No! Revenues from PEDS^® sales fund foreign language translations, validation, standardization, and accuracy studies. Revenues from PEDS^® are funneled into research and they also provide salaries for the staff who work for PEDStest.com and their families. Our overhead is low and we provide such support services as slide shows for “train the trainers”, trainees, ongoing FAQs, a discussion list on early detection, etc.

Instead, you should purchase PEDS^® for each child with whom you work. The cost is less than $0.30 per encounter. You can bill and receive often generous reimbursement for screening. This will more than cover not only the cost of PEDS^® but also your time. As importantly, if you laminate PEDS^®, you will not have a record of what the parent said. This makes longitudinal monitoring and follow-up impossible. You need to keep the latest PEDS^® Response Form in the chart at least until the next visit when a new one is completed. And, you need to keep track of each child’s results and decisions on the PEDS^® Score/Interpretation Form. So that should also remain in the child’s chart.

A good alternative is to use PEDS Online^® because it returns a record of what the parent said, diagnostic and procedure codes, automated scoring, and referral letters. These can be imported into patient records and offer good ability to track parent-child issues over time.

Please contact us for support and advice

No! PEDS Tools^® are copyrighted. By law, PEDS Tools^® forms cannot be reproduced in any manner (e.g. electronic, photocopying, transcription, lamination, etc.). Scanning of any PEDS Tools^® Forms is only allowed AFTER completed by parents or providers, and only by existing PEDS Tools^® users (print or online).

Nevertheless, licensed users of PEDS Online^® can either send a blank PEDS-R^® Response Form as an email attachment (e.g., with an appointment reminder so that parents can print and complete before a visit) and licensed users can place PEDS-R^® Response Forms on a password protected place on your site. PEDS Online^® also includes a parent-portal to allow parents to complete the measure(s) prior to office visits.

No. This is an infringement on copyright and an actionable offense. You must seek a license agreement from us in order to do this. We are happy to work with you but PEDS Tools^® must be purchased for each administration.

Another option is to use PEDS Online^®, which includes PEDS-R^®, PEDS:DM^®, and the MCHAT. It generates diagnostic and procedure codes, summary reports, and referral letters as needed. PEDS Online^® also includes a parent portal to allow parents to take the measure(s) online at home, or via in-office kiosks prior to office visits. Parents never see results, providers receive an email notification that a screen has been completed and can login to view/print/save results.

• First, photocopying is theft. It is illegal under the Bourne Convention and carries a minimum penalty of $200,000. This extends to electronic reproduction including posting copyrighted measures on websites.
• Second, even when, as is the case with some tools, photocopying is permitted, it is not cheaper. Photocopying costs—a lot.
• Third, you should be readily able to cover the minimal cost of PEDS-R^®  from reimbursement for well-visits especially now that the 96110 procedure code for screening carries separate reimbursement. If you are not getting reimbursed appropriately, please appeal your claims and contact the AAP’s Office of Billing and Coding (www.aap.org).
• Fourth, revenues from PEDS Tools^® sales support foreign-language translations and quality improvements to the tool, ensure the availability of its author to consult with providers and researchers, provide a living wage to employees of the publishing companies, and enable PEDS Tools^® to be re-standardized and validated periodically so that its psychometric underpinnings remain current and empirically sound.1.3. What happened to the 30-day exam?

We don’t currently display the results in any other format than html/plain text for copy/pasting, but you can save the results as a .pdf by saving them from our site in .pdf format (there are several free downloads available that allow this, CutePDF for example, works with both Mac and PC). Copy/pasting the text output from our site to Word or your EMR seems the easiest, fastest method, but the above will work if you prefer .pdf format.

We do not allow internal programming. Here is why:

We realize that PEDS Tools^® look simple to program, but they are definitely not. PEDS Online^® operates via a text-based scoring analyzer through which parents’ verbatim comments are identified and scored. Given that parents’ don’t always answer the question asked, the analyzer software we house on our site, looks for the content of comments and assigns them to developmental domains from which viewing risk levels/PEDS^® Paths proceeds. From age calculation, correcting for prematurity to the text-based analysis of parents’ comments, this has been a million dollar effort over the last decade. Therefore, this is not something anyone else can take on.

PEDS-R^® results are also integrated carefully with those of PEDS^®:Developmental Milestones and the Modified Checklist of Autism in Toddlers (two other measures on our site). Results from any or all, return different referral letters (when needed) and summary reports for parents. Another plus side of this approach is that it is error free, eliminates potential scoring mistakes, and thus produces accurate results. These can also be retrieved from our database which is helpful for program evaluation and reporting.

But there are ways to use PEDS Online^® with electronic records:

1. With a dedicated Information Technologist on your staff, we can create seamless integration between our site and your EHR. About 3 – 4 hours of their time is needed for working with the PEDS Online^® IT staff.
2. Easier still is just to copy and then paste results into the EHR.

So… please view PEDS Online^® as the same sort of service as any other outsourced lab work.

No. Only purchased and completed PEDS Tools^® Forms may be scanned.

A better alternative is to use our electronic version of Parents’ Evaluation of Developmental Status (PEDS Online^®), plus an autism specific screen–in compliance with American Academy of Pediatrics policy on early detection. Our other measure, PEDS^®:Developmental Milestones is also included. Both work like any other out-sourced lab work, meaning that use of our site for automated scoring, referral letters, ICD-9/10 and procedure codes as needed. PEDS Online^® also offers an accessible/exportable database of all your patients.

Options include adding a link to our site from your software (results are copied/pasted into Notes or saved as an attachment to the patient record). Another option is to work on an interface (CCR or HL-7) which we are prepared to do. Our results are provided in real-time.

It might be helpful for you to see our site, www.pedstest.com/online, where you can sign up for a free site trial. This will allow you to see first-hand how PEDS Online^® works.

We do not share pediatric encounter data with researchers without seeking permission from providers. If granted, we share only anonymized data.

For self-selected parents who come to the site outside of health care encounters, we reserve the right to share data, but again, only anonymized data is shared. and researchers must provide appropriate IRB approval. Researchers who want to use the site for prospective data collection only have the right to use their own data, again with IRB approval, but are not allowed to use other site data.

We have PEDS-R^® and PEDS:DM^® online, together with the (optional) Modified Checklist of Autism in Toddlers. All three measures are available in Spanish (although parents comments on PEDS-R^® must be translated into English). The site provides automated scoring, generates diagnostic and procedure codes, and creates a summary report for parents and a referral letter when indicated, to share with other professionals.

Pricing depends on volume. Please refer to the licensing agreement for a full price breakdown. After completing a license agreement, the site can be easily accessed by going to our online site and by simply placing a link in your electronic record (ER).

Complete integration takes time (and frankly, requires users to regularly pester their software vendors who seem slow to respond, especially if you’ve already purchased their product). Advocate before purchasing and otherwise please contact us if you’d like a trial username and password to explore the site.

There are quite a few options:

1. At Home: Families take PEDS-R^®/PEDS^®: DM/M-CHAT from home before the appointment. They would need a take-home “script” (e.g., if they are given written appointment reminder cards, those could be reprinted to ask them to go to the parent portal site, login and complete the PEDS-R^® questions a day or so before their appointment). If easier, we can put a link on clinic or company-wide websites). Clinicians or staff would then access the records on the day of the appointment, view and place into their EMR.Pros: Time required for screening is almost exclusively shifted to parents. The website will halt them if literacy isn’t demonstrated (i.e., nothing in writing/skipped questions)

   Cons: A back up plan will still be needed in case parents forget or can’t continue due to literacy issues (however unlikely if they managed to get into the site). Providers working with low income families may not view this (relatively ideal) option favorably and may not recognize just how well their families can read and also have internet access, i.e., most do.

   Logistics: Reminder cards or a leaflet put into the parent education package would be needed. You could consider putting a link on the clinic or general website

2. Waiting Room: The clinic receptionist asks the essential literacy prompt and then gives parents a copy of the PEDS-R^® Response Form and the M-CHAT? (we’ll provide photocopiable versions in various languages as part of the online license agreement), followed by Triage Area, Transcription: If PEDS-R^®/M-CHAT are completed in the waiting room in writing, the triage staff could access the site and enter parents’ comments. Clinicians would then access the site to view results, even before they enter the exam room.Pros: Time required for screening is mostly shifted to parents and back-up procedures are relatively minimal.

   Cons:

   1. Triage staff will need training so that they know that if the parent has not written any words on the PEDS-R^® Response Form, an interview (including M-CHAT items, would be needed.
   2. Parents are not as expressive in writing than in an interview and the triage area may not be conducive to optimal communication.
   3. If the M-CHAT is also used at select visits, receptionists will be challenged (different procedures at different visits is a headache).
   4. And, even if the workaround is age-specific well-visit packages that include the PEDS-R^® Response Form plus the M-CHAT at selected visits, there may not be space in the front office to store age-specific packages that receptionists could just hand over to parents.
   5. If families aren’t sitting in waiting rooms for at least 10 minutes, they may not have time to complete PEDS-R^®+the occasional M-CHAT (especially when struggling with rambunctious toddlers—although really good distracting waiting room toys might help tons).
   6. If staff time is absent, they could at least put the completed protocols next to providers work stations/offices and let clinicians enter and view results before entering exam rooms. But, that’s something of a waste of clinician though.

      Logistics: Directions to complete PEDS-R^®/M-CHAT would need to be put into the age-specific well-visit package, along with the PEDS-R^® Response Form and the M-CHAT. Receptionists could be asked to distribute the age-appropriate visit info and ask parents to fill out the forms within (thus sparing them from the challenges of providing different info/questionnaires at different ages). Depending on answers to #5 above, parents could be asked to come in 10 – 15 minutes ahead of time to complete the measures (Kaiser Permanente does this effectively and routinely)

3. Triage Area, Orally: Once families are in the triage area, the med tech could administer the PEDS-R^® questions orally, plus the M-CHAT items when indicated.Pros: This method saves clinicians time (a good thing) since we’d really like them to spend more time on parent education, service selection, referrals,

   Cons: Staff are more burdened with this approach and the triage area may not be conducive to optimal communication, based on staff skills, privacy, etc.

   Logistics: Staff would need to be trained on how to open the site and then paste in brief results plus parents’ exact concerns into EPIC.

4. Exam Room Independently: Parents, once escorted to the exam room, complete PEDS^® online through the parent portal.Pros: Time spent on administering PEDS-R^® (and the M-CHAT when indicated) is almost exclusively shifted to parents.

   Cons: Escort staff would need to probe for literacy and perhaps be prepared to sit down and interview parents (but staff rapport and personability needs to be considered carefully). The time needed for a staff interview when required (10% or so of the time but varying by clinic demographics) may not be workable in the current staffing patterns.

   Logistics: the exam room computer would need to be set to the parent portal, and/or when an interview administration is needed, staff or clinicians would need to know how to switch to the professional administration (in which case clinicians would see a screen of results, preferably turned away from the parents). If staff administer, clinicians would need skills to view records from the parent portal, ideally before they enter the exam room.

5. Exam Room by Clinician Interview: If clinicians prefer or need to interview parents in person, staff will need to make sure the exam room computer is set to the professional version and that PEDS-R^® questions are on the screen (or to a welcome prompt with language options).Pros: Parents will talk more—a good thing though. And, starting the encounter with PEDS-R^® is a great opener. It should, ideally be offered at the beginning so that clinicians can machinate about what exactly to do next .

   Cons: This approach takes providers more time than if parents can complete PEDS-R^® via the parent portal or in writing, especially when it comes to visits where the M-CHAT should be deployed.

   Logistics: Staff will need to set the exam room computer to PEDS^® online. Clinician speed at copying PEDS Tools^® results and pasting those into the EPIC patient record is essential. Clinicians will need practice with the mechanics of this but also huge familiarity with PEDS Tools^® results (seeing as how they need to just glance at the screen, absorb the info, all pretty much requiring reading at about E =MC2 so as to keep up a comfortable dialogue with families!

Professional use of PEDS Online^® requires a license. All licenses are assigned with a unique username and password and allow the professional user to administer PEDS Online^® for a specific number of times. Once we receive a signed license agreement, we’ll set up your account using your specified login information and you’ll be ready to go.

If you would like to sign up for a trial, please visit: www.pedstest.com

A recent study at Harvard by Dr. Alison Schonwald, presented at the Pediatric Academic Societies meeting last May, showed that PEDS Tools^® actually reduced visit length by about 2 minutes.

Dr. Schonwald speculates that the time-savings is due to a reduction on “oh by the way” concerns combined with a more focused visit (since you know what parents’ concerns are, and children’s risk levels, you can walk into the exam room armed with information handouts, referral information, etc.). Explaining the need for a referral is straightforward because most parents have already expressed concerns.

PEDS Online^® also by-passes all time needed for scoring, writing referral letters, etc. So, there’s lots of time-savings there as well.

Data is stored on the site under each licensed user’s agreement and unique license number. We use this for usage counting, billing, and if requested, annual reporting of screens administered and results. We can make the data “disappear” after a specified period of time but only after the requested billing interval (and because of the inevitable, but usually immediate, need to have us retrieve lost records, i.e., if your office computers crash)! PEDS Online^® is a secure site, utilizing SSL, anonymized data, and following HIPAA guidelines where PHI is concerned. Please contact us for more details on how we protect your data!

Yes! PEDS Online^® offers a parent-portal approach, which allows parents to take the measures at home, prior to office visits, or via in-office kiosks. Parents do not see the results, rather a notification email in sent to the provider alerting them that a screen has been completed.

Yes. We have a parent portal that allows parents to take our measures at home or on a waiting room computer. Parents will not see the results. Instead you are sent an email alerting you that a screen has been completed with a link to retrieve the records.

Help we can! Here are two ways:

1. We provide downloadable PEDS-R^® Response Forms in multiple languages so that families can use these in waiting/exam rooms. Otherwise, PEDS-R^® can still be administered by interview or via our patient portal (where parents do not see the results).
2. If using the PEDS:DM^® online and need a paper-pencil version, your license agreement prompts you to determine how many Family Books you’ll need for parent self-administration in waiting or exam rooms.We have the PEDS:DM^® in English, Spanish, and Taiwanese.
3. Nevertheless, both measures are short enough to deploy by interviewing parents or by eliciting (in the case of the PEDS:DM^®) children’s skills.

Please contact us. We can correct the record and send it back to you within 24 – 48 hours. If you need the parent to start over, that’s fine. Just let us know the date of testing and patient id number, and we’ll eliminate the duplicate record.

The information exchange between our site and your office is conducted like any other outsourced labwork. The site is HIPAA compliant. Although the child’s first and last name enable customization of referral letters and parent summary reports, only a unique patient identifier (this does not need to be a patient i.d. or other meaningful number), the child’s birthdate, and parents’ answers are essential for scoring and returning results to your office. We encrypt that information to add security.

As part of our license agreement, we provide photocopiable files of the PEDS-R^® Response Forms in case these are needed in waiting/exam rooms. Staff can type answers onto our site (in English) and will receive immediate results. The site also enables you/staff to interview families while typing answers into the site, again you will receive immediate results.

This is true although with PEDS Online^® there’s a huge savings in terms of reporting writing, billing/coding and scoring. And… with either, lots of technical support and advice. The average reimbursement for using the -25 modifier with 96110 under Medicaid is roughly $8.00 per screen so we still hope that screening is quite a profit center for primary care providers.

1. The Denver/PDQ were not standardized except in Colorado. What do these measures have to say about children residing elsewhere? Very little!</li
2. The Denver/PDQ were not validated and the authors provided no proof that the items actually work. Research by other authors indicate they don’t.
3. The Denver/PDQ are too long for primary care. Using selected items probably degrades accuracy even further.
4. Administering informal measures and making clinical observations take more time than it takes to give PEDS-R^®.
5. Informal checklists lack proof and decision support. If a patient fails one item, do you refer? Or do you wait until two items are failed? Three? What’s the right thing to do? Who knows? What if your patient can do all items. Do you know he or she is OK? No!
6. PEDS-R^® provides clear guidance on when to refer and when not to refer. It is OK to look further at children’s skills. But, it is not OK to over-ride the evidence PEDS-R^® provides (e.g., predictive concerns) with informal measures that lack any proof.

Parents’ concerns have ways of cropping up at inopportune times. You can prevent that by pre-empting them. With PEDS-R^®, you allow parents to express their thoughts before you work with them. This enables you to prepare, collect your thoughts and resources, and respond wisely. PEDS-R^® virtually eliminates “doorknob” concerns—the “oh by the way” ones that crop up unexpectedly at the end of an encounter and often take time from the next child and family, disrupt patient flow, etc.

Following discussions with the AAP, CIGNA HealthCare (CIGNA) issued clarifications for coding and payment for claims for limited developmental testing. The carrier verified that it will pay for both the preventive medicine evaluation and management (E/M) service in addition to the limited developmental testing (reported as CPT code 96110). Claims submitted with the preventive medicine E/M code and CPT code 96110 appended with modifier 59 (distinct procedural service) will be automatically processed in CIGNA claims system. Also, effective May 1, 2008 as an alternative acceptable modifier billing mechanism, CIGNA will also pay CPT code 96110 as a separate and distinct procedure, when submitted with a preventive medicine E/M service code appended with modifier 25. However, claims submitted with modifier 25 appended to the preventive medicine E/M service code requires manual processing by CIGNA, which may extend the claims processing timeframe. Horizon Blue Cross Blue Shield of New Jersey, the state’s largest insurer, has agreed to pay on claims using modifier 59. Originally slated to be valid January 1, 2009, Horizon has agreed to pay claims using modifier 59 as of October 1, 2008. Pediatricians experiencing denials from CIGNA for claims reporting CPT code 96110 should contact the AAP Coding Hotline at aapcodinghotline@aap.org.

Round up a month if 16 days or older (e.g., 2 months + 16 days = 3 months).

Round down if 15 days or younger (e.g., 2 months + 15 days = 2 months).

There is an age-calculator in the main menu on pedstest.com/agecalculator for which the format is dd-mm-yyyy

In some States and for some types of practices (e.g., Federally Qualified Healthcare Centers), clinics are paid a rate “per medical encounter”. When developmental screening is provided, a specified “visit code” (typically a pre-defined preventive service code) is used to trigger enhanced reimbursement. The 96110 screening code is not reimbursed separately even when States have a specified list of tools required for Early Periodic Screening, Diagnosis and Treatment (EPSDT) visits. In such clinics, adoption of quality screens is best evaluated in terms of time saved plus reductions in practice expenses. Consider these self-evaluation questions, especially in light of the advantages afforded by online screening services:

• How much time do clinicians spend eliciting informal milestones such as those on age-specific encounter forms? (Published research on this topic does not yet exist but informal time/motion studies suggest that providers spend ~ 1 – 2 minutes on these activities—time that could be saved if parents complete quality skills-focused tools on their own. Accurate parent-report tools are also known to vastly improve detection rates).
• How much time is spent eliciting parents’ concerns with informal questions? What percent of visits incur “oh by the way” concerns and how much time is required to address these? (Research shows that informal questions do not work well and result in “door knob” concerns in about 20% of visits. In contrast, accurate measures eliciting parents’ concerns, preferably by self-report in advance of the visit, shave about 3 minutes from average visit length and make encounters far more relevant. Also families are more likely to return for subsequent visits when their specific concerns are elicited and addressed.
• If using quality tools in print how much time is spent hand-scoring or administering screens by interview? Would shorter screens with online scoring save time?
• How much time is spent dictating/proofing referral letters and parent summary reports? (Published research on this issue does not yet exist but we can anticipate that for about 20% of patients, referrals and thus report dictation/proofing will be needed. These activities require at least 5 – 10 minutes of professional time. To this expense must be added requisite staff time for transcribing dictations). Would not much of this time/expense be eliminated if using an online screening service that automatically generates reports?

You may need to use the following:

1. Attach the – 25 modifier to your preventive service code or E/M service code (to denote the office visit is a separate service from the screening.Then list 96110 times the number of screens given, (e.g., X 3 if using PEDS-R^®+PEDS:DM^®+MCHAT). [Note that some States (e.g., North Carolina) does not allow an unbundled 96110 but has increased reimbursement substantially for the entire well-visit]. If billing a private payer, particularly Cigna, the -59 modifer is usually required instead of -25

2. Multiple units, with the modifier appended to the visit as described above, best describe the separate entity of performing multiple 96110s. For insurers not accepting units, the distinct procedural service of each test is best represented with – 59 modifier appended to each additional unit of 96110:
Example: A level 3 office visit in which three developmental screening instruments were administered, scored and interpreted:
99213
96110
96110-59
96110-59

Appeal all denied claims–sometimes State Medicaid Directors aren’t aware of the federal ruling from 2005, in which the Centers for
Medicare and Medicaid Services published a total relative value unit (RVU) of 0.36 for 96110, which amounts to a Medicare payment of about $10.00. For Cigna and many other private payers, reimbursement is about $20.00. This RVU represents only malpractice expense and office expense –no physician work is included–meaning that screening is largely a staff function except for explaining results to families.

None of this can guarantee that a valid claim will be accepted, so the American Academy of Pediatrics (AAP) is willing to help with denied claims via their Coding Hotline: 800-433-9016, ext. 4022, or at aapcodinghotline@aap.org

96110 or 96111 procedure codes rarely cover the Denver because it is not validated.

This answer is provided from Linda Walsh at the AAP’s Office of Coding and Reimbursement and Dr. Lynn Wegner, Chair AAP Section on Developmental and Behavioral Screening): There are two levels of coding: optimal coding and acceptable coding. While optimal coding would indicate that you link the V79.3 or V20.2 code to 96110 in a patient that screens as “normal,” payors do vary on their tendency to (financially) recognize such reporting. A coding purist would tell you to continue to report that code combination and fight it at the contractual level. That’s a viable long term solution (and one that should be taken into account when your contract next comes up for renewal) but it doesn’t work well in the short term (ie, mid-contract). Therefore, if you find that your payors are not recognizing that code combination, we suggest that you engage an acceptable coding alternative, such as seeing if a code in Chapter 16 of ICD-9-CM (Symptoms, Signs, and Ill-Defined Conditions) is a reasonable alternative. So, Developmental screening ICD-9 codes are all v codes, unfortunately. For example, Screening for: developmental handicap V79.9 (Screen developmental problems V79.c) in early childhood V 79.3 Now, if you had documented in the chart any reported delays (despite normal results after the screening), you could use: 783.42 Delayed Milestones 315.8 Other specific Delays in Dev 315.9 Unspecified Delays in Dev AFTER, the screening (ie next visit) you could NOT use these three codes as you would have screened ‘normal’.

CPT Codes and Descriptors Effective January 1, 2019

Beginning in 2019, developmental testing codes 96112 and 96113 should be used for developmental testing including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed. These codes cover administration by physician or other qualified health care professional, with interpretation of results and creating a report.

Use 96112 for the first hour of testing (> 31 minutes). (wRVU 2.56).

Use 96113 for representing each additional 30-minute increment required to complete the service (list separately in addition to code for primary procedure). Note that the mid-point rule requires 76 minutes to pass before adding the first 96113. (wRVU 1.16)

This new coding structure enables physicians or other qualified health care professionals to report these services based on total time. This is a change from the previous 96111 code which limited you to reporting a single unit of code, regardless of time spent providing the service. These new reporting codes cover multiple days of review and interpretation of data.

77-106 mins (1 hr and 46 mins)96112 and 96113

These ICD-10 codes are general in nature so as not to interfere with more refined diagnoses available when children are older and can be administered very detailed measures.

Commonly used ICD-9 codes are those sufficiently vague as to not interfere with a more complete diagnoses made by those to whom you refer:

Commonly Used Diagnosis Codes in response to screening test results include:

Yes. Like PEDS-R^®, the PEDS:DM^® stands alone. So if you are only interested in children’s skills and monitoring that, the PEDS:DM^® is a good choice. But we like the combination of PEDS-R^® and the PEDS:DM^® for addressing parents’ concerns and monitoring children’s development. This offers better compliance with the notions of screening and surveillance.

How do I decide which screening measure(s) are best for me?

Providers have preferences for early detection methods. So please consider the following to help you decide which tools you need:

• If you are reasonably confident in the value of parents’ concerns to help identify children at risk as well as parents own needs for child-rearing guidance, use Parents’ Evaluation of Developmental Status (PEDS-R^®). With 12 questions, the same at each visit from 0 – 8 years, PEDS-R^® elicits and helps you address parents concerns with evidence-based decision support. PEDS-R^® indicates when children need referral (for further screening or evaluation), which parents need guidance and exactly on what topic, which children need careful monitoring, etc. PEDS-R^® also makes it easier to make referrals because you are almost always capitalizing on parents’ own concerns. PEDS-R^® takes about 5 minutes for parents to complete (on their own or by interview).
• If you are reasonably confident in the value of eliciting and addressing parents concerns, but  also want to confirm parents’ concerns with information about children’s actual skills, use PEDS-R^® at each encounter. Then administer PEDS^®:Developmental Milestones (PEDS:DM^®) periodically, when recommended by PEDS-R^® results (usually on about 20% of children). PEDS:DM^® involves 6 – 8 questions, 1 per developmental area (expressive language, expressive language, gross motor, fine motor, self-help, social-emotional, and for older children, academic skills. There are different questions at each age, throughout the birth to 8 year age range.The PEDS:DM^® replaces informal milestones checklists with evidence, and takes about 5 minutes to complete by parent/older child report or by interview.
• If you prefer to use only a milestones approach to screening and surveillance and are comfortable with parents’ ability to report children’s skills, use the PEDS:DM^® by parent report. PEDS:DM^® takes about 5 minutes to complete by parent/older child report or by interview.
• If you are not comfortable relying on information from parents, either their concerns or their report about children’s skills, use the PEDS:DM^® by administering it directly to children. Direct administration of the PEDS:DM^® takes about 10 minutes.
• If you are working with children at high-risk (e.g., in child-find program, neonatal intensive care unit follow-up or other subspecialty health clinics such as developmental-behavioral pediatrics, or working with children in foster or adoptive care) consider using PEDS:DM^® Assessment Level (preferably along with PEDS-R^® for carefully addressing parents’ issues). The PEDS:DM^®-Assessment Level offers more items at once in order to illustrate carefully strengths and weaknesses, provides not only cutoffs but age-equivalents, tracks progress, and enables percentage of delay (or percentage of skills mastered) to be computed.
• If you are working in an electronic environment, consider using PEDS Online^® (follow links to electronic records). PEDS Online^® offers PEDS-R^®, PEDS:DM^® plus the optional Modified Checklist of Autism in Toddlers (M-CHAT). It provides automated scoring, generates summary reports for parents, referral letters when needed, billing and procedure codes, and has a searchable, exportable database.
• If you want to comply with American Academy of Pediatrics recommendations for early detection, the best approach is to use both PEDS-R^® and the PEDS:DM^® together all the time.* Because there are only 18 – 20 questions total, both can be done in less than 10 minutes. Together PEDS-R^® and the PEDS:DM^® facilitate communication between parents and providers, increases satisfaction with care, encourage families to return for well visits, enable milestones monitoring, and… both serve as surveillance and screening tools.

*along with the M-CHAT at 18 and 24 months.

The PEDS:DM^®-Assessment Level Version is designed for more detailed evaluation of children’s progress and is especially helpful with children for whom there is an elevated risk of delay and thus greater likelihood of uneven development. You can still use the primary care version of the measure as a starting point, but you will probably prefer the assessment level.

The PEDS:DM^®, with its milestones-focus is highly accurate and has its own supporting psychometry. Similarly, PEDS-R^®, with its parents’ concerns focus, is also highly accurate and has its own supporting psychometry, i.e., numerous cross-validation, predictive and criterion-related validity studies, supporting its ability to detect children with various types of problems and to identify children currently at risk and to predict which children will continue to have problems.

So each measure has a different measurement method and can be used alone, and used alone with confidence.

But, there are benefits to using both types of measurement methods (and thus better for complying with American Academy of Pediatrics policy on screening and surveillance: PEDS-R^® elicits and addresses parents’ concerns while also offering screening. The PEDS:DM^® offers milestones monitoring while also screening. Together, in a total of 18 – 20 questions, both tools are useful. Here’s why:

PEDS-R^® ensures that parents understand that developmental-behavioral pediatrics issues are a part of care. It builds collaboration between providers and parents and improves satisfaction with care. PEDS-R^® reduces the odious “oh by the way concerns” so problematic to visit length. PEDS-R^® focuses encounters on issues relevant to parents. It encourages parents to return for scheduled visits. And PEDS-R^® reduces parents’ frustrations with child rearing by facilitating parents’ use of positive-parenting practices (e.g., time-out and praise, rather than punishment). No milestones-focused measure ensures such benefits to providers as well as to parents.

Still, PEDS-R^® also calls for additional screening in about 20% of cases. These are children who may or may not be behind even though many have at least moderate levels of risk for current or future delays/school failure. Discerning who needs special services and who needs developmental promotion/careful monitoring can reduce over-referrals, however minimal these are given PEDS-R^® accuracy. Options are:

1. Refer all kids on Path B to EI/public school services; preferably for additional screening, not dx evaluations;
2. Use a milestones-focused screen such as the PEDS:DM^® to decide who needs a referral and who needs developmental promotion plus careful monitoring.

The PEDS:DM^® offers providers, especially those with strong preferences for milestones-focused measurement, a way to look at children’s skills and to monitor progress over time. PEDS:DM^®, like PEDS^®, ensures an evidence-based approach to early detection, but the PEDS:DM^® is also designed to replace non-validated checklists such as those often found in electronic records or age-specific encounter forms, with an accurate but still very brief screen.

There are indeed “different strokes for different folks”. So, providers can

1. Use PEDS:DM^® always and only;
2. Use PEDS-R^® always and only;
3. Use PEDS-R^® followed by the PEDS:DM^® in the ~ 20% of cases when PEDS-R^® results are uncertain;
4. Use both tools consistently for optimal compliance with AAP recommendations for longitudinal screening and surveillance.

We’ve had lots of experience working on State-level efforts (e.g., California, Arizona, Tennessee, North Carolina, Oklahoma, Ohio, Massachusetts, etc.). Here’s a summary of points to consider, largely focused on health care providers because “that’s where the children are”:

Models:

• the most effective State initiatives require quality tools, eliminate reimbursement when inaccurate/informal measures such as milestones checklists are used and ensure that health care providers are reimbursed appropriately
• a prodromal period is wise, such as a two year window for full compliance
• State Medicaid offices and point persons for private payers need to be involved
• offering a menu of quality tools is wise because there are indeed, “different strokes for different folks”
• please contact us if you need a current list of tools, broken out by those suitable for primary care, NICU/EI, and electronic offerings. These have been vetted by various screening test authors and researchers and show the economic implications of using each tool

Informing/Motivating:

• providers often get little feedback that they are missing children with likely disabilities–and, about 70% are. So clinicians need encouragement, information and repetition of this message.
• slide shows and other information on www.pedstest.com provides core exercises for helping providers think more carefully about early detection and how to do it better.
• such information needs to challenge, the status quo, identify referral links, parenting info (a huge consequence of screening/and thus informing parents that well-visits include db issues–a topic not often known to low SES parents).
• one of health care providers main complaints is not that good screens take too long, but that referral resources are absent. This, we know, is not true, but is a serious reflection on the dearth of communication between health care and non-medical providers. So, establishing a seamless, two-way communication/consent system for sharing reports and recommendations, and thus encouraging non-medical and medical providers to “get to know each other” is essential
• see also training issues below

Making it Work in Practice:

• establish a point person (or two) in each practice including a physician champion and a committed staff person (more links in the attached or on my site)
• train all staff within each practice on the importance of early detection and encourage staff to participate in office work flow decisions
• the clinic coordinator will need to figure out the nuances of billing/coding with private payers and Medicaid
• there are helpful implementation guidelines in the materials on our site.

Training Trainers:

• Train-the-trainer conferences are most economical, followed by local/regional training
• We have tried to ensure that training materials on our site are self-instructive (via case examples, slide shows, FAQs, short movies, and pre-post tests). But we can help further if needed, (e.g., by email, teleconferences, live presentations, etc.)
• the materials on our site also include motivation/informing suggestions on how to gently help health care providers realize they could be doing better (a good thing given the absence of feedback on their typically minimal detection rates (i.e., ~30% of kids with actual problems)

Training everyone else:

• Once trainers have mastered the materials/tools, local/regional conferences are wise
• A helpful approach is to include time toward the end of the day for regional/local non-medical and medical providers to work on an action/implementation plan (and get to know each other)
• Earlier in the day, live demonstrations of tools and electronic offerings (plus the motivational/informing guidelines) help participants realize how do-able quality screening actually is (e.g., saves time, improves care, improves reimbursement, etc.) and the availability of resources

Program Evaluation:

• you’ll probably need a way to benchmark current referral rates, for which this site is helpful: https://www.ideadata.org
• It’s also wise is a plan for how compare your benchmark to changes in referral rates so if an integrated data base between providers and EI/public schools is possible… that’s a good thing for figuring out which providers need to be targeted for more focused support.
• Harvard University’s www.developmentalscreening.org has lots of guidance on encouraging the reluctant providers, staff, etc.

Electronic Apps; Training and Implementation Issues:

• Many quality tools have electronic applications in place.
• These are available online but providers will need training in how to cut/paste into each patients’ records (see our FAQs for how to teach this).
• Related to the above, providers also need how to switch between their EHRs and a browser so they get to the abundant information on parenting issues (e.g., www.kidshealth.org).
• Providers naturally want complete integration and this is doable. Online application Information Technology (IT) specialists can send specifications on the required fields, HL-7 compliance, etc.
• Integration with EHRs, requires a committed IT person on the EHR side. So, initiatives need to ensure that there is support, commitment, and a plan for lots of reminders.
• Trials abound on publishers’ websites including this one.

The best approach (according to the American Academy of Pediatrics July 2006 policy statement) is surveillance and screening. The goal of screening is to ensure that evidence is used to make accurate referral decisions. The goal of surveillance is to intervene in risk factors than can cause developmental problems before that actually happens. Surveillance is the big picture. Screening is essential decision support.

The process involves: eliciting and addressing parents’ concerns, monitoring milestones at every visit, evaluating psychosocial risk including parental depression, identifying resilience factors, periodic use of broad-band developmental-behavioral screens, occasional use of a screen for autism spectrum disorders (at 18 and 24 months), and developmental promotion.

Although the above sounds like a very tall order, it is surprisingly do-able if you have the right tools for the job. We crafted our measures, Parents’ Evaluation of Developmental Status-Revised (PEDS-R^®) and PEDS^®:Developmental Milestones around AAP policy so that you can easily comply, i.e., provide both surveillance and screening simultaneously, save time, and get reimbursed appropriately.

The PEDS:DM^® Assessment Level offers more detail on performance which is helpful for children suspected of delays and for those with known biological or psychosocial risk. For these children it is optimal to present more items in each domain than is accorded in the PEDS:DM^® Screening Level: A view of strengths and weaknesses across all developmental domains (fine motor, receptive language, expressive language, gross motor, self-help, social-emotional, and for older children reading and math skills). The PEDS:DM^® produces age equivalent scores (as well as cutoffs) so that you can produce percentage of delay scores (or percentage of skills mastered at chronological age) most helpful for NICU Follow-up studies and EI intake. The PEDS:DM^® Assessment Level involves a reusable booklet, one per child, enabling monitoring over time.

Yes, the PEDS:DM^® can be used at those ages (30 months too as suggested by the AAP). It is a continuous set of questions so even if patients present older or younger than the well visit schedule, there’s still a set of questions that will work.

But as a reader on the panel, I don’t think members of the Committee were any too comfortable with the idea of not screening after 30 months.

Development develops and developmental problems do too. Not all language impairments can be detected by 30 months, intellectual disabilities will still be subtle, and learning disabilities aren’t even on the horizon. So, hence the (somewhat vaguely worded) comment that the policy statement, “provides an algorithm as a strategy to support health care professionals developing a pattern and practice of attention to development that can and should continue well beyond 3 years of age.”

The Committee also recognized that a 30 month encounter isn’t even on the well-visit schedule and so perhaps not reimbursable. But, they also were quite aware of research suggesting that if general pediatricians create a visit that’s just devoted to development and behavior, they are much better able to effectively address the huge range of issues.

Most importantly, the AAP also called for routinely eliciting parents’ concerns about children’s development/behavior along with documenting/maintaining a developmental history, and identifying risk and resilience factors. So a combination of PEDS-R^® (at every visit) and the PEDS:DM^® at the AAP’s recommended visits and at each visit 30 months and older (or as indicated by PEDS-R^®), is, I think, the best approach.

Both measures can be used at each visit to address parents’ concerns and monitor milestones–and all with evidence. Finally, the PEDS:DM^® includes supplementary measures for even better compliance with AAP recommendations. Included are screens for risk/resilience factors (sometimes used as new patient intake), an autism-specific screen, a mental health/ADHD screen, along with the Vanderbilt Diagnostic ADHD Scale, recommended by the AAP at 18 and 24 months.

1. Start with a quality translation that is then tried out with various professionals (e.g., physicians, nurses, social workers) so that you can make needed changes. Once providers are satisfied, check readability if parent-report is an expected application. Ideally, reading level should be lower than that of the typical 9 year old, lower still if possible.

2. Then try out the translation on a random sample comprising parents of varying socioeconomic backgrounds (preferably a sample that reflects the population parameters of the country in which you are working). Then vet the translation as an interview (especially in the case of languages such as Arabic that have a distinctly different conversational as opposed to written translation. We can send you guidelines for translations based on our many years of experience and can often put you in contact with others working on a same-language translation. If you need translation guidelines or a new translation is needed, we can provide some proscribed financial support for a thoroughly vetted translation. See contact information below.

3. Next, compare your results to the norming studies found in the original test manuals, i.e., the frequencies you’ve found; a) of parents’ concerns (in the case of PEDS^®); b) with which children perform below cutoffs (in the case of the PEDS:DM^® screening version/other measures); or c) the degree to which age-equivalent scores (in the case of the PEDS:DM^® Assessment Level) correspond to concurrent validation measures. Kappa may be helpful but it has limitations (e.g., reflects more on overall agreement and does not capture well the nuances of strengths and weaknesses across passing versus problematic scores).

4. If frequencies vary substantially, reconsider the quality of your translation. Could the wording be problematic –too strong or too weak, too politically/culturally charged? (Please read our translations FAQ and also request current guidelines that includes a description of our experiences with translation/standardization in other countries). If so, consider a re-translation. In general, the performance of children in developed nations are remarkably similar with regard to developmental tasks. Behavioral scales are another matter and much more likely to reflect cultural differences in child-rearing/disciplinary practices, so expect differences in performance if norming such measures.

5. Also consider current political/environmental issues: The circumstances of families’ lives may be particularly challenging due to wars, health issues, etc. (e.g, 90+% of families in Tanzania experiencing a malarial outbreak had major worries about their children’s development—far more than is typical). If so, consider sampling at a more auspicious time.

   It is critical to keep in mind that the goal of screening is to identify potential problems well before school entrance so that the benefits of early intervention can be conferred. In the US and most other countries, there are clear standards for success at age 5 and beyond. Thus, while we want screening tests to be sensitive to within-cultural differences, it is less than ideal to contemplate different cutoffs for various cultural groups–to the extent that all children within a country are held to the same performance expectations.

6. If, after re-vetting your translation, there is still substantial lack of concordance between original norming studies and your findings, new standardization may be needed and this process is described below.

7. Standardization: Be sure to capture a large sample that is representative of your country as a whole—in terms of socio-economic status and geographic locations. Your national census data offers a good guide to sampling. Level of parent education is one of the most critical variables to measure among socio-economic status, and in some countries, it may be essential to capture separately the perspectives and level of education of mothers versus fathers. You will need about 50 – 75 children per cutoff per age-group on the measure you are norming with optimally, an appropriate socio-economic spread within each age-group.

   It is not wise to exclude children with problems from your sample. They are part of the population as a whole and should be included at a rate that reflects their prevalence (e.g., in the US, about 16% – 18% in the 0 – 18 year level, and about 12% in the 0 – 6 year level). Nevertheless do, not seek children with known problems at this point, because their problems may be relatively severe and their unique performance can be explored during various validity studies.

8. Reliability studies of three kinds need to be conducted to ensure your directions and scoring are clear, and that nearly identical results can be rendered: a) on the same child tested within a short (usually 1 week interval), i.e., test-retest reliability rendered preferably as a percentage of agreement; b) on the same child tested and scored by two different examiners, i.e., inter-rater reliability again rendered as a percentage of agreement. For both the above types, > 90% agreement is preferable; and c) internal consistency for which Lambda and various other formulas are often used. These analyses illustrate the standard error of measurement with which scores should be banded to reflect the natural variability in children’s performance.

9. Validity covers many concepts. You will need to consider:

   1. Construct validity. This includes age-related changes in scores, i.e., older children should be successful with more skills. Additionally, a factor analysis should be conducted to determine that items measuring each dimension of development “hang together”. This can reveal when for example, a motor item, if it clusters with language instead of motor skills, has directions too difficult or verbally-laden; thus identifying needed changes to a measure. Ideally, items within a similar domain load on the same factor.

   2. Concurrent validity. This involves administering a newly developed/translated screening tool to a random sample of children in the standardization group along with criterion measures such as diagnostic tests of development. The measures chosen should have scores for each domain on the screening test under study. Comparison with existing screening measures is not recommended because there is always at least some inherent error in screening tools that can be compounded, rather than overlap. Nevertheless, assessment level tools may be used (these are measures that do not provide quotients in each domain but rather age-equivalent scores). The continuous range of results provided by diagnostic or assessment level measures is helpful for assessing the accuracy of a screen (see Accuracy below). Concurrent validity studies are typically presented as correlations. Ideally, subtests on screening test correlate highly with like measures on diagnostic/assessment measures.

   3. Discriminant validity. In these, the performance of groups of children with known disabilities on both diagnostic/assessment level measures are compared to screening test results, in an effort to ensure that there are indeed unique differences in performance (e.g., between children with cerebral palsy, learning disabilities, language impairment, autism spectrum disorders). Ideally, there will be distinct patterns of correlations for each group.

   4. Predictive validity. These studies are not often conducted on screening tests, given the slender set of items (and the challenges of longitudinal research). But, if possible, such studies are ideal and consist of looking at the performance of children (e.g., at age 4) on a screening test, and then looking at performance on diagnostic/assessment level measures at age 6 – 7). While we would not expect perfect agreement over time, predictive validity studies can help identify skills/domains associated with school success–enabling a clearer focus for intervention.

10. Accuracy. The most critical evaluation of any screening test is criterion-related validity, i.e., accuracy in identifying children with and without problems, i.e., sensitivity/co-positivity and specificity/co-negativity. Ideally, these figures are generated by administering both the screen and more detailed measure to a random sample of children in a standardization study (rather than adding in a group who may have substantive disabilities and which thus lack the “shades of grey” that constitutes the developmental continuum between typical development and disabilities, i.e., children who are at-risk/mildly-delayed but not yet disabled). In such studies, children are grouped according to at-risk/high-risk and thus disabled, versus typical, and a tests’ ability to identify these groups uniquely (e.g., with specific cutoffs per age level) is measured. The criteria used for eligibility for special services will need to be taken into consideration.

    Ideally, 70% or greater sensitivity/specificity is rendered by viewing the various cutoff options and thus selecting the optimal balance. ROC analysis is quite helpful for viewing alternative sensitivity/specificity figures and selecting the cutoff(s) that create the best balance between under- and over-detection.

    The issue of accuracy determination is critical: Measures such as the Denver-II that failed to involve validation, have not held up well with time. The Denver-II misses about 55% of children with problems because its cutoffs were not calibrated against more substantive tools.

11. We are happy to advise on translation and test psychometry issues for our measures. Please contact us as needed.

We will do our best! Here are some thoughts:

1. First, please join the Early Detection Discussion list on our site. There may be other PEDS^® users in your nation who can help.

2. Let us know if there’s no response and we’ll connect you with others as best we can.

3. Next, please send us a draft of your research plan, and request a research donation license from us. We will then send you translation guidelines and links to information about standardization in other countries.

4. The next step is to get a really good translation if that’s needed (we have many for PEDS^® and a few for the PEDS:DM^®) but languages evolve and evolve fast. So, our translations may still need work for use in other countries. Our translation guidelines, based on lots of prior experience, involve getting a first translation, then a back translation, but also sharing your version with other clinicians, and ultimately trying them out with families.

5. Please send us a copy of your vetted translation. If needed, we can try to find other clinicians who can advise.

6. Consider the nature of curricular demands at school entrance, particularly if wanting to use the PEDS:DM^®. In Chapter 6 of the PEDS:DM^® Manual is a list of milestones set at roughly the 50th percentile for developed nations. BUT if say, at age 5, children in your setting are not expected to do the same sort of things, you will need to consider new standardization and preferably new validation.

7. Standardization involves getting a large sample of children’s performance from a group who reflect population demographics for the entire country. Usually government bureaus of statistics or censuses have this information available. Critical variables include parents’ level of education, language spoken at home, poverty/income levels, and enrollment in preschool programs prior to school entrance. Health issues/risks may also be important to include.

8. Validation involves giving a diagnostic battery along side a screening test. The Denver-II is not an appropriate option since it is not diagnostic and was itself not validated (or well standardized for that matter). Measures like the Vineland, Bayley, Mullen Scales are better choices. But if there aren’t translations for such measures in your setting, you may have to rely on standardization alone.

9. In developed nations, standardization is probably not needed since there are not many differences in children’s overall performance.

10. In developing nations, new standardization (and preferably also validation) may well be needed but…remember that screening tests are ultimately designed to predict success in school, if not life. And so the goal of measuring is to identify children who may not do well, identify them early, and get them help that’s needed.

11. Nevertheless, screening can serve as needs assessment too. While some debate the ethics of this, i.e., believe that screening should always lead to services, sometimes that’s not possible until we first demonstrate the need for services.

You bet!

If you are sampling a high risk population (e.g., NICU follow-up, hospitalized children), please ask as part of your study whether children are already enrolled in services. Parents’ satisfied with programs typically don’t raise concerns (and frankly their children don’t need screening anyway). Either put them on the high-risk PEDS^® path or exclude them from your sample.

Otherwise, we encourage you to use tools like logistic regression to view unique patterns of concerns according to the condition you are studying (e.g., to predict autism spectrum disorder, motor disorders, etc.). Capturing parents’ vebatim concerns is essential because there may be unique and different categorization . We can license use of our site to facilitate such studies and export a data base you can use with any data analysis software.

If comparing various language backgrounds/cultures, the above advice is still be helpful. Ensuring literacy and a quality translation is essential so please join our Early Detection Discussion List and collaborate with us on translations. Multiple eyes on the prize is critical.

Otherwise, viewing parents’ verbatim concerns versus how they prioritize this (e.g., within “yes/no/a little” responses may be helpful for viewing cultural/linguistic differences in how PEDS^® performs and whether different scoring systems are needed for various language/cultural groups.

Please see the extended set of abstracts we house on using PEDS^® in survey research, and how we can help you, by following links to the Supporting Research

With PEDS^®, we encourage you to use all 10 its questions so that you can capitalize on the results of existing studies. While some PEDS^® questions may not seem relevant for young children, they are still worth asking to best understand parent-child issues (e.g., whether parents are trying to teach alphabet recognition to very young children), identify predictive versus non-predictive concerns, even while recognizing that parents don’t always answer the question asked, etc.

If using the PEDS:DM^®, you can select the questions within the developmental domain or age range of interest, although it is best to include items for slightly younger and older children to make sure you’ve sampled a broader range of skills. You can use the basal/ceiling rules for the Assessment Level version as a guide.

We offer an online version of PEDS^® that works with tablet PCs…and in a growing number of languages. Please contact us for more information.

As compared to national norms, you will find far more children at-risk on PEDS^®/PEDS:DM^®. This is to be expected because psychosocial risk (e.g., poverty, non-English speaking families, single parents, parents with limited education, parents with less than optimal parenting skills) takes an enormous toll on chidren’s development.

If you need more information, please contact us.

We have lots of ways to work with you. If using a computer-assisted telephone interview approach, we can support your initiative as follows:

1. A CATI appropriate version of the PEDS^® questions with improved prompts for the yes-no-a little questions is available through our online scoring service. This enables you to capture parents’ open-ended comments. And, it yields a rich exportable data set that is both qualitative and quantitative.
2. CATI PEDS^® questions can be inserted into your interview protocol and then submitted either one-at-a-time or as a batch, to our online scoring engine.
3. We’d then score PEDS^® and return parents’ comments, results, and recommendations, all within a database to export back to you. The database will work with EXCEL, SPSS, etc.

If this is a mail-out initiative instead, let us know and we’ll figure out the easiest options for you, while still enabling the online scoring option if preferred (e.g., research staff enter parents comments/answers onto our site for scoring, database populating, etc.).

Please let us know your thoughts and research plans and we’ll figure something out. contact us.

Great! The various PEDS^® studies on this issue are problematic because they did not exclude children already enrolled in services (whose parents may not raise concerns if, as we hope, they are pleased with the programs their children receive). Clinically that is still helpful, but can muck unfairly with sensitivity/specificity figures).

In your study database, please capture the actual responses of parents in your study. If you find PEDS^® isn’t working well, We’d be happy to work with you on creating a sub-taxonomy for motor comments (e.g., “is very strong”, “only 5 months old but definitely is right-handed”, “keeps her right hand in a fist”, etc.).

Using PEDS^® online may be the most efficient way to capture comments, get results and… your data can then be exported to your larger database (e.g., EXCEL, SPSS, etc.) for further qualitative, taxonomic analysis.

Sometimes literacy is a problem with parents who skip questions or only circle yes/no/a little. So it is wise to readminister by interview if possible.

If a parent refuses to given an open-ended response to one, but not all questions, and a child still lands on Path A or B, then follow those Paths. If, however, the child lands on C or E, then chose D.

If parents don’t say/write anything just circle answers, then it’s definitely a Path D, unless your clinical judgment suggests Path A would be better to follow.

Yes! First, please read this section on billing/coding. Please view item 3.8 on billing coding section. The material costs of screening measures are minor compared to reimbursement if you code/bill correctly.

Also read information on what to order in relation to your particular clinic requirements.

No. You can just buy one kit for each nurses station (assuming as we do that this where actual scoring occurs) and a Family Book for each exam room (or if using the PEDS:DM^® at check-in, enough copies of the Family Book for each well-visit scheduled at the same time. We have a large clinic discount for orders of 10 or more Family Books. Optionally, it may be wise to have a copy of the PEDS:DM^® Manual in each exam room in case providers want to explore the extent of any delays (the Manual includes a list of all items, incorrect answers and essential visual stimuli).

No. Including our items and Forms in your electronic record without a license from us, is a violation of copyright laws. Contact us and we will send an appropriate license agreement.

PEDS-R^® costs about $1.04 per visit. The PEDS:DM^® costs about $0.69 per visit. True costs, benefits, and savings deserve a bigger focus than just material cost. Clinicians have noted that PEDS-R^®, by eliciting parents’ concerns prior to the visit, reduces “oh by the way” concerns, focuses the visit, contains its length, increases teachable moments, and makes the referral process much easier (since affirming parents observations and concerns is the way to begin). Several papers (Dobrez, Pediatrics 2001) and Bethell, Pediatrics 2001) found PEDS-R^® less expensive than all other measures in terms of provider time (easier reading level, less need for interviews, parents always finished by the time the exam room is ready for them), that parents were more satisfied with care, felt they had a collaborator in child-rearing issues, and thus were more likely to use positive parenting practices (e.g., time out rather than spanking), and that providers more confident in decision-making. And, parents were more willing to return for well-visits when PEDS-R^® was used according to a study by Blue-Cross Blue Shield of Tennessee.

Abstract: Increased Well-visit Attendance When PEDS^® Is Used
In valuing the true costs/savings/benefits of the PEDS:DM^®, you need to think about the time you spend eliciting milestones. Those minutes can be saved by relying on parent report via PEDS-R^®/ PEDS:DM^®. That time savings gives you more time for more important tasks like promoting development, addressing parents? issues, making referrals, etc.

You may return purchases within 30 days and receive credit but only if materials are undamaged and unused. So pack them carefully. Do not open shrink-wrapped forms or remove sheets from pads. Undamaged returns carry a 10% restocking fee. Original shipping costs are not reimbursed.

The PEDS:DM^® Assessment Level will only produce, as its highest age-equivalent, a score of 90 months. This means that children 91 through 95 months will look slightly delayed. But, the 2% – 5% delay the PEDS:DM^® will render at this age level is not significant, and a referral is not indicated. We will work on adding items appropriate for older children so that age-equivalent scores can at least match chronological age when appropriate. Still, if you are testing kids 90 months and older, additional measurement options include the SWILS, an academic measure for children ages 6 – 14, and the PSC, a measure of mental health, behavior and attention for children ages 5 – 18+. Both measures are housed in the PEDS:DM^®. Another option is the Developmental Profile-3 (which goes through age 12). See (http://portal.wpspublish.com/portal/page?_pageid=53,186601&_dad=portal&_schema=PORTAL).

Yes! There is an Assessment Level version of the PEDS:DM^® that presents more questions at each visit, produces age-equivalent scores, and charts progress over time. Adding PEDS-R^® is wise:

• PEDS-R^® gives you insight into parents issues and needs
• PEDS-R^® helps parents think about development as a range of domains
• PEDS-R^® enhances the teachable moment
• PEDS-R^® helps parents feel they have a collaborator in child-rearing and someone they can talk to about their concerns. This is known to reduce parenting frustration and promotes positive parenting practices such as time-out, rather than spanking
• PEDS-R^® reduces “oh by the way” concerns and helps focus the visit
• The PEDS:DM^® helps confirm or disconfirm parents’ concerns, enabling providers to effectively and efficiently respond to both parents’ issues and children’s needs.

The PEDS:DM^®-Assessment Level is for NICU follow-up clinics and early identification child-find programs and could be useful in db clinics, especially if you have a triage model in place (e.g., at Vanderbilt University, we had a clinic into which we brought 3 – 5 children in per day for a db physical, social work evaluation, and mini-developmental assessment to decide if diagnostic evaluations were needed and if so which ones (e.g., from a developmental psychologist, educator, speech-language pathologist, or physical therapist, etc..) Our triage clinic was surprisingly effective, improved our ability to quickly schedule any additional evaluations, was very popular with community providers (only about a three week waiting list and short reports!), and monetarily, the clinic ran in the black—seemingly a rare occurrence in db clinics!).

The PEDS:DM^®-Assessment Level involves the same items as the screening version but they are presented in booklet form so more are presented at once (clinicians need to decide on start and stop points so that, ideally, children get 3 items in a row correct and end with three in a row incorrect). Then each correct answer is assigned a value in months to produce an age-equivalent score for each of 7 developmental-behavioral domains. From there, percentage of delay (or more positively, percentage of skills mastered, can be computed). There’s a growth chart type grid on the back to make it easy to chart progress and explain results to parents. The booklets are reusable with the same child for programs offering longitudinal monitoring (parents are asked to use a different colored marked when they work through it a second time). As a related aside, the PEDS:DM^®-Assessment Level can be administered directly to children or by parent report (actually parents are prompted to elicit skills directly from children so parents essentially serve as paraprofessionals in the process of assessment).

Timing is a major issue since we wouldn’t expect children recently removed from their homes to demonstrate all the skills they possess. Usually foster parents (many of whom are either experienced or kin) have a gist of children’s strengths and weakness early in a new placement, but may not know much about children’s actual skills. So, PEDS-R^® (our parents’ concerns measure) may be more useful around the time when children enter a new home. A loose consensus from lots of social workers and developmental-behavioral pediatricians, is that a measure of actual skills, like the PEDS:DM^®, is probably best administered, after a month or two in a new placement. This enables children time to adjust.

Still, some foster care intake programs find the PEDS:DM^® effective in the first few days if directly administered to the child, rather than by parental report. Ultimately, use your judgment about children’s ability to perform under trying circumstances, AND, about the acumen of a new foster parent—newly coping as they are too.

That depends on your time, what other issues you have to address, and the setting in which you are screening. If a home visit, and you just want a quick indicator of how a child is doing in all areas, then use the PEDS:DM^® screening version. This takes about 5 minutes or less. If you have more time, require more in-depth information, and need something other than pass/fail scores in each developmental area, use the PEDS:DM^® Assessment Level (about 20 minutes). This will give you age equivalent scores in each domain and from there you can compute percentage of delay scores (or more positively, percentage of skills mastered).

PEDS-R^® can be administered by phone. It has been studied as an interview and it works well that way. In such administrations, you should ask, “So would you say you are not concerned, a little concerned, or concerned?” after each open-ended question (in order to prompt for answers to “Yes”, “No” and “A little”)

Nevertheless, for clinical applications, PEDS-R^® is not suitable for voice recognition approaches since the measure requires parents’ comments, not just 1 – 2 syllable multiple-choice responses. Parents’ verbatim comments are essential for developmental promotion, referral planning, and follow-up.

To assist you with telephone interviews of PEDS-R^®, we also have an online computer-assisted telephone interview application. Please download and return our online license agreement.

The PEDS:DM^® can be administered by interview for the first 2 1/2 years of life or so. After that it requires parents or clinicians to actually elicit skills from children (e.g., copy a triangle, read words, etc.).

Screening is considered a staff function and both PEDS-R^® and the PEDS:DM^® can easily be administered and scored by staff. Clinicians would then explain results to parents, make referral recommendations, and typically, staff would then facilitate the actual referral process. We also have a PEDS-R^® On Demand training module.

If also using the PEDS:DM^®, staff need to work through the first three chapters of the PEDS:DM^® manual. Ultimately, it is essential that staff be trained in the rationale for early detection, and to have input into how PEDS-R^® and/or the PEDS:DM^® are implemented, Responsibility without control equals stress. Responsibility with control leads to an effective solution!

If you are not comfortable relying on information from parents either their concerns or their report about children’s skills:

Administer the PEDS:DM^® directly to children. Although parent report, i.e., endorsement of children’s skills is as accurate as parental reporting of such skills, this is a viable option, even if time-consuming.

If you prefer information on children’s skills and are comfortable with parents ability to report on these:

Use the PEDS:DM^® by parent report

If you want to focus on children’s skills but also to make it easier to give difficult news:

Administer the PEDS:DM^® first (by parent report or by direct administration) and then PEDS^® if there are problems on the PEDS:DM^® (to enhance communication and make it easier to deliver difficult news)

If you want to comply with AAP Recommendations-The Best Approach:

Use both together all the time. Because there are only 16 – 18 questions total, both can be done in less than 10 minutes)

PEDS^® has several steps:

1. Give parents the PEDS-R^® Response Form to complete or use it as an interview.
2. Take the PEDS-R^® Score Form and find the right column for the child’s age. Put a check in each box when parents had a concern.
3. Follow the directions on the PEDS-R^® Interpretation Form for deciding when to refer, screen further, give advice, wait and see, or reassure.
4. Mark the PEDS-R^® Actions steps page.

Watch our quick time movie on using the PEDS:DM^®

If also using PEDS^®, add a Response into the Family Book before giving it to the parent. Or you can view PEDS^® results first to decide if the PEDS:DM^® is needed. You can score both measures with the PEDS:DM^® Recording Form.

We have two options: purchasing print copies of PEDS-R^®/PEDS:DM^® (these, once completed, can be scanned into a child’s chart). We also have PEDS Online^® (along with the optional) Modified Checklist of Autism in Toddlers. The site can be linked to electronic records or your personal website.

The online application, PEDS Online^®, provides automated scoring, generates summary reports for parents, referral letters when needed, ICD-9/10 codes, etc., and also returns parents verbatim comments (helpful for refining parent education/referral issues). We also have a parent portal (so that parents can take our measures at home or on an office computer but will not see the results). Rather providers get an email message that screens have been completed OR can login to view/retrieve results. All results fall into a database that can be exported into EXCEL or other statistical software.

PEDS Online^® includes PEDS^®, PEDS:DM^®, and the MCHAT.

By Telephone (for Intake and Triage)

Administer PEDS-R^® first. This helps start a dialogue and sets focus for the call.

If Path B, C, or D, indentify the correct PEDS:DM^® items for the child’s age and administer these by interview.

Score the PEDS:DM^® and PEDS-R^® and follow the path identified by PEDS-R^® to decide whether the PEDS:DM^®- Assessment Level version is needed, i.e., if items are failed on the PEDS:DM^® at age level.

If so, on an Assessment Level Booklet, identify the domain(s) requiring further exploration, mark those items already administered, locate and mark answers for the items. Administer by interview, items below those already failed until reaching three passed items in a row if possible. Also probe the failed items to attain three failed items in a row.

Use the last page of the Assessment booklet to determine age-equivalent scores and percentage of delay.

An alternative is to mail the Assessment booklet to families to complete on their own. If so, you will need to make a color copy of the stimuli (from Section 3 of the Family Book) and insert these pages into the Booklet. You can also download and print a copy of these images from this web site.

If using the Assessment Booklet as a mail-out, write the word START next to the item that is 3-4 below the item for chronological age for each domain (See Chapter 8 for the relationship between items and age).

Be sure to include a self-addressed stamped envelope with the Booklet to facilitate its return.

In Person

You can administer the Assessment Level PEDS:DM^® directly to children (either in part or entirely) or let families complete items on their own.

Mark the PEDS:DM^® Assessment level booklet with starting points (at least 3 items below chronological age, or if younger than 5 months, at the first item). You can write START to indicate where parent should begin. Stopping points are described for parents on the cover (but if you think parents might be confused, write STOP about 3-4 items above chronological age associate with each item).

Attach the PEDS-R^® Response Form to the front of the PEDS:DM^® Assessment Level Booklet.

Give the parents the Family Book opened to Section 3 (where all the stimuli needed for self-administration are included), and the PEDS^® Response Form with the PEDS:DM^® Assessment booklet).

Score PEDS-R^® and the PEDS:DM^®-Assessment Level and prepare the Recording Grid for sharing with families (computing age equivalent scores, percentage of delay, or percentage of skills mastered, and using a highlighter to create the bar graph (color in spaces up to the highest pass and drawing a line to represent chronological age).

To implement PEDS-R^® easily in primary care, it is optimal, if not essential, to involve your front office staff in the process. While their first reaction may be to groan and say there is too much paperwork already, there are several things you can do to make it work smoothly and easily:

1. First give the office staff some background information on why screening is important.
2. Second, let them know that a PEDS-R^® Response Form needs to be given to every family before they see the provider, but let the staff decide where and when (e.g. in the mail or over the phone along with an appointment reminder, at-check in, when seeing the medical technician, when ushered to an exam room, etc.)
3. Office staff will also need to ask families discreetly whether they would like to complete the measure on their own or need someone to go through it with them in order to circumvent literacy issues.
4. Give office staff the option of administering an interview version when needed and scoring the measure. This speeds things up for the professional staff. However, if the office staff are unwilling to do this, the offer will at least let them see that the entire burden of screening is not falling on their shoulders and that it is shared with others in the office.
5. Have your staff locate (and preferably meet with professionals who are your referral resources) and then coordinate optimal ways to share information.
6. Consider using PEDS Online^® because this saves tons of time, because there is no need for hand-scoring, hand-written referral letters, etc.
7. If wanting to add the PEDS:DM^® to PEDS-R^® or if using the PEDS:DM^® on its own, this can be done in waiting or exam rooms. Staff will need to find the correct form in the Family for the child’s age, give parents a dry erase marker for answering the questions, and retrieve the Family Book in order to proceed to scoring and documentation.

You can use PEDS-R^® and the PEDS:DM^® in two ways: Administer both at each visit (a total of 18 – 20 items). This takes about 7 minutes total. Administer PEDS-R^® routinely and the PEDS:DM^® as indicated.

The PEDS:DM^® is designed to be administered by paraprofessionals and can also be self-administered by parent report. The manual has lots of case examples helpful for training and for ensuring your staff know how to score and explain the results to families. So your certificated early interventists should be more than qualified to use the tool and licensure isn’t needed.

But please see our section on training and join the early detection discussion list . We are working on a webinar and improved pre- and post-testing for demonstration of competence and we welcome training suggestions.

There are “target” registration marks on the template: Align the marks on the completed Form with the marks on the template. You can then see (at the top) the correct column for the child’s age by its letter name, The child’s age range is revealed at the bottom should you need to affirm this. If you can see any of the parents’ marks through the template windows (typically these are made with a red dry-erase marker) revealed by the marks are unmet milestone-and a major harbinger of problems.

We eliminated the letters “I” and “O” so there wouldn’t be confusion with “zero” and “L”. But the PEDS:DM^® Forms are continuous, meaning you can find one that’s appropriate for the child’s age, no matter how old (up to age 8).

The reason why self-help or social concerns factor into Path A is that parents with multiple predictive concerns often have a host of non-predictive concerns as well. So, when you see those present, it indicates a greater possibility of certain types of developmental problems and ideally helps hone your referrals (or requests that certain types of evaluations be prioritized).

First, adhere to PEDS-R^® scoring whether or not you think parents’ concerns are developmentally appropriate. The evidence is with PEDS-R^®, not with informal measurement. Similarly concerns such as “Should I be talking to my baby more?” or “What should he be able to say and understand at this age?” should be scored as concerns. In both situations, careful attention is needed because we should explore whether parents are: Providing appropriate language stimulation; demanding too much; and/or frustrated with their baby because they parent doesn’t know the best way to respond and if their baby is thus frustrated as a consequence.

In order to figure out what is going on, it is helpful to administer a quality second stage tool like the PEDS:DM^®. In addition, it is wise to look closely at parent-child interactions (e.g., by administering the risk/resilience measure housed in the PEDS:DM^® (Brigance Parent-Child Interactions Scale).

Let the information from the combination of PEDS-R^®+PEDS:DM^® or PEDS-R^®+ASQ or other quality tool, guide you as to whether early intervention or parent education is needed (or both)!

In the US, the Center for Disease Control holds that 16% to 18% of children 0 – 18 have disabilities. In the 0 – 4 year age range, 12% will qualify for early intervention or public school special education. Some aspects of these high rates have to do with the rigorous demands of school in the early years. 5 year olds usually struggle and fail in kindergarten if they can’t name almost all letters of the alphabet and name all numbers for example. School failure leads to being held back in grades and is associated with not finishing high school. About 18% of US children don’t finish (and for minority children, drop-out rates are often closer to 50%). We want to prevent that which is why the cutoffs on the PEDS:DM^® are set at the 16th percentile and why you see children asked to name at least a few letters and numbers at age 4–so we can intervene before they fail in school.

Parents’ responses to these questions, even if it’s laughter, are still important indicators of parenting style and parenting goals. For example, if the parent of an infant or toddler is worried that their child is not yet learning the alphabet, that is important information for guiding a family into more developmentally appropriate activities. PEDS-R^® questions are also designed to help parents look more closely at their child’s development. Parents may not realize that development is a series of domains and that the sounds their baby makes now, differentiate into varied syllables and words. By encouraging them to think carefully about each aspect of development, parents are helped to become better observers and facilitators of their child’s development.

Item selection was based on how well each discriminated overall domain performance above and below the 16th percentile at each age level (keeping sensitivity and specificity at or above 70%). So items don’t illustrate typical development (e.g. at the 50th percentile but rather identify, when failed which children are not doing well and need help. As an aside, the “Back to Sleep” campaign has altered early motor milestones and since not all parents adhere, and some kids are just plain side or front sleepers no matter what parents do, there’s much more variability in motor development than there used to be. Chapter 6 of the PEDS:DM^® Manual includes a list of milestones closer to the 50th percentile and these are better for teaching parents and trainees about development.

Nevertheless, providers working with middle/upper SES populations, may want to hold children to a higher standard of performance—because the demands these children face require average to above average performance. With the PEDS:DM^® you can probe for higher level skills by administer forms/items designed for older children.

No. Each domain renders a score, i.e., milestone met versus unmet. Act on unmet milestones specifically–with a combination of advice to parents and referrals to Early Intervention or to the public schools (depending on the child’s age).

Yes! Parents’ concern(s) should always be marked. If predictive concerns are present, use a second, validated screen to confirm or disconfirm parents’ concerns (e.g., Path B). Informal checklists such as those built into age-specific encounter forms are notorious for missing problems–only about 30% of children with disabilities are detected: Criteria are absent, the meaning of questions vague, age-limits way too loose, and milestones lists vary considerably. So the evidence resides with parents’ concerns. You can, however, add your own concerns onto the PEDS-R^® Response Form and score those along with parents. If you do want a way to confirm milestones in response to parents’ concerns, please use PEDS^®:Developmental Milestones to assist you.

We now have PEDS^®:Developmental Milestones (PEDS:DM^®). This measure adds 6 – 8 items per encounter (one item per developmental domain: fine and gross motor, expressive and receptive language, self-help, social-emotional, and for older children, reading, math and spelling). It is easy to give along side PEDS-R^® and can quickly confirm or disconfirm parental concerns.

In the PEDS:DM^® manual is a detailed list of milestones (and lots of photocopiable parent education handouts). Feel free to make use of these in order to educate parents.

Another possibility is to distribute copies of the AAP’s brochure, “Your Child’s Growth: Developmental Milestones brochure about development. This is a newly revised version, as of October 2001, and includes many more predictors of school success. The milestones are not a screening test—there is no scoring—but it can help parents get a stronger sense of what their children should be doing.

Finally, consider having some milestones posters in your waiting/exam rooms. Some great ones can be purchased from www.firstsigns.org.

How important is it to properly distinguish between social-emotional and behavioral concerns?  There is so much overlap. Most social-emotional problems have behavioral manifestations.

I agree with that and it was the hardest of categories to distinguish.

If it is test-critical to distinguish the two, how would you explain the difference? Distinguishing is indeed critical, especially for kids < 18 months because social-emotional issues at that age are predictive of problems (sometimes autism spectrum disorders) for very young children.

The best way to distinguish between the two it is to consider “feelings” versus “behaviors”. For example,”Bites others”, “hits” “aggressive” and so forth are all behaviors, and although we can guess how the child feels, parents aren’t actually commenting on emotions, just actions. In contrast words like “angry”, “shy”, “sad”, “frustrated”, even “lack of interest in others”, “unafraid of danger” are feelings (or problematic lack thereof), and thus these are social-emotional concerns.

Parents often comment on affective issues when asked about behavior and visa versa–hence why, when scoring PEDS-R^® clinicians are prompted to read through all comments and then score. PEDS Online^® sorts these well and thus eliminates the need for hand-scoring scoring (follow links on this site to electronic records if you want to see how this works).

PEDS-R^® actually enjoys more research than any other screening measure. Those parental concerns shown as predictive on PEDS-R^® are associated with high probabilities of problems. And, PEDS-R^® is known to be as accurate as screening measures that take far longer to administer.

Still, if you are uncomfortable collaborating with parents and lack confidence in their observations, a good alternative is to use PEDS^®:Developmental Milestones. This tool has the same number of items usually found on age-specific encounter forms but items that are standardized, reliable, valid and accurate.

And you can always use both tools which is what we refer to as “the best approach”–one that adheres well to American Academy of Pediatrics policy on screening and surveillance–and covers both recommendations, with much accuracy. AAP policy eliciting and addressing parents concerns at each well-visit, monitoring milestones, and screening at 9, 18, 24-30 months, and at well-visits thereafter. You can perform all of these tasks via use of PEDS-R^® routinely, PEDS:DM^® periodically, or both measures simultaneously (and all with 18 – 20 items that take less than five minutes for families to complete and about 2 – 3 minutes to score). Easier still for either or both measures is our online application that automates scoring, generates referral letters when needed, ICD-9 and procedure codes, information sheets for parents, and renders a data base for retrieving records and tracking changes given quality improvement initiatives.

You can’t! Sometimes literacy or language barriers (or both) are the problem with parents who skip questions or only circle yes/no/a little. So it is wise to readminister by interview if possible.

If oral communication is not effective with such parents, switch to the PEDS:DM^® and administer it directly children. If that doesn’t work or if time is limited, refer for further screening.

Parents sometimes comment on PEDS-R^® about themselves, family problems, and so forth. Some examples are:

“I’m getting a divorce and need to know how to help my child through this.”

“We are mostly living in our car or in and out of shelters. I worry about how this will affect my son.”

“We are coping with a recent death in the family and I’m concerned she’s not getting enough attention or help.”

“My child witnessed violence at home and I think this is having an impact on him.”

“I’m depressed and need help with this.”

“I’m looking for work and my schedule is erratic. Will this affect my child?”

For such statements, code them as “other” concerns. This will automatically render a Path B (moderate risk result) if there are no other concerns. Meaning that you’ll want to address these issues, either with referrals or in-office intervention, AND monitor development carefully. Addressing such issues may involve referrals for mental health or social services, although issues such as divorce, bereavement, managing careers and families, may be addressed sufficiently by offering parents information and guidance (although vigilant developmental monitoring is still advised). And, if parents continue to hold concerns about themselves or their child, this means that brief advice was not effective and that more intensive services are needed–support groups, parent-training, mental health services, etc..

We have downloadable parent education handouts in English and Spanish that cover these topics. And, if other information is needed, we also have a list of referral resources and parenting information sites.

If a child is less than 24 months and was born 3 or more weeks early, adjust for prematurity by subtracting as follows:

• 1 month, if > 3 weeks – 6 weeks premature
• 2 months, if 7 – 10 weeks premature
• 3 months, if 11 – 14 weeks premature
• 4 months, if 15 – 18 weeks premature

These are the adjustments made on diagnostic developmental tests and this is why we use them as well. Nevertheless, many children born prematurely are also those with many other risk factors (young single parent, with limited education or social support, etc.). Those risk factors often take a greater toll than does prematurity. So a history of prematurity, even after 24 months of age should prompt you to identify and intervene with risk factors.

Please visit pedstest.com/agecalculator

Practices who use PEDS-R^® routinely, especially in areas where parents are not highly educated, find that the first time through, parents are somewhat mute. They don’t seem to always know that developmental and behavioral concerns are of interest to pediatricians. The second time through, they’ve gotten the message but have also focused their thoughts, because the prior administration of PEDS-R^® has helped them think through development as a range of domains. As a consequence, they’ve usually honed their concerns to specific set. And, they don’t tend to raise developmental-behavioral concerns as “oh by the way” type questions which are a disruptive end to an encounter and leave providers scrambling, rushed, and… parental concerns not always well attended to.

Other than changes in parental expression of concerns from the first administration to the second, parents don’t seem to get sensitized and overly concerned. They do come to view your services as a source for parenting information. So, getting organization around information handouts is critical.

PEDS-R^® is a very helpful clinical interview. Used as such it is no longer a screening test. Thus, you should not bill for screening services if you aren’t scoring/interpreting PEDS-R^® according to evidence. Medicaid and third party payer audits require a scored/interpreted PEDS-R^® test.

Yes.

PEDS-R^® itself is a validated test, and has been used around the world in many different languages, including Chinese. We have a newly revised version of the Chinese PEDS-R^® in Simplified Chinese which was created to address some translation concerns with the old version. This has been vetted among professionals, parents, and tested for readability and comprehensibility by a 9 year old Chinese-only-speaking child. The version was also “back translated” into English to be sure it retained the proper meaning in translation, so we feel pretty good about the new version. We always welcome comments regarding administrators’ and parents’ experiences with the test.

We have PEDS-R^® in quite a few other languages. We print PEDS-R^® in English and Spanish and license all other translations. If you would like a license agreement, please contact us.

We are happy to work with you on additional translations and continually improving the ones we have: languages evolve! Please contact us with requests for new translations or suggestions for improvement.

We have extensive translation guidelines we will share with you. These are derived from years of experience with the nuances and challenges of translations. In a nutshell, back translation is a start but is never enough. Translations should be vetted with parents and other professionals to view how well they work in practice–and thus whether response rates (e.g., percentage of children with likely problems/frequency of parents’ concerns) suggest that the translation is working well.

We often have contact information for many developmentalists/researchers working on various translations and encourage you to send us an email so that all can collaborate and so we can send you guidelines, and if available, drafts of translations in progress.

If the language you wish to study is not one we have, we can also send a translations contract within which we will pay a proscribed amount for translation services and careful vetting.

Q: (continued): But I need to standardize and validate them for use in my country, where we don’t seem to have any comparison measures. What do I do?

A: Often there are measures already validated so please check with the International Test Commission (www.intestcom.org), and the Association of Test Publishers. You should find links to research and publishers in your country.
In terms of standardization (where you’d view performance on a new measure and ideally compare it to other studies of the same tool, it is important to know that often the differences aren’t huge (e.g., a  non-significant 1 point difference in IQ scores among US, Canadian, and British samples–such that validation seems hardly worth the expense–because performance as revealed by standardized studies is minimal.
That said, international studies of PEDS-R^® do find for example, in India, a greater frequency of parental concerns about self-help skills and one Australian study found these to be predictive of future problems in school (about 2 years later). A Tanzanian study (conducted in the midst of a malarial outbreak) found 90+% of parents to hold concerns suggestive of developmental problems–surely they were understandably worried about their children’s outcomes–as well they should be. Even within the US there are huge differences in frequencies of parents’ concerns–the poorer the family the more likely they are to hold significant concerns. But first, ensuring a quality thoroughly vetted translation of PEDS-R^® is fundamental. Please see other FAQs on this issue.
The PEDS:DM^®, in contrast, is something you’d want to vet for content validity and cultural relevance, especially at older ages (where we start at around age 6, presenting common US safety signs that clearly won’t work as well outside the US and Canada, and would need replacing with comparable images typical in your country and its languages(s)).

So in addition to exploring what’s available in terms of established, validated, standardized measures, it is probably wise to start by establishing an advisory panel to help you with the face validity, and necessary revisions to the visual stimuli on the PEDS:DM^®.

Yes, the parents’ concern(s) should always be marked. Unless a second, validated screen is used to confirm or disconfirm parents’ concerns (e.g., Path B), informal checklists are notorious for missing problems–only about 30% of children with disabilities are detected. Criteria are absent, age-limits are too loose, and milestone lists vary considerably. So the evidence resides with parents’ concerns. If you do want a way to confirm these, we just published PEDS^®:Developmental Milestones that can work along side PEDS-R^® or instead.

One possibility is to have copies of Your Child’s Growth: Developmental Milestones brochure about development. This is a newly revised version, as of October 2001, and includes many more predictors of school success. The milestones are not a screening test— there is no scoring—but it can help parents get a stronger sense of what their children should be doing. Another possibility is to put posters about development in your waiting room (,e.g. wall charts from www.firstsigns.org) Otherwise, we now have PEDS^®:Developmental Milestones (PEDS:DM^®). This measure adds 6 – 8 items per encounter with one item per developmental domain: fine and gross motor, expressive and receptive language, self-help, social-emotional, and for older children, reading, math and spelling. It is easy to give along side PEDS-R^® and can quickly confirm or disconfirm parental concerns.

Below are typical procedure codes followed by diagnosis codes:

*** Note: Neither 96110 or 96111 will cover the Denver because it is not validated.

Yes. Like PEDS-R^®, the PEDS:DM^® stands alone. So if you are only interested in children’s skills and monitoring that, the PEDS:DM^® is a good choice. But we like the combination of PEDS-R^® and the PEDS:DM^® for addressing parents’ concerns and monitoring children’s development. This offers better compliance with the notions of screening and surveillance.

There are registration marks on the template that look like about like this: Align the marks on the completed Form with the marks on the template. You can then see (at the top) the correct column for the child’s age by its letter name, The child’s age range is revealed at the bottom should you need to affirm this. If you can see any of the parents’ marks through the template windows (typically these are made with a red dry-erase marker) revealed by the marks are unmet milestone-and a major harbinger of problems.

The ability to view strengths and weaknesses across all developmental domains (fine motor, receptive language, expressive language, gross motor, self-help, social-emotional, and for older children reading and math skills). Age equivalent scores (as well as cutoffs) so that you can produce percentage of delay scores (or percentage of skills mastered at chronological age) Reusable booklets, one per child, for monitoring over time.

You can use PEDS-R^® and the PEDS:DM^® in two ways: Administer both at each visit (a total of 18 – 20 items). This takes about 7 minutes total. Administer PEDS-R^® routinely and the PEDS:DM^® as indicated.

The PEDS:DM^® is designed to be administered by paraprofessionals and can be self-administered by parent report. The manual has lots of case examples helpful for training and ensuring your staff know how to score and explain the results to families. So your certificated early interventists should be more than qualified to use and licensure isn’t needed.

We eliminated the letters “I” and “O” so there wouldn’t be confusion with “zero” and “L”.
But the PEDS:DM^® Forms are continuous, meaning you can find one that’s appropriate for the child’s age, no matter how old (up to age 8).

In Pathway A, when it describes two or more predictive concerns, the decision tree asks about two or more predictive concerns in self- help, etc. Self help is not shaded in any of the age ranges as a predictive concern. What is the rationale for including that area in the decision tree?

Once a child is on Path A, you look at all the parents’ concerns (predictive or not) to help decide on the best type of referral. Even though early intervention or public schools are the first choice because they are free and of good quality, it is still helpful, in your referral letter to indicate what types of testing programs should provide. So, bottom line, once on Path A look at all concerns to help focus referrals.

Item selection was based on how well each discriminated overall domain performance above and below the 16th percentile at each age level (keeping sensitivity and specificity at or above 70%). So items don’t illustrate typical development (e.g. at the 50th percentile but rather identify, when failed which children are not doing well and need help. As an aside, the “Back to Sleep” campaign has altered early motor milestones and since not all parents adhere, and some kids are just plain side or front sleepers no matter what parents do, there’s much more variability than there used to be. Chapter 6 includes a list of milestones closer to the 50th percentile and these are better for teaching parents and trainees about development.

No, because the Denver-II isn’t validated, only standardized in Colorado, and its accuracy is not good. It will either under-refer (if you don’t refer children with questionable results) or over-refer if you do. And, it doesn’t have any academic items at age 4 and up– the better predictors of school success. The PEDS:DM^® has 1619 children in its validation research, all of whom had a diagnostic battery along side the PEDS:DM^®. Its sensitivity is 70% plus percent by domain and by age. So there won’t be much in the way of over- or under-referrals.

For more information go to this article.

Yes! The PEDS:DM^® is a screening test. It is standardized, validated and accurate and it also provides the longitudinal monitoring of development recommended by the AAP. But PEDS:DM^® in combination with PEDS-R^® (which elicits and addresses parents’ concerns) offers a brief evidence-based approach to surveillance that is in keeping with AAP policy. Also the PEDS:DM^® has many supplementary measures so you could expand to a more comprehensive surveillance approach (e.g., Modified Checklist of Autism in Toddlers, Family Psychosocial screen for family issues, the Brigance Parent-Child Interactions Scale for additional risk and resilience factors. Chapter 4 in the PEDS:DM^® manual explains when these might be used. Chapter 3 covers use of both PEDS-R^® and the PEDS:DM^®.

PEDS-R^® is a 12 item screening test that makes use of parents’ concerns. We print it in English and Spanish, and license it in a large range of other languages. PEDS-R^® gives an indicator of children’s risk for developmental and behavioral problems and what to do next: when children need further assessment, additional screening, or when parents need advice, or simply reassurance. PEDS-R^® helps parents and professionals collaborate and communicate effectively. PEDS-R^® takes less than 5 minutes to complete and can easily be sent home (e.g., by a preschool program).

PEDS^®:Developmental Milestones is also a screen but views children’s actual skills in each developmental area. It is 6 – 8 items per age level. There is also an assessment level version that’s useful when children have difficulty with some of the tasks and you want to look a little further at how they are doing. The Assessment version produces age-equivalent scores and percentage of delay. PEDS:DM^® is laminated and parents (and older children) write on it with a dry erase marker. So it isn’t something you can send home but if parents are coming into a center, they can complete it on their own (or a professional can complete it directly with children).

The two measures work nicely together although each can be used separately.

Items came from two diagnostic measures widely used in education settings: the Brigance Inventory of Early Development and the Brigance Comprehensive Inventory of Basic Skills. All 1619 children in the standardization sample had one or the other measure. We selected from the more than 1200 items, those with the highest degree of sensitivity and specificity that were also easiest to administer (e.g., cutting with scissors was eliminated). We are grateful to the Albert Brigance and his publisher, Curriculum Associates, for their willingness to share their items, even more so because they’ve agreed to donate their share of royalties to the American Academy of Pediatrics’ Section on Developmental and Behavioral Pediatrics to help support its website, www.dbpeds.org.

Yes, the PEDS:DM^® can be used at those ages (30 months too as suggested by the AAP). It is a continuous set of questions so even if patients present older or younger than the well visit schedule, there’s still a set of questions that will work.

But as a reader on the panel, I don’t think members of the Committee were any too comfortable with the idea of not screening after 30 months. Development develops and developmental problems do too. Not all language impairments can be detected by 30 months, intellectual disabilities will still be subtle, and learning disabilities aren’t even on the horizon.

So, hence the (somewhat vaguely worded) comment that the policy statement, “provides an algorithm as a strategy to support health care professionals developing a pattern and practice of attention to development that can and should continue well beyond 3 years of age.”

The Committee also recognized that a 30 month encounter isn’t even on the well-visit schedule and so perhaps not reimbursable. But, they also were quite aware of research suggesting that if general pediatricians create a visit that’s just devoted to development and behavior, they are much better able to effectively address the huge range of issues.

The AAP also called for routinely eliciting parents’ concerns about children’s development/behavior along with documenting/maintaining a developmental history, and identifying risk and resilience factors. So a combination of PEDS-R^® (at every visit) and the PEDS:DM^® at the AAP’s recommended visits or as indicated by PEDS-R^®, is, I think, the best approach. And, both can be used at each visit to address parents’ concerns and monitor milestones–and all with evidence.

Finally, the PEDS:DM^® includes supplementary measures for even better compliance with AAP recommendations. Included are creens for risk/resilience factors (sometimes used as new patient intake), an autism-specific screen, a mental health/ADHD screen, along with the Vanderbilt Diagnostic ADHD Scale. recommended by the AAP at 18 and 24 months

This takes some creative thinking. PEDS Online^® requires parents (or professionals) to type parents’ comments into the site. Few clinics have patient kiosks or patient portals as part of their electronic records (which enables many families to send their responses via the internet accessed at home with scored results sent to clinicians). Having staff type in written responses is an extra step (although there’s time savings with the automated scoring, indicators for appropriate ICD-9 and procedure codes, generation of reports to share with other professionals, parent summary report, and links to services). Some clinics do PEDS Tools^® as an interview while typing in answers, often at the point the physician extender is in the exam room prior to the exam. This works well but only if if there are computers, tablet PCs or PDA in the exam room at the time. Many other clinics use the (hopefully transitional) step of purchasing scannable PEDS Tools^® Forms and forego using the site, despite its wonderful bells and whistles.

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For compliance with the AAP’s new statement you’ll need both tools. PEDS-R^® elicits parents’ concerns (in 12 questions, the same ones at each visit) and should be used at every well-child encounter. The PEDS:DM^® can either be used simultaneously or when PEDS-R^® calls for additional information before deciding whether a referral is needed. The PEDS:DM^® is 6 – 8 items per encounter and can be administered by parent-report or directly to children. Each one samples a different developmental domain: fine and gross motor, receptive and expressive language, self-help, social-emotional, and for older children math, reading, and spelling/writing. Both measures span the 0 to 8 year age range.

So in 18 – 20 items (about five minutes of parents’ time), you can provide longitudinal monitoring and address parents’ concerns. As an aside, the PEDS:DM^® is entirely laminated comes with supplemental measures (such as the Modified Checklist of Autism in Toddlers) which the AAP suggests at 18 months for all children, as well as other tools (like parent-child interactions measures, a mental health screen for older children, etc.) for a more expanded response to meet the AAP recommendations.

In the US, the Center for Disease Control holds that 16% to 18% of children 0 – 18 have disabilities. In the 0 – 4 year age range, 12% will qualify for early intervention or public school special education. Some aspects of these high rates have to do with the rigorous demands of school in the early years. 5 year olds usual struggle and fail in kindergarten if they can’t name almost all letters of the alphabet and name all numbers for example. School failure leads to being held back in grades and is associated with not finishing high school. About 18% of US children don’t finish (and for minority children, drop-out rates are often closer to 50%). We want to prevent that which is why the cutoffs on the PEDS:DM^® are set at the 84th% percentile and why you see children asked to name at least a few letters and numbers at age 4–so we can intervene before they fail in school.

After purchasing the PEDS:DM^® for each site/nursing station, the ongoing costs are only about 2 cents per visit (the Recording Form is reusable during the 0 – 8 year age range). PEDS:DM^® costs about $0.69 per visit.

We’d rather you pay a publisher than a photocopier (since Xerox, Ricoh, etc. don’t reinvest in the much needed ongoing development, support, translation, research, and restandardization of screening tools). There’s billing/coding information on our site (www.pedstest.com) and also in the PEDS:DM^® Professionals’ Manual. You should be getting reimbursed for your effort (national averages are about $13.00 per screen (twice that if two are used)! So reimbursement for screening is typically more than 60 times material costs. If you aren’t getting reimbursed for screening-something’s not right! Please see our Q and A on billing and coding!

Yes! The best approach is to use both PEDS-R^® (to elicit and address parents’ concerns) and the PEDS:DM^® (to monitor milestones). Both are screens and so address early detection, briefly and with a high degree of accuracy. The PEDS:DM^® also contains the Modified Checklist of Autism in Toddlers (recommended by the AAP at 18 and 24 months) along with measures of resilience and risk factors, mental health, and ADHD.

Yes, and here’s why:

• PEDS-R^® gives you insight into parents issues and needs
• PEDS-R^® helps parents think about development as a range of domains
• PEDS-R^® enhances the teachable moment
• PEDS-R^® helps parents feel they have a collaborator in child-rearing and someone they can talk to about their concerns. This is known to reduce parenting frustration and promotes positive parenting practices such as time-out, rather than spanking
• PEDS-R^® reduces “oh by the way” concerns and helps focus the visit
• The PEDS:DM^® helps confirm or disconfirm parents’ concerns, enabling providers to effectively and efficiently respond to both parents’ issues and children’s needs.

Indeed they are! PEDS:DM^® items have a cutoff at the 16th percentile, meaning that 84% of children are doing better than that. So a failed item is a strong predictor of the need (and eligibility for) special services.

BUT, if you want to get a sense about whether a child’s performance is closer to the 50th percentile, you can administer the next highest Form of the PEDS:DM^® (or even above that with pre-kindergarten children headed for public or private school where performance well above the 50th percentile is expected and needed).

In such cases, children typically have and need especially well-developed language and pre-academic skills. Social-emotional and motor skills usually take longer to develop and often remain tied to chronological age/50th percentile. So you can expect somewhat uneven development in children who are advanced. The PEDS:DM^® manual has information handouts you can share with parents on building skills in areas that typically don’t come along as rapidly.

Yes! PEDS:DM^® is included with PEDS Online^® suite of products. The site can be interfaced with electronic records or directly to licensed users. Another option is to use the print version of the PEDS:DM^® in the waiting or exam room and simply indicate the pass/fail results in your EMR.

To implement PEDS-R^® easily in primary care, it is optimal—if not essential—to involve your front office staff in the process. While their first reaction may be to groan and say there is too much paperwork already, there are several things you can do to make it work smoothly and easily. This involves giving the staff a strong rationale for using PEDS-R^® and lots of control in how it is delivered.

1. First give the office staff some background information on why screening is important.
2. Second, let them know that a PEDS-R^® Response Form needs to be given to every family before they see the provider, but let the staff decide where and when (e.g. in the mail or over the phone along with an appointment reminder, at-check in, when seeing the medical technician, when ushered to an exam room, etc.)
3. Office staff will also need to ask families discreetly whether they would like to complete the measure on their own or need someone to go through it with them in order to circumvent literacy issues.
4. Give office staff the option of administering an interview version when needed and scoring the measure. This speeds things up for the professional staff. However, if the office staff are unwilling to do this, the offer will at least let them see that the entire burden of screening is not falling on their shoulders and that it is shared with others in the office.

If you are already a PEDS-R^® user, here’s what you’ll need:

The PEDS:DM^® (Pediatric and Public Health Starter) .This PEDS:DM^® complete set includes the PEDS:DM^® Family Book (where the laminated PEDS:DM^® forms and illustrations need for administration are housed), the Professionals’ Manual (which includes administration directions, guides to using supplemental measures, parent information guides, etc.), the PEDS:DM^® Binder case for scoring, and 100 PEDS^® Results and Interpretation Forms. You’ll need extra copies of the Family Book if your clinic has lots of same age children arriving simultaneously, and ideally, a manual for each exam room.

Add the -25 modifer to your preventative service code (to indicate that a service was provided that is unbundled from the well-visit. Then use 96110 (times 2 if you use both PEDS-R^® and the PEDS:DM^®). The PEDS:DM^® Professionals’ Manual has suggestions for ICD-9 codes.

PEDS-R^® stands alone (as does the PEDS:DM^®). Both work together well and getting two kinds of information (parents’ concerns and information about children’s skills is helpful. PEDS-R^® calls for a second-stage screen some of the time (for kids at moderate risk–mostly Path B). All those children can be referred to EI for further assessment. But some PEDS-R^® users prefer to look further at children’s skills. Some, unfortunately, disconfirm the research behind PEDS-R^® with informal milestones checklists, key items off the Denver-II, etc. And that’s problematic since the latter lack evidence (and frankly, are probably the leading reason for low detection rates in primary care). So we put the PEDS:DM^® together to help those who require milestones (and often that’s all most clinicians use) while ensuring they have accurate ones to go by.

The PEDS:DM^® comes with a single form for storage in the patient record that tracks children’s skills over time and thus produces a bar chart of strengths and weaknesses. If PEDS-R^® is given first (easy to do, even in chaotic waiting rooms), this form shows when the PEDS:DM^® is needed and when it really isn’t (high risk and low risk families). At that point the physician extender can find the right PEDS:DM^® form for the child’s age, and pass it to families when they are first taken to the exam room, retrieving and scoring it after their interview.

But again, the PEDS:DM^® can work on its own.

One possibility is to keep a few copies of the PEDS:DM^® at the nurses station so that these could be checked in and out as needed. Another is to have parents complete the questions when getting weighed in and then attaching the score sheet to the chart (in such cases it might be helpful to have a copy of the PEDS:DM^® manual in each exam room so you can probe strengths and weaknesses). If other PEDS:DM^® users have suggestions about this, please let us know.

Have your software consultant replace informal milestones with check boxes that look like this:

There is no overall score for the PEDS:DM^®. Instead, you should act on unmet milestones with a combination of parenting information and referrals (either to the schools or to Early Intervention).

Timing is a major issue since we wouldn’t expect children recently removed from their homes to demonstrate all the skills they possess. Usually foster parents (many of whom are either experienced or kin) have a gist of children’s strengths and weakness early in a new placement. So PEDS^® (our parents’ concerns measure) is more useful around the time when children enter a new home. A loose consensus from lots of social workers and developmental-behavioral pediatricians, is that a measure of actual skills, like the PEDS:DM^®, is probably best administered, after a month or two in a new placement. This enables children time to adjust.

PEDS^® users will appreciate the supporting information the PEDS:DM^® provides:

When Path B calls for additional developmental screening, the PEDS:DM^® can quickly (via 6 – 8 items) determine whether a referral is needed or rather if developmental promotion and careful monitoring are the best responses.

Similarly, Path C often needs supporting information, especially in children 4 years and older in the presence of persistent concerns about behavior or social-emotional development. The PEDS:DM^® supplies this quickly and for older children, Section 2 of the PEDS:DM^® Family book also houses the Pictorial Pediatric Symptoms Checklist-17 which has factor scores for depression/anxiety, conduct problems, and attention problems, and the VAnderbilt ADHD Diagnostic Rating Scale.

For parents on Path D (or anytime clinicians suspect a problem but parents do not), the PEDS:DM^® can be administered directly to children or by professional observation (when children are less than two years of age). Section 2 of the Family Book also houses the Family Psychosocial Screen and the Brigance Parent-Child Interaction Scale (helpful measures to also use with Path D families)

The PEDS:DM^® Assessment Level is for NICU follow-up clinics and early identification child-find programs and could be useful in db clinics, especially if you have a triage model in place (e.g., at Vanderbilt University, we had a clinic into which we brought 3 – 5 children in per day for a db physical, social work evaluation, and mini-developmental assessment to decide if diagnostic evaluations were needed and if so which ones (e.g., from a developmental psychologist, educator, speech-language pathologist, or physical therapist, etc..) Our triage clinic was surprisingly effective, improved our ability to quickly schedule any additional evaluations, was very popular with community providers (only about a three week waiting list and short reports!), and monetarily, the clinic ran in the black—seemingly a rare occurrence in db clinics!).

The Assessment Level PEDS:DM^® involves the same items as the screening version but they are presented in booklet form so that more are presented at once (clinicians need to decide on start and stop points so that, ideally, children get 3 items in a row correct and end with three in a row incorrect). Then each correct answer is assigned a value in months to produce an age-equivalent score for each of 7 developmental-behavioral domains. From there, percentage of delay (or more positively, percentage of skills mastered, can be computed. There’s a growth chart type grid on the back to make it easy to chart progress and explain results to parents. The booklets are reusable with the same child for programs offering longitudinal monitoring (parents are asked to use a different colored marked when they work through it a second time).

As a related aside, the PEDS:DM^® can be administered directly to children or by parent report (actually parents are prompted to elicit skills directly from children so parents essentially serve as paraprofessionals in the process of assessment).

It is easiest to just use both measures at once. If so:

• Select the right set of items in the PEDS:DM^® for the child’s age (using the guide in the inside cover of the PEDS:DM^®. Ages are not shown on the forms themselves so as to minimize potential distress for families with delayed children).
• Place the PEDS^® Response Form on top of the correct PEDS:DM^® page
• Ask parents to complete both pages.

Note: the PEDS:DM^® is laminated and comes with fine point dry erase markers. Have parents use the marker to fill out PEDS^® as well (in order to avoid marring the PEDS:DM^® materials). Do not laminate the PEDS^® Response Form though. You need to keep that in the child’s chart as proof of screening and to follow up with prior concerns at the next visit. Then when a new PEDS^® Response Form is completed, you can replace the old one if your chart is getting too full!

• When they’ve finished both, first score the PEDS:DM^®, (a scoring template is placed over the completed form and immediately reveals whether there are correct answers).
• Color in the boxes on the PEDS:DM^® Growth Chart (on the back side of the PEDS^® Combined Recording Form for each passed item. Place a – in the box for each missed in item. For skipped items (in between visits), you can color those in up to the highest pass.
• Score PEDS^® as you normally would and follow directions on the PEDS^® Score Form portion of the PEDS^® Combined Recording Form to find the correct path on the PEDS^® Combined Interpretation Form. Read through the entire path to identify what to do next (e.g., refer, advise, temporize, or monitor).

That depends on your time, what other issues you have to address, and the setting in which you are screening. If a home visit, and you just want a quick indicator of how a child is doing in all areas, then use the PEDS:DM^® screening version. This takes about 5 minutes or less. If you have more time, require more in-depth information, and need something other than pass/fail scores in each developmental area, use the PEDS:DM^® Assessment Level (about 20 minutes). This will give you age equivalent scores in each domain and from there you can compute percentage of delay scores (or more positively, percentage of skills mastered).

Parents’ concerns have ways of cropping up at inopportune times. You can prevent that by pre-empting them. With PEDS-R^®, you allow parents to express their thoughts before you work with them. This enables you to prepare, collect your thoughts and resources (e.g., information handouts, referral brochures, and respond wisely. PEDS-R^® virtually eliminates “doorknob” concerns—the “oh by the way” ones that crop up unexpectedly at the end of an encounter and often take time from the next child and family, disrupt patient flow, etc. PEDS-R^® is known to retain visit length as planned, AND it encourages parents, by making visits more focused and relevant, to return for well child care.

PEDS-R^® sometimes makes clinicians worry that it is like opening a veritable Pandora’s Box of parental issues. That doesn’t seem to be the case because PEDS-R^® proscribes the topics of interest. It also decreases the numbers of “oh by the way” concerns that are so challenging in busy practices and that leave many critical concerns dangling, poorly addressed, etc. AND as a consequence PEDS-R^® maintains expected visit length, if not shortens it.

No, because the Denver-II isn’t validated, only standardized in Colorado, and its accuracy is not good. It will either under-refer (if you don’t refer children with questionable results) or over-refer if you do. And, it doesn’t have any academic items at age 4 and up– the better predictors of school success. In contrast, The PEDS:DM^® has 1619 children in its validation research, all of whom had a diagnostic battery along side the PEDS:DM^®. Its sensitivity is 70% or greater by domain and by age. So there won’t be much in the way of over- or under-referrals. For more information go to this article:

Suggested Link: http://www.health.state.mn.us/divs/fh/mch/devscrn/faq.html#denver

Items came from two diagnostic measures widely used in education settings: the Brigance Inventory of Early Development and the Brigance Comprehensive Inventory of Basic Skills. All 1619 children in the standardization sample had one or the other measure. We selected from the more than 1200 items, those with the highest degree of sensitivity and specificity that were also easiest to administer (e.g., cutting with scissors was eliminated). We are grateful to the Albert Brigance and his publisher, Curriculum Associates, for their willingness to share their items, even more so because they’ve agreed to donate their share of royalties to the American Academy of Pediatrics’ Section on Developmental and Behavioral Pediatrics to help support its website, www.dbpeds.org.

PEDS-R^® research shows that uneducated or inexperienced parents are as accurate as those who are highly educated or have several children and thus child-raising experience. Why? Because parents compare their children to others and can easily see when children are behind or ahead. Even parents without other children or who live in isolated rural areas still have opportunities (grocery stores, churches, doctors’ offices) to observe other children. Still, PEDS-R^® has mechanisms for catching parents who do not raise concerns when they should: Here’s how to do this:

1. Check for literacy barriers (incompletely filled out forms, no writing on the form, PEDS-R^® not offered in the language parent speaks normally, etc.). In these cases, you’ll want to administer PEDS-R^® by interview, use a PEDS-R^® translation in the parents’ native language, or ask a translator to help you.
2. If professionals notice a problem but the parent does not seem to, use your clinical acumen and move the child up to Path A or B (referral or second screening).
3. A third mechanism is to repeat PEDS-R^® promptly (e.g., by repeating PEDS-R^® by interview over the telephone in a few weeks). By asking parents about their concerns on multiple occasions, you encourage them to notice and think carefully about how their child is doing. This sends several important messages;
   • you are interested in parents perspectives and unique needs;
   • developmental and behavioral issues are important;
   • your service embraces early detection and developmental promotion, etc.By helping parents think about their concerns, future visits are more focused. This helps you prepare better to address families’ unique issues and needs.
4. Although PEDS-R^® is just 12 questions, there’s a fair amount of repetition. The first question explores parents’ concerns in an open-ended way. Questions 2 – 11 probe each developmental domain, and question 12 gives them one more chance. This prompts families who are reluctant to discuss concerns or who haven’t really thought about it to think carefully with encouragement express themselves.
5. Some parents, especially new ones are particularly unsure of themselves. They may preface concerns with statements like, ”he’s my first so I don’t really know but….” or “I used to be concerned but I think he’s doing better.” In such cases, ignore their disclaimers and code what they are saying as a concern. This helps improve the accuracy of PEDS-R^® with this group. AND… it gives you guidance about how to focus much needed parent education.
6. If using the PEDS:DM^®, be advised that studies show that less-educated parents, indeed all parents, are thoroughly able to report on children’s skills and that a direct-administration is not likely to yield different results. Although parents will comment about emerging skills (unlikely to be observed in unfamiliar settings, i.e., your office) that the “sometimes” response option in the PEDS:DM^® almost always captures that (and doesn’t always give credit when none is due/typical). Nevertheless, if you are less than confident in parent-report of children’s skills, you can always administer PEDS:DM^® items by interview. The PEDS:DM^® explains how.

Educated parents are more likely to mention their concerns spontaneously, which can make them seem overly worried. Educated and working parents are more likely than other parents to be concerned about behavior. Such concerns will not result in a failing (Path A or B) score on PEDS-R^®, and you can reassure these parents that their children’s development seems to be coming along normally.

You should respond with patient education materials and careful monitoring of behavioral and mental health status. Such parents will also do well with referrals to parenting classes or to quality texts on discipline.

Otherwise, PEDS-R^® has other mechanisms for catching parents who are unnecessarily concerned. First, parents who are unnecessarily worried tend to have only one of the predictive concerns and often several of the nonpredictive concerns. In these cases, you will be prompted to administer a second screen, such as the PEDS:DM^®, or to refer for additional screening (usually available without cost through early intervention/public schools services) to determine the likelihood of a real problem, and whether the best is to to wait and see (with vigilant monitoring)/counsel the parent about their concern, or refer.

PEDS-R^® helps you ask and ask well. Parents don’t respond to some types of questions. Parents with limited education don’t always know you are even interested in development. Asking carefully, lets them know that developmental behavioral issues are a part of your services. Giving them time to think is essential Second, PEDS-R^® guides you in how best to deal with concerns once they are raised. Some concerns are not significant predictors of problems, while others are. PEDS-R^® tells you children’s level of risk for developmental and behavioral problems and what to do next. It will keep you from deferring, deferring, deferring when you should be referring, referring, referring and will keep you from referring for unneeded services, as well. PEDS-R^® reduces or eliminates “doorknob” concerns—those “oh, by the way” questions that can come up just when you think you’ve finished an encounter and that can disrupt the flow of families through your office. PEDS-R^® is not only known to reduce visit length but to also increase parents’ willingness to return for well visits—a good thing.

Worth visiting is www.developmentalscreening.org a website at Harvard University where providers were detecting more children with disabilities than most; 40% in contrast with 30% (the national average). The video on the site lets you see the consternation of providers and administrators about “pushing around yet another piece of paper”. Then you’ll see, the enormously positive comments from clinicians after they’d tried PEDS-R^® and realized how many children they were missing.

Don’t worry! Research shows that over-referrals on screens tend to be children who perform in the below average range and have psychosocial risk factors. When children don’t qualify for E-services, refer them instead to Head Start, good preschool/day care program, parent training groups. Some E-services offer monitoring and regular home visits. So it is best to refer not defer.

Please visit our research pages for abstracts and references.

1. The Denver/PDQ were not standardized except in Colorado. What do these measures have to say about children residing elsewhere? Very little!
2. The Denver/PDQ were not validated and the authors provided no proof that the items actually work. Research by other authors indicate they don’t.
3. The Denver/PDQ are too long for primary care. Using selected items probably degrades accuracy even further and just gives you an informal milestones checklist.
4. Administering informal milestones checklists and making clinical observations take more time than it takes to give PEDS-R^®.
5. Informal checklists lack proof and decision support. If a patient fails one item, do you refer? Or do you wait until two items are failed? Three? What’s the right thing to do? Who knows? What if your patient can do all items. Do you know he or she is OK? No!
6. PEDS-R^® and the PEDS:DM^® provide clear guidance on when to refer and when not to refer. It is OK to look further at children’s skills. But, if just using PEDS-R^®, it is not OK to over-ride the evidence PEDS-R^® provides (e.g., predictive concerns) with informal measures that lack any proof.

Parents with depression or anxiety are known to under-rate, rather than over-rate their child’s development. Thus depressed parents are less likely to identify a child who is gifted, and somewhat more likely to rate a normal child as at-risk. That’s actually a good thing because it ensures that the child and family come under increased scrutiny. Perhaps such scrutiny comes about initially for the wrong reasons, but most non-medical service providers offer (or should) family assessments and interventions. So the family is likely to get identified for the kinds of problems they actually face, eventually. In a circuitous way, parents with mental health problems end up with an increased chance of scrutiny and thus intervention. Frankly though, a more direct approach is to also administer a measure like the Family Psychosocial Screen (which is included in the PEDS:DM^®).

In addition, the PEDS^® Brief Guide also prompts providers to use their clinical judgment to move children to Paths A and B (higher level of risk) when the clinician has concerns but the parent doesn’t (or to add their own concerns to the PEDS^® Score Form). PEDS^® also has Path D for parents with whom communication is problematic (e.g., obviously high on drugs, teen parent not actually doing much in the way of child-rearing and so not in touch with their child, parents who are clearly mentally ill, and parents with difficulties communication (e.g., because they don’t speak English, or read well in Spanish, Vietnamese, Somali, or any of the other languages for which there are PEDS^® translations).

So we encourage you to use your clinical judgment when deciding on referral options and to expand that to embrace parental issues. Parental mental health problems have a deleterious effect on children’s development. So it is wise to screen families for mental health problems, and help them into needed services.

Many questions routinely asked, (e.g., “Do you have worries about your child’s development?”) don’t work well: “worries” is too ominous and “development” is only understood by about 50% of families. Further, if parents aren’t asked or are not asked well, only the educated ones spontaneous raise concerns–leaving many of us to conclude that less educated parents don’t notice. Not true! But it is a conclusion that many providers draw. While logical, it is not factual.

What you’ll find with PEDS-R^® is that the first time through, many families won’t say much. But it makes them think and it also lets them know, that which many families don’t the first time through, that pediatrics is about child development too. So the second time they tend to come better prepared and having been better observers of their child. And they now know they can ask about discipline and other issues. That in turn, gives clinicians much more insight into the child, what goes on at home, etc. The fact that PEDS-R^® prompts clinicians to use clinical judgment [only to move kids up to Paths A or B (never down)] means that there is something of a back-up plan, and as families get more comfortable with the idea of discussing development at well-visits, and as Residents and Attendings learn more from parents, clinicians and parents become more knowledgable about development and that detection rates improve. Bottom line: PEDS-R^® doesn’t miss many children with problems because it asks parents about their concerns in a way that is proven to work.

Please see the “How PEDS-R^® Works”page.

We publish two measures: Parents’ Evaluation of Developmental Status (PEDS^®) which focuses on parents’ concerns as a way to screen children for a range of difficulties, and also PEDS^®:Developmental Milestones which is developmental screening but focused on children’s skills in each domain. The PEDS:DM^® also includes various supplementary screens such as the Modified Checklist of Autism in Toddlers, and the Vanderbilt ADHD Scale.

Yes! Research shows that parental concerns are the first and most predictive indicator of autistic spectrum disorders. Because PEDS^® captures parental concerns and captures them early, it detects symptoms of autism, PDD, and Asperger’s Syndrome, and it’s one of four screening tests recommended by the Academy of Neurology within their statement on early ID of autism. More specifically, Drs. Michelle Macias, Lynn Wegner and Frances Glascoe, completed a study showing that parents of children who fail autism specific screens, not only land on PEDS^® Path A or B, 97% of the time, but that parents of children with ASD also have a unique constellation of concerns that makes them distinguishable from children with other kinds of disabilities (such as language impairment, mental retardation, or learning disabilities). Please see our abstract on our research pages for more details.

Our next project is to view the concerns of parents with children 0 – 18 months of age (who were too young for an autism specific screen), and invite them to return to the online PEDS^® site when their children reach 18 months of age, and view the predictive validity of PEDS^®. If supported, it would help identify children on the spectrum even earlier–a good thing since the earliest possible intervention is essential for children with ASD. Bulletins as they happen and collaborators welcomed!

Some providers have wondered whether PEDS^® picks up children with cerebral palsy, especially since motor concerns are not significant predictors of problems at young ages. Although the PEDS^® research data only included about seven children with CP, all these children were detected because their parents tended to raise global, language, or other significant concerns like, “He’s behind other children,” or such other concerns as, “He’s having trouble sucking from a bottle”. But providers should feel free to elevate the PEDS^® Path to A or B if they notice something potentially problematic.

Still there is a need to study this further and we encourage research projects that attempt to refine parents’ concerns about gross motor skills into those that might be more likely to reflect early CP, such as, “He’s floppy,” “She’s very strong and can stand up for hours,” etc. Please see our section of Q and A for researchers.

It is important to remember that if using PEDS^® you are relying on standardized questions and an evidence-based interpretation which were both professionally developed. Ultimately, you are not just relying on parents, but on a huge amount of validated, standardized data. PEDS^® research, across four validation studies, found that when carefully elicited and interpreted, parents’ concerns are as accurate as measures that take far longer to give. PEDS^® has an additional value in that it ensures true collaboration between parent and provider and emphasizes a focus on families that is consistent with promoting parents as true participants in their child’s care and education. That said, many parents, especially less educated ones, don’t know that providers are interested in child development. Asking good questions is essential for encouraging parents to collaborate fully with providers. Finally, if you are concerned about a child but the parent is not, do make a referral or offer more testing. Do not, however, override a significantly predictive concern raised by a parent, even if you think the child is ok. Even if you are right, the family still needs special assistance.

BUT it is still a good idea to complement parents’ concerns with measurement of what children can actually do (and much more in keeping with American Academy of Pediatrics recommendations). Informal milestones checklists are not helpful and seem to obliterate the evidence behind PEDS^®. A far better approach is to add PEDS^®: Developmental Milestones into your screening process, either routinely or from time to time. The PEDS:DM^® tool with only 6 – 8 additional questions offers valid screening of children’s skills, can help confirm parents’ concerns and the need for referral, or disconfirm parents’ concerns and thus determine when parent education and watchful waiting is the best response, and thus give you more confidence about the need for referrals.

Parents tend to come up with concerns by comparing their children with others and families spend no small amount of time in the waiting room (grocery store, church, etc.) talking with other parents and noticing what their children are doing). So parents are busy learning about child development by watching other children. A good thing. You can sit in your waiting room for a while to witness parents learning from others!

We can send a link/logo you can put on your site. We understand that your patients/parents are accustomed to visiting your web page and so they can continue to do that. Once there, they can just click and land on our site to take the test. We’d then send a notice of a completed screen to your clinic email address so that providers can retrieve the results, referral letters, etc.