An Update on Assessing Development in the Pediatric Office: Has Anything Changed After Two Policy Statements?

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1 An Update on Assessing Development in the Pediatric Office: Has Anything Changed After Two Policy Statements? Alma D. Guerrero, MD, MPH; Nicole Garro, MPH; John T. Chang, MD, PhD, MPH; Alice A. Kuo, MD, PhD From the UCLA Center for Healthier Children, Families and Communities, Los Angeles, Calif (Dr Guerrero, Ms Garro, and Dr Kuo); Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Calif (Dr Guerrero and Dr Kuo); Zynx Health Incorporated, Los Angeles, Calif (Dr Chang); Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Calif (Dr Chang and Dr Kuo); and Department of Health Services, School of Public Health, University of California, Los Angeles, Calif (Dr Kuo) Address correspondence to Alma Guerrero, MD, MPH, UCLA Center for Healthier Children, Families and Communities, Wilshire Ave, Suite 900, Los Angeles, California ( Received for publication December 22, 2009; accepted August 10, ABSTRACT OBJECTIVE: The aim of this study was to examine parental reports of receiving a child developmental assessment (DA), and the child, family, and type of health care setting characteristics and well-child care processes associated with receiving this aspect of preventive developmental care. METHODS: The 2007 National Survey of Children s Health was used to study children, aged 10 months to 4 years, who received a DA with a structured questionnaire from their primary care provider in the previous 12 months. Data were adjusted for child characteristics, family socioeconomic factors, type of health care setting, and processes of care. RESULTS: Few children were assessed for developmental delays by using developmental questionnaires (28%). A greater percentage of parents of children with public insurance reported receiving a developmental questionnaire compared with parents of children who were uninsured or privately insured (32% vs 26% and 25%, respectively; P ¼.02). The adjusted odds of receiving a developmental questionnaire were higher for children with public insurance than private insurance (odds ratio [OR] 1.35, 95% confidence interval [CI], ), higher for children whose usual place of care was a clinic or health center than a doctor s office (OR 1.36, 95% CI, ), and higher for children reporting adequate family-centered care (OR 1.41, 95% CI, ). CONCLUSIONS: Parental receipt of developmental questionnaires is low and varies by type of insurance, type of place for usual source of care, and adequacy of family-centered care. There is room for improvement in the provision of developmental questionnaires and, our results suggest, areas for continuing research to understand variations in DA practices. KEYWORDS: developmental assessments; developmental questionnaires; developmental screening; pediatric office; primary care practices; well-child care ACADEMIC PEDIATRICS 2010;10: WHAT S NEW We describe national estimates on the recommendation to provide structured questionnaires to assess child development in primary care and explore the association of any racial and ethnic disparities in the provision of this preventive developmental care. INTRODUCTION Early identification of developmental problems is critical to ensure optimal developmental potential in children. To guide pediatricians in addressing developmental concerns in young children, the American Academy of Pediatrics (AAP) released 2 policy statements within the last decade emphasizing regularly eliciting parental concerns and administering validated and structured developmental screening tests in the pediatric office. 1,2 The availability of national surveys makes it possible to describe how well health care providers may be achieving the recommendations of the AAP. Before the release of both AAP policy statements, a study using the 2000 National Survey of Early Childhood Health found only 57% of parents of young children report receiving a developmental assessment (DA) at a well-child visit in the last year, although use of a structured questionnaire was not specified. 3 Recent survey data can help examine whether increased attention to conducting regular DAs with a structured tool has actually led to improvements in reports of parents receiving one. Using national data, we examined parental reports of the provision of DAs by using structured questionnaires. We also explored whether racial/ethnic differences in the provision of DAs exist, since disadvantaged minority children experience an increased risk for behavioral and developmental disorders, a disproportionate burden of health risk factors and morbidity, suboptimal health status, and poor quality of care. 4 7 Finally, to identify potential areas for improvement, we examined whether child characteristics, family sociodemographic factors, type of health care setting for usual source of care, and wellchild care process measures were associated with reports of receiving a DA. ACADEMIC PEDIATRICS Volume 10, Number November December 2010

2 ACADEMIC PEDIATRICS AN UPDATE ON ASSESSING DEVELOPMENT IN THE PEDIATRIC OFFICE 401 METHODS SAMPLE This study used the 2007 National Survey of Children s Health (NSCH), a survey of a nationally representative sample of parents of children aged 0 to 17 years. NSCH was designed to estimate a variety of physical, emotional, and behavioral child health care indicators. Interviews were conducted in 66% of sampled households with children, with an overall weighted response rate of 46.7%. A total of interviews were completed for the 2007 NSCH. Details on the NSCH survey methods and weighting procedures are described elsewhere. 8 Because the NSCH asks parents to report receipt of a developmental questionnaire in the prior 12 months, our analyses included children under the age of 4 to capture the upper-bound age limit (42 months) of the last recommended age to screen (30 months). We excluded children aged under 10 months or children without a doctor s visit in the past 12 months, because their parents were not asked about receiving a developmental questionnaire. Our final analytic sample included children who had nonmissing data for all of the measures of interest in our a priori model. MEASURES Parents/guardians who had reported that their child had been to a health care provider in the last 12 months were asked, During the past 12 months, did a doctor or other health care provider have you fill out a questionnaire about specific concerns or observations you may have about [child] s development, communication, or social behaviors? Responses were dichotomized as yes or no. Measures from the following 4 domains were used as covariates in our model: (1) child characteristics, (2) family sociodemographic characteristics, (3) type of health care setting, and (4) well-child care processes. All covariates have been previously associated with differential child health services 9,10 or used in previous analyses to examine the receipt of child DAs. 3 Child characteristics included age, gender, race/ ethnicity, an overall health status measure, and a child s risk of developmental and behavioral disorder based on responses from the Parents Evaluation of Developmental Status. Using responses to the specific probes and the scoring scheme developed by the Child and Adolescent Health Measurement Initiative Data Resource Center of the NSCH, 11 children were categorized as having low or no developmental risk versus high or moderate developmental risk. Family sociodemographic characteristics included maternal education, number of children in household, child s insurance status, and family poverty status. Poverty status was based on federal poverty guidelines for a family of 4 and was categorized as 0% to 99%, 100% to 199%, 200% to 399%, and $400%. The type of health care setting was categorized as a doctor s office, hospital emergency room, outpatient department, or clinic and health center. Since over 95% of parents surveyed in the NSCH 2007 reported having a usual place of care, we selected the type of health care setting parents reported as the usual source of care to examine whether this might be an important factor in receiving a DA. The well-child care process measures included having a personal provider, the number of preventive care visits in the past year, and the adequacy of family-centered care. Adequacy of family-centered care was constructed using the 6 family-centered care questions and scoring algorithm of the Child and Adolescent Health Measurement Initiative Data Resource Center. 11 Parents who responded usually or always to all components of the family-centered care composite were categorized as having adequate family-centered care. STATISTICAL ANALYSIS Data analyses were performed using Stata 10.1 (Stata- Corp LP, College Station, Tex) to account for the complex survey design of NSCH and its intention to reflect a nationally representative sample of children. Bivariate analyses were used to assess differences in the report of receiving a developmental questionnaire in the past 12 months. We used c 2 analyses to identify significant bivariate associations (P <.05). Generalized and multivariate logistic regression models were used to identify differences in the odds of reporting receiving a developmental questionnaire and each of the 4 measure domains described above. To examine which specific factors might change the odds of receiving a developmental questionnaire, the full multivariate logistic regression model included variables from all 4 domains. To assess the robustness of our findings and examine the effects on our findings of excluding those observations with any missing data, we performed sensitivity analyses examining the effect on model estimation. RESULTS Our analytic sample included children. Approximately 28% of parents of children aged 10 months to 4 years reported receiving a developmental questionnaire in the previous 12 months. Bivariate analyses revealed receipt of a developmental questionnaire was associated with a child s mean age but no other child characteristics (Table 1). A greater percentage of parents of children with public insurance reported receiving a developmental questionnaire compared with parents of children who were uninsured or privately insured (32% vs 26% and 25%, respectively; P ¼.02). Also among those reporting receiving a developmental questionnaire, there was a greater mean number of preventive visits in the past year (3.2 vs 2.8; P <.001) and a greater percentage reporting adequate family-centered care (29% vs 24%; P ¼.01). In a generalized logistic regression model examining the unadjusted odds of receiving a developmental questionnaire by race/ethnicity, black (non-latino) children had 34% greater odds compared with white (non-latino) children (odds ratio [OR] 1.34, 95% confidence interval [CI], ). No differences were found in the other racial/ ethnicity groups.

3 402 GUERRERO ET AL ACADEMIC PEDIATRICS Table 1. Sample Characteristics Characteristic Total Sample, % (N ¼ ) Received a Developmental Questionnaire, % (N ¼ ) P Value Received a developmental questionnaire Yes 27.7 No 72.3 Age, mean, y <.01 Gender.80 Male Female Race/ethnicity.30 White (non-latino) Black (non-latino) Latino (English) Latino (non-english) Multiracial/other Child health status.96 Excellent/very good Good/fair/poor Child developmental risk (PEDS)*.95 None/low Moderate/high Maternal education.64 Less than high school High school More than high school Children in household, No $ Family poverty status.28 $400% FPL % 399% FPL % 199% FPL <100% FPL Health Insurance.02 Private Public Uninsured Type of place.08 Doctor s office Hospital emergency room Hospital outpatient Clinic or health center Personal provider.55 Yes No Preventive visits in past year, mean, No <.01 Adequacy of family-centered care.01 Yes No *PEDS ¼ Parents Evaluation of Developmental Status. FPL ¼ federal poverty level. A multivariate logistic regression analysis including all covariates was used to examine the association of child and family sociodemographic characteristics, type of health care setting, and well-child care process measures with reports of receiving a DA. The odds of receiving a developmental questionnaire (Table 2) were higher for children with public insurance (Medicaid or the State Children s Health Insurance Program) than for children with private insurance (OR 1.35, 95% CI, ), higher for children whose usual place of care was a clinic or health center than a doctor s office (OR 1.36, 95% CI, ), and higher for children reporting adequate family-centered care (OR 1.41, 95% CI, ). Child characteristics, including race/ethnicity, child health status, or developmental risk were not associated with differences in receiving a DA in the adjusted model. None of the sensitivity analyses significantly changed the estimates of the multivariate logistic regression model. DISCUSSION Nationally, a low percentage of children receive a DA using a parent-completed developmental questionnaire (28%). This is much lower than the 2000 National Survey

4 ACADEMIC PEDIATRICS AN UPDATE ON ASSESSING DEVELOPMENT IN THE PEDIATRIC OFFICE 403 Table 2. Adjusted ORs for Receiving a Developmental Questionnaire* OR 95% CI Age, y Gender Male 1.0 Female Race/ethnicity White (non-latino) 1.0 Black (non-latino) Latino (English) Latino (non-english) Multiracial/other Child health status Excellent/very good 1.0 Good/fair/poor Child developmental risk (PEDS) None/low 1.0 Moderate/high Maternal education Less than high school 1.0 High school More than high school Children in household, No $ Family poverty status $400% FPL % 399% FPL % 199% FPL <100% FPL Health Insurance Private 1.0 Public Uninsured Type of place Doctor s office 1.0 Hospital emergency room Hospital outpatient Clinic or health center Personal provider No 1.0 Yes Preventive visits in past year, No Adequacy of family-centered care No 1.0 Yes OR ¼ odds ratio. *Results in bold type are statistically significant. CI ¼ confidence interval. PEDS ¼ Parents Evaluation of Developmental Status. FPL ¼ federal poverty level. of Early Childhood Health finding of 57% of parents reporting receipt of some type of DA; however, at that time use of a structured questionnaire was not specified. Our estimates seem to suggest that despite 7 years since previous national data were used to estimate parental reports of receiving DAs and 2 AAP policy statements in the interim, a substantial portion of parents with young children report receiving suboptimal DAs using structured questionnaires. One might argue that because our estimates were based on data collected within close proximity, 1 to 2 years after the most recent policy statement, these results may underestimate current performance; however, the interval between the original 2001 AAP policy statement of using structured, validated developmental tools and the 2007 NSCH suggests ample time and opportunity for practicing primary care pediatricians to implement the first set of recommendations. We also found 3 important factors associated with greater odds of receiving a DA with a questionnaire: public health insurance, type of place for usual care, and adequacy of family-centered care. These findings are consistent with previous studies where minority race and ethnicity and enrollment in public insurance were found to be protective factors associated with receiving recommended well-child care 12 ; having fewer unmet health needs 13 ; receiving more services, visits, and a preventive care visit in the last year 14,15 ; and being more likely to receive preventive health counseling. 16 Our findings therefore add to the growing literature suggesting public insurance programs promote the provision of preventive health services. Children seen at community clinics or health centers for usual care were found to have greater odds of receiving a developmental questionnaire, suggesting that their focus on comprehensive care may promote the provision of child DA activities. Community clinics and health centers often have enabling services (translation services, transportation, and child care) 17 and multidisciplinary teams that often include primary care providers, behavioral health professionals, and social workers, 18 which are important for vulnerable groups. These services are not usually provided by private pediatric offices and could explain the difference in the provision of developmental questionnaires, which is often nonreimbursable by most commercial insurance plans. Families who reported receiving adequate familycentered care had greater odds of receiving a developmental questionnaire; strategies to improve the delivery of familycentered care therefore might improve the delivery of child developmental services. For example, health care planning and delivery grounded in collaboration and partnership between health care providers and families may be particularly important for eliciting developmental concerns. Identifying developmental concerns can subsequently help health care providers determine developmental risk, which can lead to increased screening with developmental questionnaires. Promoting interactive communication loop techniques, 19,20 using medical interpreters for families with limited English proficiency, 21 and other efforts to address the core components of family-centered care have been described in the literature and warrant further attention to assess their impact on the delivery of DAs. The lack of improvement in the area of provision of DAs in the past 7 years highlights the similar challenges faced in many other areas requiring changing physicians behavior and improving systems to support physicians in order to improve the quality of care. Future solutions will likely need to take a multidisciplinary approach, including improving dissemination of evidence-based practices to physicians and parents, changing delivery systems and workflow to make it easier and effective to provide

5 404 GUERRERO ET AL ACADEMIC PEDIATRICS DAs, 22,23 and providing adequate financial support (and maybe even incentives) for the provision of these important services. Our study has several limitations. The data are crosssectional and highlight performance measurement at only one point in time. It cannot adequately assess whether children are receiving a standardized developmental screening test at all 3 intervals, 9-, 18-, and 24 to 30 months, as recommended by the AAP. Second, the data may be subject to recall and reporting bias, as the data are based on parental self-report. However, previous studies examining DAs have used comparable measures. It is also possible that parents may not recognize developmental questionnaires as such; we do not know the accuracy of parental responses on receiving a developmental questionnaire. Our estimates also exclude other forms of developmental questionnaires, such as verbal administration of a questionnaire by a nonhealth provider. CONCLUSION In conclusion, parental receipt of developmental questionnaires is suboptimal and varies by type of insurance, type of place, and adequacy of family-centered care. Examining public insurance practices, community clinic or health center practices, and approaches to improving family-centered care may offer clues to improve the provision of child developmental questionnaires in the future. ACKNOWLEDGMENT This work was supported by the Academic Pediatric Association Young Investigator Award sponsored by the Commonwealth Fund. REFERENCES 1. Council on Children With Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee, Committee MHIfCWSNPA. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics. 2006;118: Developmental surveillance and screening of infants and young children. Pediatrics. 2001;108: Halfon N, Regalado M, Sareen H, et al. Assessing development in the pediatric office. Pediatrics. 2004;113(6 suppl): Bailey DBJ, Skinner D, Correa V, et al. Needs and supports reported by Latino families of young children with developmental disabilities. Am J Ment Retard. 1999;104: Flores G, Bauchner H, Feinstein AR, Nguyen US. The impact of ethnicity, family income, and parental education on children s health and use of health services. Am J Public Health. 1999;89: Flores G, Fuentes-Afflick E, Barbot O, et al. The health of Latino children: urgent priorities, unanswered questions, and a research agenda. JAMA. 2003;288: Flores G. Zambrana RE. The early years: the health of children and youth. In: Aguirre-Molina M, Molina C, Zambrana RE eds. Health Issues in the Latino Community. San Francisco, Calif: Jossey-Bass; Blumberg SJ, Foster EB, Frasier AM, et al. Design and Operation of the National Survey of Children s Health, National Center for Health Statistics. Vital Health Stat 1. Available at:ftp://ftp.cdc.gov/ pub/health_statistics/nchs/slaits/nsch07/2_methodology_report/ NSCH_Design_and_Operations_ pdf. Accessed September 28, Flores G, Tomany-Korman SC. The language spoken at home and disparities in medical and dental health, access to care, and use of services in US children. Pediatrics. 2008;121:e1703 e Flores G, Olson L, Tomany-Korman SC. Racial and ethnic disparities in early childhood health and health care. Pediatrics. 2005;115: e183 e National Survey of Children s Health Data Resource Center. Child and Adolescent Health Measurement Initiative. Available at: Accessed June 1, Yu SM, Bellamy HA, Kogan MD, et al. Factors that influence receipt of recommended preventive pediatric health and dental care. Pediatrics. 2002;110(6):e Newacheck PW, Hughes DC, Hung YY, et al. The unmet health needs of America s children. Pediatrics. 2000;105(4 pt 2): Dubay L, Kenney GM. Health care access and use among low-income children: who fares best? Health Aff. 2001;20: Perry CD, Kenney GM. Preventive care for children in low-income families: how well do Medicaid and state children s health insurance programs do? Pediatrics. 2007;120:e1393 e Williams RL, Flocke SA, Stange KC. Race and preventive services delivery among black and white patients seen in primary care. Med Care. 2001;39: Shi L, Regan J, Politzer RM, Luo J. Community Health Centers and racial/ethnic disparities in healthy life. Int J Health Serv. 2001;31: Adashi EY, Geiger HJ, Fine MD. Health care reform and primary care the growing importance of the community health center. N Engl J Med. 2010;362: Schillinger DPJ, Grumbach K, Wang F, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163: Rao JK, Anderson LA, Inui TS, Frankel RM. Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence. Med Care. 2007;45: Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. Med Care Rev. 2005;62: Margolis PA, McLearn KT, Earls MF, et al. Assisting primary care practices in using office systems to promote early childhood development. Ambul Pediatr. 2008;8: Schonwald A, Huntington N, Chan E, et al. Routine developmental screening implemented in urban primary care settings: more evidence of feasibility and effectiveness. Pediatrics. 2009;123:

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