Infant Social-Emotional (Autism) Screening

Note: A Draft Recommendation Statement: Screening for Autism Spectrum Disorder (U.S. Preventive Services) has been posted and is available for public comment from August 4, 2015–August 31, 2015.

Social-emotional problems may include the following:
  • autism spectrum disorders
  • attachment disorders
  • feeding problems
  • behavior problems

The American Academy of Pediatrics (AAP) guidelines for developmental screening include a screen for autism spectrum disorders at 18 and 24 (or 30) months [Johnson: 2007] , but consideration of other infant mental health problems or problems of social and emotional health is also warranted. Less than 1/3 of these children with disabilities are identified before they begin school, delaying appropriate and helpful interventions. With screening for social and emotional problems in infants and toddlers, primary care providers can link their patients to these helpful early interventions.

Improving social-emotional screening requires the use of standardized screening tools rather than relying on identifying possible delays or problems from parent's questions or clinical observations during a busy well- or sick-child visit (surveillance). While some experts recommend implementing social-emotional screening at every well-child visit, choosing key visits at critical ages can be a way to introduce standardized screening with manageable changes to office procedures.

The pediatrician is the best-informed professional with whom many families have contact during the first 5 years of a child's life. Parents look to the pediatrician to be the expert not only on childhood illnesses but also on child development and child behavior. [Committee: 2001] The American Academy of Pediatrics has published guidelines for developmental surveillance and screening. [American: 2006]

As a field of study, infant mental health is "concerned with the optimal physical, social, emotional, and cognitive development of the human infant within the context of his family." In screening for healthy mental health development, the infant is best evaluated within the "primary caregiving relationship - usually with his mother- and the pair is the focus of assessment and intervention." [Frederick H. Leonhardt Foundation]

Other Names

  • Infant mental health
  • Autism spectrum disorder

Early Signs

The following behaviors may indicate social/emotional or mental health problems:

Infants and toddlers:
  • Displays very little emotion: rarely coos, babbles, or whimpers
  • Sad affect; rejects being held or touched
  • Unusually difficult to soothe or console
  • Extremely fearful or on guard
  • Does not turn to familiar adults for comfort or help
  • Rare eye contact with caregiver
  • Unable to comfort or console self

Pre-school children:
  • Rarely or never engages in pretend play with others or objects
  • Very sad or flat affect, withdrawn, expressionless
  • Absence or delayed use of language or communication
  • Extreme mood swings
  • Inappropriate responses to situations (laughs instead of cries when hurt)
  • Loss of earlier skills like toileting, language, social or motor skills
  • Reckless behavior, accident prone, destructive to self or others, frequently fights

    Adapted from [Graham: 2001].
ICD-9

783.4, Lack of expected normal physiological development in childhood

V20.2, Routine infant or child health check

V70.0, Routine general medical examination at a health care facility

V79.3, Screening for developmental handicaps in early childhood

V79.8, Screening for other specified mental disorders and developmental handicaps

V79.9, Screening for unspecified mental disorder and developmental handicap

The listed ICD-9 and V codes may be used for screening. The list does not include codes for diagnosed conditions.

CPT

96110, Developmental Screening

96111, Developmental Testing

In 2003, "two codes specifically relating to 'developmental and behavioral' pediatrics were approved by CMS and thereby setting the path for reimbursement for the services these codes cover." [Edinburgh Postnatal Depression Scale (English)]

"Billing code 96110 covers a physician or non-physician administering a standardized screening instrument (broadband or autism-specific) to a child's guardian or other observer, and reflects only the physician time reviewing the scores and interpreting the findings with the family (rather than the actual work of giving the survey). Using this code requires documentation that the screen was given and the actions taken." [Developmental Screening Toolkit (Children's Hospital Boston)]

"When adding the 96110 screening code to an evaluation and management visit, American Medical Association CPT (Current Procedural Terminology) codes guide providers to append the modifier "-25" to the E/M code. Given that the evaluation is a significant, separate service from the screening procedure, it's acceptable to bill 96110 for every screening tool used. However, individual payers may contract with participating providers to include the screen within preventive care or E/M, or may direct their providers to bill differently from the AMA's CPT guidelines." [Developmental Screening Toolkit (Children's Hospital Boston)]

Guidelines

The American Academy of Pediatrics recommends universal screening at 18- and 24-month visits and also recommends screening outside these ages if parents or a provider have concerns.
Conduct developmental surveillance for all children at well-child visits; [Bright Futures Periodicity Schedule (AAP) (PDF Document 119 KB)] [Committee: 2001]
Use standardized screening tools for low-risk children at the 9-, 18, and or 30-month well-child visits. [Committee: 2001] [American: 2006] [American: 2007]

Tools

A brief list of suggested screening tools is provided, including Autism Specific Screening Tools for primary care (see the last three). Contact your state's Medicaid agency for other possible recommended tools.

Ages and Stages Questionnaire: Social-Emotional (ASQ:SE)

Description: A screening tool for social-emotional developmental screening that can be filled out by parents or providers and is designed for children from 6 to 60 months of age.. Sensitivity= 71-85%; specificity= 90-98%. [Overview of the ASQ:SE (PDF Document 38 KB)]

Source: Questionnaires are available , for a fee, n English and Spanish from the Brookes Publishing Company at Ages and Stages Questionnaire: Social-Emotional (ASQ:SE-2) (Brookes). Scoring instructions are available in the User's Guide. Other items are available for purchase, including the User's Guide and videos. Paper questionnaires are photocopiable. Questionnaires from the CD-ROM can be posted to password-protected web sites.

Parent's Evaluation of Developmental Status (PEDS)

Description: A developmental screening tool that can be filled out by parents and is designed for children from birth to 8 years of age. Estimated to take 2 - 10 minutes to complete. Sensitivity= 74-79%; specificity= 70-80%.

Source: Forms are available, for a small fee, in English and Spanish from Ellsworth & Vandermeer Press at Parent's Evaluation of Developmental Status (PEDS) site. Parent's Evaluation of Developmental Status (PEDS) site Scoring instructions are available in the Brief Administration and Scoring Guide. Other items are available for purchase including the Comprehensive PEDS Manual and a Discounted Bulk Order Package. Paper forms cannot be photocopied. Replacement forms must be purchased. Online options are available for purchase.

Temperament and Atypical Behavior Scale (TABS)

Description: A developmental screening tool that can be filled out by parents and is designed for children from 11 to 71 months of age. Sensitivity= 98%; specificity= 85%. The Evidence for Clinical Judgment in Early Intervention (PDF Document 72 KB)

Source: Forms are available, for a fee, in English from Brookes Publishing Company at Temperament and Atypical Behavior Scale (TABS). Temperament and Atypical Behavior Scale (TABS) Scoring instructions are in the Manual. Other items are available for purchase including the Manual and the Assessment Tool.

Modified Checklist for Autism in Toddlers – Revised, with Follow-Up (M-CHAT-R/F)

Description: The new MCHAT-R/F (released in 2013) is a free, 2-step tool that is more accurate than the previously used M-CHAT. It screens for autism from 16–30 months of age using a 20-item parent questionnaire that stratifies children’s risk for autism and may include a follow-up interview in the office or over the telephone:

  • Low risk (0–2 positives): No follow-up interview is required unless there are other risk factors noted during surveillance. Routine surveillance and repeat autism screening at 24-30 months still should be performed.
  • Medium risk (3–7 positives): Perform follow-up interview, which takes 5–10 minutes. Refer for formal autism evaluation and early intervention if interview scores are ≥2.
  • High risk (8–20 positives): Refer directly for a formal autism evaluation and early intervention.
The follow-up interview is important, especially for low-risk children, because it raises the positive predictive value from only 0.36 to 0.74. Use of the M-CHAT-R/F improves ASD identification time by about 2 years compared to use of surveillance alone. Of the 7% of children who were in the medium or high risk categories, about half ended up with a diagnosis of ASD, and the majority of the remaining children were found to have another developmental disorders or concerns. [National: 2013]

Source: Modified Checklist for Autism in Toddlers – Revised, with Follow-Up (M-CHAT-R/F) questionnaires are available from Dr. Robins. The checklist is free for reproduction provided that it is not modified and the copyright remains intact (see instructions on the screening tool).

Communication and Symbolic Behavior Scales Developmental Profile™ (CSBS DP™) Infant Toddler (CSBS-DP-IT) Checklist

Description: For use with children younger than 18 months. A 24-item parent-report questionnaire which quantifies an infant’s proficiency in three subdomains: social and emotional communication, receptive and expressive speech, and symbolic behavior. Uses the 10th percentile cutoff scores and estimated to take 5 - 10 minutes to complete by caregivers and scored in less than 2 minutes by medical staff.

Source: Free download with scoring sheet: Infant/Toddler Checklist from the Communication and Symbolic Behavior Scales Developmental Profile (PDF Document 56 KB)

Childhood Autism Syndrome Test (CAST)

Description: For preschool-aged and elementary schoolchildren. A 37-item parental self-completion screening questionnaire with a scoring range from 0 to 31. For the 31 scoring items, an autism-positive response scores 1 and an autism-negative response scores - cut-point for concerns of possible autism-spectrum condition is 15 or higher. At that cut-point, sensitivity has been shown to be 100%, specificity 97%

Source: Free download: Childhood Austism Syndrome Test (CAST)

Response to a Positive Screen

Primary Care

Well-child exams in the first years of life offer opportunities for early detection of problems with a child's development. Screening with a standardized instrument is the most reliable method of identifying developmental problems. Screening at well child visits should identify early disruptions in the attachment process.

  • When a delay is uncertain or not yet confirmed:
    • Help parents by recommending activities and resources to enhance development in the home
    • Continue to monitor the child's development closely and to address concerns of parents
    • If the screening tool indicates a possible delay, additional assessment may be needed and may be provided by the following service(s): see all Early Intervention Programs services providers (52) in our database
  • If delay is confirmed, make a referral to an early intervention program.
    • Know what a quality Early Intervention Program should provide:
      • full assessment of a child's current health and developmental status
      • service coordination among providers, programs, and agencies
      • strategies to build on family concerns, priorities, and resources
      • services including Occupational Therapy, Physical Therapy, and Speech Language Therapy
    • Fill out any necessary referral/release forms (see Resources) and refer to the following service(s): see all Early Intervention Programs services providers (52) in our database.
    • If possible, establish etiology of delay to determine:
      • Risk of recurrence
      • Prognosis
      • Need for follow-up of known complications
      • If there are available therapeutic interventions (available in rare cases)
    • Offer support to parents: One of the most difficult tasks in identifying a potential delay is sharing the concern with the parent. The following quote highlights the importance of focusing on the child rather than the potential label.
      • " Whenever I hear something "new" about Becca's condition or abilities, I have to remind myself that it didn't change her right then. We just now have a name for it. We have to take all of those labels and realize that all of those together are the beautiful child that we love so much and that it can be helpful to name the problem so that we can work on it, but it doesn't change her or our love for her." Diana S.
    • Coordinate care: Link children with special health care needs and their families to services and resources in a coordinated effort to maximize the potential of the children and provide them with optimal health care. [Council: 2005]

Specialty Care

There are a variety of services that are available to help treat social-emotional delays, including those associated with the autism spectrum.
  • Early intervention programs are federally-supported and provide assessments and treatments for children ages 0-36 months (see all Early Intervention Programs services providers (52) in our database).
  • Infant/pre-school services, such as Early Head Start for children ages 0-3 years and Head Start for children ages 3-5 years, provide learning opportunities and parent training to help children maintain or develop skills to help them enter school healthy and ready to learn (see all Mental Health Infant/Preschool services providers (14) in our database).
  • Behavioral programs focus on improving behavioral skills for children with identified developmental delays or behavioral conditions (see all Behavioral Programs services providers (31) in our database).
  • Child psychologists can evaluate developmental delays and provide treatment therapies (see all Psychologist, Child-18 services providers (151) in our database).
  • Child psychiatrists, often working with child psychologists, can prescribe medications that treat underlying medical or mental health conditions (see all Psychiatrist, Child-18 services providers (28) in our database).
  • Condition-specific clinics, such as a clinic for autism, may be available where children have access to specialized and multi-disciplinary care (see all Autism Clinics services providers (7) in our database).
  • Sometimes known as Children with Special Health Care Needs Clinics, some states may have state- or federally-funded clinics, which have expertise in diagnosing or coordinating care for children with complex conditions including those with developmental delays (see all CSHCN Clinics services providers (15) in our database).

Resources

Information & Support

For Professionals

Utah Medicaid Provider Manual for CHEC (PDF Document 130 KB)
The Utah Medicaid Provider Manual for Child Health Evaluation and Care (CHEC) Services provides regulations for the Early Periodic Screening, Diagnosis and Treatment (EPSDT) Program including a list of recommended developmental screening tools.

Utah Public Mental Health Practice Model (PDF Document 44 KB)
The Utah Public Mental Health Practice Model for Infants and Toddlers (Birth to Five), approved by the Utah Division of Substance Abuse and Mental Health, was developed for providers and agencies serving young children in Utah.

Utah Association for Infant Mental Health
Hosted by Utah State University, this site includes: an overview of infant mental health; announcements; and tool kits (with documents, presentations, sample agreements, patient education materials).

Developmental Screening (CDC)
Provides an overview of screening, the pros and cons of screening tools, links to federal resources; Centers for Disease Control and Prevention.

Parent's Evaluation of Developmental Status (PEDS) site
PEDS and PEDS:DM provide 5-minute screenings, longitudinal surveillance, and triage for developmental as well as behavioral/social-emotional/mental health problems. Can be completed by parent self-report, interview, or administered directly to children; available for a fee.

Early Childhood Mental Health: What is it all about? (PDF Document 33 KB)
This 2001 paper by Cindy Oser, RN, MS at Zero To Three discusses a framework for the context, content, and cornerstones of infant mental health and includes references, links, and resources.

What is Child Traumatic Stress?
Child traumatic stress occurs when children and adolescents are exposed to traumatic events or situations that overwhelm their ability to cope. This area of the NCTS website has many handouts with education and questions and answers about child traumatic stress.

The Adverse Childhood Experiences (ACE) Study (CDC)
One of the largest investigations ever conducted to assess associations between childhood maltreatment and later-life health and well-being; Centers for Disease Control and Prevention.

The Infant Mental Health Specialist (PDF Document 686 KB)
This 2000 paper by Deborah J. Weatherston provides information about the skills, clinical strategies, role, and training of an infant mental health specialist.

Developmental Screening and Assessment Instruments (PDF Document 997 KB)
This 20-pg document, published in 2008, compares developmental and social-emotional screening instruments with descriptions; age ranges; time to administer, scoring procedures, psychometric properties; requirements for administrators; who can administer the instrument; and more. From the National Early Childhood Technical Assistance Center, with funding from the U.S. Office of Special Education Programs.

DBPeds.org Screening and Assessment
This web page contains links to a number of screening and assessment tools available for different aspects of developmental, behavioral and emotional health, including the Modified Checklist for Autism in Toddlers (M-CHAT) form, available for free download.

M-CHAT-R/F Screen (PDF Document 1 KB)
Parent-completed questionnaire designed to identify children at risk of autism. A copyrighted instrument available for free download in different languages for clinical, research, and educational purposes.

For Parents and Patients

Early Developmental Guide for Parents
From the Utah Department of Health, a list of milestones for ages 1-2 months, 3-4 months, 6 months, 9 months, 12 months, 18 months, 2-3 years. Includes development, nutrition, communication/hearing/vision, and guidance for parents

Parenting Children Aged Zero to Three
A webpage from the Zero to Three national, nonprofit organization dedicated to supporting families and communities in the care of young children. This site has links to FAQs; parenting tips; and reproducible handouts for parents. Topics include behavior, play, language, and more.

Practice Guidelines

American Academy of Pediatrics.
Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening.
Pediatrics. 2006;118(1):405-20. PubMed abstract / Full Text
Children diagnosed with developmental disorders should be identified as children with special health care needs, and chronic-condition management should be initiated. Identification of a developmental disorder and its underlying etiology may also drive a range of treatment planning, from medical treatment of the child to family planning for his or her parents.

Johnson CP, Myers SM.
Identification and evaluation of children with autism spectrum disorders.
Pediatrics. 2007;120(5):1183-215. PubMed abstract
Comprehensive clinical report addressing the definition, history, epidemiology, diagnostic criteria, early signs, neuropathologic aspects, and etiologic possibilities in autism spectrum disorders. This report also provides the primary care provider with an algorithm for assistance in the early identification of children with autism spectrum disorders.

Services

Autism Clinics

See all Autism Clinics services providers (7) in our database.

Behavioral Programs

See all Behavioral Programs services providers (31) in our database.

CSHCN Clinics

See all CSHCN Clinics services providers (15) in our database.

Early Intervention Programs

See all Early Intervention Programs services providers (52) in our database.

Family Support Organizations

See all Family Support Organizations services providers (7) in our database.

Mental Health Infant/Preschool

See all Mental Health Infant/Preschool services providers (14) in our database.

Psychiatrist, Child-18

See all Psychiatrist, Child-18 services providers (28) in our database.

Psychologist, Child-18

See all Psychologist, Child-18 services providers (151) in our database.

For other services related to this condition, browse our Services categories or search our database.

Helpful Articles

Pinto-Martin JA, Dunkle M, Earls M, Fliedner D, Landes C.
Developmental stages of developmental screening: steps to implementation of a successful program.
Am J Public Health. 2005;95(11):1928-32. PubMed abstract / Full Text

Pierce K, Carter C, Weinfeld M, Desmond J, Hazin R, Bjork R, Gallagher N.
Detecting, Studying, and Treating Autism Early: The One-Year Well-Baby Check-Up Approach.
J Pediatr. 2011. PubMed abstract / Full Text
The 1-Year Well-Baby Check-Up Approach shows promise as a simple mechanism to detect cases of ASD, LD, and DD at 1 year.

Miller JS, Gabrielsen T, Villalobos M, Alleman R, Wahmhoff N, Carbone PS, Segura B.
The each child study: systematic screening for autism spectrum disorders in a pediatric setting.
Pediatrics. 2011;127(5):866-71. PubMed abstract
A partnership between pediatricians and autism specialists resulted in effective, systematic autism screening. Future studies should examine how to create effective systems of care.

Authors

Authors: Sarah Winter, MD - 5/2011
Paul Carbone, MD - 5/2011
Contributing Author: Alfred Romeo, RN, PhD - 11/2010
Content Last Updated: 8/2011

Page Bibliography

American Academy of Pediatrics.
Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening.
Pediatrics. 2006;118(1):405-20. PubMed abstract / Full Text
Children diagnosed with developmental disorders should be identified as children with special health care needs, and chronic-condition management should be initiated. Identification of a developmental disorder and its underlying etiology may also drive a range of treatment planning, from medical treatment of the child to family planning for his or her parents.

American Academy of Pediatrics.
Recommendations for preventive pediatric health care.
Pediatrics. 2007;120(6):1376. PubMed abstract / Full Text

Committee on Children with Disabilties.
Developmental surveillance and screening of infants and young children.
Pediatrics. 2001;108(1):192-6. PubMed abstract / Full Text
This article encourages physicians to use standardized developmental screening tools and suggests that testing children at periodic intervals will increase accuracy and further early intervention.

Council on Children with Disabilities.
Care coordination in the medical home: integrating health and related systems of care for children with special health care needs.
Pediatrics. 2005;116(5):1238-44. PubMed abstract / Full Text

Graham, MA; White, BA; Clarke, CC; Adams, S.
Infusing infant mental health practices into front-line caregiving.
Infants and Young Children. 2001;14(1):14-23.

Johnson CP, Myers SM.
Identification and evaluation of children with autism spectrum disorders.
Pediatrics. 2007;120(5):1183-215. PubMed abstract
Comprehensive clinical report addressing the definition, history, epidemiology, diagnostic criteria, early signs, neuropathologic aspects, and etiologic possibilities in autism spectrum disorders. This report also provides the primary care provider with an algorithm for assistance in the early identification of children with autism spectrum disorders.

National Institutes of Health.
Revised autism screening tool offers more precise assessment.
U.S. Department of Health & Human Services National Institutes of Health; (2013) http://www.nih.gov/news/health/dec2013/nichd-23.htm. News release.. Accessed on August 2015.