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Developmental Screening: Navigating the Pediatrician Visits
The AAP recommends conducting general developmental screening at 9, 18, and 30 months, or whenever a concern is expressed. In addition, autism-specific screening is recommended at ages 18 and 24 months of age. When families arrive for their child's well-visits, how can each pediatrician be sure the right screening is taking place to identify any developmental delays quickly and effectively? Hear from Cy Nadler, Phd, and Sarah Nyp, MD, as they discuss the screening process and how to navigate the world of developmental delays and disabilities.
Featured Speakers:
Learn more about Cy Nadler, PhD
Sarah S. Nyp, MD, received her medical degree from the University of Missouri Kansas City School of Medicine. Dr. Nyp then completed both her residency and fellowship at Children’s Mercy Kansas City with her fellowship focused on Developmental and Behavioral Pediatrics. Dr. Nyp is certified in both pediatrics and developmental behavioral pediatrics.
Learn more about Sarah S. Nyp, MD
Cy Nadler, PhD | Sarah Nyp, MD
Cy Nadler, PhD, received his PhD degree from Idaho State University in 2012. In 2012, Dr. Nadler completed his residency in pediatric psychology at Munroe-Meyer Institute/University of Nebraska Medical Center. He then completed his fellowship in 2013 in clinical child psychology and special needs at Children’s Mercy Kansas City.Learn more about Cy Nadler, PhD
Sarah S. Nyp, MD, received her medical degree from the University of Missouri Kansas City School of Medicine. Dr. Nyp then completed both her residency and fellowship at Children’s Mercy Kansas City with her fellowship focused on Developmental and Behavioral Pediatrics. Dr. Nyp is certified in both pediatrics and developmental behavioral pediatrics.
Learn more about Sarah S. Nyp, MD
Transcription:
Developmental Screening: Navigating the Pediatrician Visits
Dr. Michael Smith (Host): Our topic today is developmental screening. My guests are Dr. Sarah Nyp and Dr. Cy Nadler. Dr. Nyp is a Developmental and Behavioral Pediatrician at Children’s Mercy and Dr. Nadler is a clinical psychologist at Children’s Mercy. Doctors, welcome to the show.
Dr. Cy Nadler (Guest): Good morning.
Dr. Sarah Nyp (Guest): Thank you. Good morning.
Host: Dr. Nyp, let’s start with you. How about if you do a nice run through of the basic screening process in primary care, pediatric practice.
Dr. Nyp: Sure, so the American Academy of Pediatrics has provided some recommendations for primary care providers of children that really recommends something called developmental surveillance at every well child visit and then developmental screening at the 9, 18, and 30 month visit. So developmental surveillance is really just a broad term that means checking in on the child’s development. So this could be a conversation with the parent about what kinds of milestones the child’s meeting or if development seems typical to the parent. Where as developmental screening is using a standardized tool to really hone in on any areas that may require additional evaluation or exploration.
Host: And so when you look at a very busy pediatric practice, a general pediatric practice, are there some best practices to follow to make sure that the right screening is being done at the right time?
Dr. Nyp: There are, there’s several screening tools that are available. Some of them are tools that can be sent home to parents to complete and return to the pediatrician’s office at the time of the visit. Others are tools that could be administered by a nurse or some other ancillary staff member in the pediatrician’s office and then the pediatrician would review the results of those screening measures with the parent to determine if further evaluation were to be needed. There’s not a particular scale that must be used. There’s several options that may work better for one office than another.
Host: And is there a resource? Like if you were running a general practice, is there a resource where you could learn about these different tools and see what is appropriate for your practice?
Dr. Nyp: Sure, the different tools are outlined on the American Academy of Pediatrics’ website, and there are some charts available that even talk about what the benefits of one scale over another may be.
Host: So Dr. Nadler, I also understand that there is an autism specific screening. Can you tell us a little bit about that?
Dr. Nadler: Absolutely, so the American Academy of Pediatrics has additional guidelines. We want to make sure that in addition to those general developmental delays or speech delays that might be identified that autism specific red flags are caught and we really need a specialized tool to do that. So at the 18 and 24 or 30 month visits, so twice in that early childhood period, pediatrician’s offices are supposed to administer and autism specific screening tool, and by far and away the most common tool used is called the MCHAT, that’s the modified checklist for autism in toddlers and much like the general developmental tools, it starts with a one page questionnaire, asking parents does your child look at things when you look at them, does your child show unusual movements or behaviors, things like that and somewhat different from the general developmental screeners, there’s actually a second part, and while the MCHAT is used in many, many offices, it is actually rarely used correctly, meaning using the complete form. So once the parents fill out that first part, it’s supposed to be scored and for kids that score in sort of a middle risk range, there’s actually a standardized follow up interview that takes about a minute or two for either the pediatrician or an ancillary staff member to complete, basically making sure that the parent understood the question and that we get a really robust result from that to make a determination of risk.
Host: And so when you say that this is used in a lot of offices and practices but it’s not complete, is it that second part that’s not being done, that follow up question?
Dr. Nadler: It’s the second part, you’re absolutely right, and part of the confusion was because, the original version of the MCHAT, which I think came out in the early 2000s, didn’t have the clearest of instructions or people missed the boat on the follow up interview, but in the revision that came out in 2014, the instructions are very explicit that you need to start with the first questionnaire, and then if you don’t include the follow up in your procedures, you basically are missing out on the value of a standardized tool, meaning it’s not better than using your eyes alone which are quite fallible in such a brief encounter.
Host: Dr. Nyp, when a developmental delay or disability is caught or noticed either by a parent or through an actual screening process, what’s the next step in most cases? Can you help us navigate that a little bit?
Dr. Nyp: Yeah and I think it even happens before we have a confirmation of a developmental delay. If there is concern that there could be a developmental delay, that child really deserves referral to the birth to three program if the child’s less than 36 months of age in their state to have more evaluation and to see if they would qualify for intervention. We really found that children who receive intervention at the earliest possible time have the best outcome in the end, and so it’s really not necessary to wait for confirmation of a delay, but as soon as there’s a concern that child should be referred on.
Host: Yeah so what I’d like to do at this point since you guys are experts in developmental screenings, I would like for you guys to share with my audience just a general what you really think is the most important thing to know about developmental screening, from a parent’s perspective and also from a pediatrician’s perspective. Dr. Nyp, would you like to start?
Dr. Nyp: Sure, I think that – you know Dr. Nadler mentioned that pediatrician’s visits are very, very short and pediatricians are trying to see more and more patients, and it can be really hard to pick up on more subtle delays that can really have a tremendous impact on the child’s long term success and developmental progress, and so I think that if that developmental screening can really be performed in a standardized way using those standardized tools at the 9, 18, and 30 month visits we have an opportunity to really catch these kids and have a big impact on their long term developmental learning.
Host: Dr. Nadler, what would you like for the audience to know about developmental screening?
Dr. Nadler: You know I think I’ll echo Dr. Nyp’s comments that the screening is really just there to let you as a pediatrician rest easy that you don’t have to be an expert in development or autism to catch things. You can identify risk really easily using these tools in the standardized way and the wait and see days are over. We do not want kids to wait a minute before they get referred to an appropriate evaluation and treatment.
Host: Dr. Nyp and Dr. Nadler I want to thank you for the work that you’re doing at Children’s Mercy and thank you for coming on the show today. You’re listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information, you can go to childrensmercy.org, that’s childrensmercy.org. I’m Dr. Mike Smith, thanks for listening.
Developmental Screening: Navigating the Pediatrician Visits
Dr. Michael Smith (Host): Our topic today is developmental screening. My guests are Dr. Sarah Nyp and Dr. Cy Nadler. Dr. Nyp is a Developmental and Behavioral Pediatrician at Children’s Mercy and Dr. Nadler is a clinical psychologist at Children’s Mercy. Doctors, welcome to the show.
Dr. Cy Nadler (Guest): Good morning.
Dr. Sarah Nyp (Guest): Thank you. Good morning.
Host: Dr. Nyp, let’s start with you. How about if you do a nice run through of the basic screening process in primary care, pediatric practice.
Dr. Nyp: Sure, so the American Academy of Pediatrics has provided some recommendations for primary care providers of children that really recommends something called developmental surveillance at every well child visit and then developmental screening at the 9, 18, and 30 month visit. So developmental surveillance is really just a broad term that means checking in on the child’s development. So this could be a conversation with the parent about what kinds of milestones the child’s meeting or if development seems typical to the parent. Where as developmental screening is using a standardized tool to really hone in on any areas that may require additional evaluation or exploration.
Host: And so when you look at a very busy pediatric practice, a general pediatric practice, are there some best practices to follow to make sure that the right screening is being done at the right time?
Dr. Nyp: There are, there’s several screening tools that are available. Some of them are tools that can be sent home to parents to complete and return to the pediatrician’s office at the time of the visit. Others are tools that could be administered by a nurse or some other ancillary staff member in the pediatrician’s office and then the pediatrician would review the results of those screening measures with the parent to determine if further evaluation were to be needed. There’s not a particular scale that must be used. There’s several options that may work better for one office than another.
Host: And is there a resource? Like if you were running a general practice, is there a resource where you could learn about these different tools and see what is appropriate for your practice?
Dr. Nyp: Sure, the different tools are outlined on the American Academy of Pediatrics’ website, and there are some charts available that even talk about what the benefits of one scale over another may be.
Host: So Dr. Nadler, I also understand that there is an autism specific screening. Can you tell us a little bit about that?
Dr. Nadler: Absolutely, so the American Academy of Pediatrics has additional guidelines. We want to make sure that in addition to those general developmental delays or speech delays that might be identified that autism specific red flags are caught and we really need a specialized tool to do that. So at the 18 and 24 or 30 month visits, so twice in that early childhood period, pediatrician’s offices are supposed to administer and autism specific screening tool, and by far and away the most common tool used is called the MCHAT, that’s the modified checklist for autism in toddlers and much like the general developmental tools, it starts with a one page questionnaire, asking parents does your child look at things when you look at them, does your child show unusual movements or behaviors, things like that and somewhat different from the general developmental screeners, there’s actually a second part, and while the MCHAT is used in many, many offices, it is actually rarely used correctly, meaning using the complete form. So once the parents fill out that first part, it’s supposed to be scored and for kids that score in sort of a middle risk range, there’s actually a standardized follow up interview that takes about a minute or two for either the pediatrician or an ancillary staff member to complete, basically making sure that the parent understood the question and that we get a really robust result from that to make a determination of risk.
Host: And so when you say that this is used in a lot of offices and practices but it’s not complete, is it that second part that’s not being done, that follow up question?
Dr. Nadler: It’s the second part, you’re absolutely right, and part of the confusion was because, the original version of the MCHAT, which I think came out in the early 2000s, didn’t have the clearest of instructions or people missed the boat on the follow up interview, but in the revision that came out in 2014, the instructions are very explicit that you need to start with the first questionnaire, and then if you don’t include the follow up in your procedures, you basically are missing out on the value of a standardized tool, meaning it’s not better than using your eyes alone which are quite fallible in such a brief encounter.
Host: Dr. Nyp, when a developmental delay or disability is caught or noticed either by a parent or through an actual screening process, what’s the next step in most cases? Can you help us navigate that a little bit?
Dr. Nyp: Yeah and I think it even happens before we have a confirmation of a developmental delay. If there is concern that there could be a developmental delay, that child really deserves referral to the birth to three program if the child’s less than 36 months of age in their state to have more evaluation and to see if they would qualify for intervention. We really found that children who receive intervention at the earliest possible time have the best outcome in the end, and so it’s really not necessary to wait for confirmation of a delay, but as soon as there’s a concern that child should be referred on.
Host: Yeah so what I’d like to do at this point since you guys are experts in developmental screenings, I would like for you guys to share with my audience just a general what you really think is the most important thing to know about developmental screening, from a parent’s perspective and also from a pediatrician’s perspective. Dr. Nyp, would you like to start?
Dr. Nyp: Sure, I think that – you know Dr. Nadler mentioned that pediatrician’s visits are very, very short and pediatricians are trying to see more and more patients, and it can be really hard to pick up on more subtle delays that can really have a tremendous impact on the child’s long term success and developmental progress, and so I think that if that developmental screening can really be performed in a standardized way using those standardized tools at the 9, 18, and 30 month visits we have an opportunity to really catch these kids and have a big impact on their long term developmental learning.
Host: Dr. Nadler, what would you like for the audience to know about developmental screening?
Dr. Nadler: You know I think I’ll echo Dr. Nyp’s comments that the screening is really just there to let you as a pediatrician rest easy that you don’t have to be an expert in development or autism to catch things. You can identify risk really easily using these tools in the standardized way and the wait and see days are over. We do not want kids to wait a minute before they get referred to an appropriate evaluation and treatment.
Host: Dr. Nyp and Dr. Nadler I want to thank you for the work that you’re doing at Children’s Mercy and thank you for coming on the show today. You’re listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information, you can go to childrensmercy.org, that’s childrensmercy.org. I’m Dr. Mike Smith, thanks for listening.