VERMONT CHILD HEALTH IMPROVEMENT PROGRAM

Developmental Screening
“Preferred Tool List” for Children
Birth to Three years
Submitted to the Agency of Human Services
Office of Vermont Health Access

Kimberly J. Aakre, MD; Kim Paul, BSN; Sara Barry, MPH

5/15/2010

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Developmental Screening “Preferred Tool List”

Table of Contents
Section Pages
Overview of Developmental and Autism Tool Selection Process …………………… 3 - 5

Developmental Screening ―Preferred Tool List‖ ……………………………………… 6 -25

Overview Screening Tool Selection Algorithm for Children Birth – Three years ….. 26

Screening Tool Selection Algorithm for Children Birth – Three years .…………….. 27

Appendices

AAP 2006 Policy Statement ―Identifying Infants and Children with Developmental
Disorders in the Medical Home‖

AAP 2006 Developmental Screening Algorithm

AAP 2007 Identification and evaluation of children with autism spectrum disorders

Developmental screening in primary care: The effectiveness of current practice

and recommendations for improvement

Selecting developmental surveillance and screening tools

Screening for autism in young children: the Modified Checklist for Autism in
Toddlers (M-CHAT) and other measures

Impact of implementing developmental screening at 12 and 24 months in a

pediatric practice

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 Overview of Developmental and Autism Tool Selection Process

Early identification of developmental disorders in the birth-to-three population has been

highlighted as a priority in the Policy Statement of July 2006 from the Council on Children with
Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering
Committee, and Medical Home Initiatives for Children with Special Needs Project Advisory
Committee (Pediatrics, Vol 118, 2006). These recommendations are integrated into the Bright
Futures Guidelines for Health Supervision, Third Edition. Specifically, the guidelines
recommend developmental screening at 9, 18, and 30 months (or at 24 months if the 30 month
visit is not yet routine), and whenever surveillance indicates a concern. In addition, autism
screening is recommended at 18 and 24 month visit.

The Vermont Child Health Improvement Program (VCHIP), in collaboration with project
stakeholders, researched and developed a ―preferred list‖ of developmental screening
instruments for use in primary care drawn from the American Academy of Pediatrics (AAP)
policy statement Identifying Infants and Young Children with Developmental Disorders in the
Medical Home: An Algorithm for Developmental Screening and Surveillance, July 2006. The
AAP policy statement included an extensive listing of available screening instruments, but
neither endorsed nor discussed the specific merits or limitations of the listed instruments.

VCHIP has undertaken a more thorough review of the aforementioned list of tools in order to more
thoughtfully provide concrete recommendations to primary care practitioners for developmental
screening in the birth to three population.

Developmental screening instruments that sufficiently met the criteria outlined under the
categories of Instrument Purpose, Validity, and Sensitivity/Specificity are recommended to be
included on the ―preferred list‖. It should be noted that information regarding specific
instruments was not always extensively or optimally available, thus decisions to include a
particular tool is based on current best knowledge. Research and updated knowledge of
evidence based practice regarding developmental screening will need to be reviewed regularly
and integrated into the current recommendations.

Consideration of instruments meeting the approval/recommended status was based on fulfilling

the criteria below:
 Instrument purpose
The instrument was evaluated to ensure that it focused on screening and determining the
presence of delays and risk status, rather than being better suited for the purposes of
surveillance or diagnostic evaluation. Additionally, the instrument must assess the target
population within the age range recommended for universal developmental and autism
screening (9, 18, 24/30 months or under three years).

 Developmental domains
The following domains must be included in developmental screening: motor, language,
cognitive, and social-emotional.
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 Validity
Validity is an indicator of the accuracy of a test [1]. The instrument should have a validity
score of approximately 0.70 or above.

 Sensitivity/Specificity
Sensitivity and specificity are the primary means of evaluating a developmental screening
instrument’s capacity to correctly identify children with delays. Sensitivity refers to the
proportion of children who have delays and are correctly identified as such by the test.
Specificity refers to the proportion of children who are not likely to have delays and are
correctly excluded from further diagnostic assessment [1]. The instrument should have
sensitivity and specificity scores of minimally 0.70 or above.

Additionally, the following items are important considerations in selection of an instrument.

Issues related to these items did not alone contribute to a ―not recommended‖ status, but when
combined with concerns in the previously mentioned criteria relating to sensitivity and
specificity, may have resulted in an instrument ultimately not being recommended.

 Practicality
Practicality refers to the ease of administration of the screening instrument, and the amount
of time needed to administer and score the screening instrument. The instrument should
typically take 20 minutes or less to administer, whether completed by a parent or clinician.
Physicians and staff must be able to implement the screening tool with relative ease in a
primary care setting. More complex screening tools may meet other requirements but may
be recommended preferentially as a second level screen.

 Ease of use (relative to office staff/MD)

Screening instruments are designed to be administered by persons with varying levels of
expertise. Some instruments allow for the screening instrument to be administered by a
paraprofessional, but review by a clinician is necessary for interpretation of results and
decision making regarding disposition.

 Ease of use (relative to parent/family)

Screening tool reflects cultural sensitivity, including availability in other languages as well as
the tool ability to accurately screen children from diverse cultures.

 Cost and access to the instrument

Information on developmental screening instruments was gathered from several sources,

including: review of the literature, practice guidelines developed by professional societies,
administration manuals, technical documents, and information from the publisher.
Developmental screening tool recommendations were reviewed from selected states (OH, MA,
NM, UT, MN). Additionally, VCHIP coordinated a committee of developmental and primary care
pediatricians to review and comment on this information.

Ultimately, a ―preferred list‖ of developmental screening instruments was developed based on

the information gathered.

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The following table is a listing of all the tools listed in the 2006 AAP Policy statement. The tools
are listed by category— e.g. general screening tools vs. more domain specific tools. Within
each category, those that have a gray background are tools that are not being endorsed by
Vermont Medicaid for the birth-three population. The rationales for these decisions are
indicated on the chart. In general, the reasons for not endorsing a tool include: the tool not
appropriate for the age group being addressed, the tool is out-dated, or the tool does not show
sufficient instrument purpose, validity, and sensitivity/specificity. Tools targeting only older age
groups may be appropriate for those age ranges, but were not specifically researched for ages
beyond birth to three years.

For most primary care physicians, tools that fall under the general screening category are going
to be most useful and appropriate—(please see the accompanying Screening Tool Selection
Algorithm.) The domain specific tools may be appropriate in certain situations and clinical
environments, and the decision to use such tools should be based on individual practice needs,
physician experience, population needs, etc. The use of Social-Emotional screens have not
been specifically addressed in terms of when or how they should be employed, however it is
anticipated that recommendations and guidelines for use of these tools will be forthcoming in
the future.

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 Developmental Screening Tools, Birth – 3 Years
Screening Tool Name Age Electronic Cost to Tool type Language Reading Psychometric Properties Strengths

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th rd
X X Ages & Stages 1-66 mo 10-15 Online access $249 X English 4-6 Technical report 3 edition—sensitivity Strengths:
Questionnaire (ASQ) Third min; and scoring; starter Spanish grade 0.86 overall (0.75-1.0), specificity 0.85  Easy to use –clear drawings and
Edition 1-5 working on kit–can French overall (0.70-1.0)—validated on 574 instructions for families
rd
(2009) minutes EMR copy (French children. Revisions to 3 edition based on  New version covers all ages correlating
Developmental Screening Tools

www.agesandstages.com to score integration forms and Korean analysis of 18,572 questionnaires from with recommended WCC ages
prior ASQ-2 [2].  One of the most widely used and
edition) studied tools
Second edition (revised) ASQ: normative  Asks about specific skills, in addition to
data on 2008 children, with 81% at risk. parent concerns
Validated on subset (247) of normative
set. Overall sensitivity varies per age Limitations:
range, with lowest obtained in 4 mo old
 Some studies indicate good
(0.51), otherwise average was 0.72, with
identification of severe delay in
range up to 0.90; specificity 0.81-0.96
premature infants; less sensitive with
(higher at higher age ranges)[3].
mild delay
 Study comparing PEDS with ASQ
Testing in premature/high risk population:
indicated discordance in children
sensitivity 0.90; specificity 0.77 [4].
identified by each screen [8]

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 Screening Tool Name Age Electronic Cost to Tool type Language Reading Psychometric Properties Strengths

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Comments:
Rydz study of psychometric properties of  Addresses five developmental areas per
18 mo ASQ showed low sensitivity and age assessed – communication, gross
specificity (0.67 and 0.39) in Quebec motor, fine motor, problem solving and
population [5] Subsequent questions personal-social
raised regarding conclusions, study design  Cut off scores are > 2 SD below mean in
and abridged tool use [6, 7] one or more developmental areas.
 Further evaluation recommended for 1
or more areas below cutoff
 Used by community teams –
coordination and avoidance of
duplication needs to be addressed
nd
. X X X Battelle Developmental Birth- 10-30 min Scoring $311 X X English NA Full BDI-2 editions – Normative data Strengths:
Inventory: 2nd Edition 8yrs software add’l Spanish from 2500 children, demographic  Well standardized
 2 edition normalized tables cover
nd
(BDI-II) - Screening Test forms information matched 2000 US Census
(2006) 52¢ each data; additional bias reviews performed to smaller age ranges
www.riverpub.com adjust for gender and ethnicity concerns;
sensitivity: 0.72–0.93 ; specificity:0.79–88.
BDIST consists of a subset of items from Limitations:
the full BDI Manual - [9]  Higher level of skill needed in
assessment
Other studies—BDIST validated on 104  Can be challenging to administer
children 7-86 mo, moderate sensitivity  4-6 hours of training required
0.75 and specificity 0.73 [10])  Screening inventory over or under
referred children who were close to the
limits in age bracket
 Few items per domain per age bracket

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 Screening Tool Name Age Electronic Cost to Tool type Language Reading Psychometric Properties Strengths

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Comments:
 Yields cutoff scores(1.0, 1.5 and 2.0
below mean)
 Cutoff scores of 1.5 below mean provide
best sensitivity and specificity.
 Domains addressed included adaptive,
personal-social, communication, motor
and cognitive.
 Screening test consist of subtest item
from full inventory. BDIST norms and
reliability derived from BDI. Scoring is
similar.
 May not be practical for most primary
care physicians unless strong
interest/training in developmental
assessment
 Would not be our first recommendation
for an expanded developmental
screener
X Bayley Infant 3-24 mo 10-15 min X English Manual: tested on nonclinical sample of Comments:
Neurodevelopmental Spanish 600 children representative of 1988  Outdated version. Update to Bayley
Screener (BINS) census. Sensitivity 0.75 and specificity Scales of Infant and toddler
(1995) 0.86 across ages [11] Development—III, Screener
 Scoring: low, moderate, high risk by cut
Normative data from 1700 children, scores in each of 3 domains tested
stratified on age, to match the 2000 US
Census; sensitivity: 75–86%;
specificity:0.75–0.86

Subsequent study found sensitivity 0.70

and specificity 0.71 in premature
population at ages 12-24 months. [12]

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 Screening Tool Name Age Electronic Cost to Tool type Language Reading Psychometric Properties Strengths

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X X X Bayley Scales of Infant and 1-42 mo 15-25 min Scoring $209, X English NA Updated from Bayley Infant Strengths:
Toddler Development: 3rd software add’l Neurodevelopmental Screener  Tested in high risk populations
Edition (Bayley-III) ($208) forms Limitations:
Screener (2005) 60¢ each Extensive validity, sensitivity and
 Developmental background skills helpful
www.pearsonassessments. specificity studies. Specificity 0.77-1.0,
 Training required
com Sensitivity and validity with varying
correlations. Comments:
 Screens cognitive, fine motor, gross
motor, receptive and expressive
communication with cut scores relating
to category of risk (competent,
emerging, at risk)
 May not be practical for most primary
care physicians unless strong
interest/training in developmental
assessment
X X X Brigance Early Childhood 0-90 mo 10-15 Online scoring $279 + X English NA Manual: Full tool standardized on 1156 Strengths:
Screens min; 5 and aggregate forms Spanish children from 29 clinical sites in 21 states.  0-2 year old can be done as all parent
(2005) min to results 98¢ each Overall Sensitivity: 0.82 ; specificity: 0.75 report
www.curriculumassociates score (range 0.72-1.0 across various ages) [13]  Website has training materials
.com Limitations:
Study of Brigance Infant & Toddler screens  Developmental background skills helpful
in 0-24 month olds, with validity data on  Training required

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 Screening Tool Name Age Electronic Cost to Tool type Language Reading Psychometric Properties Strengths

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408 children, found sensitivity 0.76-0.77, Comments:
specificity 0.85 - 0.86 [14].  9 forms for each 12 month age range
 Covers language, motor, cognitive,
readiness skills, plus math/reading at
older ages
 Scores with overall cutoff, quotients,
percentiles, and age equivalents
 Separate cutoff for children with
psychosocial risk who have recently
entered EI programs (to avoid over
referral)
 Screener items taken from larger
Brigance Inventory of Early
Development
 May not be practical for most primary
care physicians unless strong
interest/training in developmental
assessment
th
X Child Development 15 mo – 30-50 min None $150 X English 7-8 Normative sample included 568 children Strengths:
Inventory (1992) 6yrs starter Spanish grade from south Saint Paul, MN [15].  May be more suitable for assessment
www.childdevrev.com kit -- versus screening
manual, In validity testing, CDI compared to BSID-II Limitations:
Broken into Child answer in a high-risk follow-up program of 63  Relatively high reading level required
Development Inventories forms, toddlers (only 43 completed surveys).  Long administration time
(plural)— Infant scoring Sensitivity: 0.80; specificity: 0.96 for
Developmental Inventory template detecting delays [16]. Comments:
(IDI) and Child  Original tool with 300 items—very long
Development Review  Measured 8 developmental domains
(CDR) below with yes/no questions
 Borderline or delayed based on scores
falling 1.5 and 2.0 SD below chronologic
age (25% and 30% respectively).

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 Screening Tool Name Age Electronic Cost to Tool type Language Reading Psychometric Properties Strengths

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X X Infant Development 1 mo-18 5-10 min Online form Forms X English Studied in 86 high-risk 8-mo-olds seen in a Strengths:
Inventory (IDI) mo and scoring 56¢ each perinatal follow-up program and  Easy to use Developmental chart similar
(1998) compared with the Bayley scales; to Denver – “visual chart” of milestones
www.childdevrev.com sensitivity: 0.85 specificity: 0.77 [17]. for age
Limitations:
IDI compared to other test in 202, 8  Tool appropriate up to age 18 months
month olds, including 48 low birth weight only
infants. IDI most strongly related to full
Comments:
Bayley test. Sensitivity 0.90 and specificity
 Five domains scored as delayed if >30%
0.93 [18]
below chronological age, or borderline if
25-30% below chronological age
th
X Child Development Review 18 mo 12-20 min Online form Manual $ X English 6 grade Manual: CDR Standardized with 220 Strengths:
Parent Questionnaire to and scoring 40, Spanish children aged 3-4 y; Sensitivity 0.68 and  Easy to use Follows the IDI for
(CDR-PQ) 1990 kinderg forms specificity 0.88 [15] toddlers/preschool age assessment
arten 56¢ each Limitations:
 Limited data on this tool did not find
sufficient information or data meeting
psychometric criteria
 May not be as discriminating at older
ages.

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 Screening Tool Name Age Electronic Cost to Tool type Language Reading Psychometric Properties Strengths

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Comments:
 Questionnaire has: 6 questions
regarding parental concerns, description
of child; 26 item problem checklist; and
a child developmental chart covering
social, self-help, gross motor, fine motor
and language
 Question and Problem checklist
classified into “no problem” to “possible
problem” to “possible major problem”;
developmental chart normed by age as
typical, borderline or delayed.
 More data may support use of tool in
future
 Use is primarily in Minnesota (origin of
tool)
X Denver-II Developmental 0-6 yrs 20 min Online option $111; X X Denver II revised/normalized on 2096 Strengths:
Screening Test with ability to add’l 30% 70% children from Colorado aged 2-36  Most commonly used tool and one most
(1992) import pdf forms months—neither version published with doctors are familiar with/ trained to use
Initial Denver reports into 32¢ each validity data/sensitivity/specificity.
Developmental screening EMR. $49.99 Evidence of delay based on children falling Limitations:
test introduced 1967 per month outside of normal range. Revised screener  Low sensitivity or specificity depending
www.denveriionline.com (unlimited incorporated increased language items on scoring method
use) (major deficit in first Denver) [19].  Based on normative data (kids are
Other studies with Denver II: identified by falling outside of normal)
104 children—sensitivity 0.83 and  Frequently used inappropriately,
specificity 0.43. Attempts to score so that compromising validity

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 Screening Tool Name Age Electronic Cost to Tool type Language Reading Psychometric Properties Strengths

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specificity increased to 0.80, led to Comments:
unacceptable drop in sensitivity to 0.56  The Denver prescreening questionnaire
[20]. excerpted from DDST- same limitations
and concerns
 Original Denver missed up to 50% of
children with MR, and 70% with
language delay, multiple studies
identified unacceptably low sensitivity.
[21]
 Tool revised but with persistent
limitations.
 Recognized in many states as
inadequate tool and clear trend toward
disuse.
th
X Parents’ Evaluation of 1 mo - 8 2-10 min Online option, $36, X Multiple 4-5 Standardized and validated with 771 Strengths:
Developmental Status yrs integrate to add’l languages grade children from diverse ethnic and  Easy to use and short
(PEDS) EMR; Includes forms socioeconomic backgrounds, including  Strength may be as a surveillance tool
(1997) 36¢ each Spanish speaking; sensitivity: 0.74–0.79;
MCHAT; $1-2 Limitations:
www.pedstest.com specificity: 0.70–0.80 across all ages [22].
per use  Not best tool for high risk population
Evaluation of very preterm population  Secondary screener recommended if
(<1250gm BW) indicated at 2 years positive area of concern identified (or
sensitivity 0.38-0.39 and specificity 0.84- referral)
0.85 [23].  May not always be possible to use
second level screener – creating risk for
Multiple studies indicate parent report of under or over referral.
concerns can accurately predict Comments:
developmental status, [22]  2 open ended & 8 yes/no questions
 Scoring stratifies risk: low, medium, high
 High risk requires referral for evaluation
(70% found to have significant delays),
medium risk requires further screening
(30% have delays) [24]

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 Screening Tool Name Age Electronic Cost to Tool type Language Reading Psychometric Properties Strengths

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nd
X PEDS: Developmental 0 -8 yrs 3-10 Online version $275, X X English <2 Standardized on 1296 children. Strengths:
Milestones minutes coming soon add’l Spanish grade Sensitivity and specificity between 0.70  Longitudinal scoring, can be followed
(2006) forms and 0.97 across ages; sensitivity 0.75-0.80 over time
www.pedstest.com 32¢ each and specificity 0.71-0.88 across Limitations:
developmental domains [25].  Test materials seem somewhat
cumbersome
Data from developmental testing of 1619  Subject to misinterpretation with
children mined for items best predicting “sometime” response option
performance in developmental domains.
Comments:
Sensitivity 0.83 and specificity 0.84 for
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performance <16 percentile [26].  Intended for use in conjunction with
PEDS to optimize screening
 6-8 items per visit
 Performance > 16 percentile =pass
th

X Checklist for Autism in 18- 24 5 min Free X X English Original standardization sample included Strengths:
Toddlers (CHAT) mo 41 siblings of children with autism and 50  Easy to administer
controls 18 months of age in Great Britain
Autism Screening Tools

Limitations:
(CHAT 23)—combo of [27]; 6 year follow-up study on 16,235  Low sensitivity in population-based
MCHAT and CHAT items— children validated using ADI-R and ICD-10 sample
increased sensitivity and criteria resulted in low sensitivity, high  Better distinguishes Autism versus
specificity, slightly longer specificity; sensitivity: 0.38–0.65 Autism Spectrum Disorder
to give, combo of specificity: 0.98–1.0 [28]  No reason not to update use to MCHAT
report/direct
Comments:
 ~14 items – 9 questions/parent report
and 5 direct observation by clinician
 Designed for use at 18 months

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 Screening Tool Name Age Electronic Cost to Tool type Language Reading Psychometric Properties Strengths

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X X Modified Checklist for 16-30 5-10 min Forms Free X English Standardization sample included 1293 Strengths:
Autism in Toddlers mo available Spanish children screened, 58 evaluated, and 39  Easy to use
(MCHAT)(1999) online Turkish diagnosed with an autistic spectrum  Most frequently used autism screener
http://www.firstsigns.org/ Chinese disorder; validated using ADI-R, ADOS-G,  Intended to expand the CHAT to
screening/tools/rec.htm#a Japanese CARS, DSM-IV; sensitivity: 0.85–0.87 ; identify a greater range of children with
sd_screens specificity: 0.93–0.99. [29]. ASD/PDD
Limitations:
Other studies at 27 months: sensitivity  Over identifies children with language
0.95-0.99; specificity 0.95-0.99 [30] and developmental delays
 Improved specificity with use of follow
up questionnaire
Comments:
 23 yes/no test items , 6 critical items
 Refer for evaluation if two critical or
three noncritical items are positive
 Intended for evaluation at 18 and 24
months
X X Pervasive Developmental 12-48 10-15 None $155 + X English Validated using extensive multi-method Limitations:
Disorders Screening Test-II mo min; 5 forms @ diagnostic evaluations on 681 children at  Not many studies comparing to other
(PDDST-II), Stage 1 Primary min score 63¢ each risk of autistic spectrum disorders and 256 tools
care screener(2001) children with mild-to-moderate other  Validated on children at risk, not in
developmental disorders; no general population
sensitivity/specificity data reported for Comments:
screening of an unselected sample;  22 questions – 9 questions regarding
sensitivity: 0.85-0.92; specificity: 0.71– behaviors emerging between 12-18
0.91 [31] months, 14 questions between 18-24
months. Answered as “yes-usually true”
or “no-usually not true”

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 Screening Tool Name Age Electronic Cost to Tool type Language Reading Psychometric Properties Strengths

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X X Screening Tool for Autism 24-35 20 min None $520 + X English Two samples were used: for development Limitations:
in Two-Year-Olds (STAT) mo forms @ of scoring algorithm, 7 children with  Training required
http://kc.vanderbilt.edu/tr $1 each autism, 33 with non autistic  Experience with autism important
iad/training/page.aspx?id+ developmental disorders; for validation  Designed for 24-36 months
821 sample, 12 children with autism, 21 with  Designed to detect autism & not broad
non autistic developmental disorders. spectrum diagnosis/PDD [34]
Validated using CARS, ADOS-G, and DSM- Comments:
IV criteria. This is a second-level screen
 An evaluation or level 2 tool, not a
requiring training before administration;
screener
sensitivity: 0.83-0.92; specificity: 0. 85–
0.86 [32].

Some potential utility in young children

(14-23 months) referred because of
concerns or sibling with ASD. Sensitivity
0.95 and specificity 0.73 [33].

X Social Communication >4 5-10 min Unlimited $105 + X English Validated using the ADI-R and DSM-IV on Strengths:
Questionnaire (SCQ) years Scoring CD forms 200 subjects (160 with pervasive  Easy to use
formally ASQ (2003) ($456.56) @$1.60 developmental disorder, 40 without  Based on ADI assessment tool
each pervasive developmental disorder). ; Limitations:
Manual: Sensitivity: 0.85 ; specificity: 0.75  Awareness of tool properties and
[35] limitations very important
Lower sensitivity in younger ages and
Comments:
poorer specificity across ages at given
cutoff score - suggested adjusting cutoff  Helpful tool but not designed for use in
scores according to age and purpose [36]. the <4 year-old population.
 Available in 2 forms: lifetime and
current.
 40 yes/no answers, cut off of >15 for
autism spectrum disorder
 Indicated for children with age >4 and
mental age >2 ½ years.

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 Screening Tool Name Age Electronic Cost to Tool type Language Reading Psychometric Properties Strengths

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X X X Ages & Stages 6-60 mo 10-15 min Online access $194.95, X English Investigated with over 3,000 children Strengths:
Questionnaires: Social- and scoring. can copy Spanish across the age intervals and their families.  Easy to use/understand
Emotional (ASQ:SE) (2002) forms Reliability is 94%; validity is between 75  Follows format of the ASQ
www.agesandstages.com and 89 %. Sensitivity 0.71-0.85, specificity  Simply worded and appropriate for
0.90-0.98 (ASQ Technical Report, [37] ) families of diverse backgrounds.
Social Emotional Screening Tools

Comments:
 30 items for each of 8 visits between 6-
60 months. Items focus on self-
regulation, compliance, communication,
adaptive functioning, autonomy, affect,
and interaction with people
 Single cut-off score indicating need for
referral
 Designed to supplement the ASQ
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X X Child Behavior Checklist 1.5-5 Assessment $160 + X Multiple 5 grade Extensive study and use in multiple Strengths:
(CBCL) Achenbach System years data manager, forms languages, countries [38]  Extensive use and reporting
(rev 2000) module, multi-  Multi-informant with comparative
http://www.aseba.org/ online manual cultural reporting
($255); Web reporting Limitations:
based module feature  Lengthy for parents to complete
avail Jan 2010  Training required for interpretation

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 Screening Tool Name Age Electronic Cost to Tool type Language Reading Psychometric Properties Strengths

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Comments:
 100 questions and additional open
ended questions divided into
internalizing and externalizing problems
with further breakdown into specific
problem areas including emotionally
reactive, anxious/depressed, somatic
complaints, withdrawn, attention
problems, aggressive behavior, and
sleep problems. Also DSM oriented
scales corresponding with DSM
diagnostic categories of affective
problems, anxiety, PDD, ADHD and ODD
 No “gold standard” for assessing SE and
behavioral disorders in young children.
Tool intended to be a way to gather
information from multiple sources and
then integrated with other data as part
of a comprehensive assessment.
 Strong interest for widespread use in VT,
pilot study in Burlington practice testing
at 18 months and 4 years
X Pediatric Symptom 4-18 Checklist Free X Limitations:
Checklist years available download  Outside 0-3 age range
online
x Cognitive Adaptive 1-36 mo 10-20 min Electronic $375 X English Standardized on 1055 North American Strengths:
Screeni
Langua

Cogniti

Tools

 Widely tested with many studies

ge &

Test/Clinical Linguistic format (includes Spanish children aged 2–36 months; correlations
ng
ve

available manual, Russian high with Bayley Scales of Infant  Easy to administer

18
 Screening Tool Name Age Electronic Cost to Tool type Language Reading Psychometric Properties Strengths

Administration
recommended
High risk pop
Second level
General pop
Publisher Website Range Format Practice Available Level Limitations

Time
Comments

NOT

Report
Parent

Admin
Direct
Auditory Milestone Scale scoring Development. Sensitivity: 0.21–0.67 in Limitations:
[CAT/CLAMS] also known sheets, low-risk population and 0.05–0.88 in high-  Training required
as Capute Scales (2005) and kit) risk populations; specificity: 0.95–1.00 in  Seems to be more predictive in higher
low-risk population and 0.82–0.98 in high- risk populations & slightly older
http://brookespublishing.c risk populations. toddlers/children [43]
om/store/books/accardo-  Issues with cutoff scores and use for
8167/excerpt.htm In 328 normal children tested at 18 and 30 primary screening [12].
months, compared to Bayley; Sensitivity Comments:
0.21-67; specificity 0.95-1.0of respective  100 item scale, averaging of 5 items per
ages. [39] age level that can address global
developmental delay, or dividing into
In 61 infants and toddlers with suspected tests of expressive and receptive
delay, compared with Bayle; Sensitivity language and visual motor functioning
0.88 and specificity 0.67 for BSID <70 [40]
 Generally found to correlate with Bayley
but rated ~10% higher than
In 12 and 18 month preterm (<31weeks)
corresponding score, which diminished
sensitivity 0.64-0.88, specificity 0.97-0.98
sensitivity
respectively [41]
 Issues relating to variability in age
groups, population and risk makes this
In 78 high risk or premature 6-26 month
not desirable for primary care screening
olds, cut off issue identified with poor
 Consists of 2 parts – CAT: visual/motor
sensitivity (0.36), but good specificity
problem solving tasks and CLAMS:
0.95-0.98 [12]
receptive/expressive language skills.
In 68 children(14-48 months) with
suspected delays, high correlation with
Bayley, sensitivity 0.95and specificity 0.84
[42]

19
 Screening Tool Name Age Electronic Cost to Tool type Language Reading Psychometric Properties Strengths

Administration
recommended
High risk pop
Second level
General pop
Publisher Website Range Format Practice Available Level Limitations

Time
Comments

NOT

Report
Parent

Admin
Direct
x x x Communication and 6-24 mo 5-10 min Easy score CD- Free X English, Checklist standardized on 2188 North Strengths:
Symbolic Behavior Scale- ROM infant Spanish, American children aged 6-24 months;  Addresses social communication &
Developmental Profile available. checklist Slovenian, sensitivity: 0.76–0.88 in low- and at-risk language issues in children <24 mo.
(CSBS-DP):Infant Toddler Chinese, children at 2 years of age; specificity:  Sensitive to communication delays and
Checklist $399 for German 0.82–0.87 in low-and at-risk children at 2 identifying children with ASD plus
http://www.brookespublis full tool years of age [44]. communication delay [46]
hing.com/store/books/wet Checklist compared to standardized Comments:
herby-csbsdp/index.htm testing in 232 children 12-24 months (half
 Infant checklist is one of three parts to
with language delay and half normal
the CBSB (Caregiver questionnaire and
development): Sensitivity 0.87 and
th behavior sample are the remaining two
specificity 0.75 using 1.25 SD or 10
elements of full scale.)
percentile below mean as criterion for risk
 Checklist used alone as screener to
[45]
determine if more complete evaluation
needed
 Intended as a first level screener for a
broad array of communication delays.
 24 questions with three composite
areas—social, speech, symbolic
communication with scores identified as
of concern/no concern (correlates with
th
<1.25 SD below mean or 10 percentile)
x x x Early Language Milestone 0-36 mo 1-10 min no $180 for X Small cross-sectional standardization Strengths:
Scale (ELM Scale-2) initial kit, sample of 191 children; 235 children for  Fairly easy to administer
http://www.proedinc.com Forms @ speech intelligibility item; sensitivity: 0.97  Format and form similar to Denver
/customer/ProductLists.as 62¢ each and specificity 0.93 in high-risk
px?SearchWord=ELM population. Sensitivity: 0.83–1.0 in low-
risk and high-risk populations, specificity:
0.68–1.0 in low-risk and high-risk Limitations:
populations [47].  Small group of children (191) used to
establish norms. Not necessarily
657 children 0-36 months, compared to representative of general population.
Sequenced Inventory of Communication

20
 Screening Tool Name Age Electronic Cost to Tool type Language Reading Psychometric Properties Strengths

Administration
recommended
High risk pop
Second level
General pop
Publisher Website Range Format Practice Available Level Limitations

Time
Comments

NOT

Report
Parent

Admin
Direct
Development. Poor correlation under 12 Comments:
months. 13-24 month ELM correctly  The ELM Scale-2 consists of 3 items
captured 0.79 and 0.89 of 25-36 month arranged in three divisions: Auditory
olds. Poorer results in younger age may Expressive, Auditory Receptive and
have related to scoring format of SCID Visual
[48].  Cut point is at age where 90% pass a
language milestone
 The ELM Scale-2 may be administered
using either a pass/fail or a point scoring
method. The pass/fail method yields a
global “pass” or “fail” rating for the test
as a whole, whereas the point scoring
method yields percentiles values,
standard score equivalents and age
equivalents for each area of language
function as well as a Global language
score
th
x x x Language Development 18-35 10 $65 X English, 5 grade 24-38 months: Sensitivity 0.53-0.89 and Comments:
Survey (LDS) mo minutes French, Specificity 0.86-1.00. Greater sensitivity  Part of the Achenbach System of
http://www.aseba.org/ Italian, with more inclusive delay criteria [49]. Empirically Based Assessment (ASEBA)
Romanian, inventory of tools for 1 ½ to 5 year olds
Dutch, 18-30 months: Sensitivity 0.67-1.00;  310 words arranged in 14 semantic
Turkish, Specificity 0.90-1.00 [50] categories. Parent circles words child
Greek, uses spontaneously, notes word combos
Portuguese 306 infants (24-29 months) screened by and best phrases.
mailed questionnaire with a sample of 64  Gender specific norms provided for 3
undergoing clinical evaluation: Sensitivity age ranges
 Scores below 15 percentile suggest
0.91; specificity 0.87 [51] th

delay.
24-29 month olds further screened with
additional questions relating to parental
concern and history of chronic OM:
Sensitivity 0.91; specificity 0.96 [52]

21
 Screening Tool Name Age Electronic Cost to Tool type Language Reading Psychometric Properties Strengths

Administration
recommended
High risk pop
Second level
General pop
Publisher Website Range Format Practice Available Level Limitations

Time
Comments

NOT

Report
Parent

Admin
Direct
x x Alberta Infant Motor Scale 0-18 mo 20-30 min $39.95 X Standardized on 2022 infants of Alberta, Strengths:
(AIMS) (1994) Canada for ages 1 week to 18 months  High risk infants
http://www.us.elsevierhea  Easy to use
lth.com/ 164 infants at 4 and 8 months for  Predictive of developmental disability at
product.jsp?isbn=9780721 predication of neurologic outcome at 18 9 months
th
647210 months. At 4 months (using 10  May increase surveillance skills
percentile as cutoff): Sensitivity 0.73 and indirectly
th
specificity 0.80. At 8 months (using 5  Delays in motor development often the
percentile as cutoff): Sensitivity 0.80 and first sign easily detectable in global
specificity 0.94 [53] developmental delay
Motor Screening Tools

506 (0-18 mo) infants participated in Limitations:

reliability and validity testing. Construct  Not as discriminating after about 9
validity determined by comparing 70 months or weight bearing well-achieved
children at risk or with known motor [55]
delays against established norms.  Some training required
Concurrent validity determined by  Tested on Canadian children. Not
comparing 103 typically developing necessarily valid for other cultures, Dutch
infants to 68 infants at risk or with known norms significantly different [56]
motor delays with PDMS and Bayley [54]  Preterm infants shown to have different
gross motor developmental trajectories
which may vary from stated norms [57]
Comments:
 Developed for use by PT/OT to identify
motor delay
 58 item observational assessment of
motor performance in 4 positions:
prone, supine, sitting and standing.

22
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23. Pritchard, M.A., P.B. Colditz, and E.M. Beller, Parents' evaluation of developmental status in
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27(2 Suppl): p. S111-9.
31. Siegel, B., Pervasive Developmental Disorder Screening Test-II (PDDST-II) Early childhood
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Year-Olds (STAT) for children under 24 months: an exploratory study. Autism, 2008. 12(5): p.
557-73.
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<http://www.agesandstages.com/downloads/ASQ-SE_TechnicalReport.pdf>.
38. Rescorla, L., Assessment of young children using the Achenbach System of Empirically Based
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Test/Clinical Liguistic and Auditory Milestone. Clin Pediatr (Phila), 1994. 33(7): p. 404-409.
40. Hoon, A., et al., Clinical adaptive test/clinical linguistic auditory milstone scale in early cognitive
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41. Vincer, M., et al., A population-based study to determine the performance of the Cognitive
Adaptive Test/Clinical Linguistic and Auditory Milestone Scale to Predict the Mental
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24
43. Voight, R., et al., Concurrent and predictive validity of the cognitive adaptive test/clinical
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Bayley Scales of Infant Development. Clin Pediatr (Phila), 2003. 42: p. 427-432.
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Profile. 2002, Paul H Brookes Publishing Co. : Baltimore, MD.
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Journal of Autism and Developmental Disorders, 2004. 34(5): p. 473-493.
47. Coplan, J., et al., Validation of an early language milestone scale in a high-risk population.
Pediatrics, 1982. 70(5): p. 677-83.
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Pediatrics, 1989. 83(2): p. 284-8.
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25
 Screening Tool Selection Algorithm

The following schematic/algorithm is intended to provide general guidance to a clinician for the
process of selecting an appropriate developmental screening tool for use in young children.
This algorithm most specifically addresses the array of tools focusing on structured
developmental screening, but also recognizes the recommendations for surveillance at every
well child visit as well as autism screening at specific ages (18 and 24 months). The Bright
Futures toolkit also provides support and suggestions for surveillance.

At this point in time, the recommended screening tool for autism is the MCHAT. New tools are
under development and future recommendations are likely to change as options for autism
screening increase.

The selection of appropriate developmental screening tools requires a thoughtful appraisal of

the intended purpose of screening, the patient population being served, the skills and interest of
the clinician, and the interface with the office ―system‖. The pathway most relevant is thus on
the left of the algorithm in the ―white‖ (unshaded) area under ―general screening‖. For the vast
majority of practices/clinicians, the tool of choice is one appropriate for general screening and
addresses the level of risk within the population. Developmental risk factors are listed in a box
at the side, and presence of these factors should lead to use of a tool more appropriate for a
―general/high risk population‖.

For screening a general population inclusive of children at higher risk for developmental delays,
the choice to be made is between parent report tools versus clinician administered instruments.
Parent report tools have shown excellent validity compared to physician/clinician administered
tools and are generally easier to administer and incorporate into an office system compared to
the more time-consuming clinician administered tools (which also often require some additional
training).

The dark gray box highlights ―second level screeners‖ and options for tools that may be of
interest to clinicians with greater interest/experience in developmental assessments, or that
address specific developmental areas in more detail. Tools from this latter group may be useful
in further pursuing concerns identified on more general screening tools (such as the PEDS).
Social emotional screens are currently listed as second level screening tools, although future
recommendations are likely to endorse concrete guidelines for targeted social-emotional
screening.

26
 Screening Tool Selection Algorithm for Children: Birth - Three years

Autism Developmental Developmental

‡Developmental Risk Factors
Prematurity
Screening Screening** Surveillance*
Prenatal Exposure to Drugs/ETOH/Tob
Feeding/Growth Problem/Disorders
Lead/Toxin Exposure
Low Birth Weight MCHAT PEDS†
Genetic Disorder Bright Futures
Chronic Illness
Poverty
Foster Care
International Adoption Specific
Parental depression or mental illness General
Parental Substance Use Screening Developmental
Family hx of Developmental Problems 2nd Level Problems
or Disorders Screeners
Infrequent well child care
Single Parent/Multiple Care Givers
Teen Parent
General/Low General/High Social
Risk Risk Language Emotional
Population‡ Population‡

Abbreviations
ASEBA: Achenbach System of
ASQ:SE
Empirically based Assessment
ASQ: Ages & Stages Questionnaire PEDS† Screening ASEBA
Screening
CSBS: Communication and Symbolic ASQ Tool Type Tool Type
Behavior Scale Developmental
Profile
ELMS: Early Language Milestone Scale
IDI: Infant Development Inventory Parent
LDS: Language Development Survey - Clinician Parent Clinician
Report Measure
component of Achenbach Sytem Report Measure
MCHAT: Modified Checklist of Autism
in Toddlers
PEDS: Parents’ Evaluation of
Developmental Status Brigance screen LDS (18-35 mo)
ASQ Bayley screen CSBS (<24 mo) ELMS
IDI (<18 mo) Batelle screen

Footnotes:
† If PEDS shows concern consider: Screen with ASQ or ASQ:SE or other second level screen.
*Developmental Surveillance: The ongoing, longitudinal, cumulative process, of recognizing children who may be at risk for developmental delays.
**Developmental Screening: Use of brief standardized tool at regular intervals to identify and refine a child's risk of developmental delay. Enhances the
process of surveillance.

Created by K. Aakre, MD December 2009, Developmental Screening in Primary Care