Where to refer a 5-year-old patient with developmental and psychological delays?

Referral Pathways for a 5-Year-Old with Developmental and Psychological Delay

A 5-year-old with developmental and psychological delays requires simultaneous referrals to three essential services: (1) the public school special education department for diagnostic developmental evaluation and educational supports, (2) pediatric subspecialists (developmental-behavioral pediatrics, neurology, or psychology) for comprehensive medical evaluation, and (3) early childhood professionals for therapeutic interventions. 1

Primary Referral Destinations

Public School Special Education System

• Children 3 to 5 years of age with significant developmental delay or disabilities are entitled to early childhood special education through their local school district. 1
• The school system provides diagnostic developmental evaluation using standardized tools including Bayley Scales of Infant and Toddler Development, Woodcock-Johnson Psychoeducational Battery, Stanford-Binet Intelligence Scale, Battelle Developmental Inventory, and Brigance System. 1
• School-based services include developmental therapies, social work services, service coordination, and educational supports through an Individualized Education Program. 1

Pediatric Subspecialists for Medical Evaluation

• Refer to developmental-behavioral pediatrics, pediatric neurology, or pediatric psychology for comprehensive medical assessment. 1
• These specialists conduct objective vision and hearing evaluation, metabolic testing, and blood lead level screening. 1, 2
• Optional evaluations include genetic testing (particularly if dysmorphic features, family history, or multiple system involvement are present), blood iron level, electroencephalography, and brain imaging based on clinical indicators. 1, 2

Early Childhood Professionals for Therapeutic Services

• Refer to early childhood professionals including educators, psychologists, social workers, occupational therapists, physical therapists, and speech-language pathologists for targeted interventions. 1
• At age 5, therapeutic services may be arranged through both the local school district and the primary care medical home. 1

Domain-Specific Referrals Based on Delay Pattern

For Speech and Language Delays

• Formal evaluation by a speech-language pathologist is essential when speech/language impairments are identified. 1
• Assessment should include oral-motor functioning, articulation, and expressive/receptive language ability. 3
• Audiological assessment with play audiometry is mandatory to rule out hearing loss, which averages 28 dB HL in children with chronic otitis media with effusion. 3

For Motor Delays

• Physical therapy referral is urgent if motor delays are present, addressing hypotonia, gross motor delays, and gait abnormalities. 4
• Occupational therapy should be initiated for fine motor delays. 1, 4
• Pediatric neurology evaluation is critical to assess for cerebral palsy, neuromuscular disorders, or structural brain abnormalities. 4

For Behavioral and Psychological Concerns

• Behavioral therapy or mental health services should be considered if behavioral, sensory, social, emotional, or communication concerns are present. 3
• Screening for autism spectrum disorder is essential, as delayed speech and language are common early signs. 3

Critical Timing Considerations

Do not delay referrals waiting for a specific diagnosis—early intervention services should begin immediately while diagnostic workup proceeds. 4, 2 Studies demonstrate inconsistent evaluation and referral patterns among physicians can hinder identification and impede outcomes, making timely, comprehensive referral imperative. 1

The family physician serves as the coordinator of evaluations and authorizations within the patient-centered medical home model. 1 For children 5 years of age, special educational supports and therapies are arranged through both the local school district and the medical home provider. 1

Common Pitfalls to Avoid

• Never rely solely on clinical judgment without standardized screening tools, as physician impression alone misses 45% of children eligible for early intervention. 3
• Do not substitute auditory brainstem response or otoacoustic emissions for behavioral pure tone audiometry, as these test auditory pathway integrity rather than functional hearing. 3
• Avoid single-specialty referral, as developmental delays require multidisciplinary assessment including therapy services, medical evaluation, and developmental assessment. 4
• Do not overlook treatable causes such as hypothyroidism, lead toxicity, hearing loss, or vision impairment that can contribute to developmental delay. 2