Fall 2007

Early Detection: Red Flags and Referral Resources

Alfred Healy, MD, Professor Emeritus, UI Department of Pediatrics
Steven Wolfe, MD, Professor, UI Department of Family Medicine
Kay DeGarmo, Director, Iowa Prevention of Disabilities Policy Council
 

Early detection of developmental, behavioral, and emotional risks, delays, and disabilities is an important responsibility of each child’s primary health care provider. Late detection or delayed referral can prevent the provision of needed services and supports that will benefit the child, family, and society. Research suggests that early identification and intervention improve outcomes for children with social-emotional risk factors as well as for those with biologically-based conditions; well-designed early childhood interventions have been found to generate a return to society from $1.80 to $17.07 for each dollar spent (Rand).

The winter 2007 issue of this newsletter detailed the need for a change in the way practitioners conduct developmental surveillance and screening of young children, and provided information about new protocols that promote early identification. This article addresses the need to act once you have identified a child at risk, for identification accomplishes little if the child and family do not get appropriate and timely follow-up care.

Quality surveillance at each well-child visit is the cornerstone of a systematic approach to early detection of developmental, behavioral, and social-emotional concerns. Iowa Child Health and Development Records (Iowa CHDR) identify “red flags” that, if found during surveillance, signal the need to provide or refer for immediate screening or evaluation. Age-appropriate red flags for the child are identified in the developmental section of the CHDR; red flags that signal caregivers or families are in need of assistance are found in the social history section.

Sadly, surveillance and screening results are often not taken seriously, and children identified as at-risk are not referred. Too many practitioners follow a “wait and see” philosophy. Some are concerned about over-referral. Others want to avoid alarming parents until the practitioner is convinced a problem exists. However, no evidence supports delaying referral in situations like this, and the child is often harmed by the delay in identification and intervention.
 

When surveillance raises a red flag, it is important to provide for immediate screening or evaluation.  If a red flag indicates a missed milestone at a child’s 6-month exam, a 3-month delay in further screening means that 33% of that child’s life — and development — will have passed before intervention can be started. For the same reason, if further screening suggests a child is at risk, timely evaluation is essential.

Effective screening leads to correct decisions about diagnosis and intervention at least 70% to 80% of the time. Evidence suggests that children considered to be “over-referred” often have numerous psycho-social risk factors, and perform well below average on diagnostic measures (Glascoe); in other words, many will actually benefit from extra attention.

Iowa Child Health and Development Records

Iowa CHDR (pron. cheddar)  provide a checklist of age-appropriate child development milestones for use in each well-child exam. These checklists were previously called Iowa Health Maintenance Clinical Notes.

Practitioners concerned about worrying parents needlessly or encountering parental resistance may find that actively involving parents as partners throughout the process can open communication and prevent problems. In “Interpreting Screening Tests to Families,” Glascoe suggests that practitioners begin preparing parents by explaining that the visit is “an opportunity to view how children are coming along developmentally and behaviorally and to provide… suggestions about addressing any difficulties children are experiencing.”

Referral assistance

Many practitioners are understandably reluctant to screen for concerns if they believe no services are available to treat the problem. Some question whether screening in this instance is even ethical. It is helpful to know that today in Iowa, quality services exist in many communities to address the majority of the concerns identified by health care providers.

EPSDT Care for Kids Coordinators

Referral assistance, available through EPSDT Care for Kids coordinators, can help providers identify local resources for developmental services for children and their families. In Iowa, these resources include:

• Early ACCESS, a partnership of families with children 0-3 and providers from Child Health Specialty Clinics and from the Iowa Departments of Education, Public Health, and Human Services, links children to screening for most childhood risk factors. Intervention services are available to many children at risk as well as to children with documented delay. Families and staff work together to identify, access, and coordinate services. Contact via Iowa COMPASS: 1-800-779-2001, iowa-compass@uiowa.edu.

• Iowa Community Empowerment provides funding for community programs that include home visit and parent education programs, and in some instances screening services as well.

• Child Health Specialty Clinics throughout Iowa provide screening services through regional centers; some of these also offer evaluation and care coordination.

• Community Mental Health Centers offer evaluation and treatment services to parents; some now provide or plan to expand their services to include young children.

• Early Head Start programs are available in 31 Iowa counties; these offer parent education, developmental screening for children, and a variety of direct services to encourage healthy development.

Practitioners can call on these resources as they work to establish office practices and processes that:

• Provide systematic surveillance and monitor risk for each child at every well-child exam

• Identify risk factors through the consistent use of red flag checklists that can guide the timely transition from surveillance to screening, and from screening to evaluation

• Develop partnerships with community agencies before the need arises in order to link families with appropriate services in a timely way

References
Glascoe, FP. “Interpreting Screening Tests to Families and Encouraging Follow Through.”
Glascoe FP. “Early detection of developmental and behavioral problems.” Peds Rev 2000.
Rand Labor and Population Research Brief: Proven Benefits of Early Childhood Interventions, 2006.

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