Developmental/Behavioral Screening:

Frances Page Glascoe Dept of Pediatrics Vanderbilt University

Screens:

•

Identify the likelihood of a disability

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Do not provide a diagnosis

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Can help identify a range of possible diagnoses that help focus referrals

EPSDT benefit requires com

prehensive health and developmental history, i.e., screening for developmental and mental health status

AAP Committee on Children with Disabilities recommends routine standardized developmental and behavioral screening

Early Intervention Efficacy

JAMA. 1990;263:3035-3042

Pediatric Care Intervention Arkansas Einstein Harvard 85 74 96 99 85 97 Miami PA Texas Washington Yale TOTAL 66 92 80 92 91 85 81 95 87 100 103 94

Early Intervention Benefits: Rationale For Screening

Individuals with Disabilities Education Act Availability of services Family interest in participation Better outcomes for participants: H igher graduation rates, reduced teen pregnancy, higher employment rates, decreased criminality and violent crime $30,000 to >$100,000 benefit to society

Detection rates without screening tests

70% of children with developmental disabilities not identified (Palfrey et al. J PEDS. 1994;111:651-655) 80% of children with mental health problems not identified ( Lavigne et al. Pediatr. 1993;91:649 - 655)

Sample Checklist

Uses hungry, tired, thirsty Climbs stairs without holding on Stacks 12 blocks Knows colors Dresses self completely Plays games with rules

Effects of Psychosocial Risk

125

Factors on Intelligence

Percentiles 120 115 84th 110 75th 105 IQ 100 50 th 95 90 85 25 th 16 th 80 0 1 2 3 4 5 6 7+

RISKS: < HS, > 3 children, stressful events, single parent, parental mental health problems, < responsive parenting, poverty, minority status, limited social support

NORMAL DEVELOPMENT Parents often need

minimal psychosocial risk factors

training, and social services. Children need BELOW AVERAGE DEVELOPMENT enrichment tutoring, mentoring, mental health,

frequent psychosocial risk factors

DISABLED

some psychosocial risk factors

etc.

and/or organicity

Parents often need advice about behavior Children need special education, speech therapy, etc.

Detection rates WITH Screening Tests

70% to 80% of children with developmental disabilities correctly identified Squires et al

,

JDBP. 1996;17:420 - 427 80% to 90% of children with mental health problems correctly identified Sturner, JDBP . 1991

;

12

:

51-64 Most over-referrals on standardized screens are children with below average development and psychosocial risk factors

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Glascoe, APAM. 2001; 155:54-59.

Reasons for limited use of screening tests at well visits: COMMON MYTHS

common screening tests too long many difficult to administer children uncooperative reimbursement limited referral resources unfamiliar or seemly unavailable

So what should we do?

Use newer, brief, accurate tools Make use of information from parents

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

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.

Six Quality Tests Parents’ Evaluation of Developmental Status (PEDS)

0 through 8 years

Child Development Inventories (CDIs)

0 to 6 years

Ages and Stages

(0 to 6 years)

Pediatric Symptom Checklist (PSC)

4 through 18 years

Brigance Screens

0 to 8 years

Safety Word Inventory and Literacy Screener (SWILS )

6 – 14 years

Excluded Tests:

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

PARENTS’ EVALUATION OF DEVELOPMENTAL STATUS

A Method for Detecting and Addressing Developmental and Behavioral Problems

• • • • • • •

For children 0 through 8 years In English, Spanish and Vietnamese Takes 2 minutes to score Elicits parents’ concerns Sorts children into high, moderate or low risk for 4 th developmental and behavioral problems – 5 th grade reading level so > 90% can complete independently Score/Interpretation form printed front and back and used longitudinally

PEDS Response Form 1. Please list any concerns about your child’s learning,

development, and behavior.

2. Do you have any concerns about how your child talks and makes speech sounds?

Circle: Yes No A little Comment:

7. Do you have any concerns about how your child gets along with others?

Circle: Yes No A little Comment:

1. Global/Cognitive - PEDS Score Form 0 – 4 mos 2yrs 3yrs 4yrs 8 2. Expressive Language 3. Receptive Language 4. Fine Motor - - - - - - 5. Gross Motor - - - - - 6. Behavior - - - - - - - 7. Social-Emotional - 8. Self-Help - - - - - - - - 9. Academic/Preacad

Concerns?

No?

PEDS Interpretation Form

Yes

Path A: Two or More Predictive Path B: One Concerns?

No?

Yes

2 or more concerns about self-help, social, school, or receptive language skills?

Path C: NonPredictive

Yes?

No ?

Counsel in areas of difficulty and follow-up in several weeks.

Refer for audiological and speech -language testing. Use professional judgment to decide if referrals are also needed for social work, occupational/ physical therapy, mental health services, etc.

decide if speech- language, or other evaluations are also needed If unsuccessful, screen for emotional/behavioral problems and refer as indicated. Otherwise refer for parent training, behavioral intervention, etc.

Specific Decision 0 - 3 mos:__ ___________ ___________ 4 - 5 mos:__ ___________ ___________ 6 - 11 mos:_ ___________ ___________ 12 - 14 mos:

___________

___________ ___________ 15 - 17 mos: __________ ___________ ___________ 4 - 4½yrs:___ __________ ___________ ___________ 4½ - 6 yrs:__ __________ ___________ 7 – 8 yrs___ ___________ ___________

PEDS’ Evidenced Based Decisions

when and where to refer (e.g., mental health services, speech-language or developmental/school psychologists) when to screen further (or refer for screening) when to offer developmental promotion when to provide behavioral guidance when to observe vigilantly when reassurance and routine monitoring are sufficient

“

Oh, by the way

…..” Other PEDS Features Reduces “doorknob concerns” Shortens visit length/focuses visit Facilitates patient flow Improves parent satisfaction and positive parenting practices Increases provider confidence in decision making

3 screens for children 0 - 6 years: Infant Development Inventory 0 – 18 months Early Child Development Inventory 18 – 36 months Preschool Development Inventory 36 – 72 months

o

Each screen: Has 60 items —all short descriptions of child behavior and development

o

Takes about 10 minutes for parents to complete

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Written at the 9 th grade level

o o o

Takes about 2 minutes to score Infant Screen shows strengths and weaknesses in each domain Screens for older children provide a single cutoff score

o

Available in English and Spanish

AGE Parents place a ‘B’ next to things their child is beginning to do and a



next to skills their child is doing regularly Clinicians draw lines to represent child’s age, 30% below, and 30% above Patterns of strength and weaknesses focus referrals Social Self-Help Gross Motor Fine Motor Language 6 mos

.

Reaches for familiar persons Looks for object after it disappear Rolls from back to stomach Transfer objects from hand to hand Babbles __ Responds to name

• Parents mark YES or NO to 60 statements • Clinicians count the number of YES statements and compare to cutoff for age • Optional items address behavioral/emotional concerns but are not formally scored

Sample Items:

1. Y N Walks without help 5. Y N Washes and dries hands 4. Y N Feeds self a cracker or cookie 24. Y N Kicks a ball

Parents mark YES or NO to 60 statements Clinicians count the number of YES statements and compare to cutoff for age Optional items address behavioral/emotional concerns but are not scored Enter total score T ____ Enter cutoff for age C

Ages and Stages Questionnaire (ASQ) 4 mos – 6 years

A different 3 –4 page form for each well visit 30 – 35 items per form describing skills Forms include helpful illustrations Completed by parent report Taps major domains of development Takes about 15 minutes, and 5 to score ASQ-Social-Emotional works similarly and measures behavior, temperament, etc.

ASQ Sample Items

3. Using the shapes below to look at, does your child copy at least three shapes onto a large piece of paper using a pencil or crayon, without tracing? Your child’s drawings should look similar to the design of the shapes below, but they may be different in size.

Yes Sometimes Not Yet

  

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.



Scores in shaded areas, prompt a referral

ASQ Scoring - II



OPTIONAL: The specific answers to each item on the questionnaire can be recorded below on the summary chart.

PEDIATRIC SYMPTOM CHECKLIST (PSC)

For children 4 – 18 Screens for mental health and behavioral problems Presents parents with a list of problematic behaviors Produces four distinct factors: Internalizing (depressed, withdrawn, anxious) Externalizing (conduct, problem behavior, etc.) Attentional (impulsivity, distractibility, etc.) Academic/Global Takes about 7 minutes for parents to complete Takes 4 –5 minutes to score factors Available in English, Spanish and Chinese

PSC Sample Items

NEVER SOMETIMES OFTEN 1. Complains of aches or pains __ ___ __ 2. Spends more time alone __ ___ __ 3. Tires easily, little energy 4. Fidgety, unable to sit still __ ___ __ __ ___ __ 5. Has trouble with a teacher __ ___ __ 35. Refuses to share . . . . . __ ___ __

PSC Scoring

1. Assign a value of 0 to Never, 1 to Sometimes, and 2 to often 2. Add scores 3. If ages 4 & 5, omit items 5,6,17, and 18. If value is > 24 refer. For older children, > 28 indicates need for referral. 4. View factor scores if scores are above cutoffs.

Curriculum Associates, Inc. | 153 Rangeway Road | North Billerica, MA 01862phone (800)225-0248 ext 219/978-667-8000 | fax 800-366-1158 /978-667-5706 • •

Takes 10 – 15 minutes of professional time Produces a range of scores across domains

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Detects children who are delayed as well as advanced

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9 separate forms across 0 – 8 year age range—similar format to Denver-II

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Each produces 100 points and is compared to an overall cutoff

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Available in multiple languages

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Widely used by schools/practices with PNPs

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Computer scoring software, online version soon

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Can be administered by interview and/or direct elicitation

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Separate form for 0 through 11 months, 12 through 23 months

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Provides scores for 6 developmental domains: fine/gross motor, receptive/expressive language, self-help, social-emotional

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Detects children who are delayed as well as advanced

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Can plot progress over time

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Includes examiner observations of psychosocial risk

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Includes a small materials kit (you’ll add crackers)

For children 2 – 8 years 1 form per each year of age Takes 10 – 15 minutes of professional time All items require direct elicitation Blocks, crayons, provided Samples all developmental domains, with increasing emphasis on better predictors of school success: language and academics

Other features

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Strong predictive validity

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Good option for practices with NPs

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Has instructional videos

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Separate cutoffs for children at psychosocial risk who have just entered intervention programs (to minimize unnecessary referrals for dx

Curriculum Associates, Inc. | 153 Rangeway Road | North Billerica, MA 01862phone (800)225-0248 ext 219/978 667-8000 | fax 800-366-1158 /978-667-5706 •

services) Test forms come in triplicate for ease of sharing with other providers

Safety Word Inventory and Literacy Screener (SWILS)

29 common signs and safety words Child given credit for correct pronunciation Number correct is compared to a cutoff for age Performance correlates with reading and math 6 – 14 years of age takes 1 – 5 minutes public domain May serve as a springboard to injury prevention counseling

Safety Word Inventory and Literacy Screener (SWILS)

No Trespassing

EMERGENCY FIRE ESCAPE

High Voltage

POISON

Age Range Years--months

Safety Word Inventory and Literacy Screener

Date Cutoff Results < 6 – 6 6-7 to 6-10 6-11 to 7-2 7-2 to 7-6 7-7 to 7-10 7-11 to 8-3 8-3 to 8-6 8-7 to 8-10 8-11 to 9-2 < 1 < 2 < 3 < 5 < 5 < 12 < 12 < 12 < 19 Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail

0 – 4

Screen Selection Flow Chart:

4 – 6 Age Range 6 – 8 8 – 18 PEDS or CDIs or ASQ or Brigance PEDS or CDIs or ASQ or Brigance ( + PSC) PEDS or Brigance or SWILS ( + PSC) SWILS and/or PSC

Organizing Offices for Efficient Screening Provide office staff a rationale for screening. Clearly state goals—screening at each well visit Allow staff some control over when and where Ensure that staff ask families whether they would like to complete the measure on their own or be interviewed Give office staff the option of administering an interview version when needed and scoring the measure. Keep a list of referral contact information handy

in the handout for this talk you will find:

Procedures and diagnosis codes for billing Sources for patient education materials Information about obtaining the various screens A guide to explaining test results Information about the AAP’s Section on Developmental and Behavioral Pediatrics website Information on organizing offices for efficient screening and developmental promotion Information on referral resources How to lead a screening initiative in a practice

Final Comments

Developmental services are available and non-medical providers play a big role More detailed screening and developmental diagnostics can be provided by preschool IDEA and/or public schools Ideally, get to know key non-medical providers and establish a referral relationship: Head of school psych dept. or SE Local preschool IDEA coordinator Supervisor of family and children’s services at mental health centers