Dissertations and Theses

Date of Degree


Document Type


Degree Name

Doctor of Public Health (DPH)


Health Policy and Management


Alexis Pozen

Committee Members

Betsy Eastwood

Mary Clare Lennon

Deborah Perry

Subject Categories

Health Policy | Maternal and Child Health | Other Mental and Social Health | Pediatrics | Primary Care | Public Health


Development, child, health, policy, screening, survey


Background: The skills and capacities developed during early childhood are the foundation for a child’s future academic functioning, economic productivity, and lifelong health and mental health. When young children have developmental delays or disabilities, early identification and intervention lead to better outcomes; however, only a minority are identified before school entry. Primary care is an important setting for identification of developmental and behavioral conditions as most young children attend well-child visits regularly and parents expect developmental guidance from pediatricians. Two key pediatric preventive services are recommended: developmental monitoring/surveillance at every well-child visit and developmental screening at 9 months, 18 months, and 30 months (or 24 months) or if a concern is raised at any other visit. Research has shown that when health care providers conduct screening (using a standardized, validated screening tool), they are more likely to identify developmental and behavioral conditions than when they conduct monitoring (eliciting parent concerns and using observation and clinical judgment). In addition, health care providers are less likely to identify developmental and behavioral conditions among black children, Latino children, and low-income children.

Aims: To describe rates of developmental and behavioral screening and monitoring across subgroups of children. To determine whether there are racial/ethnic disparities in receipt of screening and monitoring. To describe the variation in screening and monitoring rates across states and identify state-level policy factors that may influence screening rates.

Methods: We used data from the 2011/2012 National Survey of Children’s Health (NSCH) for children 5 years and under who saw a health care provider in the previous 12 months. Patterns in children’s receipt of screening and monitoring were assessed, including changes from the 2007 NSCH. Multilevel logistic regression models evaluated socio-demographic, health care and developmental risk factors associated with children’s receipt of screening and monitoring. Policy data from a 2011 survey of state Medicaid officials were used to examine the association between receipt of screening and two Medicaid policies.

Results: Nationally, fewer than one in three children 5 years and under (30.8%) were reported to have received a parent-completed, screening in the previous 12 months, with rates varying from 17.5% in Mississippi to 58.0% in North Carolina. Rates of developmental and behavioral monitoring varied from 39.8% in Mississippi to 66.6% in Vermont, with a national average of 51.8%. Forty percent of children received neither monitoring nor screening. Children under 3 years of age were more likely to receive screening and monitoring than were preschool-age children. There were no differences in receipt of screening by sex, race/ethnicity, household income, insurance type, or access to a patient-centered medical home. In contrast, there was considerable variability in developmental and behavioral monitoring across subgroups of children. Black children and Latino children from non-English speaking homes had lower odds of receiving monitoring that white children. Children in a medical home were almost twice as likely to be monitored than children who were not in a medical home. From 2007 to 2011/12, screening rates increased overall but the percent change was lower for black children than for white children and for children living in poverty than for higher income children. Some states were more successful at increasing their screening rates from 2007 to 2011/12 than others, with Massachusetts showing the largest increase. State Medicaid policies to require screening and to pay an additional fee for screening were not associated with increased odds of children on Medicaid being screened.

Conclusions: There are significantly lower rates of screening and monitoring of young children’s development and behavior than recommended in pediatric practice guidelines. Monitoring, specifically eliciting parent concerns, is unevenly applied across patient populations. By using standardized, parent-completed screening tools, it is possible to access parent-reported information directly rather than relying on the provider to elicit parent concerns. Screening could therefore be a means to reduce racial/ethnic disparities in identification of developmental and behavioral conditions and potentially reduce disparities in young children’s outcomes. Children 3 to 5 years of age had significantly lower screening rates than children under 3, suggesting the importance of targeted efforts to increase screening for the preschool age group to ensure identification of developmental and behavioral concerns before school entry. Certain states are more successful in increasing screening rates than others; further study of their state-level policies is warranted.

Policy Implications: It is a public health priority to identify developmental and behavioral conditions in an accurate, timely, and equitable manner. States have access to several important policy levers to incentivize health care providers to incorporate screening into their practices. Screening mandates may be particularly important, along with provider training and education, family engagement, easier access to intervention services, and integrated data systems with a requirement to track and report screening. Reimbursement for screening may be used across Medicaid fee-for-service and Medicaid managed-care systems. It is important to promote linguistic and cultural competence in screening and engage parents to act on the results. Use of a combination of state-level universal screening policies as well as targeted strategies for specific populations may increase identification of developmental and behavioral conditions among all young children while helping to reduce disparities in identification. This would help ensure young children are linked to appropriate interventions that improve their developmental and health outcomes.



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