OBJECTIVES To assess the degree to which a national sample of pediatric practices could implement American Academy of Pediatrics (AAP) recommendations for developmental screening and referrals, and to identify factors that contributed to the successes and shortcomings of these efforts.

BACKGROUND In 2006, the AAP released a policy statement on developmental surveillance and screening that included an algorithm to aid practices in implementation. Simultaneously, the AAP launched a 9-month pilot project in which 17 diverse practices sought to implement the policy statement’s recommendations.

METHODS Quantitative data from chart reviews were used to calculate rates of screening and referral. Qualitative data on practices’ implementation efforts were collected through semi-structured telephone interviews and inductively analyzed to generate key themes.

RESULTS Nearly all practices selected parent-completed screening instruments, and half chose PEDS®. Instrument selection was frequently driven by concerns regarding clinic flow. At the project’s conclusion, practices reported screening more than 85% of patients presenting at recommended screening ages. They achieved this by dividing responsibilities among staff and actively monitoring implementation. Despite these efforts, many practices struggled during busy periods and times of staff turnover. Most practices were unable or unwilling to adhere to 3 specific AAP recommendations: to implement a 30-month visit; to administer a screen after surveillance suggested concern; and to submit simultaneous referrals both to medical subspecialists and local early-intervention programs. Overall, practices reported referring only 61% of children with failed screens. Many practices also struggled to track their referrals. Those that did found that many families did not follow through with recommended referrals.

CONCLUSIONS A diverse sample of practices successfully implemented developmental screening as recommended by the AAP. Practices were less successful in placing referrals and tracking those referrals. More attention needs to be paid to the referral process, and many practices may require separate implementation systems for screening and referrals.

Comment by Dr. Glascoe: Implementing quality screens in primary care is a challenge. But referral coordination with non-medical services is even more problematic in terms of actually getting a child with apparent problems to services. Both medical and non-medical providers need to collaborate in making this process easier for families. Non-medical providers, in particular, need to provide health care clinicians feedback about outcomes (e.g., when a referral is received, when appointments are scheduled, AND send the results to providers). When children don’t qualify for IDEA, clinics need to know so they can refer to Head Start or other services, i.e., most non-qualifying children remain at risk and careful monitoring of progress is essential.