Narrative ReviewIs a Positive Developmental-Behavioral Screening Score Sufficient to Justify Referral? A Review of Evidence and Theory
Section snippets
Overstated Values
Group-level statistics like PPV overstate the value of recommended screening thresholds. Screening instruments are often evaluated according to the proportion of children with disabilities who score positive (ie, sensitivity), and the proportion of children without disabilities who score negative (ie, specificity). Many guidelines—including the AAP's—recommend minimum values of 70% for sensitivity as well as specificity.1, 6 Statistics like sensitivity and specificity are extremely useful for
Unaccounted Costs
Recommended screening thresholds often fail to account for the expected costs and benefits of available referral options. How high must threshold probability be to justify a referral? Decision analysis offers a clear response: A child should be referred if the probability of disability is high enough that the benefits of referral are likely to outweigh costs and potential for harm.10 Because of uncertainty about the precise extent and severity of a child's symptoms, it is often unclear whether
Screening Policy
We argue that policy statements should not recommend referral for all children with positive screening results unless there is evidence that the benefits are likely to outweigh costs and harms for children who score at recommended screening thresholds. Because of the absence of such evidence for developmental-behavioral screening, current recommendations should be significantly revised to offer more specific guidance regarding expectations for individual practitioners. Referrals for all
Education
With increased emphasis on clinical judgement, improvements in education are also warranted. To improve the diagnostic process, the IOM/NAM specifically recommends enhancing professional education and training in “clinical judgement” and “appropriate use of diagnostic tests and the application of these results on subsequent decision-making.”11pp364 If screening is not sufficient to drive referral decisions, then enhanced training in clinical reasoning might be needed. A large literature in
Research
Most research on screening focuses on the standardization, construct validity, and diagnostic accuracy of screening instruments. In contrast, the IOM/NAM describes diagnosis as a longitudinal, iterative process that often involves multiple team members and close engagement with families. This perspective suggests that research on screening should not be confined to the accuracy of screening instruments when used alone, but should also address their ability to improve clinical decision-making in
Acknowledgments
Financial disclosure: Research support was provided by NICHD R01 HD072778. The opinions expressed in this article are the author's own and do not reflect the view of the National Institutes of Health, the Department of Health and Human Services, or the United States government.
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2020, Academic PediatricsCitation Excerpt :Further improvement in predictive value was obtained when the referral threshold was increased while keeping the nonreferral threshold stable and defining an in-between group with LR's too weak to qualify for referral and too strong to dismiss it. Variants of this approach have been championed by Sheldrick et al8,9,19 and others20 as resembling what happens in clinical practice. Clinicians often feel very confident about referring some children and not referring others but seek additional information to resolve uncertainty in making a decision for individuals in the in-between group.
Psychometric Properties of Two Developmental Screening Instruments for Hispanic Children in the Philadelphia Region
2019, Academic PediatricsCitation Excerpt :The generally poor positive predictive values for both instruments imply that a large number of false positives will be associated with both tests, and the generally good negative predictive values suggest that both instruments functioned quite well in ruling out the presence of any developmental delays. Positive predictive value is a common characteristic of screening tools, especially for lower incidence concerns.32,33 These findings support that screening should be a part of a broader process of developmental surveillance which includes consideration of parental concerns, medical history, and the family and neighborhood environment.
The authors have no conflicts of interest to disclose.