PEDIATRICS FOR THE CLINICIAN
A. Frederick North, Jr., M.D.
Front the Department of Pediatrics, Unicersity of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
The eight papers in this symposium have been
brought together to help practicing pediatricians evaluate the place of screening, and of particular screening procedures, in their own practices and
in programs of child health care in which they
Advancing technology is making available an
increasing number of tests and observations which
might be employed in the early detection of
health problems. The Federal government has
mandated an Early and Periodic Screening
Diag-nosis and Treatment (EPSDT) program for all
Medicaid eligible children, and California has
mandated health screening for school attendance. With this kind of pressure to “screen,” how should
the pediatrician react? We hope that this sympo-5mm
Thefirst two papers discuss definitions and criteria,
the followingfive illustrate the application of these criteria in speci-fic areas of current interest and controversy, and the final paper attempts to summarize the current
status of screening and to predict some future
directions for screening in the health care of
(Note: Bound reprints of this section on screening can be obtained from Dr. North.)
and the Pediatrician
Ken Lessler, Ph.D.
For a pediatrician to evaluate his position and role in the health care of children, he must have clearly delineated what he means by “health.” If, in addition, the pediatrician is to consider his
stance with regard to screening, he must specify
what he means by “screening,” and outline what
constitutes a “screening program.”
The pediatrician’s commitment to child
devel-opment and the “welfare of children” suggests
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PEDIATRICS FOR THE CLINICIAN 609 that he is interested in far more than biological
survival or the absence of disease. His relative
commitment to the two poles of this conceptual
continuum-biological survival vs total human
formation and growth-will strongly affect his
ap-proach to health screening. With one
commit-ment, he will choose to put money and time into identifying comparatively rare but potentially fatal or crippling conditions; with a different per-spective he may advise that resources be devoted
to identifying conditions which are much more
common but less physically dangerous. With one
viewpoint, he will devote energy to identifying
and helping children with language delays and
other learning, social and emotional problems. With the other viewpoint, he may elect to screen only for heart disease, PKU, sickle cell disease and tuberculosis.
Although the choice may often be pragmatic rather than philosophical, the pediatrician must
agree with Richmond and Weinberger that any
consideration of the child “must include elements of the entire social milieu in which children devel-op-the educational system, the social system, the physical and emotional environment itself.”1
Such an expanded concept of health requires a
definition of screening which is less restrictive
than the one recommended to the World Health
Organization (quoted by Frankenburg2 in his
symposium). The following alternative definition is proposed:
Screening is the acquiring of preliminary information about characteristics which may be significant to the health, education, or well-being of the individual and which are ret-evant to his life tasks. The means of data collection must be appropriate and reasonable with regard to the economics of time, money and resources for dealing with large numbers of persons.3
This definition makes it explicit that screening may consider a wide range of characteristics of a child, not simply the likelihood that a disease is present or absent, and that the characteristics se-lected should be relevant to his life tasks. Since the child’s stage of development defines his life tasks, age is an important determinant of which charac-teristics should be assessed through screening.
Measurements related to immediate survival are
most appropriate at the time of labor and deliv-ery. Measures relevant to parent-child nurturance are critical in the first days and weeks of life. The identification of strengths and problems relevant to learning to read and write are of concern as the child enters school, and characteristics relevant to
career planning and reproduction may be most
relevant in adolescence.
Thedefinition specifies that acquired
informa-lion is preliminary and tentative rather than
diagnostic or conclusive. “Positive” screening
findings indicate a need for more extensive
evalua-lion; however, all too often positive findings are either ignored or are regarded as adequate evi-dence on which to base treatment or other inter-vention. “Negative” screening information is very frequently accepted as conclusive evidence that no problem is present, and often is unrecorded, unreported and ignored. Actually, both “positive”
and “negative” screening information should be
regarded as tentative. Screening data comprise a
part of continued efforts to help the child through
acquiring knowledge about his strengths and
about his weaknesses. Neither positive nor
nega-tive findings should be interpreted as “final”
The definition also specifies that the means of data collection must be practical and economical for use with large numbers of persons. Economy must be considered both in the acquisition of
in-formation and also in the use of the information. If
a test is quick and cheap, but irrelevant and mac-curate, it will cost more in the long run than no screening at all. if, on the other hand, the test is
very time-consuming or expensive to perform, it
must have a very high “pay-off” in the form of
benefits to those screened in order to justify its use for all children in the population. As is discussed by Frankenburg,2 the relative “costs” of false-neg-ative and false-positive test results will be very
im-portant determinants of what characteristics are
considered, what tests are used and what criteria are selected.
Screening is the acquisition of information; a
screening program puts the information to use.
Screening without a program for using the infor-mation gathered is a waste of effort. Screening programs must be designed not to count problems but to help people.
Thecharacteristics of diseases and problems which make them suitable targets for screening, and the characteristics of tests which make them suitable for use in screening programs are discussed byFrankenburg. Given suchmformation-gathering
ability, what are the goals of a program that will both gather and make use of such information?
1. A screening program must ensure that
screening information is utilized to provide treat-ment or remediation of the diseases, deficits or disabilities identified and to promote the growth and positive development of each child.
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2. A screening program must provide
informa-tion to those who need it-those who work with
3. A screening program must be self-critical and self-monitoring, and it must be open to posi-tive change.
4.A screening program must promote primary prevention, family participation and a commit-ment to individual growth.
A “program” designed to meet these goals may
exist within an individual medical practice, be
part of a formal comprehensive medical care pro-gram, or be a designated screening program in an
agency or community. Some general
considera-tions apply, whatever the setting and scope of the screening process.
Coordinate Information on Multiple
Most traditional screening programs attend to only a single characteristic: sickle cell trait, PKU, tuberculin sensitivity, learning problems, etc. Most frequently information about one character-istic is useful in the evaluation of other
character-istics. Unless all information from a variety of
screening procedures is brought together in one
place, much potentially useful information may
be sacrificed. Screening for multiple
characteris-tics at a single session makes coordination of
information easier and usually makes both
screening and interpretation more economical
Provide Follow-Through for Each Child
The screening program is often complex,
in-cluding initial screening, rescreening of those with positive test results, diagnosis and treatment which may involve referral to more than one pro-vider of services, and continued management and monitoring. Missed appointments or inadequate
transmittal of information can occur at any of
these multiple steps, leading to program failure. This can be avoided by having a single individual follow the progress of each child until the child reaches the endpoint: a negative screening report, a diagnostic report indicating no need for treat-ment, or evidence that treatment is taking place and will be completed. Such monitoring is espe-cially important in multiple screening since a sin-gi e child may require care by more than one spe-cialist for more than one problem.
Provide Necessary Information to All
Unless parents, physicians, teachers and others
concerned with the care of the child receive
necessary information from the screening
pro-gram, the stage is set for duplication or gaps in ser-vices. In addition, those working with the child are forced to proceed without information which
could be of significant help. The program must
plan in advance to provide needed information to appropriate persons, and it must also have a plan for transmitting the information effectively. Pedi-atricians should insist that screening programs supply them with complete reports of all work on their patients.
Provide Program Audit
All program phases, from the first screening to
the final interventions, must be audited or
re-viewed at frequent intervals to be sure that the program is actually operating as planned and that established standards are being followed. Such re-view can be accomplished by a program director,
but periodic review by an “outside” evaluator is
desirable. Without such audits, personnel in vari-ous parts of the program may develop a certain myopia concerning their own role in the total pro-gram.
Provide for Review of Data
Data must be managed to allow for data review that can identify points where preventive or ear-her intervention efforts can profitably take place.
Itusually is not practical for individual projects to attempt “hard” research on outcome, instrument
efficiency, or the determination of numbers of
false positives and negatives; such “hard” research should be reserved for special efforts-those
pro-jects with research staff and program designs
which allow for this type of evaluation.
How-ever, each project should review its own results
to determine what local preventive efforts are
Provide for Integration of Screening With the
TotalSystem of Health and Developmental Services
Many screening programs operate within a lim-ited time frame, even though it is clear that long-term benefits cannot be achieved without atten-tion to overall planning. Program organizers must integrate screening into the fabric of the system
within which it operates or screening will be a
one-time affair. Surveillance of health problems over time, updating information, rechecking ques-tionable results, and attending to new cohorts of children will be neglected if the program focuses only on a single year. A pattern of screening must be established, complete with ongoing funds and ongoing responsibilities. Otherwise, we delude ourselves into thinking we have done a good job,
PEDIATRICS FOR THE CLINICIAN 611 The Pediatrician’s Role as Provider of
It is obvious that much of what has been dis-cussed is as relevant to the screening which is an
everyday part of the pediatrician’s practice as it is
to screening efforts in special programs, schools
and health departments. The pediatrician often
has at his disposal a variety of bits of information about the child which might be of value to others. The child’s teacher, in particular, needs to know
whether there is some developmental slowness
which sets him apart from his classmates, whether he has a vision or hearing problems, severe ane-mia, or rheumatic heart disease. Yet, routine pro-cedures for providing this information to schools
(except, possibly, for school physical exam
re-ports) are not standard in most pediatricians’
This lack of information-sharing is understand-able (although not desirable) since, outside of hos-pita! or clinic settings, the pediatrician often
works alone except for occasional referrals to
specialists. The parents are his primary allies and treatment resources. Yet, teachers see all
chil-dren; and many children are seen by other care
givers who work with them on speech, learning or emotional problems, or physical development.
This overall network of interrelationships too
often becomes obscured, and is not acknowledged and not used.
For example, the knowledge that a child has re-current ear infections is important not only to the pediatrician but also to many others working with the child. How often is the teacher alerted to the manifestations of hearing loss? How often is the child disciplined because he is not “paying
atten-tion”? How much language delay has resulted
from early infections and now needs remedial
help? How many children are helped to deal with the social and emotional impact of reduced hear-ing or are taught to recognize impending infec-tions before they feel pain in their ears? The net-work of persons for whom this specific problem has implications is critical but too often over-looked.
Physicians are accustomed to thinking in terms of a specific cure, not a system of intervention which includes, but is not limited to, specific
treatment. However, many of the areas which
concern pediatricians require the involvement of
parents, teachers, and very often a variety of other
personnel. It is not merely good manners to let
these people know what is going on; one cannot be effective without their attention and coordinated work. They, in turn, cannot work most effectively without the information held by pediatricians.
Pediatricians must be willing to transmit their
own esoteric information in language meaningful
to others, and to convert in-office practices to a
community orientation by making use of parents
and other care givers as therapeutic agents. Pedia-tricians are not alone in their offices; they are re-sponsible for sharing what they know for the bene-fit of the child.
The Pediatrician as Utilizer of Screening
Usually, the pediatrician has available data pro-vided by the child’s parents, possibly some past
medical records, and his own observations. But
most often he is in an information vacuum vis-a-vis the schools and other screening programs in the
community. How many reports do pediatricians
receive from schools about a child’s progress? How many pediatricians receive the results of (1) the routine vision screening done by most schools,
(2) the hearing screening done by large numbers of schools, or (3) results of screening for anemia or
tuberculosis done by health departments? The
pediatrician may learn of problems when
refer-rals are made; but, even then, he is too often pro-vided with scant information. He has a right, an obligation, and a need to know, just as much as he
has the obligation to share his knowledge with
others who are working with him toward the
overall development of the child.
The process of acquiring and sharing informa-tion may at first not seem to be worth the effort, which is often time-consuming and requires much coordination. However, if there is to be a total care program rather than a series of isolated en-deavors, the task must be accepted. Information-sharing is one important start, with all of its impli-cations for trust and mutual caring for children.
Pediatricians are in a position to be heard, to have a say, to make a difference. Sometimes they will directly operate screening programs in the community, but more often they can be advisors, consultants, and positive forces. Their sense of re-sponsibility and sense of what is and is not possible is a very necessary input into all screening pro-grams for children.
1. Richmond, J. B., and Weinberger, H. L.: Essential Ele-ments for Comprehensive Health Care for Chil-dren and Youth. Paper prepared for the conference on The Role of Maternal and Child Health and Crippled Children’s Programs in Evolving Systems of Health Care, Ann Arbor, Michigan, March
2. Frankenburg, W. K. : Selection of diseases and tests in pe-diatnc screening. Pediatrics, 54:612, 1974.
3. Lessler, K.: Health and educational screening of school-age children-Definition and objectives. Amer. J
Public Health, 62:191, 1972.
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Screening, Screening Programs and the Pediatrician
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