Transcript General
Windows to Success:
Developmental Screening In the
Early Years
Jane Squires, Ph.D.
Chile Grows With You
November, 2008
Santiago, Chile
[email protected]
Objectives
What is risk in early
development?
What is the
importance of early
identification?
Why screen young
children?
Risk factors
Factors that hamper typical development in
young children
Environmental
• Poverty
• Teen parents
• Abuse/neglect
Biological
• Low birth weight
Identified/established delays
• Down syndrome
Cumulative Effects of Risk
Sameroff et al, 1987
Poverty
How does poverty affect developmental
outcomes?
Is not a direct cause of poor outcomes
Parents in poverty are not “poor parents”
Produces a constellation of stresses and risks
Poverty
Lack of food
Iron deficiency
• Anemia
• Problems with problem-solving, concentration, lower
IQ
Housing Problems
Homelessness
• Infant mortality, asthma, delayed immunizations
• Frequent moving
• Not completing high school
Poverty
Family stress
• Perceived financial
hardship
• Parent stress and
depression
• Family conflict, less
effective parenting behavior
• Child behavior problems,
aggressiveness, learning
problems
Poverty
Fewer resources for learning
Inferior child care
• Less exposure to print, learning materials
• More child stress--anxious, aggressive, less active
Financial barriers for school, college
• Less educational attainment
Meaningful Differences
in the Everyday Experiences of
Young American Children
Hart & Risley, 1995, Brookes Publishing
Meaningful Differences
in the Everyday Experiences of
Young American Children
Hart & Risley, 1995, Brookes Publishing
How can we improve child outcomes?
Early Child Development
Series of interactions
between child and
environment
Series of qualitative
reorganizations among
and within biological
systems stimulated by
environmental
interactions
Transactional Model of Development
Reciprocal, ongoing exchanges between the
child and environment serve as the foundation
of development.
Child is active participant in development.
Outcomes depend upon quality of caregiving
environment as well as the child’s
characteristics.
Plasticity of Young Brain
Brain imaging research shows affects of
stimulating environment on young children
Children of depressed mothers show 40% less
brain activity (Shore, 1997)
With rich interactions from the environment,
brain develops in optimal way
Differential genetic susceptibility to effects of
caregiving environment
Genes + caregiving environment = adult
outcomes
Early Identification
On going monitoring
of young children’s
development
Identifying children
with delays in
development
Providing
enrichment activities
and/or special
education
Early Intervention
Early intervention provides continuum of supports
to children and families
Intervening early is necessary to compensate
Continued intervention and support are often
necessary to sustain gains
Early intervention makes a substantial difference in
the lives of young children and families
Evidence for Early Intervention
Intelligence is enhanced in some children.
Substantial gains are made in all developmental
areas
Secondary handicapping conditions are inhibited
or prevented.
Family support is provided.
Evidence for Early Intervention
Dependency is reduced
Need for special education services at school age
is reduced.
Substantial cost savings in health care and
education costs.
Incidence of children identified as
having a disability by age
2.3%
5.9%
11.6 %
Prevention Triangle
Tertiary
Level
Special education, OT/PT
Secondary
Prevention
Targeted interventions with
risk population
Primary Prevention
Building Positive Relationships for Families
Screening, education, health
Early childhood programs
save money
3 to 1 benefit-cost ratio
Better health and academic outcomes
$3-9 for every dollar invested
16% annual return
• http://epinet.org
• http://brookings.edu
• http://minneapolisfed.org/
Heckman, J. (2006). Skill formation and the economics of investing indisadvantaged children.
Science 312(5782), pp. 1900-1902.
Risk Factors and Development:
Review
• Environmental, medical, and combination risk
factors affect development
• Quality of caregiving environment can mitigate
effects of risk
• Poverty presents most devastating risk factors for
young children
• Prevention is cost-efficient and effective
WHAT IS SCREENING?
Screening
A brief assessment procedure designed to
identify children who should receive more
intensive diagnosis or evaluation from local
education, health, mental health agencies
Screening
Beyond Cutoff
Professional
Assessment
Eligible
Not Eligible
Near Cutoff
Not near cutoff
Continue to monitor
(re-screen) & use
curriculum-based
assessment to
develop learning
plans
WHY SCREEN YOUNG CHILDREN?
Why use screening tests?
Clinical judgment is not accurate
Increases identification rates of children with
delays
If used system-wide, increase
communication, collaboration
among agencies
Why screen?
Increased rates of poverty for families
with young children
Poverty associated with increased medical,
developmental, and social-emotional problems
Medical interventions increasing numbers
of children with delays
Children born below 1500 grams have greatly
increased chance for developmental delays
Increased use of illegal substances by
stressed families
Why screen?
Early childhood time for
brain plasticity and growth
Neurons to Neighborhoods,
http://www4.nationalacademies.org/
Early intervention is effective
For low-birth weight children
McCormick et al. 2006
Ecological focus on family and child
Bronfenbrenner, 1977; Sameroff & Fiese, 2000
Home and center based programs effective
Olds, 1997; Ramey & Ramey, 2000
Identification by pediatricians
In U.S. 60-80% with delays not identified
early
American Academy of Pediatrics 2006:
Pediatricians recommended screening at
9, 18-24, 30 months
Referral rates in 1 practice increased
224% in one year with formal screening
test (Hix-Small, Marks, Squires & Nickel, 2007)
What are effective screening
measures?
Qualities of assessment tools to
consider
Validity
Reliability
Adequate normative
population
Cultural sensitivity
Comprehensiveness
Attractiveness to children
Types of screening instruments
Professionally-administered
Parent-completed
Information on screening tools
http://www.dbpeds.org/
http://www.fpnotebook.com
http://www.cimh.org
Individual publishers
Professionally-administered
Battelle Developmental Inventory Screen, 2nd
(http://www.assess.nelson.com)
Bayley Scales of Infant Development Screen, 3rd
(http://harcourtassessment.com)
Brigance Screens
(http://www.curriculumassociates.com)
Denver II
(http://www.denverii.com/DenverII.html)
Early Screening Inventory
(www.pearsonearlylearning.com)
Parent-Completed
Pediatric Evaluation of Developmental
Status PEDS--Glascoe
• www.pedstest.com
MacArthur Communicative Development
Inventory--Fenson et al.
Minnesota Child Development Inventories
•
http://www.childdevrev.com/cdi.html
Ages & Stages Questionnaires
• http://www.brookespublishing.com
• http://agesandstages.com
Assessment
“the science of examining the strange
behaviors of children in a strange
situation with strange adults for the
briefest possible periods of time”
(Bronfenbrenner, 1979)
Advantages of Parent-Completed
Screening Measures
Engaging families in the
assessment of their child
Parents are reservoirs of rich
information about their
children
Parental involvement reduces
cost
Screening structures
observations, reports and
communications about child
development
Engaging families in the
assessment of their child
Screening may become a teaching tool for
parents and teaching staff
Information/communication can be useful
for primary health care providers and
communication based rehabilitation center
Effective and efficient method of early
identification
Research on parent report of
child developmental level
As accurate as formal measures for identifying cognitive
delay (Glascoe, 1989, 1990; Pulsifer, 1994)
As accurate as formal measures for identifying language
delay (Tomblin, 1987)
As accurate as formal measures for identifying symptoms
of ADHD and school related problems (Mulhern, 1994)
More accurate than Denver for predicting school-age
learning problems (Diamond, 1987)
Accuracy of low and middle
income parents
Agreement between parent-completed ASQ and
professionally administered standardized
assessment:
Low income parents
.85
(below federal poverty level)
Middle income parents
.89
No statistical significance between groups
(Squires, Potter, & Bricker, (1998) Early Childhood Research
Quarterly,13, 2, 345-354.)
Advantages of parent-completed
screening tests
Parents/caregivers can provide rich
information about child across settings
Parent involvement reduces cost
• 3-5 times less
Screening structures observations, reports,
communications about child development
Cost Effective
Parent-completed assessments
range between $3-10 per assessment
(U.S. interview/mail models)
Professionally-administered cost 3-5
times more
(Chan & Taylor, 1998; Dobrez Lo Sasso, Holl et
al., 2001; Glascoe, Foster, & Wolraich, 1997)
Factors that may affect the
accuracy of parental report
Characteristics of parents
Impaired mental functioning
Mental health issues
Cultural and language differences
Involvement with child protective
agencies
Low literacy
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/family-focused/culturally
competent
• Sorts children into high, moderate or low risk
• 4th – 5th grade reading level
• Score/Interpretation form printed front and back
•
and used longitudinally
• Screens for developmental and behavioral/mental
health problems
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:
What are the ASQ and ASQ:SE?
Series of parent- completed developmental
questionnaires
Screen children for possible developmental
delays, difficulties
Monitor the development of young children from
1 month to 5 years
Enlist parents and caregivers in assessment
process
ASQ Communication
12 month ASQ
• Does your baby follow one simple command, such as
Come here, Give it to me, Put it back, without your
using gestures?
Yes
Sometimes
Not Yet
• Does your baby say one word in addition to Mama and
Dada?
Yes
Sometimes
Not Yet
ASQ Fine motor
24-month ASQ
• Does your child turn the
pages of a book by himself?
(He may turn more than one
page at a time.)
Yes
Sometimes
Not Yet
• Does your child flip switches
off and one?
Yes
Sometimes
Not Yet
12 month ASQ:Social Emotional
• Does your baby laugh or smile at you and other
family members?
(z)Most of the time
(v) Sometimes
(x) Rarely or never
• Does your baby like to be picked up and held?
(z)Most of the time
(v) Sometimes
(x) Rarely or never
24 month ASQ:Social Emotional
• Does your child seem too friendly with
strangers?
(x)Most of the time
(v) Sometimes
(z) Rarely or never
• Do you and your child enjoy mealtimes
together?
(z)Most of the time
(v) Sometimes
(x) Rarely or never
ASQ & ASQ:SE for autism
ASQ identified 76/76 children in retrospective
study (Nickel, 2006)
70/76 parents made comments in overall
section
ASQ:SE in clinical settings is identifying children
with autism
Two studies just beginning using ASQ and
ASQ:SE
ASQ Office Study
12 and 24 months
20 pediatric practitioners
76% agreement between ASQ and pediatrician
estimate of development (OK, at risk)
Pediatricians referred mostly for communication,
gross motor delays
Referrals for further assessment increased 224%
in one year
Control and screening year
referrals
70
60
50
40
control year
screening year
30
20
10
0
12-months
24-months
Control and screening year
referrals
45
40
35
doc control
year
doc screening
year
asq screening
30
25
20
15
10
5
0
12-months
24-months
Recommendations for
a screening system
Best practices in screening
Use formal, validated screening measures
Include parents in decision making
Consider cultural adaptations
Develop systematic screening and referral
procedures
Include personnel and agency training
Evaluate screening system
Cost
Efficacy
Utility
Include social-emotional areas
Links between earliest emotional development
and later social behavior. (Cicchetti & Cohen
1995; Reynolds et al., 2001)
Behaviors, even in infancy, signal the need for
intervention (Shonkoff & Phillips, 2000)
Links between early risk factors, poor outcomes
& violence (Conroy & Brown, 2004)
By third grade, programs for children with antisocial behavior are mostly ineffective (Walker,
2004; Greenberg et al., 2003)
21st Century Screening Programs
Short, effective screening tests
Increased use of parent report
Internet-based
Touch screens at health and educational
centers
Follow-up through health and educational
outreach staff
In Summary
Early identification is critical for improving
developmental outcomes
Valid and reliable screening tests are central to
early identification efforts
Several parent-completed screening tests assist in
early identification efforts
Early identification and intervention have
extensive cost savings as well as improving
child and family outcomes
To make change, we must have
unwarranted optimism about our
children and our future
• “All this will not be finished in the first 100 days..
Nor will it be finished in the life of this
Administration, nor even perhaps in our lifetime on
this planet. But let us begin.”
John F. Kennedy, 1961
• “We must become the change we seek to create.”
Gandhi
Thank you