pediatrician (or, in this case, the grandfather.)  I often see parents who do not want to say that they are worried about their children's development, or simply do not know it is a problem that they should mention to their child's doctor.

So the latest attempt by the U.S. Preventive Services Task Force last week to streamline pediatric appointments by cutting out some development screening is a bit disturbing to a practicing primary care practitioner such as me.

The USPSTF released a statement saying there is not enough evidence to assess the benefits and harms of speech and language screenings for "asymptomatic" children 5 years and younger. The statement applies to cases in the primary care setting in which the parents and doctor do not have specific concerns about the child's speech, language, hearing, or development before special screening.

But many parents in my diverse practice do not know when their children are behind.  More than 20 percent of our patients' parents are not native English speakers and over 30 percent are first time parents. Children who grow up in multilingual homes do acquire language more slowly, but they acquire two or more languages at the same time. Most girls in multilingual homes do fine, but many boys find the multiple languages difficult to assimilate.  Many first-time parents do not know what to expect in many cases.

The past chairman of the American Academy of Pediatrics Section on Developmental and Behavioral Pediatrics Executive Committee Michelle Macias responded to the USPSTF: "Certainly what we want is to not miss any children who may have a delay and...we have done studies (showing) that formal screening as well as formal surveillance enhances a physician's, a pediatrician's clinical judgment." The AAP, in spite of these articles published in their own journal, continues to recommend screening children for developmental disorders.

So what are these absolutely opposing statements talking about and why is it important for your children and grandchildren?

Essentially, the USPSTF is saying that detailed (and sometimes expensive) developmental screening surveys that primary care children's practitioners use to see if a child needs extra help with developing skills for life and school do not do any better than just asking a parent or guardian: "Does your child speak and move normally?"

In my practice, we use special developmental screening surveys, Parental Evaluation of Developmental Status (PEDS), at 9 to 12 and at 18 to 24 months. These 10 questions ask parents to think about their child and to compare them to other children the same age to see if the parents observe any major differences.  Basically, these written questions ask in 10 different ways: "Does your child speak and move normally?"

We find that people are more likely to write down problems than to tell the doctor or nurse directly, and by asking the same question over and over again in different ways, the parents are more likely to describe differences that may be important.  A written questionnaire does have problems if the parents do not read and write English (or Spanish) fluidly.  At least 10 percent of native English speakers are functionally illiterate and many not native English speakers do not read and write English well.

But the PEDS questionnaire does seem to catch some developmental delay, especially milder forms of autism, which the medical practitioner would otherwise miss.  There are studies that show that starting rehabilitation in language or physical delay earlier, markedly improves long-term outcome.

I strongly believe in evidence-based medicine, but I think this dispute is more about how obvious a developmental delay has to be to require treatment for long-term improvement. Also, whether "labeling" children early will hurt, rather than help, once they get to school.  If you tell a teacher a child is bright, that child will do better in school than if you say the same child is average (and if you tell a teacher a child is slow they will do worse than they should).

The USPSTF has an important point, but I think they are overstating it.  I think primary care practitioners have to help children with mental or physical delay before these children end up so far behind that they will have trouble catching up.

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