Transcript AAP Screening-Developmental Screening Tools (D

Developmental Screening Tools
Michelle M. Macias, MD
D-PIP Training Workshop
June 16, 2006
I have no relevant financial relationships with the manufacturer(s) of any commercial product(s)
and/or provider of commercial services discussed in this CME activity.
Learning Objectives
Understand
properties of good
screening tools
Review the screening tool grid
What is screening?
Use of a brief, objective, and validated instrument
 Goal to help differentiate children that are “probably
ok” vs. those “needing additional investigation”- those
with unsuspected deviations from normal
 Performed at a set point in time

– 9, 18,(24), 30 months
Objective vs. subjective impressions
 Results always interpreted in context

– Never in isolation
– Aid to ongoing surveillance
Why Screen?
Most
obvious problems are the least
prevalent
“New
morbidities”
Cannot
rely solely on clinical judgment
for identification of developmental
problems
WHY SCREEN?
CLEARLY
NORMAL
?
CLEARLY
ABNORMAL
Benefits of Screening
Assists in sorting children into 3 categories:
 Needs
screen
additional evaluation - Did not pass
 Needs
close monitoring/surveillance- Passed
screen but has risk factors
 Needs
ongoing monitoring in the context of
well-child care - Passed screen and has no
known risk factors
Screening Challenges
 Use
of informal checklists of developmental skills
– Lack proof that they predict developmental status
– Lack criteria to indicate when a referral is indicated
 Informally
eliciting parents’ concerns (Are you
worried about your child’s development?)
– Parents often not sure if they are worried
– The word “development” is understood by only ~50% of
parents
 Accuracy
of clinical judgment
– detects fewer than 30% of children who have
developmental disabilities
Developmental Screening Tools
 Developmental
screening tools are used to
enhance the surveillance process and increase
detection rates
– Parent-completed questionnaires
– Directly administered instruments
Standards for Screening Tests
 Standardized
 Proof
on national sample
of reliability
– ability of a measure to produce consistent results
 Evidence
of validity
– ability of a measure to discriminate between a child at
a determined level of risk for delay (i.e. high,
moderate) from the rest of the population (low risk)
Standards for Screening Tests
 Accuracy
in ability to categorize is measured
by:
– Sensitivity: accuracy of the test in identifying
delayed development
– Specificity: accuracy of the test in identifying
individuals who are not delayed
For developmental screening tests,
Sensitivity and Specificity of 70-80% are
acceptable
High Sensitivity Trade-off
Abnormal test result
Cutoff
Normal test result
false
positives
High Specificity Trade-off
cutoff
Abnormal test result
false
negatives
Normal test result
Standards for Screening Tests
Accuracy of the Denver-II
Developmental Diagnosis
NO
YES
PASS
69
8
86
FAIL
17
10
27
86
Sensitivity = 10/18 = 56%
Specificity = 69/86 = 80%
18
Denver-II
Screening Pitfalls
 Relying
on informal methods
– Checklists!
– provide no validated criteria for referral
– have unknown reliability
 Using
a measure not suitable for primary care
(i.e. too long)
– results in two things
 using
tests only with selected patients, usually those
with observable problems
 nonstandard administrations
Screening Pitfalls:
The Damage
 Relying
on informal methods
– ignores the asymptomatic who are those most in
need of screening
 Using a measure too time consuming for
primary care
– reduces screens to the status of checklists with
their inherent lack of criteria and unproven
sensitivity and specificity
Let’s Review the Developmental
Screening Tools Grid!
Developmental Screening Tools Grid:
Components

Organized from general
screening tools to
domain/disorder specific
screening tools
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General Screens
Language and cognitive screens
Motor screens
Autism screens
 Information
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provided
Description
Age Range
Number of Items
Administration Time
Psychometric
Properties
Scoring Method
Languages available
How to obtain
Key references
Developmental Screening Instruments:
General
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Ages and Stages Questionnaire
Battelle Developmental Inventory (BDI) Screening Test
Bayley Infant Neurodevelopmental Screener (BINS)
Brigance Screens-II
Infant Development Inventory
Child Development Review
Child Development Inventory (CDI)
Denver-II Developmental Screening Test
Parents' Evaluation of Developmental Status (PEDS)
Developmental Screening Instruments:
Domain-specific
 Gross
motor
– Early Motor Pattern Profile (EMPP)
– Motor Quotient (MQ)
 Communication/Cognition
– Capute Scales (aka Cognitive Adaptive Test/Clinical
Linguistic Auditory Milestone Scale-CAT/CLAMS)
– Communication and Symbolic Behavior ScalesDevelopmental Profile (CSBS-DP): Infant Toddler
Checklist
– Early Language Milestone Scale (ELMS -2)
Developmental Screening Instruments:
Disorder-specific
Autism and pervasive developmental disorders
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–
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Autism Behavior Checklist (ABC)
Checklist for Autism in Toddlers (CHAT)
Modified Checklist for Autism in Toddlers (M-CHAT)
Modified Checklist for Autism in Toddlers-23 (CHAT-23)
Pervasive Developmental Disorders Screening Test-II (PDDST-II) Stage 1-Primary Care Screener
– Pervasive Developmental Disorders Screening Test-II (PDDST-II) Stage 2-Developmental Clinic Screener
– Screening Tool for Autism in Two-Year-Olds (STAT)
– Social Communication Questionnaire (SCQ) (formerly Autism
Screening Questionnaire-ASQ)
Examples: Parent Report Screens
 Ages
and Stages Questionnaire (ASQ) 4
months to 6 years
 Parents’
Evaluation of Developmental
Status (PEDS) 0 to 8 years
Can parents be counted upon to give accurate
and good quality information?
YES!



Screens using parent report are as accurate as those
using other measurement methods
Tests correct for the tendency of some parents to
over-report
Tests correct for the tendency of some parents to
under-report
Can parents read well enough to
fill out screens?
Usually! But first ask,
“Would you like to complete this on your
own or have someone go through it with
you?”
Also, double check screens for completion and
contradictions
Ages and Stages Questionnaire
(ASQ) 4 months to 6 years
•
19 color-coded questionnaire for use at 4, 6, 8, 10, 12,
14, 16, 18, 20, 22, 24, 27, 30, 33, 36, 42, 48, 54, and 60
months
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30 – 35 items per form describing skills
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Completed by parent report
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Taps most domains of development
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Takes about 10-15 minutes, and 3 to score
•
ASQ-Social-Emotional works similarly and measures
behavior, temperament, etc.
•
Can be photocopied
ASQ Sample Items
1. When your child wants
something, does she tell you by
pointing to it?
Yes
4. Does your child say
eight or more words in
addition to “Mama” and
“Dada”?
Yes


Sometimes Not Yet
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Sometimes Not Yet
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
ASQ Scoring
Assign a value of 10 to yes, 5 to sometimes, 0 to never
Add up the item scores for each area, and record these
totals in the space provided for area totals
Indicate the child’s total score for each area by filling in
the appropriate circle on the chart below
Communication
Gross Motor
Fine Motor
Problem solving
Personal-social
Scores in shaded areas prompt a referral
PARENTS’ EVALUATION OF
DEVELOPMENTAL STATUS
•
•
•
•
•
For children 0 to 8 years
In English, Spanish, Vietnamese, Somali, Chinese
Takes 2 minutes to score
Elicits parents’ concerns
Sorts children into high, moderate or low risk for
developmental and behavioral problems
• 4th – 5th grade reading level
• Score/Interpretation form printed front and back
and used longitudinally
Two Directly Administered Screening
Tools
 Bayley
Infant Neurodevelopmental Screener
(BINS)
 Brigance
Screens-II
Bayley Infant Neurodevelopmental
Screener (BINS)
Takes 10 - 15 minutes
 Assesses neurological processes (reflexes, and tone);
neurodevelopmental skills (movement, and symmetry)
and developmental accomplishments (object
permanence, imitation, and language)
 Uses 10 - 13 directly elicited items per 3 - 6 month age
range
 Categorizes performance into low, moderate or high risk
via cut scores. Provides subtest cut scores for each
domain
 For use from 3 - 24 months

BINS Risk Scores
Brigance Screens
Takes 10 – 15 minutes of professional time
 Produces a range of scores across developmental
domains
 Relies primarily on observation and elicitation of
skills (0-2 year age range can be administered by
parent report)
 Detects children who are delayed as well as
advanced
 9 separate forms across 0 – 7 years of age
 Each produces 100 points and is compared to an
overall cutoff
 Available in multiple languages
 Computer scoring software

How to Explain Screening Test
Results
 Use
language that encourages follow-up
 Avoid
 Be
negative and meaningless words
sensitive to cultural meanings of words
Developmental Screening
Principles (AAP 2006)

When the results are normal:
– Inform the parents and continue with other aspects of the
preventive visit
– Provide an opportunity to focus on developmental
promotion

When administered due to concerns:
– Schedule early return visit for additional surveillance, even if
the screening tool results do not indicate a risk of delay

When results are concerning:
– Schedule developmental evaluations
– Schedule medical evaluations
Developmental Screening:
Recommendations
 Infants
and young children should be screened
for developmental delays using reliable and valid
screening techniques at 9,18,(24), 30 months
 Use
of standardized developmental screening
tools at periodic intervals will increase accuracy
 Use
parent-report questionnaires or directly
administered tools with sensitivity and specificity
of at least 70-80%