Developmental assessment of childrenBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.e8687 (Published 15 January 2013) Cite this as: BMJ 2013;346:e8687
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I work with Children in Care, a number of whom have developmental delays, some temporary and some more long lasting and we need means of ensuring an accurate assessment of the care plan as soon as possible on entry into care.
Use of the Schedule of Growing Skills which is a screening tool has not been sensitive enough, particularly to identify more subtle delays in communication skills and understanding.
It is important in this population to use a validated and objective assessment tool because of the complexity of a number of different carers changing and the environmental input being so crucial. We currently use the Griffiths developmental assessment tool as it has been well validated and researched. It does seem to pick up on areas that need additional support, but will be looking more into this area in order to ensure that our children get the best support possible in as timely way as possible.
Thank you to the speech therapist for the useful additional red flags which are the ones that would be the most applicable to the children we see.
Competing interests: No competing interests
We were interested to read the article by Bellman et al.(1) Although described as a review of the literature on the assessment of child development, no information was provided on how the literature was gathered and appraised. The authors did not indicate the basis on which they selected the tools they suggest for assessing development and in their description of them referred to validation studies which were conducted mainly in the USA and/or are now dated.
We also felt that the title developmental assessment was rather misleading as it was often unclear whether what was being addressed was assessment, surveillance or screening and there are important differences. While screening is applied to people where a problem has not been suspected in an attempt to separate those at higher risk of a condition from those at a lower risk, assessment is usually a more detailed description of a condition as a result of a problem being suspected. This distinction is not just academic pedantry. Screening tests, because they are usually applied to the whole population, need to be relatively brief and easy to administer, and the outcome is usually a dichotomy of pass/fail or problem suspected/not suspected. On the other hand, assessments are applied to a smaller group, need more time and skill to complete, and the outcome should be a detailed description of the problem. Screening often forms part of surveillance.
The evidence in support of using a particular screening tool is often lacking, either in general, or in the proposed target population. It is not sufficient to validate it in one population and then apply it to another, and even less appropriate to take components of the tool and use them without validating their use in the way intended. While PEDs and ASQ are promising screening tools to use in the UK, they have neither been validated nor standardised for use in a UK population.
The same limitations apply to the M-CHAT. The reference used for M-CHAT is quite old and had a number of limitations set out by the authors themselves. A much later study reported in 2011(2) was in fact the first to examine M-CHAT in an unselected group of children. In this study, to increase the specificity, a follow-up phone call was planned for all those screened positive. About a quarter could not be contacted and half screened negative, leaving only a quarter of the original screen positives to be further evaluated. This phone call is an important part of the screening package and the resource for it should not be underestimated.
An issue that wasn’t considered in the article and which is of fundamental importance is that a number of children move in and out of the normal range and that, in any case, the normal range is often a statistical construct, i.e. within 2 SDs of the mean, rather than defined on the basis of need.
In summary this is a very complex topic and it is essential, just as with any procedure, that before being introduced, it is properly piloted in the target population. The Departments of Health and for Education have set up a working party to advise on the process and content of an integrated review at 2-2 ½ years of age. We suggest that no one changes their practice at 2- 2 ½ years until this working party reports.
1. Bellman M, Byrne O, Sege R. Developmental assessment of children. BMJ. 2013 Jan 15;346:e8687. doi: 10.1136/bmj.e8687.
2. Miller JS, Gabrielsen T, Villalobos M, et al. The each child study: systematic screening for autism spectrum disorders in a pediatric setting. Pediatrics. 2011 May;127(5):866-71.
Competing interests: Both HB and DE are members of the integrated review working party . The Children and Young People Policy Research Unit, UCL Institute of Child Health has been commissioned by DH to look at a population measure of child development at 2 ½ years old as part of an integrated review and HB is leading this work.
I enjoyed the article ‘Developmental assessment of children’ and found the table of ‘normal developmental milestones’ and the list of ‘red flag’ indicators very useful. However, as a speech and language therapist, I believe there was an important omission in that there were no pointers for detecting difficulties with the comprehension of spoken language. This is more subtle than a child’s expressive language to detect, and can be easily missed, yet the implications can be more serious.
In box 3 you suggest asking ‘Do you have concerns about how your child talks and understands what you say?’ which is a good lead-in question. However, in my experience many parents think that their child understands what is being said to them whereas they are often picking up visual clues from the situation e.g. the family is ready to go out and the child responds to ‘get your shoes’.
I would therefore suggest that at 2 years a ‘red flag’ warning should be given if the child is not responding to their name, and shows no situational understanding. Also if they are not able to understand one key word from what is said to them e.g. ‘Where’s mummy?’, ‘Where’s the ball?’ (from a selection of 3 objects e.g. a cup, a ball and a spoon’) or‘Get your spoon’. It is better if objects are used before pictures as this follows the developmental sequence.
At 3 years there should be a red flag warning if the child is not following simple instructions e.g. ‘Give me the car’ or ‘Give the banana to mummy’. It will of course be important for the professional not to give cues in the form of eye pointing or a hand gesture so that it is clear that the child is responding to spoken language. It will also be important to take into account the child’s single channelled attention span between the ages of 2 – 3 years so that if the child is playing, he may not be able to listen at the same time.
The earlier that comprehension difficulties are identified, the sooner that support can be given in the form of reducing the language that is used when talking to the child, slowing the pace by using pauses, the use of signing alongside language and using visual prompts, such as objects and pictures, when conversing with the child.
In practice I have seen many children (usually boys) between the ages of 2 years to 2 years 6 months who may be using very little expressive language but who have good comprehension, and they will often go on to develop skills within the normal range. Therefore, to a speech and language therapist alarm bells will ring if a child is not understanding spoken language rather than the emphasis you have given in your article to the number of words that a child is saying at a given stage.
Competing interests: No competing interests
Global developmental delay is common affecting 1-3% of children in the UK . The clinical review on its assessment should be commended to all general practitioners who are likely to be the first port of call for anxious parents .
Once the decision to refer has been made Bellman et al understandably avoid the topic of the confusing and variable provision of specialised services across the UK and abroad.
The parental reaction is far more universal and in my experience under appreciated.
We took our 12 month old daughter to our general practitioner with concerns that she was not moving. Our concerns were listened to and she was examined in much the way that the review advocates. The consultation ended with “ we need to refer as she is quite obviously not normal”. That is all I remember.
Parents usually go through a form of grief reaction, grieving for their lost hopes and expectations. Support from the primary care team in coming to terms with this difficult diagnosis and navigating the minefield of ongoing secondary care is vital.
1. Baird G, Simonoff E, Pickles A, Chandler S, Loucas T, Meldrum D, et al. Prevalence of disorders of the autism spectrum in a population cohort of children in South Thames: the Special Needs and Autism Project (SNAP). Lancet 2006;368(9531):210-5.
2. Bellman M, Byrne O, Sege R. Developmental assessment of children. BMJ 2013;346:e8687.
Competing interests: No competing interests