Clinical Judgment and Child Development, Revisited.

Abstract

Child development is the clinical process that distinguishes pediatrics from all other medical specialties, and concerns about development, learning, and behavior are among the most prevalent clinical issues encountered by all pediatricians. Thus, clinical judgment in child development should be highly valued. Instead, pediatrician clinical judgment has been widely criticized, shifting recent focus to parent-completed developmental screening.1,2 The article by Zubler et al3 in this issue of Pediatrics may provide an opportunity to reassert clinical judgment into the medical developmental assessment process.The sensitivity and positive predictive value (PPV) of developmental screens drops considerably when moving from research to real-world clinical settings. For example, recent studies of the use of the Modified Checklist for Autism (M-CHAT) for screening in large health care networks in the United States have reported sensitivities ranging from only 33% to 39% and PPVs ranging from only 15% to 18%.4,5 A population-based study in Norway reported the PPV of the M-CHAT to be only 1.5%, which is equivalent to the PPV of a coin flip.6 Similarly, general developmental screening using instruments such as the Ages and Stages Questionnaire has been shown to have variable utility with very young children and children in low-resource settings.7 It seems, then, that rather than focusing exclusively on parent-completed screens, the clinical judgment and accumulated clinical experiences of pediatricians should be taken advantage of in the developmental assessment process.Developmental screening certainly has an important role in the developmental assessment process; standardized parent-completed screens are clearly a quick and efficient way to identify the chief complaint of a developmental concern. The most recent American Academy of Pediatrics clinical report on developmental surveillance and screening recommends consideration of referring those children who fail screening to a pediatric medical subspecialist, such as a neurodevelopmental pediatrician, developmental-behavioral pediatrician, pediatric neurologist, or pediatric physiatrist, for developmental evaluation and diagnosis.8 However, the severe discrepancy between the nearly 20 million children in the United States with concerns about development, learning, and/or behavior and the low numbers of pediatric medical subspecialists to whom to refer (including <800 practicing board-certified developmental-behavioral pediatricians) makes this recommendation unfeasible for the vast majority of children who fail screening.9 It seems more achievable to remodel pediatric training (beyond the current 4-week rotation in developmental–behavioral pediatrics) and practice to improve clinical developmental assessment, and the work of Zubler et al is a first step in this direction.3Zubler et al have established evidence-informed developmental milestones across motor, cognitive, language/communication, and social-emotional domains that are easily observed in natural settings for use in developmental surveillance at specific health supervision visit ages.3 Developmental surveillance is all about clinical judgment, and it contains the essence of medical training: taking a history and performing an examination (in this case, taking a developmental history and performing a developmental examination). The evidence-informed developmental milestones provided by Zubler et al provide some standardization to this clinical process of developmental surveillance.3 These evidence-informed milestones can be used to obtain a developmental history that identifies both perturbations in development (delay, dissociation, and deviation) that characterize specific developmental diagnoses and the pattern of developmental delay (static, acute, or progressive) that is critical for medical workup and recommendations for therapeutic intervention. Such historical information based on evidence-informed milestones, combined with the clinical judgment of well-trained and experienced pediatricians, should provide far more robust developmental information than a pass/fail score from a screen.Given the number of children with concerns about development, learning, and behavior, and the performance of developmental screens in real-world practice, attempts to validate clinical developmental assessment in primary care may be the best solution to the gross mismatch between the demand for and supply of pediatric medical subspecialists; although, to be truly successful, efforts to improve clinical developmental assessment must be linked to efforts to ensure access to early intervention. Zubler et al have provided milestones to inform clinical judgment in developmental history-taking, so the next step might be to design a similar evidence-informed developmental examination process that pediatricians can use to confirm the historical information provided by parents. In this way, all pediatricians may be able to practice their basic science of child development10 using valid and reliable clinical tools such as those suggested by the work of Zubler et al.3