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Are Overreferrals on Developmental Screening Tests Really a Problem?
Frances Page Glascoe, PhD
Arch Pediatr Adolesc Med. 2001;155:54-59.
Background Developmental screening tests, even those meeting standards for screening
test accuracy, produce numerous false-positive results for 15% to 30% of children.
This is thought to produce unnecessary referrals for diagnostic testing or
special services and increase the cost of screening programs.
Objectives To explore whether children who pass screening tests differ in important
ways from those who do not and to determine whether children overreferred
for testing benefit from the scrutiny of diagnostic testing and treatment
planning.
Methods Subjects were a national sample of 512 parents and their children (age
range of the children, 7 months to 8 years) who participated in validation
studies of various screening tests. Psychological examiners adhering to standardized
directions obtained informed consent and administered at least 2 developmental
screening measures (the Brigance Screens, the Battelle Developmental Inventory
Screening Test, the Denver-II, and the Parents' Evaluations of Developmental
Status) and a concurrent battery of diagnostic measures, including tests of
intelligence, language, and academic achievement (for children aged 2
years and older). The performance on diagnostic measures of children who failed
screening but were not found to have a disability (false positives) was compared
with that of children who passed screening and did not have a disability on
diagnostic testing (true negatives).
Results Children with false-positive scores performed significantly (P<.001) lower on diagnostic measures than did children with true-negative
scores. The false-positive group had scores in adaptive behavior, language,
intelligence, and academic achievement that were 9 to 14 points lower than
the scores of those in the true-negative group. When viewing the likelihood
of scoring below the 25th percentile on diagnostic measures, children with
false-positive scores had a relative risk of 2.6 in adaptive behavior (95%
confidence interval [CI], 1.67-4.21), 3.1 in language skills (95% CI, 1.90-5.20),
6.7 on intelligence tests (95% CI, 3.28-13.50), and 4.9 on academic measures
(95% CI, 2.61-9.28). Overall, 151 (70%) of the children with false-positive
results scored below the 25th percentile on 1 or more diagnostic measures
(the point at which most children have difficulty benefiting from typical
classroom instruction) in contrast with 64 (29%) of the children with true-negative
scores (odds ratio, 5.6; 95% CI, 3.73-8.49). Children with false-positive
scores were also more likely to be nonwhite and to have parents who had not
graduated from high school. Performance differences between children with
true-negative scores and children with false-positive scores continued to
be significant (P<.001) even after adjusting for
sociodemographic differences between groups.
Conclusions Children overreferred for diagnostic testing by developmental screens
perform substantially lower than children with true-negative scores on measures
of intelligence, language, and academic achievement—the 3 best predictors
of school success. These children also carry more psychosocial risk factors,
such as limited parental education and minority status. Thus, children with
false-positive screening results are an at-risk group for whom diagnostic
testing may not be an unnecessary expense but rather a beneficial and needed
service that can help focus intervention efforts. Although such testing will
not indicate a need for special education placement, it can be useful in identifying
children's needs for other programs known to improve language, cognitive,
and academic skills, such as Head Start, Title I services, tutoring, private
speech-language therapy, and quality day care.
From the Department of Pediatrics, College of Medicine, The Pennsylvania
State University, East Berlin; and the Department of Pediatrics, Vanderbilt
University, Nashville, Tenn.
Corresponding author: Frances Page Glascoe, PhD, Department of Pediatrics,
College of Medicine, The Pennsylvania State University, 25 Bragg Dr, East
Berlin, PA 17316 (e-mail: Frances.P.Glascoe{at}Vanderbilt.edu).
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