The Importance of Social and Emotional Screening

More than ever before, U.S. healthcare providers are promoting early literacy and language skills for children zero to five years of age. We preach "the 4 Ts":

  1. Talk, talk, talk.
  2. Take turns taking.
  3. Tune into what your child is doing and saying.
  4. Turn off your TV and cell phone!

National campaigns like Too Small To Fail emphasize “Talking is Teaching: Talk, Read, Sing”—aspiring to close the word gap between low-income and affluent children.

My professional opinion is that public awareness campaigns promoting early language and literacy skills would be more effective if they were paired with a campaign about the need to screen children for developmental-behavioral problems. Although their recommendations are a bit complicated, the American Academy of Pediatrics (AAP) recommends universally screening young children for developmental delays, social-emotional/behavioral problems, autism and psychosocial risk conditions like maternal depression/anxiety. Parents need to know—screening is the new standard of care.

Interestingly, screening rates have approximately doubled over the past fifteen years. According to AAP surveys, 23% of pediatricians “self-reported always/almost always using 1 or more standardized screening tools” in 2002 and 48% used them in 2009. Nowadays, states like Oregon even have quality incentives that hold healthcare providers accountable for universally screening children.

So what is screening supposed to look like at a doctor's office? If you're the parent of a young child, does the process in this video look vaguely familiar? Hopefully, your answer is yes.

Here’s why: 15-17% of U.S. children have a developmental disability and about 20% have a mental health disorder at any given time. Estimated prevalence rates are similar in 2- to 5-year-old children. By 16 years, 37-39% will have been diagnosed with a mental health disorder. Unfortunately, pediatrician impression alone (without screening) fails to timely identify and refer 60–80% of children with developmental delays.

Furthermore, children exposed to multiple adverse childhood experiences disproportionately require special education, drop out of school, get addicted to substances of abuse, and have suicidal ideation or attempts. They inordinately burden our judicial and penal systems with anti-social/criminal behavior and our healthcare system with mental illness, obesity and many other chronic ailments. Early intervention (EI) saves the brains of children with adverse childhood experiences and those with emerging disorders, like autism. For every dollar spent on high-quality early learning programs, there’s a 7-10 percent annual return rate in cost savings—and the younger the child served, the wiser the investment.

Beyond healthcare settings, the federal government wants screening to also occur in daycares, preschools, homeless shelters and at nurse home visits. “Birth to Five: Watch Me Thrive!” is a wide-scale, coordinated initiative to universally screen children at-risk for developmental-behavioral problems. Unfortunately, the average American parent knows little to nothing about their resources for families.

Every parent looks forward to seeing their child’s first smile, step, and words. Regular developmental-behavioral screenings help raise awareness of a child’s development, make it easier to celebrate milestones and identify red-flag concerns as early as possible. With early and periodic screening, parents can make sure that their children get the support they need to succeed in school and thrive alongside their peers.

“Do more talking and reading” is generally great advice but if parents have developmental, behavioral or learning concerns, be wary if a healthcare provider quips, “let’s just wait and see if he grows out of it” without first interpreting a screening tool. When clinicians notice “red-flags” or there is an atypical screening result, the new mantra is “let’s play it safe and give them a call”—“them” being an EI agency and/or other community resource.

Unfortunately, many referred children/families never receive high-quality services in a timely manner. Parents might have negative perceptions about referrals. They can seem like an externally imposed value system. At times, a healthcare provider’s recommendations can seem unhelpful or formulaic. The office staff might appear judgmental, intrusive, or overbearing. Many “lost-to-follow up” children/families are overwhelmed by life stressors like poverty, marital discord, domestic violence, mental illness, a language barrier, a disconnected phone service or recent move, etc.

At-risk/disadvantaged children are frequently overlooked if their state has strict EI eligibility criteria or lacks system-wide care coordination. Among states with narrow eligibility criteria, poor children are 18% less likely to receive EI services. Others live in a community where an early detection system struggles to address parental language or literacy barriers. Disparities exist in screening/referral support for Latino populations which negatively affects children’s involvement in EI. African American children with developmental delay(s) are 5 times less likely than were white children to receive EI services. All not good.

Alas, the new message for parents should be: "Talk, Read, Sing, Screen!" If your healthcare provider or high-quality screening tool indicates there’s an emerging problem, don’t wait. Get your child swiftly linked to an EI program and/or other beneficial program. Let’s expect 100% of healthcare providers to routinely use high-quality screening tools. Let's tell policy makers to improve our care coordination systems to enhance the long-term success of our children.

Kevin P. Marks M.D., F.A.A.P. is a general pediatrician at PeaceHealth Medical Group in Eugene, Oregon