First Five Sonoma County

Why Screen and Refer for Developmental Delays?

Unidentified developmental delays can interfere with early learning and later academic success as well as diagnoses of underlying medical problems. Children from families below the federal poverty level have higher rates of developmental disabilities, in part due to greater exposure to poverty, family violence, parental substance abuse or other early trauma.  In spite of the importance of screening for developmental disabilities and disabling behavioral problems, less than half of children with these issues are identified before the age of five.

Over 80% of Sonoma County health center patients under 6 years of age are from households with incomes below the federal poverty level. By improving screening at well child visits and effectively referring children to early intervention services, low-income children will have an opportunity to reach their full potential


What We Do

The goal of this partnership between First 5 Sonoma County and Redwood Community Health Coalition (RCHC) is to improve systems for developmental screening and appropriate referral to early intervention services for children 0-5 years of age served by health centers in Sonoma County. Over the three year project, RCHC has been working in collaboration with local community health centers, First 5 Sonoma County, Public Health, local early intervention service agencies, Sonoma County Office of Education and local school districts to develop and implement a sustainable system that support effective developmental screening and referral.

First 5 funding supports this collaboration, as well as health center pilot projects for implementation of developmental screening using evidence-based tools and successful linkages for assessment and treatment. Community health centers participating in the pilot are focused on achieving improvements in the rate of developmental screenings administered at periodic well-child visits, improving referral processes to address positive screens and connecting families to much needed community resources.

Clinical Guidelines

  • Ages and Stages Questionnaire 3
  • Ages and Stages Questionnaire Social-Emotional

For access to these tools, please contact Michelle Rosaschi.


RCHC Training Calendar


As part of this grant, participating health centers are:

  • Standardizing use of an evidence-based tool for developmental surveillance and screening: Ages and Stages Questionnaire (ASQ-3).
  • Systemizing referral processes for children under the age of 3 and over age 3 using standard referral and consent forms.
  • Training health center staff on the importance of incorporating developmental screening and early intervention into routine well-child visits.
  • Updating medical providers on the clinical evaluation needed for children with developmental delay.
  • Helping families navigate community resources for developmental assessment and treatment.
  • Building relationships and establishing regular communication with early intervention specialists, Special Education Directors and local school districts to identify barriers to early identification of developmental delays and linkage for assessment, evaluation, and treatment

Who We Serve

Health Center patients ages 0-5 in Sonoma County and their families.


This project is funded by First 5 Sonoma County.

Project Timeline

July 2014 – June 2017


Process Measures Outcome Measures
# of well-child visits for children ages 0-5 % children 0-5 years that receive recommended well-child visits
# of screenings completed % children 0-5 years administered the ASQ3 at periodic well-child visits
# of referrals to Early Learning Institute (ages 0-3) % of children 0-3 with positive screens receiving early intervention services
# of referrals to neighborhood school districts (ages 3-5)  % of children 3-5 with positive screens receiving early intervention services
# of referrals with evaluation/treatment reports sent back to health center % referrals for evaluation and treatment where report is received by health center
# of providers and staff trained


Wave 1: During Wave 1 of this project, we convened a Community Advisory Group to better understand and improve the referral systems in Sonoma County. This collaboration resulted in development of resources for health centers including system maps for referral of children ages 0-3 years and 3-5 years, standard referral forms, and contact information for community partners.

Wave 2: Wave 2 of this project began in November 2015 with pilot projects at the participating health centers. Results of Wave 2 will be available in mid-2017.


Health Centers:

  • Petaluma Health Center
  • Santa Rosa Community Health – Southwest
  • Sonoma County Indian Health Project

Strategic Partners:

  • First 5 Sonoma County
  • Early Learning Institute (ELI)
  • North Bay Regional Centers (NBRC)
  • Sonoma County Office of Education (SCOE)
  • Special Education Local Area Plan (SELPA)
  • Partnership HealthPlan of California
  • Marin Community Clinics

Evaluation Assistance:

  • First 5 Sonoma County


For more information, please contact Michelle Rosaschi.


  • HRSA HCCN Grant
  • QIP


Success Story

“MH is a 3-year old male who came to our health center several months ago for a well child exam, his first encounter with us. His mother expressed no concerns about his development, except that he was “shy with people he doesn’t know.” Because he was between 25 and 30 months of age we did a routine developmental screening. His mother easily completed the tablet-based ASQ-3 and was surprised by the results: MH had global developmental delays affecting three domains: communication, fine motor and personal-social. The MCHAT-R autism screen was normal. The child was referred to ELI through our referrals coordinator and is now completing his evaluation there.

This is a “screening success story,” as the parent was unaware that her child was delayed, and had no developmental concerns about her “shy” child. In addition, my assessment without the ASQ-3 would have been limited, as the child would not engage with me. Without the routine screening MH might have slipped through to school entry without getting the help that he needed.”

– Dr. Mark Sloan, Petaluma Health Center