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1 CHiLD s name To ensure that no child reaches kindergarten with an undetected developmental condition Other Routine Screening & Immunization Record Developmental Screening record, f i r st edition february 2009 P AV I N G C O M M U N I T Y P A T H W AY S cultivatin g c h a m p i o n S For gr ow i n g K i DS the Developmental screening initiative new Mexico (Dsi) is a collaboration between the Center for Development and Disability and envision new Mexico, both within the Pediatric Department of the university of new Mexico school of Medicine. Dsi is a statewide community-based, systems-focused, and evidence-directed project promoting standardized developmental screening as the standard of practice for all children, birth to five years of age. Dsi provides education, quality improvement training, and on-going support for medical providers and all professionals working with young children. funded in part by new Mexico Human services Department and new Mexico Department of Health for further information on Dsi go to: to connect with other parents and/or resources in your community, call Parents reaching out: (se habla español) university Center for excellence in DeveLoPMentaL DisaBiLities, education, research, and services

2 Message for Parents & Caregivers: This Developmental Screening Record booklet is intended to be a guide for you to follow and talk about your child s development with his or her provider. Bring this booklet to each Well Child Visit and ask your child s provider to fill in the information for your records. Screening and immunizations may vary depending on your child s special needs. Check this booklet for missing information and ask questions about anything you do not understand. Screening is a health service to check whether or not your child would benefit from testing. The purpose of screening is to assure that your child receives any services he or she may need early in life in order that your child will achieve optimal development. The American Academy of Pediatrics recommends developmental screening for all children using a standardized tool (typically, a set of questions previously tested on many children) at 9-, 18-, and 30-month Well Child Visits (or at 24-months in place of 30-months). Your child s provider may talk with you about additional screening for your child based on specific concerns. Anytime you have concerns about your child s development or behavior, you should ask about additional screening or options for further testing. Results of your child s developmental screening will suggest next steps. Next steps may be to repeat screening at an older age or schedule a return visit to repeat screening sooner or to refer your child for testing. Plans for next steps for your child should be your decision based on what you learn through talking about your child s screening results with his or her provider. Sherri L. Alderman, MD, MPH, IMH-E, FAAP Developmental-Behavioral Pediatrician

3 Developmental Screening Record, Other Routine Screening & Immunization Record To ensure that no child reaches kindergarten with an undetected developmental condition Birth to Five Years Old Child s Name: Date of Birth: Gestational Age at Birth*: Primary Care Provider: contact: *For prematurity (less than 38 weeks gestation at birth), adjust age for developmental screening tool until the child s second birthday.

4 BIRTH 6 Months Developmental Screening: Talk to your child s provider about whether or not your child should receive developmental screening. Newborn Hearing* Newborn Metabolic & Hemoglobinopathy #1 Newborn Metabolic & Hemoglobinopathy #2 Maternal Depression (at 6 weeks) *Hearing screening after the newborn period is recommended periodically and is not specially scheduled in this booklet. Both hearing and vision should always be discussed with your child s provider anytime you, the caregiver, have concerns. Vaccine Date Given administered By (Person/Office) DTaP #1 DTaP #2 DTaP #3 Hib #1 Hib #2 Hib #3 IPV #1 IPV #2 HBV #1 HBV #2 PCV #1 PCV #2 PCV #3 Rota #1 Rota #2 Rota #3

5 6 12 Months Developmental Screening*: Recommended for all children at the 9-Month Well Child Visit Standardized Tool Used Date Given Age of Tool Results Plan (check all that apply) q Repeat at 18-months (recommended for all children) q Close follow-up; adjusted for R repeat in month(s); prematurity? A appointment date: q yes q Refer to: q no, child was born full term for developmental assessment Anemia Dental Referral Lead #1 Vaccine Date Given Administered By Person/Office IPV #3 HBV #3 Influenza *There currently are no recommendations for universal social-emotional developmental screening. Standardized screening tools for social-emotional development are available and can begin as young as in infancy. Talk with your child s provider about your child receiving social-emotional developmental screening anytime you, the caregiver, have concerns about behavior or temperament.

6 12 24 Months Developmental Screening: Recommended for all children at the 18-Month Well Child Visit Standardized Tool Used Date Given Age of Tool Results Plan (check all that apply) q Repeat at 30-months (recommended for all children) q Close follow-up; Adjusted for Repeat in month(s); prematurity?: A appointment date: q yes q Refer to: q no, child was born full term for developmental assessment Autism (at 18-months) Lead #2 (optional) Vaccine Date Given Administered By Person/Office DTaP #4 Hib #4 IPV #3 (if not done previously) MMR #1 VZV #1 PCV #4 HAV #1 HAV #2 HBV #3 (if not done previously) Influenza

7 24 36 Months Developmental Screening: Recommended for all children at the 30-Month Well Child Visit or, alternatively, at 24-Months Standardized Tool Used Date Given Age of Tool Results Plan (check all that apply): q Continue with routine surveillance (recommended for all children) q Close follow-up; repeat in month(s); appointment date: q Refer to: for developmental assessment Autism (at 24-months) Vision (depending on child s ability to cooperate) Body Mass Index (BMI) Vaccine Date Given Administered By Person/Office Influenza

8 4 & 5 Years Developmental Screening: Talk to your child s provider about whether or not your child should receive developmental screening during this time. Body Mass Index (BMI) Vision (if not done previously) (See also Footnote below) Vaccine Date Given Administered By Person/Office DTaP #5 IPV #4 MMR #2 VZV #2 Influenza Footnote: School (Education) Readiness is, in part, a combination of social-emotional development and academic performance. Social- Emotional Developmental Screening using a standardized tool can begin as young as in infancy. Regarding academic performance testing, caution is advised when interpreting any such results in early childhood. Any School (Education) Readiness Screening should be used as guidance for the school s readiness (preparation) for your child and NOT for excluding your child from the education to which he/she is entitled. For further information about whether or not your child should receive screening or testing before starting kindergarten, talk with your child s provider.

9 Sources: Hagan JF, Shaw JS, Duncan PM, eds Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents Third Ed., Elk Grove, IL: American Academy of Pediatrics. Recommended Immunization Schedule for Persons Ages 0-6 Years United States 2009, accessed January 13, Disclaimer: This booklet is intended to be a guide for parents. General recommendations change over time and with each individual person. Medical management decisions should always be made in collaboration with your child s provider and override any guides or suggestions. This booklet is an important health record for a young child. If found, please return to the Primary Care Provider named on the inside cover of this booklet.