START Surveillance & Screening

Screening Tools and Referral Training (START)


Most pediatric health professionals practice developmental surveillance. Surveillance is a flexible, ongoing process where knowledgeable professionals perform skilled observations of children during the health care visit. The components of developmental surveillance include:

  • Eliciting and attending to parental concerns;
  • Maintaining a developmental history;
  • Making accurate and informative observations of children;
  • Identifying the presence of risk and protective factors
  • Maintaining an accurate record of documenting the process and findings.1

Pediatricians and other health care providers often use age-appropriate developmental checklists to record milestones during preventive care visits as part of developmental surveillance. To be in compliance with EPSDT, clinicians should be doing this routinely and documenting this as part of the well child visit. The Developmental Milestones Checklist is one form that can be used during the visit to document developmental surveillance that has been performed during the patient visit.


Developmental screening, on the other hand, is a brief procedure, using a standardized validated tool, available either commercially or in the public domain, to determine whether a child requires further and more comprehensive evaluation. Developmental screening enhances surveillance. Screening may be a part of routine well child visit or it may be used during acute care visits in response to a specific concern about a child. The AAP recommends routine surveillance and using standardized developmental and behavioral screening at least 3 specific times: the 9, 18 and 24/30 month visits.2

To view a list of Developmental and Behavioral Health Screening Tools, click HERE.

Evidence for Using Screening

Federal legislation, through the Individuals with Disabilities Act (IDEA), Part C, mandates early identification of, and intervention for, young children with developmental disabilities through community-based systems. This legislation was implemented to:

  • Enhance the development of infants and toddlers with disabilities and to minimize their potential for developmental delay;
  • Reduce the educational costs to our society, including our nation's schools, by minimizing the need for special education and related services after infants and toddlers with disabilities reach school age;
  • Minimize the likelihood of institutionalization of individuals with disabilities and maximize the potential for their independently living in society;
  • Enhance the capacity of families to meet the special needs of their infants and toddlers with disabilities; and
  • Enhance the capacity of State and local agencies and service providers to identify, evaluate, and meet the needs of historically underrepresented populations, particularly minority, low-income, inner-city, and rural populations.3

It is estimated that between 12-16% of American children have developmental or behavioral disorders.4 The earlier a disability or disorder is identified the sooner appropriate intervention can begin.

In an updated 2006 policy statement, the AAP recommends routine surveillance and standardized developmental and behavioral screening. The statement reiterates what was said in the 2001 policy statement but also provides an algorithm as a strategy to support health care professionals in developing a pattern and practice for addressing developmental concerns in children from birth through 3 years of age. It recommends that developmental surveillance be incorporated at every well-child preventive care visit and any concerns raised during surveillance should be promptly addressed with standardized developmental screening tools. In addition, screening tools should be administered regularly at the 9, 18, and 24 or 30-month visits.1

While standardized and routine screenings are recommended, a 2003 Periodic Survey of Fellows (PS53)5 concludes that, despite the AAP's policy and national efforts to improve developmental screening in the clinical setting, only 50% of the participating pediatricians said they used standardized techniques to screen for developmental problems. Physicians often rely on lists of developmental milestones or prompting for parental concern6 or depend on clinical judgment. Some may administer a screening tool only after a problem is noticed.

The result of these prevailing practices is under detection. Research shows that clinical judgment detects fewer than 30% of children who have mental retardation, learning disabilities, and other developmental disabilities, and clinical judgment identifies fewer than 50% of children who have serious emotional and behavioral disturbance.7 Currently, the pediatrician sees more children with suspected Autistic Spectrum Disorder (ASD) diagnosis, and is faced with the challenge of early detection and diagnosis in order to implement a timely treatment plan.8

AAP Periodicity Guidelines (American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care)

AAP Periodicity Guidelines (American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care)” followed by in the paragraph” AAP Periodicity Guidelines (American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care) call for a developmental/behavioral assessment by history and appropriate physical examination at each visit interval. If findings identify concerns, specific objective developmental screening is needed. Developmental surveillance and developmental screening are the recommended methods for early detection of problems. The AAP recommends developmental screening be performed at set points in time - 9, 18 and 30 months (or 24 months if a practice has not yet implemented the 30-month visit) - or if a specific concern arises. Autism screening is recommended at 18 and 24 months visits in addition to the developmental screening. Alcohol and Drug Use assessment is recommended yearly starting at age 11. The AAP recommends the CRAFFT screening tool to screen for Alcohol and Drug Use. Depression screening is recommended yearly starting at age 11.

  • To learn more about Tennessee’s EPSDT Screenings click HERE.

Currently, there are tools available that are both efficient and effective in the pediatric office and other health care settings. To view a list of Developmental and Behavioral Health Screening Tools, click HERE.


  • To view a list of references for this page, click HERE

START Contact Information

Susan Rollyson, M.Ed.
Training Coordinator
Phone: 615-956-7815
Fax: 615-383-7170