What is the recommended approach for preschool screening and interventions?

Preschool Screening: Recommended Approach

All preschool-age children should receive standardized developmental screening using validated parent-completed tools at regular intervals during well-child visits, combined with continuous developmental surveillance by physicians at every encounter. 1

Core Screening Strategy

Use Validated Parent-Completed Screening Tools

• Deploy parent-completed screening instruments rather than directly administered tools, as these are more practical for primary care settings and have been extensively validated 1
• The two most extensively evaluated parent-completed tools are the Parents' Evaluation of Developmental Status (PEDS) and the Ages and Stages Questionnaire (ASQ) 1
• Administer standardized screening at regular, repeated intervals in addition to physician surveillance at all well-child visits 1
• The Preschool Pediatric Symptom Checklist (PPSC) is validated for social-emotional screening in children 18-60 months and shows strong reliability for identifying behavioral concerns 2

Implement Continuous Developmental Surveillance

• Conduct developmental surveillance as a longitudinal process incorporating professional observations into decision-making about children's developmental needs at every visit 3
• Address parental concerns about development at every encounter, as it is the physician's responsibility to seek out and address these concerns 1

Specific Screening Protocols by Domain

General Developmental Screening

• Screen for developmental delays affecting 12-16% of U.S. children, recognizing that up to half of affected children will not be identified before kindergarten if screening is inadequate 1
• Use multi-method, multi-informant assessment approaches given young children's inability to provide self-reports 4

Autism Spectrum Disorder (ASD) Screening

• Perform ASD-specific screening at 18 and 24 months for all children, as recommended by the American Academy of Pediatrics 1
• Children who screen positive on ASD-specific tools should be immediately referred for diagnostic evaluation and appropriate intervention concurrently, without waiting for diagnostic confirmation 1
• Siblings of children with ASD face 14-18% recurrence risk and require intensified surveillance with ASD screening at minimum at 18 and 24 months 1
• ASD diagnoses made before 24 months show high stability, particularly for autistic disorder (85-93% stability), though pervasive developmental disorder NOS shows more modest stability (47-62%) 1

Social-Emotional and Behavioral Screening

• Screen routinely for social-emotional and behavioral problems using validated instruments, as significant psychopathology exists in young children and early identification enables intervention 4
• The PPSC identifies four dimensions: Externalizing, Internalizing, Attention Problems, and Parenting Challenges 2

Critical Implementation Considerations

Overcome Common Barriers

• Establish office-based systems for screening and referrals to overcome barriers including lack of time, inadequate reimbursement, workflow disruption, and unfamiliarity with tools 1
• Ensure capacity exists in the health system to support children who screen positive, as only 61% of children with failed screens in one study were actually referred 1
• Provide training and infrastructure support to practices, which can mediate reimbursement challenges and improve screening uptake 1

Ensure Appropriate Follow-Up

• Complete additional evaluations and referrals when developmental delay is identified or suspected, as mandated by the Individuals with Disabilities Education Act Amendments of 1997 and Title V of the Social Security Act 1
• Recognize that early detection is critical because opportunities for early intervention may be lost if delays are detected too late 1

Common Pitfalls to Avoid

• Do not rely solely on clinical judgment without validated screening tools, as this approach misses many children with developmental concerns 1
• Do not use ASD-specific screening alone; general developmental screening tools like PEDS miss approximately 75% of children who screen positive on the M-CHAT 1
• Do not delay referral while awaiting diagnostic confirmation—refer immediately when screening suggests concerns 1
• Avoid screening programs that lack established referral protocols and feedback mechanisms to referring offices 1
• Do not screen children who are tired or stressed, as this yields inaccurate results 5
• Correct for prematurity when assessing development in infants born before 36 weeks gestation to avoid overestimating developmental delays 5