Amer. 1. Orthopsychiat. 48(1). January 1978
IMPLEMENTING THE DEVELOPMENTAL ASSESSMENT Beatrice D. Moore Director, Office of Child Health, Medicaid Bureau, Health Care Financing Administration, Dept. of Health, Education, and Welfare, Washington, D.C.
This paper discusses the role of developmental assessment within the EPSDT program, describes eflorts to develop guides for implementing this component of the program, and summarizes the “developmental review” proposed by the American Association o f Psychiatric Services f o r Children.
Early and Periodic Screening, DiT heagnosis, and Treatment Program (EPSDT) became a mandated service under the Medicaid Program through the 1967 amendments to the Social Security Act (Title X I X , Section 1905(a) ( 4 ) ( B ) ) , which states: . . . such early and periodic screening and diagnosis of individuals who are eligible under the plan or are under the age of 21 to ascertain their physical or mental defects, and such health care, treatment, and other measures to correct or ameliorate defects and chronic conditions discovered thereby as may be provided in regulations of the Secretary.
The program is administered by the Medicaid Bureau, previously the Medical Services Administration (MSA), of the Health Care Financing Administration. Developed in response to mounting,
well-founded concerns about the poor health of low-income children, the program was designed for early detection and prevention of conditions that are potentially debilitating or disabling if not identified and treated in their early stages. States offer to an estimated 12 million Medicaid-eligible children and youth a range of services including a physical examination; appropriate laboratory procedures; immunizations; mandated vision, hearing, and dental examinations; and a developmental assessment. Participation in the program is voluntary, although the aim is that effective outreach services to eligible families will help parents to understand the value of early detection, prevention, and treatment of health prob-
Invited b y the Editor for inclusion in this section of rhe loctmal.
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BEATRICE D. MOORE
lems. Children enrolled in the program are rescheduled for the full range of services at appropriate periodic intervals. States must provide for all treatment available in their Medicaid programs for all conditions detected in screening that require follow-up. Treatment for vision, hearing, and dental problems is required without regard for the limitations of states’ Medicaid plans. In most states, EPSDT is administratively linked to state welfare departments and most EPSDT eligibles are Aid to Families with Dependent Children (AFDC) recipients; EPSDT health services, however, are actually delivered by health, not welfare, professionals. Eight states rely entirely on private physicians for screening as well as treatment under EPSDT. Twenty-two states use a mix of health department facilities, special screening clinics, and private physicians. Twenty-three states have arranged contracts with state and local health departments to carry out the screening portion of the program. Treatment is, of course, carried out by qualified practitioners of the required services.
23 (the) individual(’s1 development. A test such as the Denver Developmental test can also be used for this purpose. This part of the screening procedure should include assessment of eye-hand coordination, gross motor function (walking, hopping, climbing), fine motor skills (use of hand, fingers), speech development, self-help skills (dressing, eating, personal care), and behavioral development.
All states include developmental assessment in their EPSDT program services; however, procedures for making such assessments vary between and within states. A 1976 HEW survey of states showed that, of 48 jurisdictions reporting, twenty use the Denver Developmental Screening Test (DDST) alone, and thirteen use the DDST and a variety of other tests, including the WISC, Stanford-Binet, and material developed for the state. The District of Columbia uses an assessment scale developed in a special demonstration project. Ten states report using no structured format, relying on the screener/ physician judgment of the need for a formal assessment. Children for whom follow-up after screening is indicated are referred to such resources as community mental health centers, diagnostic DEVELOPMENTAL ASSESSMENT centers, special education programs, IN EPSDT PROGRAMS: STATUS mental retardation programs, and child The statutory requirement for an as- guidance clinics. In many instances, besessment for “mental defects” has been cause of limitations of available redefined operationally as a developmental sources, there is a long waiting period assessment. A developmental assessment for diagnostic or treatment services. In is an appraisal of a child’s progress in rural areas, transportation problems adterms of defined milestones of organic ditionally complicate referral. Whcre and functional development. In 1972, there is no indication of a referral made for a suspected condition, the reason the EPSDT Program Regulation Guide recommended the following procedures most often given is a lack of the necessary treatment resource. for developmental assessment: There is an agreed upon need to imInformation from the parent or other person prove the developmental assessment who has knowledge of the child’s development, observation of the child, and talking component of EPSDT. However, a plan with the child can all be useful in assessing for full implementation challenges the
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limits of the state-of-the-art. The EPSDT program sees its mandate to provide for early detection and treatment of potentially handicapping conditions as an opportunity to respond to a long unmet need in a large segment of the population. It must be acknowledged that poor children have traditionally not received an appropriate share of available services. Indeed, in the case of scarce services, the poor are often simply neglected when there are not enough to go around. EPSDT provides an opportunity to develop and delivcr these services, and to do so “early and periodically,” before the problems are manifested in terms of their toll on the child. Data on conditions discovered through developmental screening in EPSDT demonstration projects reinforce expectations that there is a significant need for services. The District of Columbia National Capitol Child Day Care Association Project, using a test normed for black, inner-city prcschool children, tested language, cognition, memory, and development. Forty percent of 208 children showed a six-months lag in responses in one or more areas. Fourteen percent were lagging twelve months or more in one or more areas. Children having a lag of six months or more in any two areas were recommended for remediation-in this case, 22.6%. In the Cuba, New Mexico, EPSDT project, 42% of 806 five-to-seven-yearolds had two or more problems in screens of intellectual, visual, emotional, or language adjustment. Fourteen percent of this number required diagnostic follow-up using severity criteria that the child did not attain appropriate levels on at least three of the four items tested. In the EPSDT Barrio Project in San Antonio, Texas, five percent (68) of
IMPLEMENTING EPSDT
1295 children given the DDST failed to pass appropriate items, due principally to language problems. (These children were referred to the Barrio Special School for further evaluation and for remedial assistance as indicated.) Recognizing the potential as well as the hazards of the task, the plan for full implementation of the developmental assessment component of EPSDT services relies on maximum involvement of professional organizations, universities, and relevant HEW agencies. The problems and issues inherent in this activity require the full support of the professional community, and the complexity of the work calls for the fullest use of available expertise. To elicit this involvement, representatives of professional and consumer organizations and leading experts representing virtually every discipline have been consulted. In 1974, the EPSDT program contracted with the American Orthopsychiatric Association ( AOA) to develop a guide for states’ use in implementing the developmental assessment component of their programs. After more than a year’s effort, however, the AOA concluded that: 1. Children in poverty are not served a&quately or appropriately by existing service structures, and their special needs require development of a range of innovative approaches and instruments. 2. Preparation of a guide to implementation of the developmental asssssment portion of EPSDT as it is presently constituted is premature, and not in the best interests of those it is meant to serve. 3.Guides for an effective national program should be explored in small, earefully planned EPSDT pilot programs aimed at determining and enhancing individual children’s strengths to help offset developmental weaknesses and at defining structures of service useful to the Medicaid population.1
BEATRICE D. MOORE
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The EPSDT program and the National Institute of Mental Health (NIMH) have held major conferences on developmental assessment in EPSDT programs. In addition, an agreement between the Medical Services Administration and NIMH brought together the resources and expertise of these agencies to “develop guidelines and models for States concerning the mental health . . . dimensions of the developmental assessment and treatment component of EPSDT.” In a 1975 memorandum L‘ to the Commissioner of the Medical Services Administration (Medicaid), the Director of NIMH reported the conclusions of these meetings: There is a consensus on the need to protect children from insensitive, invalid, or simply unhelpful professional judgments. Concerns include inappropriate labeling and incorrect, even damaging, therapeutic interventions. In the context of the above, there is the desire to: ( a ) cultivate community acceptance and trust of prevention and early intervention, and ( b ) mobilize our existing rescurces to affect positively the growth and development of this Nation’s children and youth. EPSDT and EPSDT-like programs are recognized as having this potential.
The NIMH report delineated principles to be applied in planning the “mental health dimension’’ of developmental assessment in EPSDT programs. These included considerations of the child’s total development, strengths and weaknesses, in a familiar setting, by socially and culturally compatible or sensitive screeners. Exploration of the potential value of “natural raters,” parents and guardians, was encouraged. Prescriptive
* This
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diagnoses and concomitant treatment regimens were deemed appropriate alternatives to diagnostic labels. Boards of laymen and professionals were recommended for consultation on local standards and for monitoring program implementation. In 1976, the American Association of Psychiatric Services for Children (AAPSC) agreed to develop working papers and to conduct a working conference on critical conceptual and operational issues. The final report of this conference, held in San Diego, California, in February 1977, offered specific recommendations for implementation of the developmental assessment component of EPSDT.5 The recommendations address the issues and principles identified by the NIMH and the AOA; however, they also prescribe a process of “developmental review” through which children can receive the benefits of services that are currently available or can be readily developed within the limitations of the present state-of-the-art. The AAPSC report also specifies where improvements in existing capabilities should be focused, and what procedures, materials, and systems must yet be developed. DEVELOPMENTAL REVIEW
Developmental review in the context of a health program has three goals: 1 ) the promotion of the strengths of child and family to cope with the various tasks of living, 2 ) the prevention of specific developmental disabilities, and 3 ) early case finding. An adequate review should include biological dimensions, psycho__
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section and the one to follow (Ethical and Legal Consideraticns) are based on, and substantially use direct quorations or paraphrasing of, the American A \ ~ c i a t i o nc f Psychiatric Services for Children report, prepared by Dorothy S. Huntington, Ph D -b
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logical dimensions, family dimensions, and environmental, social, and cultural elements. The review should be conducted in three stages. In Stage One, the biological dimensions should be reviewed within the framework of the pediatric physical assessment. This phase also should include an assessment of the child’s functioning based on the parent’s report, an opportunity for the parent alone or in interaction with health personnel to comment on the child’s developmental progress, coping skills, temperament, and the like. On the basis of the informal observations and parent inventories relating to development and behavior, a decision would be made on the need for a child’s referral to Stage Two of the review. Stage Two should be direct, structured observation of the child’s functioning. This might be accomplished using a variety of broad developmental screening inventories or instruments that are currently available. Paraprofessionals may be trained to administer these screening inventories if interpretation of results and constant monitoring of reliability remain the responsibility of more highly trained professionals. A child found to need a more intensive review based on findings in Stage Two would be referred to a Stage Three assessment of functioning. Stage Three of a developmental review should include detailed aspects of the four domains: 1 ) biological, 2 ) psychological, 3) family, and 4) environmental/social/cultural. The psychological domain would include a wide variety of functions-cognitive development, emotional development, language and speech development, auditory perception, visual perception, and physical
IMPLEMENTING EPSDT
functions. This extensive review of a child‘s development-this professional assessment-must be done with clinical sensitivity by people highly skilled in both child development and in working with parents. In the developmental review, the orientation is toward the child’s competencies and forces which are facilitating or could facilitate the child’s development. The basic questions center around the area of significant problems in development. The final question is, of course, “Is intervention necessary?” The entire developmental review is a process of attempting to understand in successively finer terms the situation of the child and family that would lead to positive action. It is widely recommended that the Medicaid Bureau take a leadership role in establishing task forces and demonstration projects to further develop Stage One and Stage Two type review procedures which will be appropriate to the population being screened, will be reliable and cost effective: and can be used by paraprofessionals. In fact, appropriate instruments need to be identified or developed in order that all stages of developmental review may be carried out adequately. In this context, it has also been recommended that a separate task force supply the Medicaid Bureau with an inventory of tests available, and with information on how well they meet criteria of appropriateness (as described below under “Measures of Development”). It has been suggested that, after two years, no standardized procedure should be utilized in the program until it has been approved for use i n EPSDT pursuant to regulations adopted by the Secretary of HEW. In the interim period,
BEATRICE D. MOORE this task force should review standardized tests and procedures currently in use to determine their compliance with the above mentioned criteria, and should recommend appropriate regulations to the Secretary. Measures of Development
At this time, no group is ready to recommend lists, instruments, or observation schema for review and assessment of children in the EPSDT program. However, it is acknowledged that it is necessary that instruments be developed for adequate developmental reviews. The recurrent theme in reports and discussions is that, while i t is desired that there be a uniformly acceptable set of review procedures relative to psychometric validity, norms, cultural/ethnic validity, etc., there is no such set of procedures currently available. There are procedures, however, that have reasonable utility in selected aspects of the developmental review process, and are acceptable in certain situations. The following criteria were proposed by the AAPSC for instruments to be used in the different stages of the process, whether the review is direct, with the child, or indirect, through the parent or other caregiver. The instrument must be: 1 ) acceptable to parent, child, and professionals; 2 ) appropriate to the population to be reviewed, considering at least the following: age, sex, race, language, socioeconomic status, and geographic area; 3 ) demonstrated reliable; 4 ) demonstrated valid and accurate in problem identification; 5 ) amenable to administration and scoring by trained paraprofessionals (if it is to be used in the Stage Two review); 6 ) cost effective; and 7) readily available. If the instruments used conform to
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these criteria, and if appropriate consideration is given to cultural, ethnic, racial, and socioeconomic factors that may influence interpretation of the findings, then this proposed system of developmental review has the following desirable characteristics: 1. It does not attach a label or categorize a child prior to a Stage Three review. 2. It makes a dedicated effort to engage the primary caregiver as a collaborator in the developmental review process, and to ensure that interpretations of findings are culturally relevant as well as psychologically sound. 3. It establishes definitive criteria for any developmental review instrument to be used. 4. It attempts to establish a brief, workable system that is functionally effective in terms of cost and benefits. 5 . It recognizes a multiplicity of instruments that have practical utility in differing situations. The first two stages of developmental review would not attempt to categorize or “label” children; rather, the system of developmental review would be devoted primarily to determining whether, in fact, there is cause for concern and, if so, what further efforts must be made to determine whether the concern is valid or merely reflects transient problems. Given this orientation, the question of false positives/false negatives is moot. The relevant question might be posed, “Is there sufficient consensus among the developmental reviewer, the parent, and the child (in the case of older children) that there is need for further review?” If the answer is affirmative, then the recommendation would be that of referral for Stage Three review. The proposed method of identification
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of children who may be at risk for developmental difficulties is both empirical and objective, and does not “label” or diagnose a child. The assumption is that the Stage One review (other than the health examination in some locations) will be done by paraprofessionals, while Stage Two would likely be a combination of professional and paraprofessional efforts, i.e., supervised administration (but not interpretation) of the developmental review instruments by paraprofessional personnel. Stage Three must be carried out by experienced and skilled professionals.
The Role of the Parent The cooperation of the parent or other caregiver is essential in assessing a child’s strengths and weaknesses. The parent is the only observer of a child’s rate of growth from birth until school age. Health professionals are not predictably involved in any consistent manner. Therefore, the parent must be engaged early in the infant’s life in order to utilize his observational skills in developmental review. Parent engagement Of course’ voluntary and be based on the parent’s understanding of the benefits of participation. It would be important to have a health worker who is bicultural and bilingual, if culture or language differences exist between parent and worker. A model providingfor parents as first evaluators of the child-a parent inventoV-With OPPOrtunitY to discuss areas of concern a~ well a~ strengths, allows parents to look toward assistance rather than fear criticism. There is an obvious charge to developers of parent questionnaires that they not be trivial; they must have developmental implications.
IMPLEMENTING EPSDT
It should also be obvious that they must have cross-cultural validity. Parents are also vital to the developmental review process for their observations on the family environment. The review of the characteristics of the family and its social and economic circumstances should be oriented toward identifying the stresses, strengths, and supports available to the child. Parental involvement in each step of developmental review is essential. Parents need to understand their children’s abilities and assets, as well as disabilities and deficiencies. Further, treatment of developmental problems might frequently involve educational programs that parents may carry out with their children. “Treatment” may also be education of the parent to support the child’s strengths. An EPSDT developmental review task force must collate and make available to local communities the varying models of parent-based “treatment” programs that have been developed. This should include the wealth of parent education materials that currently exist in many scattered places. This particular use of parent education materials holds a truly exciting and innovative approach to health care in this country. Support Systems for EPSDT
Creation of an EPSDT Coordinator, an EPSDT office, and support personnel for EPSDT districts, and the establishment of community Coordinating councils (to include the schools and all service agencies, as well as representatives of parents and service providers) were recommended by the AApSC. These support systems would make possible and facilitate 1 ) planning and implementation on the local level, 2 ) identifi-
BEATRICE D. MOORE
cation of gaps and needs in the service resources; 3 ) coordination and stimulation of services relevant to achieving goals of EPSDT; and 4 ) cooperation and contribution to the external evaluation of EPSDT. The manpower issues involved in training, consultation, and technical assistance are primary. Qualifications of personnel involved in each stage, cultural appropriateness of personnel, and their training and education, must be carefully reviewed. Multiple models of service delivery were recommended, depending on the characteristics of individuals and agencies available as support systems. ETHICAL AND LEGAL CONSIDERATIONS
General Premises Ethical considerations need to be viewed against the backdrop of two different normative models: 1 ) the disease recognition and prevention model, and 2) the cultural diversity model. The former emphasizes identifiable organic pathologies that imply some type of medical treatment. Within this model, the basic assumption is that false positives carry no risk aside from those associated with further diagnostic procedures; on the other hand, failing to detect pathology could lead to serious and possibly irreversible consequences. The “cultural diversity” normative model focuses on behaviors that deviate from the expectations of the social group. In this case, the basic assumption is that false positives are more serious than false negatives in screening because labeling a child as deviant tends to trigger social responses such as tracking into special programs, institutionalization, changed perceptions and expecta-
tions, etc., which in themselves may have irreversible consequences. Any developmental review system should reflect this distinction. Screening may legitimately utilize the “disease” model during the years of infancy and early childhood development, when the child’s primary social group is the family. In doing so, however, developmental review must focus primarily on the child‘s physiological development. Conversely, as children enter the school system, and their behavior is evaluated with reference to the expectations of the social group, developmental assessment necessarily encompasses behavioral measures, and policies must therefore be formulated within the normative framework of the “cultural diversity” model. In a free, pluralistic society, there are clear boundaries on the scope of legitimate inquiry into personal familial concerns. Therefore, a federally financed assessment program should be limited to those measures of organic functioning and basic, adaptive coping skills that enjoy a high degree of consensus within the health professions and affected communities; and those behavioral factors especially associated with learning, language and speech development, motor skills and perceptual abilities. Specific assessment of emotional and behavioral adjustment and parent/child interactions should be left to parental initiative and sensitive clinical observation (Stage Three as herein proposed). It is not ethically mandatory to limit the scope of review because treatment is unavailable for the identified condition. This is true whether or not there is known treatment, treatment is not available in the community, or, if available, is too costly. Reasons offered for this position include the following: without
IMPLEMENTING EPSDT
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such data about existing conditions the need for the development of new treatment capabilities may never become apparent; the information may be useful to the provider in counseling the parent about managing the problem, and in developing a parent-oriented treatment program; and treatment may later become ava.ilable.
Informing Parents of Results If the developmental review suggests that the child is in developmental difficulty, the health professional should iniorm the parent of the general area of concern, being careful to avoid arousing undue parental anxiety, before recommending referral for diagnostic (Stage Three) evaluation. If the diagnosis is positive, the professional should inform the parents fully of the child’s developmental status and discuss the treatment alternatives. If treatment services are not available in the community, then the diagnosing professional should counsel the parent, utilizing her own clinical judgment in determining what information to disclose and what is to be done. It is also important to inform parents when no indications of difficulty are found during any of the stages of developmental review. Criteria Governing Use of Standardized Procedures Standardization of all procedures used in screening or diagnosis that are correlated with sociocultural factors must be done with appropriate sociocultural norms, and all testing must be administered in the language spoken by the child. Each standardized procedure should have predictive validity for the behavior or conditions it purports to measure and for children of each of the
sociocultural groups with whom the procedure is to be used.
Records and Confidentiality All patient records should be created and maintained in accord with the customary practices of the health professions. Confidentiality should be carefully preserved, and no information should be released without parental consent. Under no circumstances should Stage One and Stage Two information be transferred to the school system. “Medical” information from these records may be disclosed to authorized persons in the educational system with parental consent in accord with usual procedures. “Screening” information for the individual child should not be disclosed at all. Additional information from the records may be disclosed to authorized persons with parental consent only after the EPSDT Coordinator has consulted with the parent and they have made an independent determination that the disclosure is in the child’s best interests. With appropriate regard for age and maturity, the child’s consent should be included as a condition of information transfer. SUMMARY
In summary, developmental review is a total process. The first two stages are “screens” in the sense of identification of persons needing closer review, but with emphasis on the balance of strengths and weaknesses. The three stages are a means to the end of early detection of children who may need special help or the benefits of closer attention. The legislation authorizing EPSDT makes it national policy that the development of our children be safeguarded
BEATRICE D. MOORE
so as to insure that each child reaches maturity functioning at a maximum level of development. This goal is more than the finding, the study, and the treatment of disease. The guardianship of the health of children is in the national interest as well as in the interest of the individuals; this is the essence of EPSDT.
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professional assistance. These agencies -the Office of Child Development, the Bureau of Education for the Handicapped, the Office of Developmental Disabilities, the National Institute of Mental Health, and the Bureau of Maternal and Child Health-have expertise and resources that should be brought to bear on the problem. Further, we and these agencies share the population at FUTURE DIRECTIONS risk and provide many similar services. The EPSDT program accepts the rec- We will take seriously the charge given ommendation that emphasis be shifted us in many quarters to seek opportunifrom the detection of dysfunction to the ties to gain maximum benefit from proprotection of child development. Many, gram resources. Beyond existing HEW resources, the perhaps most, of the recommendations Carter Administration has proposed of the AAPSC outlined above can be incorporated into guidelines to be issued child health legislation, the Child Health to states in the coming work year. The Assessment Program (CHAP), which developmental review system is the con- will expand and modify the EPSDT proceptual and operational guidance they gram and improve the quality of serhave sought. EPSDT coordinating of- vices. Under this proposal, uniform stanfices, local support systems, and coor- dards for health assessments will be dination of existing services can become defined by regulations. These definitions part of a state’s program implementation will include the components of the plan. health assessment and the schedule for The EPSDT program and the AAPSC periodic reassessments. CHAP will rehave agreed to collaborate in developing quire that states deliver the full range parent education materials and training of services provided for by Title XIX materials for professionals and para- of the Social Security Act to all assessed professionals within a year. This col- children, not just those available under laboration will also begin planning for a specific state’s Medicaid plan. Also, program standards development, evalu- an assessed child’s eligibility for services ation of tools and materials, and pro- will be extended for six months beyond gram review procedures. These are longthe time that changes in his family’s cirrange activities, of course, and the first cumstances would normally mean a loss year may well be spent on basic exploraof eligibility. This provision assures tion and planning. Meanwhile, major greater opportunity for follow-through confidentiality and legal issues will be on conditions detected in assessments. addressed in interim guidelines, as will The CHAP proposal permits states to criteria for Stage Two utilization of set limits on expanded treatment of existing tools. In addition to its work with the “mental illness, mental retardation, deAAPSC, the EPSDT program looks to velopmental disabilities, and dental related HEW agencies for technical and problems.” However, it adds such ser-
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IMPLEMENTING EPSDT
vices as correction of speech and lan- effort. There is work enough to go guage disorders, and physical and occu- around. pational therapy. Further, it mandates states’ assurance of case management REFERENCES 1. AMERICAN ORTHOPSYCHIATRIC ASSOCIATION. and supportive services, and emphasizes 1978. Developmental assessment in services coordination. Thus, while it is EPSDT. Amer. J. Orthopsychiat. 48( 1 ) : regrettable that fiscal constraints led to 7-2 1. 2. BROWN, B. 1975. NIMH Recommendalimitations on some services, the CHAP tions to the Medical Services Adminisproposal promises quality features which tration Concerning the Mental Health Diwill substantially improve our capability mensions of Developmental Assessment in the EPSDT Program. Memorandum to support the developmental review from the Director of NIMH to the Comprocess. missioner of MSA, Sept. 8, 1975. It is clear to all involved-public and 3. Cooperative Agreement Between the Medical Services Administration and the Naprivate-that there is major, intensive, tional Institute of Mental Health of the and complex work ahead. Nevertheless, Alcohol, Drug Abuse and Mental Health we believe that the need of the services Administration, May 12, 1975. 4. HEALTH SERVICES RESEARCH INSTITUTE. for the disadvantaged children of Amer1976. Demonstration Projects Evaluation ica, indeed, for all children, is critical, Report (An Interim Report): April 1, and that EPSDT offers a unique oppor1974-March 31, 1975. University of Texas Health Science Center, San Antonio. (p. tunity to make major gains in the devzliv) opment of these services. We believe 5. HUNTINGTON, D., ed. 1977. Developmental also that the approach is reasoned and Review in the EPSDT Program. American Association of Psychiatric Services for responsible, that the potential benefits Children, Washington, D.C. to children well outweigh the risks, and 6. Program Regulation Guide. MSA-PRG2 1, Medical Services Administration, that the risks can be controlled. Social and Rehabilitation Service, DepartWe hope that this presentation will be ment of Health Education, and Welfare, viewed as a call to participate in the June 29, 1972. (p. 14)
For reprints: Office of Child Health, Health Care Financing Administration. Department of Health, Education, and Welfare, 330 C St. SW, Washington, D.C. 20201
IMPLEMENTING THE DEVELOPMENTAL ASSESSMENT Beatrice D. Moore Director, Office of Child Health, Medicaid Bureau, Health Care Financing Administration, Dept. of Health, Education, and Welfare, Washington, D.C.
This paper discusses the role of developmental assessment within the EPSDT program, describes eflorts to develop guides for implementing this component of the program, and summarizes the “developmental review” proposed by the American Association o f Psychiatric Services f o r Children.
Early and Periodic Screening, DiT heagnosis, and Treatment Program (EPSDT) became a mandated service under the Medicaid Program through the 1967 amendments to the Social Security Act (Title X I X , Section 1905(a) ( 4 ) ( B ) ) , which states: . . . such early and periodic screening and diagnosis of individuals who are eligible under the plan or are under the age of 21 to ascertain their physical or mental defects, and such health care, treatment, and other measures to correct or ameliorate defects and chronic conditions discovered thereby as may be provided in regulations of the Secretary.
The program is administered by the Medicaid Bureau, previously the Medical Services Administration (MSA), of the Health Care Financing Administration. Developed in response to mounting,
well-founded concerns about the poor health of low-income children, the program was designed for early detection and prevention of conditions that are potentially debilitating or disabling if not identified and treated in their early stages. States offer to an estimated 12 million Medicaid-eligible children and youth a range of services including a physical examination; appropriate laboratory procedures; immunizations; mandated vision, hearing, and dental examinations; and a developmental assessment. Participation in the program is voluntary, although the aim is that effective outreach services to eligible families will help parents to understand the value of early detection, prevention, and treatment of health prob-
Invited b y the Editor for inclusion in this section of rhe loctmal.
22
BEATRICE D. MOORE
lems. Children enrolled in the program are rescheduled for the full range of services at appropriate periodic intervals. States must provide for all treatment available in their Medicaid programs for all conditions detected in screening that require follow-up. Treatment for vision, hearing, and dental problems is required without regard for the limitations of states’ Medicaid plans. In most states, EPSDT is administratively linked to state welfare departments and most EPSDT eligibles are Aid to Families with Dependent Children (AFDC) recipients; EPSDT health services, however, are actually delivered by health, not welfare, professionals. Eight states rely entirely on private physicians for screening as well as treatment under EPSDT. Twenty-two states use a mix of health department facilities, special screening clinics, and private physicians. Twenty-three states have arranged contracts with state and local health departments to carry out the screening portion of the program. Treatment is, of course, carried out by qualified practitioners of the required services.
23 (the) individual(’s1 development. A test such as the Denver Developmental test can also be used for this purpose. This part of the screening procedure should include assessment of eye-hand coordination, gross motor function (walking, hopping, climbing), fine motor skills (use of hand, fingers), speech development, self-help skills (dressing, eating, personal care), and behavioral development.
All states include developmental assessment in their EPSDT program services; however, procedures for making such assessments vary between and within states. A 1976 HEW survey of states showed that, of 48 jurisdictions reporting, twenty use the Denver Developmental Screening Test (DDST) alone, and thirteen use the DDST and a variety of other tests, including the WISC, Stanford-Binet, and material developed for the state. The District of Columbia uses an assessment scale developed in a special demonstration project. Ten states report using no structured format, relying on the screener/ physician judgment of the need for a formal assessment. Children for whom follow-up after screening is indicated are referred to such resources as community mental health centers, diagnostic DEVELOPMENTAL ASSESSMENT centers, special education programs, IN EPSDT PROGRAMS: STATUS mental retardation programs, and child The statutory requirement for an as- guidance clinics. In many instances, besessment for “mental defects” has been cause of limitations of available redefined operationally as a developmental sources, there is a long waiting period assessment. A developmental assessment for diagnostic or treatment services. In is an appraisal of a child’s progress in rural areas, transportation problems adterms of defined milestones of organic ditionally complicate referral. Whcre and functional development. In 1972, there is no indication of a referral made for a suspected condition, the reason the EPSDT Program Regulation Guide recommended the following procedures most often given is a lack of the necessary treatment resource. for developmental assessment: There is an agreed upon need to imInformation from the parent or other person prove the developmental assessment who has knowledge of the child’s development, observation of the child, and talking component of EPSDT. However, a plan with the child can all be useful in assessing for full implementation challenges the
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limits of the state-of-the-art. The EPSDT program sees its mandate to provide for early detection and treatment of potentially handicapping conditions as an opportunity to respond to a long unmet need in a large segment of the population. It must be acknowledged that poor children have traditionally not received an appropriate share of available services. Indeed, in the case of scarce services, the poor are often simply neglected when there are not enough to go around. EPSDT provides an opportunity to develop and delivcr these services, and to do so “early and periodically,” before the problems are manifested in terms of their toll on the child. Data on conditions discovered through developmental screening in EPSDT demonstration projects reinforce expectations that there is a significant need for services. The District of Columbia National Capitol Child Day Care Association Project, using a test normed for black, inner-city prcschool children, tested language, cognition, memory, and development. Forty percent of 208 children showed a six-months lag in responses in one or more areas. Fourteen percent were lagging twelve months or more in one or more areas. Children having a lag of six months or more in any two areas were recommended for remediation-in this case, 22.6%. In the Cuba, New Mexico, EPSDT project, 42% of 806 five-to-seven-yearolds had two or more problems in screens of intellectual, visual, emotional, or language adjustment. Fourteen percent of this number required diagnostic follow-up using severity criteria that the child did not attain appropriate levels on at least three of the four items tested. In the EPSDT Barrio Project in San Antonio, Texas, five percent (68) of
IMPLEMENTING EPSDT
1295 children given the DDST failed to pass appropriate items, due principally to language problems. (These children were referred to the Barrio Special School for further evaluation and for remedial assistance as indicated.) Recognizing the potential as well as the hazards of the task, the plan for full implementation of the developmental assessment component of EPSDT services relies on maximum involvement of professional organizations, universities, and relevant HEW agencies. The problems and issues inherent in this activity require the full support of the professional community, and the complexity of the work calls for the fullest use of available expertise. To elicit this involvement, representatives of professional and consumer organizations and leading experts representing virtually every discipline have been consulted. In 1974, the EPSDT program contracted with the American Orthopsychiatric Association ( AOA) to develop a guide for states’ use in implementing the developmental assessment component of their programs. After more than a year’s effort, however, the AOA concluded that: 1. Children in poverty are not served a&quately or appropriately by existing service structures, and their special needs require development of a range of innovative approaches and instruments. 2. Preparation of a guide to implementation of the developmental asssssment portion of EPSDT as it is presently constituted is premature, and not in the best interests of those it is meant to serve. 3.Guides for an effective national program should be explored in small, earefully planned EPSDT pilot programs aimed at determining and enhancing individual children’s strengths to help offset developmental weaknesses and at defining structures of service useful to the Medicaid population.1
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The EPSDT program and the National Institute of Mental Health (NIMH) have held major conferences on developmental assessment in EPSDT programs. In addition, an agreement between the Medical Services Administration and NIMH brought together the resources and expertise of these agencies to “develop guidelines and models for States concerning the mental health . . . dimensions of the developmental assessment and treatment component of EPSDT.” In a 1975 memorandum L‘ to the Commissioner of the Medical Services Administration (Medicaid), the Director of NIMH reported the conclusions of these meetings: There is a consensus on the need to protect children from insensitive, invalid, or simply unhelpful professional judgments. Concerns include inappropriate labeling and incorrect, even damaging, therapeutic interventions. In the context of the above, there is the desire to: ( a ) cultivate community acceptance and trust of prevention and early intervention, and ( b ) mobilize our existing rescurces to affect positively the growth and development of this Nation’s children and youth. EPSDT and EPSDT-like programs are recognized as having this potential.
The NIMH report delineated principles to be applied in planning the “mental health dimension’’ of developmental assessment in EPSDT programs. These included considerations of the child’s total development, strengths and weaknesses, in a familiar setting, by socially and culturally compatible or sensitive screeners. Exploration of the potential value of “natural raters,” parents and guardians, was encouraged. Prescriptive
* This
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diagnoses and concomitant treatment regimens were deemed appropriate alternatives to diagnostic labels. Boards of laymen and professionals were recommended for consultation on local standards and for monitoring program implementation. In 1976, the American Association of Psychiatric Services for Children (AAPSC) agreed to develop working papers and to conduct a working conference on critical conceptual and operational issues. The final report of this conference, held in San Diego, California, in February 1977, offered specific recommendations for implementation of the developmental assessment component of EPSDT.5 The recommendations address the issues and principles identified by the NIMH and the AOA; however, they also prescribe a process of “developmental review” through which children can receive the benefits of services that are currently available or can be readily developed within the limitations of the present state-of-the-art. The AAPSC report also specifies where improvements in existing capabilities should be focused, and what procedures, materials, and systems must yet be developed. DEVELOPMENTAL REVIEW
Developmental review in the context of a health program has three goals: 1 ) the promotion of the strengths of child and family to cope with the various tasks of living, 2 ) the prevention of specific developmental disabilities, and 3 ) early case finding. An adequate review should include biological dimensions, psycho__
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section and the one to follow (Ethical and Legal Consideraticns) are based on, and substantially use direct quorations or paraphrasing of, the American A \ ~ c i a t i o nc f Psychiatric Services for Children report, prepared by Dorothy S. Huntington, Ph D -b
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logical dimensions, family dimensions, and environmental, social, and cultural elements. The review should be conducted in three stages. In Stage One, the biological dimensions should be reviewed within the framework of the pediatric physical assessment. This phase also should include an assessment of the child’s functioning based on the parent’s report, an opportunity for the parent alone or in interaction with health personnel to comment on the child’s developmental progress, coping skills, temperament, and the like. On the basis of the informal observations and parent inventories relating to development and behavior, a decision would be made on the need for a child’s referral to Stage Two of the review. Stage Two should be direct, structured observation of the child’s functioning. This might be accomplished using a variety of broad developmental screening inventories or instruments that are currently available. Paraprofessionals may be trained to administer these screening inventories if interpretation of results and constant monitoring of reliability remain the responsibility of more highly trained professionals. A child found to need a more intensive review based on findings in Stage Two would be referred to a Stage Three assessment of functioning. Stage Three of a developmental review should include detailed aspects of the four domains: 1 ) biological, 2 ) psychological, 3) family, and 4) environmental/social/cultural. The psychological domain would include a wide variety of functions-cognitive development, emotional development, language and speech development, auditory perception, visual perception, and physical
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functions. This extensive review of a child‘s development-this professional assessment-must be done with clinical sensitivity by people highly skilled in both child development and in working with parents. In the developmental review, the orientation is toward the child’s competencies and forces which are facilitating or could facilitate the child’s development. The basic questions center around the area of significant problems in development. The final question is, of course, “Is intervention necessary?” The entire developmental review is a process of attempting to understand in successively finer terms the situation of the child and family that would lead to positive action. It is widely recommended that the Medicaid Bureau take a leadership role in establishing task forces and demonstration projects to further develop Stage One and Stage Two type review procedures which will be appropriate to the population being screened, will be reliable and cost effective: and can be used by paraprofessionals. In fact, appropriate instruments need to be identified or developed in order that all stages of developmental review may be carried out adequately. In this context, it has also been recommended that a separate task force supply the Medicaid Bureau with an inventory of tests available, and with information on how well they meet criteria of appropriateness (as described below under “Measures of Development”). It has been suggested that, after two years, no standardized procedure should be utilized in the program until it has been approved for use i n EPSDT pursuant to regulations adopted by the Secretary of HEW. In the interim period,
BEATRICE D. MOORE this task force should review standardized tests and procedures currently in use to determine their compliance with the above mentioned criteria, and should recommend appropriate regulations to the Secretary. Measures of Development
At this time, no group is ready to recommend lists, instruments, or observation schema for review and assessment of children in the EPSDT program. However, it is acknowledged that it is necessary that instruments be developed for adequate developmental reviews. The recurrent theme in reports and discussions is that, while i t is desired that there be a uniformly acceptable set of review procedures relative to psychometric validity, norms, cultural/ethnic validity, etc., there is no such set of procedures currently available. There are procedures, however, that have reasonable utility in selected aspects of the developmental review process, and are acceptable in certain situations. The following criteria were proposed by the AAPSC for instruments to be used in the different stages of the process, whether the review is direct, with the child, or indirect, through the parent or other caregiver. The instrument must be: 1 ) acceptable to parent, child, and professionals; 2 ) appropriate to the population to be reviewed, considering at least the following: age, sex, race, language, socioeconomic status, and geographic area; 3 ) demonstrated reliable; 4 ) demonstrated valid and accurate in problem identification; 5 ) amenable to administration and scoring by trained paraprofessionals (if it is to be used in the Stage Two review); 6 ) cost effective; and 7) readily available. If the instruments used conform to
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these criteria, and if appropriate consideration is given to cultural, ethnic, racial, and socioeconomic factors that may influence interpretation of the findings, then this proposed system of developmental review has the following desirable characteristics: 1. It does not attach a label or categorize a child prior to a Stage Three review. 2. It makes a dedicated effort to engage the primary caregiver as a collaborator in the developmental review process, and to ensure that interpretations of findings are culturally relevant as well as psychologically sound. 3. It establishes definitive criteria for any developmental review instrument to be used. 4. It attempts to establish a brief, workable system that is functionally effective in terms of cost and benefits. 5 . It recognizes a multiplicity of instruments that have practical utility in differing situations. The first two stages of developmental review would not attempt to categorize or “label” children; rather, the system of developmental review would be devoted primarily to determining whether, in fact, there is cause for concern and, if so, what further efforts must be made to determine whether the concern is valid or merely reflects transient problems. Given this orientation, the question of false positives/false negatives is moot. The relevant question might be posed, “Is there sufficient consensus among the developmental reviewer, the parent, and the child (in the case of older children) that there is need for further review?” If the answer is affirmative, then the recommendation would be that of referral for Stage Three review. The proposed method of identification
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of children who may be at risk for developmental difficulties is both empirical and objective, and does not “label” or diagnose a child. The assumption is that the Stage One review (other than the health examination in some locations) will be done by paraprofessionals, while Stage Two would likely be a combination of professional and paraprofessional efforts, i.e., supervised administration (but not interpretation) of the developmental review instruments by paraprofessional personnel. Stage Three must be carried out by experienced and skilled professionals.
The Role of the Parent The cooperation of the parent or other caregiver is essential in assessing a child’s strengths and weaknesses. The parent is the only observer of a child’s rate of growth from birth until school age. Health professionals are not predictably involved in any consistent manner. Therefore, the parent must be engaged early in the infant’s life in order to utilize his observational skills in developmental review. Parent engagement Of course’ voluntary and be based on the parent’s understanding of the benefits of participation. It would be important to have a health worker who is bicultural and bilingual, if culture or language differences exist between parent and worker. A model providingfor parents as first evaluators of the child-a parent inventoV-With OPPOrtunitY to discuss areas of concern a~ well a~ strengths, allows parents to look toward assistance rather than fear criticism. There is an obvious charge to developers of parent questionnaires that they not be trivial; they must have developmental implications.
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It should also be obvious that they must have cross-cultural validity. Parents are also vital to the developmental review process for their observations on the family environment. The review of the characteristics of the family and its social and economic circumstances should be oriented toward identifying the stresses, strengths, and supports available to the child. Parental involvement in each step of developmental review is essential. Parents need to understand their children’s abilities and assets, as well as disabilities and deficiencies. Further, treatment of developmental problems might frequently involve educational programs that parents may carry out with their children. “Treatment” may also be education of the parent to support the child’s strengths. An EPSDT developmental review task force must collate and make available to local communities the varying models of parent-based “treatment” programs that have been developed. This should include the wealth of parent education materials that currently exist in many scattered places. This particular use of parent education materials holds a truly exciting and innovative approach to health care in this country. Support Systems for EPSDT
Creation of an EPSDT Coordinator, an EPSDT office, and support personnel for EPSDT districts, and the establishment of community Coordinating councils (to include the schools and all service agencies, as well as representatives of parents and service providers) were recommended by the AApSC. These support systems would make possible and facilitate 1 ) planning and implementation on the local level, 2 ) identifi-
BEATRICE D. MOORE
cation of gaps and needs in the service resources; 3 ) coordination and stimulation of services relevant to achieving goals of EPSDT; and 4 ) cooperation and contribution to the external evaluation of EPSDT. The manpower issues involved in training, consultation, and technical assistance are primary. Qualifications of personnel involved in each stage, cultural appropriateness of personnel, and their training and education, must be carefully reviewed. Multiple models of service delivery were recommended, depending on the characteristics of individuals and agencies available as support systems. ETHICAL AND LEGAL CONSIDERATIONS
General Premises Ethical considerations need to be viewed against the backdrop of two different normative models: 1 ) the disease recognition and prevention model, and 2) the cultural diversity model. The former emphasizes identifiable organic pathologies that imply some type of medical treatment. Within this model, the basic assumption is that false positives carry no risk aside from those associated with further diagnostic procedures; on the other hand, failing to detect pathology could lead to serious and possibly irreversible consequences. The “cultural diversity” normative model focuses on behaviors that deviate from the expectations of the social group. In this case, the basic assumption is that false positives are more serious than false negatives in screening because labeling a child as deviant tends to trigger social responses such as tracking into special programs, institutionalization, changed perceptions and expecta-
tions, etc., which in themselves may have irreversible consequences. Any developmental review system should reflect this distinction. Screening may legitimately utilize the “disease” model during the years of infancy and early childhood development, when the child’s primary social group is the family. In doing so, however, developmental review must focus primarily on the child‘s physiological development. Conversely, as children enter the school system, and their behavior is evaluated with reference to the expectations of the social group, developmental assessment necessarily encompasses behavioral measures, and policies must therefore be formulated within the normative framework of the “cultural diversity” model. In a free, pluralistic society, there are clear boundaries on the scope of legitimate inquiry into personal familial concerns. Therefore, a federally financed assessment program should be limited to those measures of organic functioning and basic, adaptive coping skills that enjoy a high degree of consensus within the health professions and affected communities; and those behavioral factors especially associated with learning, language and speech development, motor skills and perceptual abilities. Specific assessment of emotional and behavioral adjustment and parent/child interactions should be left to parental initiative and sensitive clinical observation (Stage Three as herein proposed). It is not ethically mandatory to limit the scope of review because treatment is unavailable for the identified condition. This is true whether or not there is known treatment, treatment is not available in the community, or, if available, is too costly. Reasons offered for this position include the following: without
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such data about existing conditions the need for the development of new treatment capabilities may never become apparent; the information may be useful to the provider in counseling the parent about managing the problem, and in developing a parent-oriented treatment program; and treatment may later become ava.ilable.
Informing Parents of Results If the developmental review suggests that the child is in developmental difficulty, the health professional should iniorm the parent of the general area of concern, being careful to avoid arousing undue parental anxiety, before recommending referral for diagnostic (Stage Three) evaluation. If the diagnosis is positive, the professional should inform the parents fully of the child’s developmental status and discuss the treatment alternatives. If treatment services are not available in the community, then the diagnosing professional should counsel the parent, utilizing her own clinical judgment in determining what information to disclose and what is to be done. It is also important to inform parents when no indications of difficulty are found during any of the stages of developmental review. Criteria Governing Use of Standardized Procedures Standardization of all procedures used in screening or diagnosis that are correlated with sociocultural factors must be done with appropriate sociocultural norms, and all testing must be administered in the language spoken by the child. Each standardized procedure should have predictive validity for the behavior or conditions it purports to measure and for children of each of the
sociocultural groups with whom the procedure is to be used.
Records and Confidentiality All patient records should be created and maintained in accord with the customary practices of the health professions. Confidentiality should be carefully preserved, and no information should be released without parental consent. Under no circumstances should Stage One and Stage Two information be transferred to the school system. “Medical” information from these records may be disclosed to authorized persons in the educational system with parental consent in accord with usual procedures. “Screening” information for the individual child should not be disclosed at all. Additional information from the records may be disclosed to authorized persons with parental consent only after the EPSDT Coordinator has consulted with the parent and they have made an independent determination that the disclosure is in the child’s best interests. With appropriate regard for age and maturity, the child’s consent should be included as a condition of information transfer. SUMMARY
In summary, developmental review is a total process. The first two stages are “screens” in the sense of identification of persons needing closer review, but with emphasis on the balance of strengths and weaknesses. The three stages are a means to the end of early detection of children who may need special help or the benefits of closer attention. The legislation authorizing EPSDT makes it national policy that the development of our children be safeguarded
BEATRICE D. MOORE
so as to insure that each child reaches maturity functioning at a maximum level of development. This goal is more than the finding, the study, and the treatment of disease. The guardianship of the health of children is in the national interest as well as in the interest of the individuals; this is the essence of EPSDT.
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professional assistance. These agencies -the Office of Child Development, the Bureau of Education for the Handicapped, the Office of Developmental Disabilities, the National Institute of Mental Health, and the Bureau of Maternal and Child Health-have expertise and resources that should be brought to bear on the problem. Further, we and these agencies share the population at FUTURE DIRECTIONS risk and provide many similar services. The EPSDT program accepts the rec- We will take seriously the charge given ommendation that emphasis be shifted us in many quarters to seek opportunifrom the detection of dysfunction to the ties to gain maximum benefit from proprotection of child development. Many, gram resources. Beyond existing HEW resources, the perhaps most, of the recommendations Carter Administration has proposed of the AAPSC outlined above can be incorporated into guidelines to be issued child health legislation, the Child Health to states in the coming work year. The Assessment Program (CHAP), which developmental review system is the con- will expand and modify the EPSDT proceptual and operational guidance they gram and improve the quality of serhave sought. EPSDT coordinating of- vices. Under this proposal, uniform stanfices, local support systems, and coor- dards for health assessments will be dination of existing services can become defined by regulations. These definitions part of a state’s program implementation will include the components of the plan. health assessment and the schedule for The EPSDT program and the AAPSC periodic reassessments. CHAP will rehave agreed to collaborate in developing quire that states deliver the full range parent education materials and training of services provided for by Title XIX materials for professionals and para- of the Social Security Act to all assessed professionals within a year. This col- children, not just those available under laboration will also begin planning for a specific state’s Medicaid plan. Also, program standards development, evalu- an assessed child’s eligibility for services ation of tools and materials, and pro- will be extended for six months beyond gram review procedures. These are longthe time that changes in his family’s cirrange activities, of course, and the first cumstances would normally mean a loss year may well be spent on basic exploraof eligibility. This provision assures tion and planning. Meanwhile, major greater opportunity for follow-through confidentiality and legal issues will be on conditions detected in assessments. addressed in interim guidelines, as will The CHAP proposal permits states to criteria for Stage Two utilization of set limits on expanded treatment of existing tools. In addition to its work with the “mental illness, mental retardation, deAAPSC, the EPSDT program looks to velopmental disabilities, and dental related HEW agencies for technical and problems.” However, it adds such ser-
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IMPLEMENTING EPSDT
vices as correction of speech and lan- effort. There is work enough to go guage disorders, and physical and occu- around. pational therapy. Further, it mandates states’ assurance of case management REFERENCES 1. AMERICAN ORTHOPSYCHIATRIC ASSOCIATION. and supportive services, and emphasizes 1978. Developmental assessment in services coordination. Thus, while it is EPSDT. Amer. J. Orthopsychiat. 48( 1 ) : regrettable that fiscal constraints led to 7-2 1. 2. BROWN, B. 1975. NIMH Recommendalimitations on some services, the CHAP tions to the Medical Services Adminisproposal promises quality features which tration Concerning the Mental Health Diwill substantially improve our capability mensions of Developmental Assessment in the EPSDT Program. Memorandum to support the developmental review from the Director of NIMH to the Comprocess. missioner of MSA, Sept. 8, 1975. It is clear to all involved-public and 3. Cooperative Agreement Between the Medical Services Administration and the Naprivate-that there is major, intensive, tional Institute of Mental Health of the and complex work ahead. Nevertheless, Alcohol, Drug Abuse and Mental Health we believe that the need of the services Administration, May 12, 1975. 4. HEALTH SERVICES RESEARCH INSTITUTE. for the disadvantaged children of Amer1976. Demonstration Projects Evaluation ica, indeed, for all children, is critical, Report (An Interim Report): April 1, and that EPSDT offers a unique oppor1974-March 31, 1975. University of Texas Health Science Center, San Antonio. (p. tunity to make major gains in the devzliv) opment of these services. We believe 5. HUNTINGTON, D., ed. 1977. Developmental also that the approach is reasoned and Review in the EPSDT Program. American Association of Psychiatric Services for responsible, that the potential benefits Children, Washington, D.C. to children well outweigh the risks, and 6. Program Regulation Guide. MSA-PRG2 1, Medical Services Administration, that the risks can be controlled. Social and Rehabilitation Service, DepartWe hope that this presentation will be ment of Health Education, and Welfare, viewed as a call to participate in the June 29, 1972. (p. 14)
For reprints: Office of Child Health, Health Care Financing Administration. Department of Health, Education, and Welfare, 330 C St. SW, Washington, D.C. 20201
