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Screening in Early Childhood: 2002–2009

WHAT’S KNOWN ON THIS SUBJECT: Early identification of developmental delays is essential for optimal early intervention. Increasingly, developmental screening is recognized as a key component of high-quality care. The American Academy of Pediatrics has issued policy statements supporting the importance of developmental screening along with implementation strategies.

WHAT THIS STUDY ADDS: Despite increased policy, research, and educational efforts to support implementation of

standardized developmental screening, no national surveys have assessed whether use of formal tools has increased. This study examines changes between 2002 and 2009 in pediatricians’ developmental screening practices.

abstract

BACKGROUND:Early identification of developmental delays is essential for optimal early intervention. An American Academy of Pediatrics (AAP) 2002 Periodic Survey of Fellows found⬍25% of respondents consistently used appropriate screening tools. Over the past 5 years, new research and education programs promoted screening implementation. In 2006, the AAP issued a revised policy statement with a detailed algorithm. Since the 2002 Periodic Survey, no national surveys have examined the effec-tiveness of policy, programmatic, and educational enhancements. OBJECTIVE:The goal of this study was to compare pediatricians’ use of standardized screening tools from 2002 to 2009.

METHODS:A national, random sample of nonretired US AAP members were mailed Periodic Surveys (2002:N⫽1617, response rate: 55%; 2009: N⫽1620, response rate: 57%).␹2analyses were used to examine

re-sponses across survey years; a multivariate logistic regression model was developed to compare differences in using ⱖ1 formal screening tools across survey years while controlling for various individual and practice characteristics.

RESULTS:Pediatricians’ use of standardized screening tools increased significantly between 2002 and 2009. The percentage of those who self-reported always/almost always usingⱖ1 screening tools increased over time (23.0%– 47.7%), as did use of specific instruments (eg, Ages & Stages Questionnaire, Parents’ Evaluation of Developmental Status). No differ-ences were noted on the basis of physician or practice characteristics. CONCLUSIONS:The percentage of pediatricians who reported usingⱖ1 formal screening tools more than doubled between 2002 and 2009. De-spite greater attention to consistent use of appropriate tools, the percent-age remains less than half of respondents providing care to patients younger than 36 months. Given the critical importance of developmental screening in early identification, evaluation, and intervention, additional research is needed to identify barriers to greater use of standardized tools in practice.Pediatrics2011;128:14–19

AUTHORS:Linda Radecki, MS,aNina Sand-Loud, MD,b

Karen G. O’Connor, BS,cSanford Sharp, BS,aand Lynn M.

Olson, PhDa

aDepartment of Research andcDivision of Health Services Research, American Academy of Pediatrics, Elk Grove Village, Illinois;bDepartment of Pediatrics, Dartmouth Medical School and Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire

KEY WORDS

developmental screening, primary care, early intervention, developmental surveillance

ABBREVIATIONS

AAP—American Academy of Pediatrics

PDQ—Prescreening Developmental Questionnaire

The views represented here are those of the authors and do not necessarily reflect the views of the American Academy of Pediatrics.

www.pediatrics.org/cgi/doi/10.1542/peds.2010-2180 doi:10.1542/peds.2010-2180

Accepted for publication Mar 11, 2011

Address correspondence to Linda Radecki, MS, Department of Research, American Academy of Pediatrics, 141 Northwest Point Blvd, Elk Grove Village, IL 60007. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2011 by the American Academy of Pediatrics

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Early identification of children with de-velopmental delays is essential to

pro-viding optimal early intervention ser-vices. In the 2003 National Survey of Children’s Health, 10% to 20% of par-ents of children aged 5 years and

younger expressed concern about their child’s development.1 Results

from the national Early Childhood Lon-gitudinal Study–Birth Cohort indicate

that at 24 months of age, nearly 14% of children have developmental delays that are likely to make them eligible for early intervention services as speci-fied in the Individuals With Disabilities

Education Improvement Act.2

In recognition of both the importance

of early identification of children with developmental disabilities and the need for more methodical assess-ments, in 2001 the American Academy of Pediatrics (AAP) put forth

recom-mendations that all children should receive standardized developmental screening as part of well-child care.3

Screening was defined as a “brief

as-sessment procedure designed to iden-tify children who should receive more intensive diagnosis or assessment.” However, the implementation of these recommendations was slow. A 2002

AAP survey of its members regarding the use of developmental screening tools and referrals to early interven-tion found that only 23% of pediatri-cians consistently used effective

stan-dardized screening instruments to assess their patients for developmen-tal problems.4 In a 2004 national

sur-vey of primary care practitioners,

Sices et al5found that in the absence of

standardized screening, both pediatri-cians and family physipediatri-cians were in-consistent in their referral patterns for children with possible

developmen-tal delays. The main barriers cited in preventing the use of such tools in-cluded time limitations, lack of staff to perform screening, inadequate

reim-bursement, and lack of confidence in their ability to screen.

Over the next few years, many new re-search and educational programs were launched to implement the 2001 screening recommendations. Pro-grams included the Assuring Better Child Health and Development pro-gram,6which encompassed the North

Carolina effort that gradually introduced standardized screening throughout the state.7Other projects includeBright

Fu-tures,8,9Child Find Demonstration

Proj-ects, the TRACE program, and the Healthy Steps for Young Children Program.10The

goal of all of these projects has been to facilitate the implementation of develop-mental screening into pediatric well-child care.

In 2006, the AAP issued a revised policy statement, including a detailed devel-opmental screening algorithm, in an effort to clarify how and when develop-mental screening should take place.11

Recommendations included using “good” (sensitivity and specificity) standardized developmental screen-ing tools at the 9-, 18-, and 30-month visits as part of appropriate well-child care in the medical home. The policy statement provided additional support for the importance of such screening along with implementation strategies.

After the 2006 AAP statement was issued, a developmental surveillance and screening policy implementation pilot study assessed the feasibility of imple-menting the recommendations in a vari-ety of practice settings.12 Results

re-vealed that nearly all participating study practices had successfully implemented the AAP’s recommendations on develop-mental surveillance and screening. How-ever, at the same time, using a national sample, Rosenberg et al2reported that

only 10% of children with developmental delays were receiving services for their developmental needs.

Since the report of Sand et al4detailing

the 2002 AAP Periodic Survey results,

there has been substantial research and education in the area of imple-menting developmental screening as part of well-child care, as well as more specific recommendations for screening and guidance13,14to support

implemen-tation. In 2004, the Current Procedural

Terminology code for developmental

testing (96110) was also valued for the first time in the Medicare resource-based relative value scale physician fee schedule.15 Despite these efforts,

no national surveys have assessed whether these efforts have improved use of formal screening tools. In this study, we examine changes between 2002 and 2009 in pediatricians’ devel-opmental screening practices using the AAP’s Periodic Survey of Fellows.

METHODS

Data Collection

Periodic Surveys, conducted by the AAP’s Division of Healthy Services Re-search, are national, random sample surveys of nonretired, US AAP mem-bers. The 2002 Periodic Survey (survey 53) was mailed to 1617 potential re-spondents between May and Septem-ber 2002; the 2009 Periodic Survey (survey 74) was sent to 1620 possible respondents from February to July 2009. Both surveys were approved by the AAP’s institutional review board. All survey mailings included a letter of in-troduction from the AAP’s executive di-rector and a postage-paid return enve-lope. Potential participants received up to 7 repeated mailings to encour-age survey completion and return.

Among other topics, the 2002 and 2009 surveys included an identical item re-garding use of developmental screen-ing tools (“How often do you or your staff use the following methods or tools to identify children birth through 35 months of age at risk for develop-mental delay or problems?”). A subset of questions followed to ask about spe-cific assessment methods and tools:

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of a screening instrument/checklist; clinical assessment guided by the Den-ver Developmental Screening Test or other instrument; informal (eg, office-generated) checklist filled out by par-ents; informal (eg, office-generated) checklist completed by the AAP mem-ber or staff; formal screening using a specific instrument (eg, Bayley Infant Neurodevelopmental Screener, Denver II, Ages & Stages Questionnaire, Par-ents’ Evaluation of Developmental Sta-tus, other [specify]).

Respondents could select ⬎1 item, and 3 response choices (always/al-most always, sometimes, or rarely/ never) were included for each item. A combined variable was also created to indicate whether the respondent used

ⱖ1 formal screening tools always or almost always.

Data Analysis

Analyses excluded pediatricians who practiced general pediatrics⬍10% of the time (2002:n⫽222; 2009:n⫽282) and those who reportedⱖ1% of their time (2002:n⫽26; 2009:n⫽17) in a developmentally oriented subspecialty (eg, developmental/behavioral pediat-rics, neurology, neonatology, perina-tology, genetics). All respondents in-cluded in the analyses reported they provide health supervision/preventive care to children younger than 36 months of age and reported assessing for developmental risk (2002:n⫽594; 2009:n⫽560).

␹2analyses were used to compare the

use of the individual formal screening tools across survey years. A multivari-ate logistic regression model was also developed to compare differences in using ⱖ1 formal screening tools across survey years while controlling for various individual and practice-characteristic variables (physician age, gender, practice type, practice

lo-cation, percentage reporting high/low proportion of patients with public in-surance, practice region, and training status). Odds ratios and 95% confi-dence intervals were reported.

RESULTS

Sample Characteristics

Overall response rates for Periodic Sur-vey 53 (2002) and Periodic SurSur-veys 74 (2009) were 55% and 57%, respectively.

Table 1 presents demographic and practice characteristics for all respon-dents included in the analyses; there were no significant differences across surveys.

Use of Standardized Screening Tools

Pediatricians’ use of standardized screening tools increased significantly from 2002 to 2009 (Table 2). The

per-centage of those who self-reported al-ways/almost always usingⱖ1 screen-ing tools increased over time (23.0%– 47.7%); likewise, the percentage of those who reported use of clinical as-sessment without a formal tool de-creased (71.0%– 60.5%).

Use of specific instruments also in-creased from 2002 to 2009 (Table 2). In particular, a significantly greater per-centage of pediatricians reported us-ing the Ages & Stages Questionnaire and the Parents’ Evaluation of Develop-mental Status in 2009 than 2002. In both years, some pediatricians re-ported conducting formal screening with “other” tools. In 2009, 57 respon-dents specified they used the Modified Checklist for Autism in Toddlers. Twenty-two respondents specified other tools, such as Bright Futures; Early Periodic Screening, Diagnosis

Periodic Survey 53 (2002)

Periodic Survey 74 (2009)

P

All respondents,N 894 927 Eligible pediatricians for analysis,n(%)a 646 (72.3) 628 (67.7)

Female gender,n(%) 373 (57.8) 377 (60.0) .41 Age, mean (SD), y 41.7 (10.4) 44.4 (11.3)

Post residency status,n(%) 525 (81.4) 533 (84.9) .09 Practice location,n(%) .48

Inner city 131 (20.7) 140 (22.8) Urban, not inner city 174 (27.5) 146 (23.7) Suburban 251 (39.7) 251 (40.8) Rural 77 (12.2) 78 (12.7)

Practice type,n(%) .83

Solo or 2-person 197 (16.4) 100 (17.7) Group/staff HMO 322 (54.6) 300 (53.2) Hospital/clinic/medical school 171 (29.0) 164 (29.1)

Region,n(%) .46

Northeast 174 (26.9) 145 (23.1) Midwest 148 (22.9) 148 (23.6) South 213 (33.0) 219 (34.9) West 111 (17.2) 116 (18.5)

ⱖ50% time spent in general pediatrics,n(%) 584 (90.4) 571 (90.9) .75 Ethnicity,n(%)

White, non-Hispanic NA 439 (71.6) Asian/Pacific Islander NA 98 (16.0)

Hispanic NA 34 (5.5)

Black NA 28 (4.6)

American Indian NA 0 (0.0)

Other NA 14 (2.3)

HMO indicates health maintenance organization; NA, not available.

aRespondents were eligible for analysis if they practiced general pediatrics10% of the time and spent1% of their time

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and Treatment Programs; a formal screening tool on the electronic medi-cal record; the Prescreening Develop-mental Questionnaire (PDQ); the Com-munication and Symbolic Behavior Scales–Developmental Profile; and the Ireton Child Development Chart. In 2002, 20 respondents specified the use of certain tools; for example,Bright Fu-tures/Bright Futures guidelines; Cog-nitive Adaptive Test/Clinical Linguistic Auditory Milestone Scale; Early Lan-guage Milestone Scale; Early Periodic

Screening, Diagnosis and Treatment Programs; and the PDQ, the PDQ II, and

the revised form of the PDQ. In 2009, respondents also reported greater use of informal checklists completed by parents than in 2002 (27.9% vs 15.3%, respectively;P⬍.000).

The difference in the use ofⱖ1 formal screening tools across survey years remained significant within the multi-variate model (odds ratio: 2.99 [95% confidence interval: 2.17– 4.13]). None

of the other physician and practice characteristics examined were statis-tically significant related to use of for-mal screening tools (Table 3).

DISCUSSION

Findings from a recent AAP Periodic Survey of Fellows suggest encouraging trends in pediatricians’ use of appro-priate developmental screening tools. The percentage of pediatricians who reported usingⱖ1 standardized tools more than doubled between 2002 and 2009, demonstrating significant im-provement after changes in AAP policy, enhanced guidance on reimbursement, and increased emphasis on develop-mental screening through research and educational programs as well as the newBright Futures9guidelines.

Despite these gains, however, there re-mains room for improvement. Approx-imately half of the pediatricians

re-TABLE 2 Pediatrician Self-reported Use of Developmental Screening Methods, 2002 and 2009 Variable Periodic Survey

53 (2002)

Periodic Survey 74 (2009)

P

n % n %

Clinical assessment without screening tool

Always/almost always 401 71.0 312 60.5 Sometimes 79 14.0 83 16.1

Rarely/never 85 15.0 121 23.4 .000 Clinical assessment guided by the Denver

or other instrument

Always/almost always 185 33.2 221 42.7 Sometimes 223 40.0 146 28.0

Rarely/never 150 26.9 151 29.2 .000 Informal checklist

Parents

Always/almost always 82 15.3 140 27.9 Sometimes 118 22.1 109 21.8

Rarely/never 335 62.6 252 50.3 .000 You/staff

Always/almost always 200 36.7 189 37.3 Sometimes 103 18.9 86 17.0

Rarely/never 242 44.4 232 45.8 .712 Formal screening

BINS

Always/almost always 12 2.4 9 2.3 Sometimes 42 8.3 32 8.0

Rarely/never 452 89.3 357 89.7 .983 Denver II

Always/almost always 77 14.1 80 18.3 Sometimes 140 25.7 100 22.9

Rarely/never 328 60.2 257 58.8 .173 Ages & Stages Questionnaire

Always/almost always 37 7.3 99 22.4 Sometimes 29 5.7 79 17.9

Rarely/never 440 87.0 263 59.6 .000 PEDS

Always/almost always 12 2.4 68 15.9 Sometimes 28 5.6 56 13.1

Rarely/never 460 92.0 305 71.1 .000 Use 1 or more formal screening tool

(always/almost always)

Yes 130 23.0 257 47.7

No 435 77.0 282 52.3 .000

Denver indicates the Denver Developmental Screening Test; BINS, Bayley Infant Neurodevelopmental Screener; PEDS, Par-ents’ Evaluation of Developmental Status.

TABLE 3 Factors Related to Use of Formal Developmental Screening Tools, 2002 and 2009

Variable Odds Ratio (95% CI) Survey year 2.99 (2.17–4.13)a

Physician age 1.23 (.86–1.75) Physician gender 1.32 (.95–1.83) Practice type

Solo or 2-person Reference Group/staff HMO .91 (.60–1.39) Hospital/clinic/medical

school

1.43 (.79–2.61) Practice location

Inner city Reference Urban, not inner city .67 (.40–1.14) Suburban .71 (.42–1.20) Rural .83 (.45–1.54) Practice region

Northeast Reference Midwest .80 (.50–1.28) South 1.00 (.67–1.50) West .72 (.44–1.20) % reporting high/low

proportion of patients with public insurance

99 (.66–1.48)

Training status (resident vs postresident)

1.30 (.69–2.44)

CI indicates confidence interval; HMO, health maintenance organization.

aStatistically significant.

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tools with patients younger than 36 months of age. Many continue to rely on informal checklists completed by the pediatrician, office staff, and/or parents.

Findings from the present study are limited in several ways. First, esti-mates of standardized screening tool usage are based on physician self-report rather than observed documen-tation or chart review. Social desirabil-ity may have motivated pediatricians to over-report their application of these instruments given current atten-tion to the importance of early identifi-cation of developmental delay. We lack parent-reported data to corrobo-rate whether formal developmental screenings are being conducted. Ob-taining information from parents is particularly important because par-ents do have concerns about their chil-dren’s growth and development, and they expect their health care providers to address these issues and con-cerns.16Recent findings from the 2007

National Survey of Children’s Health in-dicate that⬎40% of parents of chil-dren aged 4 months through 5 years reported ⱖ1 concerns about their child’s physical, behavioral, or social development.17When the 2000 National

Survey of Early Childhood Health asked parents of children ages birth through

⬎40% of parents reported no.18

Par-ents who did report receiving a

devel-opmental assessment were more

likely to be satisfied with their child’s medical care.

Second, the present inquiry does not allow us to determine who is adminis-tering these tools and whether screen-ing is bescreen-ing conducted appropriately. Also unknown is the outcome of screening (eg, referral patterns, follow-up).

In 2009, Sheldrick and Perrin19noted

that screening has become accepted as a “core element of pediatric prac-tice.” However, they also argued that instruments must not only be scientif-ically valid but also practical, in terms of administration time and cost, for the office setting. It is plausible that barriers such as these continue to im-pede increased use of appropriate screening methods. In addition, an-other barrier identified in early stud-ies remains problematic today: the lack of a gold standard formal screen-ing tool for young children.20–22 As

Sices noted,23 there are a variety of

tools available, but many of these in-struments are limited in sensitivity and specificity.

Increasingly, developmental screening is recognized as a key component of high-quality care; thus, it is likely the

will continue to grow.24A notable

devel-opment in quality measurement is that the initial recommended core set of chil-dren’s quality measures for voluntary use by Medicaid and the Children’s Health Insurance Program, mandated under the Children’s Health Insurance Program Reauthorization Act, includes “screening using standardized screen-ing tools for potential delays in social and emotional development.”25

The past decade has brought about a significant increase in the number of standardized screening tools available for young children as well as the adop-tion of these tools by pediatricians. Un-addressed, developmental delays can negatively affect children’s future health and educational attainment.26

Appropriate screening is critical to early identification, evaluation, and in-tervention for developmental delays. Because pediatricians are the most fre-quent point of contact for the health needs of young children, additional work is needed to identify and address re-maining barriers to even greater use of formal tools in pediatric practice.

ACKNOWLEDGMENTS

We acknowledge the helpful com-ments of William Cull, PhD, and Paul H. Lipkin, MD, on an earlier version of this manuscript.

REFERENCES

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of infants and young childre. Pediatrics.

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4. Sand N, Silverstein M, Glascoe FP, Gupta VB, Tonniges TP, O’Connor KG. Pediatricians’ re-ported practices regarding developmental screening: do guidelines work? Do they help?Pediatrics. 2005;116(1):174 –179 5. Sices L, Feudtner C, McLaughlin J, Drotar D,

Williams M. How do primary care physi-cians manage children with possible devel-opmental delays? A national survey with an experimental design. Pediatrics. 2004; 113(2):274 –282

6. National Academy for State Health Policy.

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Assistance Center for Children’s Mental Health; 2006

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10. Centers for Disease Control and Prevention. National and Multistate Intervention Pro-grams Related to Developmental Screening. Available at: www.cdc.gov/ncbddd/child/ interventions.htm. Accessed December 17, 2010

11. Council on Children With Disabilities, Sec-tion on Developmental Behavioral Pediat-rics, Bright Futures Steering Committee, Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental sur-veillance and screening.Pediatrics. 2006; 118(1):405– 420

12. King TM, Tandon SD, Macias MM, et al. Im-plementing developmental screening and referrals: lessons learned from a national project.Pediatrics. 2010;125(2):350 –360 13. Macias MM, Lipkin PH. Developmental

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Making developmental-behavior screening work in your practice.Contemporary Pedi-atrics. 2009;26(12):38 – 45

15. Centers for Medicare & Medicaid Services. Medicare program; changes to Medicare payment for drugs and physician fee sched-ule payments for calendar year 2004. In-terim final rule. Fed Regist. 2004;69(4): 1083–1267

16. Cheng TL, Savageau JA, DeWitt TG, Bigelow C, Charney E. Expectations, goals, and per-ceived effectiveness of child health supervision: a study of mothers in a pediat-ric practice.Clin Pediatr (Phila). 1996;35(3): 129 –137

17. Child and Adolescent Health Measurement Initiative. 2007 National Survey of Children’s Health. Available at: www.nschdata.org. Ac-cessed March 3, 2010

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chil-dren’s behavior and development: practical solutions for primary care.J Dev Behav Pe-diatr. 2009;30(2):151–153

20. Aylward GP. Developmental screening and assessment: what are we thinking?J Dev Behav Pediatr. 2009;30(2):169 –173 21. Jensen RE, Chan KS, Weiner JP, Fowles JB,

Neale SM. Implementing electronic health record-based quality measures for develop-mental screening.Pediatrics. 2009;124(4).

Available at: www.pediatrics.org/cgi/ content/full/124/4/e648

22. Sices L, Stancin T, Kirchner HL, Bauchner H. PEDS and ASQ developmental screening tests may not identify the same children.

Pediatrics. 2009;124(4). Available at: www. pediatrics.org/cgi/content/full/124/4/e640 23. Sices L. Developmental Screening in

Pri-mary Care: The Effectiveness of Current Practice and Recommendations for Im-provement. New York, NY: The Common-wealth Fund; 2007

24. US National Institutes of Health. Translating Evidence Based Developmental Screening Into Pediatric Primary Care (TEDS). Avail-able at: http://clinicaltrials.gov/ct2/show/ study/NCT00844246. Accessed December 17, 2010

25. US Department of Health and Human Ser-vices, Agency for Healthcare Research and Quality. Initial Core Set of Children’s Health-care Quality Measures, Identification of Ini-tial Core Set of Measures for Voluntary Use by Medicaid and Children’s Health Insur-ance Program (CHIP) Programs. Available at: www.ahrq.gov/chipra/listtable.htm. Ac-cessed March 5, 2010

26. Halfon N, Inkelas M, Abrams M, Stevens G.

Quality of Preventive Health Care for Young Children: Strategies for Improve-ment.New York, NY: The Commonwealth Fund; 2005

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DOI: 10.1542/peds.2010-2180 originally published online June 27, 2011;

2011;128;14

Pediatrics

Olson

Linda Radecki, Nina Sand-Loud, Karen G. O'Connor, Sanford Sharp and Lynn M.

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DOI: 10.1542/peds.2010-2180 originally published online June 27, 2011;

2011;128;14

Pediatrics

Olson

Linda Radecki, Nina Sand-Loud, Karen G. O'Connor, Sanford Sharp and Lynn M.

2009

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Trends in the Use of Standardized Tools for Developmental Screening in Early

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Figure

TABLE 1 Description of Respondents: AAP’s Periodic Survey of Fellows Grouped According toSurvey Year (2002 and 2009)
TABLE 2 Pediatrician Self-reported Use of Developmental Screening Methods, 2002 and 2009

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