Developmental Screening and Sharing Concerns With Families

Sooner or later you'll work with a child whose development worries you. Perhaps a 2-year-old isn't putting words together, or a child who used to chatter has gone quiet. You may be the first adult outside the family who notices. How you handle the next few weeks can change how soon that child gets help, and it can also make or break your relationship with the family.

This is careful work. You have useful knowledge, but also clear limits. A caregiver watches, records and shares. A caregiver doesn't diagnose.

What You Will Be Able to Do

• Explain the difference between monitoring, screening, evaluation and diagnosis.
• Use CDC milestones correctly, and know what they can't tell you.
• Prepare your evidence before you talk to a family.
• Share a concern clearly and kindly, without labeling a child.
• Point a family to early intervention or their school district, and know what happens next.

Four Different Steps

People use these words loosely, but they mean different things. Getting them right keeps you inside your role.

Monitoring is your daily work. Screening may be part of your job, depending on your program. Evaluation and diagnosis aren't. Your program's concern is to get a child to the right people. Even a poor screening result isn't a diagnosis. It's a sign that someone should look more closely.

Warning: Don't use words such as autism, ADHD, delayed, disabled or "on the spectrum" when you talk to a family about their child. You aren't qualified to say so, and you could be wrong. A word like that can stay with a family for years, and it can send them in the wrong direction.

Using CDC Milestones Correctly

The CDC's Learn the Signs. Act Early. program has free milestone checklists for ages 2, 4, 6, 9, 15, 18 and 30 months, and for ages 1, 2, 3, 4 and 5 years.

The lists were revised in 2022, and one change matters a great deal to how you read them. Each milestone is now something that at least 75 percent of children are expected to do by that age. So it isn't the average age. Most children reach these skills earlier. A child who hasn't reached one by that age may need a closer look, and it's better not to wait and see.

A few examples from the CDC lists:

Always use the current list, from the CDC. Older handouts may use different ages and different numbers.

These checklists have limits. They aren't validated tests, they can't replace a screening tool, and they can't give a diagnosis. What they do well is start a conversation.

The CDC advises acting early when a child is missing one or more milestones, has lost skills they once had, or if there's any other concern. A loss of skills, at any age, should go to your supervisor the same day.

How Screening Works

A screening tool is short and standardized, which means it's always given and scored the same way, and it's been tested on large groups of children. It's a different thing from an informal checklist.

The American Academy of Pediatrics recommends general developmental screening at the 9-, 18- and 30-month well-child visits, and autism screening at 18 and 24 months. It also recommends screening any time a family or a doctor has a concern. Not every child gets these screenings, so it's worth asking a family if their child has had one.

Two widely used tools are:

Don't use a tool unless you've been trained on it, and always follow its manual. If your program screens, the steps usually look like this:

1. Explain the purpose to the family, and get their written permission.
2. Give the tool in the family's preferred language. Use an interpreter if needed.
3. Include what the family knows. They see their child in more places than you do.
4. Score it exactly as the manual says.
5. Share the result in private, and in plain words.
6. Agree on the next step, and write it down.

Head Start programs have a set rule. Under federal standards, a child must be screened within 45 calendar days of first attending, or within 30 days for programs that run 90 days or less. They use research-based standardized tools, with family and staff input, and they need a parent's consent. Other programs follow their state and licensing rules, and some don't screen at all. If yours doesn't, you can still encourage a family to ask their child's doctor.

Before You Talk to a Family

Don't start with a chat at the door. Prepare first.

1. Gather your evidence. Pull dated notes from several days and more than one setting. Aim for examples rather than impressions.
2. Consider other explanations. Has the child been sick? Is there a new baby, a recent move, a change in custody, or a new language? Could the child have a hearing or vision problem?
3. Talk to your supervisor. Follow your program's process. Don't raise a concern with a family on your own unless that's your role.
4. Check the current milestones. Use the CDC list for the child's age.
5. Plan the meeting. Choose a private place, set enough time, and decide who will attend. Two staff is usually enough, because a large group can feel like an ambush.
6. Arrange an interpreter if needed. Use a trained one. Don't ask a sibling or a child to interpret.
7. Bring resources. Have the CDC checklist, and your local early intervention or school district contact. The CDC's website at cdc.gov/FindEI can help you find it.

For a child who was born early, ask the child's doctor how to treat age on a checklist.

Having the Conversation

Think of this as a talk between two people who care about a child. Your goal isn't to convince a family of anything. Your goal is to share what you've seen, learn what they've seen, and agree on a step.

1. Start with the child's strengths. Be specific, and be honest. "Marcus lights up when we sing, and he remembers all the actions."
2. Ask what they see at home. "How does he let you know what he wants at home?" Listen before you go further.
3. Share what you've seen, using examples. "Over the past three weeks, I've heard about 15 different words. He doesn't put two words together yet."
4. Give your reason for bringing it up. "Most children are doing this by now, so I'd like to be sure that he's getting all the support he can."
5. Say what you don't know. "I can't tell you why. I'm not qualified to say. A doctor or an early intervention team can look at this closely."
6. Suggest a clear next step. "Would you be willing to talk with his doctor and ask about a developmental screening?"
7. Agree on a follow-up. "Can we check in again in two weeks?"

Say what you saw, and leave the meaning to those trained to find it.

Both extremes cause harm. Saying "He's fine, boys talk late" could delay help. Saying "I'm sure something's wrong" could frighten a family, and you might be wrong.

Worked example. Dana, a toddler teacher, has notes on 30-month-old Eli. She's seen about 20 words over a month, no two-word phrases, and good play with blocks. The CDC list for 30 months includes about 50 words. She shows the notes to her director, who joins her for a meeting with Eli's mother. Dana starts with how carefully Eli builds. She asks what words he uses at home. His mother says he speaks more in Spanish, at home with his grandmother. Dana hadn't known that, and she notes it, as a child's words in both languages should be counted. They agree that his mother will count his words at home for a week and ask the doctor about a screening. Dana books a follow-up in two weeks.

When a Family Reacts Strongly

Families may feel worried, relieved, angry, sad or defensive. They may blame themselves, or they may blame you. Stay calm, and don't take it personally.

• Allow silence, and don't rush to fill it.
• Say what you've heard: "I can see that this is a lot to take in."
• Don't argue about what the child can do. Offer your examples, and leave it there.
• If they say that the child is fine at home, take that seriously. Children do act differently in different places.
• If they want time, give it. Offer to talk again.

The decision belongs to the family. If they say no, keep caring for the child in the same way, keep observing, and offer another chance to talk after a set time. If the family's choice worries you, talk to your director. Disagreeing with you about a screening isn't, on its own, a sign of abuse or neglect.

Language and Culture

Studies have repeatedly found that learning two languages doesn't cause a language delay. A real delay can still happen in a child who speaks two languages, so don't explain away a concern, and don't assume one, because of a child's language.

• Count words in all the child's languages. Ask the family for help.
• Use screening tools in the family's language where they exist.
• Learn how the family thinks about development. When children feed themselves, sleep alone or speak to adults differs between cultures.
• Don't take a family's views as a lack of concern. Some families aren't used to talking with outsiders about their child, or they may fear what a label will bring.

What Happens After a Referral

Federal law, the Individuals with Disabilities Education Act (IDEA), offers two routes, based on age.

Under Part C, the evaluation, the assessment and service coordination are provided at no cost to families. Some states charge fees for certain later services. Who qualifies differs by state, so a child who gets a plan in one state might not get one in another.

Parents can contact early intervention on their own. They're listed in the federal rules as a referral source, along with doctors and child care programs. Those rules ask that a referral happen as soon as possible, and no more than 7 days after a child is identified. Your program will have its own way of handling referrals and family permission. Ask your director before you contact anyone. Don't share a child's information with an outside agency without the proper permission.

While a family waits, keep doing what you do well. Keep observing, stay in touch with the family, and build support into daily routines. With the family's written permission, share your notes with the specialists. If a plan is written, ask how you can support its goals.

Keeping a Child in Care

A concern isn't a reason to push a child out. Under the Americans with Disabilities Act (ADA), most private child care programs can't exclude a child because of a disability. A center may only exclude a child if they pose a direct threat to others' health or safety, or if including them would fundamentally change the program. Programs must make reasonable changes, and generally can't charge extra for them. Rules differ for programs run by religious groups, and state law may add more. Never suggest to a family that they should leave. Take any problem to your director.

Mandated Reporting Is a Separate Track

A developmental concern and suspected abuse or neglect are two separate things, and each has its own process. The steps here are for development only.

If you suspect abuse or neglect, you may have a legal duty to report, and that duty is set by state law. Rules, timelines and who must report all vary by state. Follow your state's law and your program's policy right away. Don't ask the family first, and don't wait for a planned meeting.

Writing It Down

After the meeting, add a short note to the child's file. Include the date, who attended, what you shared, what the family said, what was agreed, and when you'll follow up. Keep it factual, and keep it private. Then actually follow up on that date. A concern that's raised and then forgotten doesn't help anyone.

Common Mistakes

Check Your Understanding

1. A 2-year-old in your room has few words, and a coworker says, "I think he has autism. You should tell his mother." What do you say?

Neither of you can say that. Write down what you've actually seen, and talk to your director. Any talk with the family should be about what was observed, with a suggestion to ask the child's doctor about a screening.

2. You're looking at a CDC checklist for 18 months, and a child can do all but one of the skills. Should you ignore it, since it's only one?

No. Each item is something at least 75 percent of children can do by that age, and the CDC advises acting early if even one is missing. That doesn't mean something's wrong. Record it, talk to your supervisor, and follow your program's process.

3. A parent says, "He's fine at home, and I don't want him tested." How do you respond?

Take it seriously, and don't argue. Thank them for telling you, keep your door open, and agree on a time to talk again. Keep supporting the child and keep your notes. The decision is theirs.

4. A 4-year-old attends your private preschool, and her parents want an evaluation. Which route applies?

Children age 3 and older go through their local public school district, even if the child is in a private preschool. The family can ask about a Part B evaluation.

5. While preparing notes for a concern about speech, you see bruises that worry you. Is this part of the same process?

No. Suspected abuse goes down a different track. Follow your state's reporting law and your program's policy right away. Don't wait for the family meeting.

Key Takeaways

• Caregivers observe, record and share. They don't diagnose.
• Monitoring, screening, evaluation and diagnosis are four different steps.
• CDC milestones show what at least 75 percent of children do by that age, so don't wait and see.
• Prepare with dated examples, talk to your supervisor, and meet in private.
• Start with strengths, ask what the family sees, and share facts and a clear next step.
• Children under 3 go to early intervention, and children 3 and older go to the local school district.
• Suspected abuse or neglect is a separate duty under state law.