Transcript Slide 1

Surveillance and Screening
Partnerships and Advocacy:
Integrated Services in the Early Years
Jill Houbé, MD, MPhil, FAAP, FRCP(C)
Surveillance and Screening
• Current child health status
• Definition of terms
• Tools and experience
• Partnerships and advocacy
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BC Child Health Status
• Outcome measures
• Process measures
• Social determinants
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Healthy Child Development
Domains directly related to
adult well-being:
–Socio-emotional
–Language/cognitive
–Physical health
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Early Development
Instrument (EDI)
• Kindergarten year
• 5 scales
• Vulnerable if below “BC
cut-offs” 10%
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BC EDI Results
• No neighbourhood is
immune
• Vulnerability ranges from
13.4% to 39.6%
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Corrected EverRiskMap
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Why Does Early Identification Matter?
• Documentation of benefits
– for physical handicaps, mental retardation
• improved family functioning
– for environmental risk (e.g., Head Start)
• decreased likelihood of grade repetition
• less need for special education services
• fewer dropping out of school
• Clearer delineation of adverse influences
• low-level lead exposure
• adverse parent-infant interaction
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Why Does Early Identification Matter?
Legal Mandate
• Canadian Charter of Rights and
Freedoms (1985)
− Section 7 Legal rights
− Section 15 Equality Rights
• BC Human Rights Code (1996)
• BC School Act (revised 1989)
Guralnick 1987
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Child Health Status
• 16% of children have
disabilities
• 20 – 30% detected before
school entrance
• There are known risk factors
for delay and disability
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NORMAL
Guidanc
e
BELOW AVERAGE
•Parenting
•Mental health
DISABLED
•Enrichment
•Therapy
•Special
Ed
Glascoe, 1997
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Effects of Psychosocial Risk
Factors on Intelligence
Percentiles
125
120
84th
75th
115
110
105
IQ
50th
100
95
90
25th
16th
85
80
0
1
2
3
4
5
6
7+
Risk Factors
Glascoe, 1997
Poor health status, > 3 children, stressful events, single parent,
parental mental health problems, less responsive parenting,
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poverty, minority status, limited social support
Surveillance and Screening
• Current child health status
• Definition of terms
• Tools and experience
• Partnerships and advocacy
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Surveillance and Screening
Hand in Hand
Developmental Surveillance
“…flexible, continuous process in which
knowledgeable professionals perform skilled
observations of children ...
With proper techniques, surveillance is familyfocused, accurate, efficient, …”
Dworkin, 2004
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Developmental Surveillance
• Eliciting/attending to parents’
concerns
• Obtaining a relevant developmental
history
• Skillfully observing children’s
development
• Sharing opinions with other
professionals
Dworkin, 2004
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Developmental Surveillance
Children’s developmental
competencies are best determined
over time
– “spurts” and pauses
– variable rate across domains
– longitudinal aspect of health
supervision
Dworkin, 2004
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Attending to Parents’ Concerns
• There is a strong relationship between
parents’ concerns and child’s
developmental status
• Parents have high levels of sensitivity for
problems regarding fine motor, language,
cognitive and school skills
• Parental concerns about gross motor,
hearing and medical status are highly
related to developmental problems
Dworkin, 2001
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DEVELOPMENTAL SURVEILLANCE
Parents’ Appraisals
• In 87% of children with ADHD, parents have
concerns related to impulsiveness,
inattention or over activity
• Absence of parental concerns or concerns in
other areas (self-help or socialization)
correlates with children without
developmental disorders
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DEVELOPMENTAL SURVEILLANCE
Elicit Parents’ Opinions and Concerns
• Information available from parents
– Appraisals (opinions of children’s
development)
• concerns
• estimations
• predictions
– Descriptions
• recall
• report
Dworkin, 2004
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DEVELOPMENTAL SURVEILLANCE
Parents’ Appraisals
• Concerns
– accurate indicators of true problems
• speech and language
• fine motor
• general functioning (“he’s just slow”)
– self-help skills, behavior less sensitive
• “Please tell me any concerns about the way
your child is behaving, learning, and
developing”
– “Any concerns about how she…”
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Dworkin, 2004
DEVELOPMENTAL SURVEILLANCE
Parents’ Appraisals
• Estimations
– “Compared with other children, how old would
you say your child now acts?”
– correlate well with developmental quotients
• cognitive, motor, self-help, academic skills
• less accurate for language abilities
• Predictions
– likely to overestimate future function
• if delayed, predict average functioning
• if average, “presidential syndrome”
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Dworkin, 2004
DEVELOPMENTAL SURVEILLANCE
Parents’ Descriptions
• Recall of developmental milestones
– notoriously unreliable
– reflect prior conceptions of children’s
development
– accuracy improved by records, diaries
– even if accurate, age of achievement of
limited predictive value
Dworkin, 2004
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DEVELOPMENTAL SURVEILLANCE
Parents’ Descriptions
• Report
– accurate contemporaneous descriptions of
current skills and achievements
– importance of format of questions
• recognition: “Does your child use any of the
following words…”
• identification: “What words does your child
say?”
– produces higher estimates than assessment
• child within a familiar environment
• skills inconsistently demonstrated
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Dworkin, 2004
Developmental Surveillance
Eliciting Parents’ Opinions and Concerns
Caveat: Detection without referral/intervention is
ineffective and may be judged unethical
Dworkin, 2004
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Developmental Surveillance
An appropriate response to parents’ behavioral
concerns is to seek additional information about
children’s development
– important indicators of children’s status
– need for cautious interpretation
Dworkin, 2004
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Developmental Surveillance
Opinions of other professionals offer valuable
information regarding children's developmental
functioning
– input from preschool teachers, child care providers,
visiting nurses
– preschool teachers’ predictions of school readiness,
kindergarten success
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Dworkin, 2004
Screening
• Identify the likelihood of a disability
• Do not provide a diagnosis
• Can help identify a range of possible
diagnoses that help focus referrals
Prieto 2004
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Screening
• Brief
• Standardized
administration
• Proven valid & reliable
• For the asymptomatic
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Detection rates:
No risk factors and no screening
• 30% of developmental
disabilities
• 20% of mental health
problems
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Detection rates:
No risk factors and screening
• 70–80% dev disabilities
• 80–90% mental health
problems
• Over referrals related to
psychosocial risk
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Surveillance and Screening
• Current child health status
• Definition of terms
• Tools and experience
• Partnerships and advocacy
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PDQ
Denver-II
Early Screening Profile
DIAL-III
Early Screening Inventory
ELM
Gesell
Due to absence of validation, poor validation, norming on
referred samples, and/or poor sensitivity/specificity
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Glascoe, 1997
Six Quality Tests
1. Parents’ Evaluation of Developmental Status
(PEDS) (0 through 8 years)
2. Child Development Inventories (CDIs)
(0 to 6 years)
3. Ages and Stages (0 to 6 years)
4. Pediatric Symptom Checklist (PSC)
(4 through 18 years)
5. Brigance Screens (0 to 8 years)
6. Safety Word Inventory and Literacy Screener
(SWILS ) (6 – 14 years
Glascoe, 1997
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Screen Selection Flow Chart
0–4 yrs
PEDS or
CDIs or
ASQ
or
Brigance
Age Range
4–6 yrs
6–8 yrs
PEDS or
CDIs or
ASQ or
Brigance
( + PSC)
PEDS
or
Brigance
or
SWILS
( + PSC)
8–18 yrs
SWILS
and/or
PSC
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Glascoe, 1997
Behavioral/Emotional Screening
• Pediatric Symptom Checklist (PSC)
• Eyberg Child Behavior Inventory
• Family Psychosocial Screening
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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
Glascoe, 1997
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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.
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Glascoe, 1997
When Should You Ask for
Further Evaluation?
Sudden Unexpected Change
In Developmental Trajectory
• Unexplained regression
• Sudden change in personality
• Change in mood or emotional well-being
– May be due to disease or illness
– May reflect important events occurring at home
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When Should You Ask for
Further Evaluation?
• Global Developmental Delay
– Persistent significant delay in all domains that cannot be
attributed to other known factors
• Delays in a sphere of development that
adversely impact the child’s functioning
– At home
– Daycare
– School
• Significant Emotional Concerns
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What Do You Ask For?
• Community health unit and GP
– Hearing screen
– Vision screen
– Speech and language evaluation
– Paediatrician referral
• Infant Development Program
• Child Development Centre
• Sunny Hill Health Centre
• BC Children’s Hospital Child Psychiatry
• School Principal and Individual Education Plan
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Sunny Hill Health Centre
Outpatient Clinics
• School Consults & SERT Team (Substance
Exposure Resource Team)
• Brain Injury
• Craniofacial Clinic, Downtown Eastside Clinic &
SERT Team
• Visually Impaired Program
• Preschool and Developmental-Genetics Clinic
• Hearing Loss Team
• SERT Team
• Neuromotor/Spasticity/Feeding
• Provincial Autism Program
http://www.sunny-hill.bc.ca/sunnyhill/shhcc/default.asp
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Alan Cashmore Centre
• Child-Family Therapy Centre (604) 454-1676
• Under umbrella of services provided by Vancouver Coastal
Health
• Parent Infant Program – home based therapy for
mother/family/infant having difficulties in the initial stage
of their relationship (birth to 30 months of age)
• Parent Child Therapy Program – therapy services for
families finding it challenging to care for their young child
(21/2 to 7 years of age)
• Parent Child Day Program – intensive services for families
experiencing a significant social, emotional and/or
behavioral difficulties in parenting their young child (2 ½
to 6 years)
• Childcare Centre Outreach program – consultation and
support to childcare staff in their own centres in managing
children with social, emotional and/or behavioral
challenges.
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Mental Health Services
• Alan Cashmore Centre
Child-Family Therapy
Centre
(604) 454-1676
• BC Psychological Association www.psychologists.bc.ca
• UBC Psychology Clinic http://www.psych.ubc.ca/clinic/
• SFU Psychology Clinic 604-291-4720
• New Westminster Counselling
– Tel: (604) 525-6651
– Treatment is free and patients can self-refer
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Other Sources of Information
• MCFD website http://www.mcf.gov.bc.ca/
• Redbook http://www2.vpl.vancouver.bc.ca/dbs/r
edbook/htmlpgs/home.html
• Community Brain Injury Program
coordinated by Center for Abilities
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Psychiatry Clinics At
BC Children's Hospital
• Psychiatry
• Mood Disorders Clinic
• Neuropsychiatry Clinic
• Attention Deficit Hyperactivity
Disorder Clinic
• Infant Psychiatry
• Urgent Assessment
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Surveillance and Screening
• Current child health status
• Definition of terms
• Tools and experience
• Partnerships and advocacy
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Who does what?
• Look where children are
found
• Use a valid, reliable tool
• Talk to other people
• Document
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Current practices
• Local initiatives
• Targeted clinical risk
• Only 1 in 3 BC children with
developmental disorder
receive screening/
assessment/intervention
• IDP/CDC
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Research and Experience
• CHILD
• Neonatal Follow-Up
Program
• Early Hearing Program
• BC Healthy Child
Development Alliance
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Advocacy
• Public awareness
• Training
• Policy
– Wait lists
–Database
• Public Health Act 2007?
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Acknowledgements
• Hillel Goelman and Clyde
Hertzman: CHILD and HELP
• BC Healthy Child Development
Alliance
• Neonatal Follow-Up Program
• Dana Brynelsen and IDP
• Sunny Hill Foundation
• CFRI
[email protected]
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References
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Glascoe, Peds In Rev 2000. Chis, Peds Rev 2000
Glascoe, Peds 95, 97; Glascoe, Ped 91. Diamond , J Div Early Childhood 87
Glascoe, Clin Pediatr 91, 94
Mulhern et al, Am J Dis Child. 93
Glascoe FP, Am J Dis Child 89
Perrin E. J Dev Behav Pediatr 1998; 19: 350-352
Palfrey et al. J PEDS. 1994;111:651-655
Lavigne et al. Pediatr. 1993;91:649 – 655
Sturner, JDBP . 1991; 12: 51-64
Glascoe, APAM. 2001; 155:54-59
http://cshcnleaders.ichp.edu/Presentations/screening.htm#PowerPoint%20Presenta
tions
http://www.aap.org/catch/6
www.dbpeds.org
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References
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American Academy Of Pediatrics. Committee on Children With Disabilities
Developmental Surveillance and Screening of Infants and Young Children
Pediatrics. 2001;108:192-196. http://www.aap.org/policy/re0062.html
Dworkin PH. British and American Recommendations for Developmental
Monitoring: The Role of Surveillance. Pediatrics. 1989;84:1000 1010
Dworkin PH. Detection of behavioral, developmental, and psychosocial problems
in pediatric primary care practice. Curr Opin Pediatr. 1993; 5: 531-536.
Dworkin PH. Detection of behavioral, developmental, and psychosocial problems
in pediatric primary care practice. Curr Opin Pediatr. 1993; 5: 531-536.
Frankenburg WK. Selection of diseases and tests in pediatric screening. Pediatrics.
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Glascoe, F.P. (2000). Early detection of developmental and behavioral problems.
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Meisels SJ, Provence S. Screening and Assessment. Guidelines for Identifying
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Washington, DC: National Center for Clinical Infant Programs; 1989
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