StephenAshwal, Loma Linda University Schol of Mediciane CAsashwal@ahs.llumc.edu
Michael Shevell, Carmela Tardo and Gary Franklin
Submitted June 19, 2003
Practice Parameters are guidelines that through systematic review of
the literature address the goal of achieving best practice. In the
evaluation of the child with global developmental delay (GDD),
developmental performance is targeted in follow-up programs addressing
children at increased biological or social risk. Developmental concerns
prompt early intervention programs and referral for further evaluation.
[1, 2] The definition in the parameter [3] distinguishes the evaluation
approach taken for this clinical problem from that which would be taken
for a child with a delay restricted to a single domain (i.e. motor delay,
specific language impairment). Cognitive delay invariably includes
language and activity of daily living skills, and thus is included within
our definition. The distinction between GDD and autistic spectrum
disorders should not be troublesome as the latter requires observation of
specific abnormalities in language and social skills beyond mere
quantitative delay.
We appreciate that Crawford et al. consider the GDD practice
parameter a "laudable exercise" the product of "considerable efforts" to
yield a framework "for a proper diagnostic assessment". With regards to
their specific points, the value of a diagnosis is indeed highly variable
depending on the results obtained and its implications for child and
family. However it cannot be known a priori before undertaking a search
for causality. Perhaps, potential value can be judged by the overwhelming
willingness of families to undergo the studies requested. Careful reading
of the parameter reveals that the practitioner must consider and balance
potential risks of various studies against their potential yield.
Similarly, we acknowledge in the document that local limitations in access
may modify the actual selection of tests. Additionally we emphasize the
importance of the history and physical examination in the evaluation of
the child with GDD. Clearly, one size or a single standard as suggested by
Crawford et al. would not be suitable for all children. By emphasizing the
importance of the history and physical examination throughout the
document, we hope to capture the multidimensional nature of a diagnostic
evaluation while at the same time providing a rational basis for selected
testing.
Practice parameters involve multiple reviewers with many
perspectives. All comments were carefully considered. Dr. Whelan was the
sole reviewer during this lengthy process to raise concerns regarding our
working definition. The editorial by Franklin and Zahn [4] cited by Dr.
Whelan does not endorse her request for publication of a single
'dissenting opinion'. Dr. Whelan's comments regarding the process of how
this practice parameter was developed and approved are inaccurate. The
first draft of this document was prepared on August 12, 1999 and underwent
multiple revisions before the Quality Standards Subcommittee (QSS) of the
American Academy of Neurology (AAN) (August 11, 2001) first reviewed it.
It was revised and then reviewed by members of the Child Neurology Society
(CNS) Practice Committee and the AAN Reviewers Network. It was also
reviewed by selected members of other organizations including the American
Association of Mental Retardation, three sections from the American
Academy of Pediatrics including the Section on Children with Disabilities,
Section on Neurology and Section on Developmental and Behavioral
Pediatrics as well as the Committee on Quality Improvement. An additional
section with consensus-based recommendations for selective screening and
an algorithm were also added. The document was again reviewed and
approved by QSS on April 16, 2002. It then underwent further peer review
by four individuals from Neurology and again by members of the CNS
Practice Committee. This committee (June 30, 2002) voted to approve the
document by email. Of 21 members who received the document, 14 responded--
11 approved the document, two made comments, and one (Dr. Whelan)
disapproved. The final draft was accepted by Neurology for publication on
July 16, 2002 approved by QSS on August 1, 2002 and by the AAN Practice
Committee on August 3, 2002. The Executive Boards of both organizations
(CNS, August 15, 2002; AAN, October 19, 2002) then gave final approval.
Overall nearly 100 individuals from multiple disciplines reviewed drafts
of the document during this three-year period. All comments were
addressed by a specific QSS developed process that explicitly documented
the reviewer's concerns and how the authors addressed each issue. We feel
that this process as it has done with previously published evidenced-based
practice parameters sponsored by the AAN, results in documents of value to
physicians and their patients.
References
1. Committee to Advise the Public Health Service on Clinical Practice
Guidelines, Institute of Medicine. Field MJ, Lohr KN, eds. Clinical
practice guidelines: directions of a new program. Washington, DC: National
Academy Press, 1990.
2. American Academy of Pediatrics Committee on Children with
Disabilities. Developmental surveillance and screening in infants and
young children. Pediatrics 2001;108:192-196.
3. Shevell M, Ashwal S, 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;60:367-80.
4. Franklin GM, Zahn CA. AAN clinical practice guidelines: Above the
fray. Neurology 2002;59:975-976.
Practice Parameters are guidelines that through systematic review of the literature address the goal of achieving best practice. In the evaluation of the child with global developmental delay (GDD), developmental performance is targeted in follow-up programs addressing children at increased biological or social risk. Developmental concerns prompt early intervention programs and referral for further evaluation. [1, 2] The definition in the parameter [3] distinguishes the evaluation approach taken for this clinical problem from that which would be taken for a child with a delay restricted to a single domain (i.e. motor delay, specific language impairment). Cognitive delay invariably includes language and activity of daily living skills, and thus is included within our definition. The distinction between GDD and autistic spectrum disorders should not be troublesome as the latter requires observation of specific abnormalities in language and social skills beyond mere quantitative delay.
We appreciate that Crawford et al. consider the GDD practice parameter a "laudable exercise" the product of "considerable efforts" to yield a framework "for a proper diagnostic assessment". With regards to their specific points, the value of a diagnosis is indeed highly variable depending on the results obtained and its implications for child and family. However it cannot be known a priori before undertaking a search for causality. Perhaps, potential value can be judged by the overwhelming willingness of families to undergo the studies requested. Careful reading of the parameter reveals that the practitioner must consider and balance potential risks of various studies against their potential yield. Similarly, we acknowledge in the document that local limitations in access may modify the actual selection of tests. Additionally we emphasize the importance of the history and physical examination in the evaluation of the child with GDD. Clearly, one size or a single standard as suggested by Crawford et al. would not be suitable for all children. By emphasizing the importance of the history and physical examination throughout the document, we hope to capture the multidimensional nature of a diagnostic evaluation while at the same time providing a rational basis for selected testing.
Practice parameters involve multiple reviewers with many perspectives. All comments were carefully considered. Dr. Whelan was the sole reviewer during this lengthy process to raise concerns regarding our working definition. The editorial by Franklin and Zahn [4] cited by Dr. Whelan does not endorse her request for publication of a single 'dissenting opinion'. Dr. Whelan's comments regarding the process of how this practice parameter was developed and approved are inaccurate. The first draft of this document was prepared on August 12, 1999 and underwent multiple revisions before the Quality Standards Subcommittee (QSS) of the American Academy of Neurology (AAN) (August 11, 2001) first reviewed it. It was revised and then reviewed by members of the Child Neurology Society (CNS) Practice Committee and the AAN Reviewers Network. It was also reviewed by selected members of other organizations including the American Association of Mental Retardation, three sections from the American Academy of Pediatrics including the Section on Children with Disabilities, Section on Neurology and Section on Developmental and Behavioral Pediatrics as well as the Committee on Quality Improvement. An additional section with consensus-based recommendations for selective screening and an algorithm were also added. The document was again reviewed and approved by QSS on April 16, 2002. It then underwent further peer review by four individuals from Neurology and again by members of the CNS Practice Committee. This committee (June 30, 2002) voted to approve the document by email. Of 21 members who received the document, 14 responded-- 11 approved the document, two made comments, and one (Dr. Whelan) disapproved. The final draft was accepted by Neurology for publication on July 16, 2002 approved by QSS on August 1, 2002 and by the AAN Practice Committee on August 3, 2002. The Executive Boards of both organizations (CNS, August 15, 2002; AAN, October 19, 2002) then gave final approval. Overall nearly 100 individuals from multiple disciplines reviewed drafts of the document during this three-year period. All comments were addressed by a specific QSS developed process that explicitly documented the reviewer's concerns and how the authors addressed each issue. We feel that this process as it has done with previously published evidenced-based practice parameters sponsored by the AAN, results in documents of value to physicians and their patients.
References
1. Committee to Advise the Public Health Service on Clinical Practice Guidelines, Institute of Medicine. Field MJ, Lohr KN, eds. Clinical practice guidelines: directions of a new program. Washington, DC: National Academy Press, 1990.
2. American Academy of Pediatrics Committee on Children with Disabilities. Developmental surveillance and screening in infants and young children. Pediatrics 2001;108:192-196.
3. Shevell M, Ashwal S, 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;60:367-80.
4. Franklin GM, Zahn CA. AAN clinical practice guidelines: Above the fray. Neurology 2002;59:975-976.
.