Practice parameter: Evaluation of the child with global developmental delay: Report of the Quality
Thomas OCrawford, Johns Hopkins University School of Medicine Baltimore MDtcrawfo@jhmi.edu
Anne Comi, John M Freeman, Eric H Kossoff, Harvey Singer, Eileen P G Vining and Kaleb Yohay
Submitted June 19, 2003
The evaluation of a child with developmental delay is complex. There
are, and should be, many different competing concerns in planning this
evaluation. We find the recently published practice parameters for
developmental delay a laudable exercise in evidence-based medicine, but
find the recommendations insufficiently deferential to these concerns. [1]
There are many complexities requiring consideration:
1) The value of diagnosis is highly variable. Some diagnoses will
initiate a successful therapy or prevent the initiation of inappropriate
therapy, some will permit informed genetic counseling, and some will
provide the solace of explanation to distressed family members. The value
of a potential diagnosis must be balanced against the burdens of obtaining
that diagnosis.
2) The certainty of specific diagnoses varies, and come findings
(e.g. sulcal widening on MRI or diffuse slowing on EEG) have descriptive,
but little etiologic, significance.
3) The costs associated with various tests, both in financial terms
and the potential for untoward complications of studies under sedation or
general anesthesia, must be part of the equation.
4) The population to be evaluated is poorly defined. Those with
deficits in the development of motor ability, speech and language,
cognitive, personal and social skills, or activities of daily living,
either in isolation or in various combinations with one another, will have
very different diagnostic yields on individual tests.
5) Local variation in the quality, cost, and logistic difficulties
encountered in obtaining various tests are not accounted for, nor are
variations in the level of expertise required to initiate a work up. The
history, physical examination and opinion of subspecialists in neurology,
neurodevelopmental disabilities, and genetics, as opposed to those of
primary care providers, will likely introduce differences in the pretest
probability of a positive result and alter the predictive value of
individual diagnostic tests.
Practice parameters, as opposed to practice guidelines, have the
potential for generating legal liability. They set a single standard
against which the performance of pediatricians and pediatric
subspecialists will be measured. We believe that the diagnostic evaluation
of the child manifesting signs of abnormal development is sufficiently
multidimensional that the available data, collected on widely varying
populations by investigators with widely varying resources and expertise,
do not permit establishment of such a standard. Nonetheless, we welcome
and value the committee's considerable efforts as a first approximation
for a proper diagnostic assessment.
Reference:
1) Shevell M, Ashwal, Donley D, et al. Practice Parameter: Evaluation
of the child with global developmental delay. Report of the Quality
Standards Subcommittee of the American Academy of Neurology and The
Practice Committee of the Child Neurology Society. Neurology 2003;60:367-
380.
The evaluation of a child with developmental delay is complex. There are, and should be, many different competing concerns in planning this evaluation. We find the recently published practice parameters for developmental delay a laudable exercise in evidence-based medicine, but find the recommendations insufficiently deferential to these concerns. [1]
There are many complexities requiring consideration:
1) The value of diagnosis is highly variable. Some diagnoses will initiate a successful therapy or prevent the initiation of inappropriate therapy, some will permit informed genetic counseling, and some will provide the solace of explanation to distressed family members. The value of a potential diagnosis must be balanced against the burdens of obtaining that diagnosis.
2) The certainty of specific diagnoses varies, and come findings (e.g. sulcal widening on MRI or diffuse slowing on EEG) have descriptive, but little etiologic, significance.
3) The costs associated with various tests, both in financial terms and the potential for untoward complications of studies under sedation or general anesthesia, must be part of the equation.
4) The population to be evaluated is poorly defined. Those with deficits in the development of motor ability, speech and language, cognitive, personal and social skills, or activities of daily living, either in isolation or in various combinations with one another, will have very different diagnostic yields on individual tests.
5) Local variation in the quality, cost, and logistic difficulties encountered in obtaining various tests are not accounted for, nor are variations in the level of expertise required to initiate a work up. The history, physical examination and opinion of subspecialists in neurology, neurodevelopmental disabilities, and genetics, as opposed to those of primary care providers, will likely introduce differences in the pretest probability of a positive result and alter the predictive value of individual diagnostic tests.
Practice parameters, as opposed to practice guidelines, have the potential for generating legal liability. They set a single standard against which the performance of pediatricians and pediatric subspecialists will be measured. We believe that the diagnostic evaluation of the child manifesting signs of abnormal development is sufficiently multidimensional that the available data, collected on widely varying populations by investigators with widely varying resources and expertise, do not permit establishment of such a standard. Nonetheless, we welcome and value the committee's considerable efforts as a first approximation for a proper diagnostic assessment.
Reference:
1) Shevell M, Ashwal, Donley D, et al. Practice Parameter: Evaluation of the child with global developmental delay. Report of the Quality Standards Subcommittee of the American Academy of Neurology and The Practice Committee of the Child Neurology Society. Neurology 2003;60:367- 380.