Transcript Electronic PEDS:DM and PEDS

Innovative Approaches to
Preschool Developmental
and Behavioral Screening
and Follow-up Services
Frances Page Glascoe
Professor of Pediatrics
Vanderbilt University
Disclosures
• Dr. Glascoe is the author of several
developmental-behavioral screens may receive
royalties on those not in the public domain
• She assures you that this is not a get rich quick
scheme!
• She is from the United States and may have
vocabulary lapses!
Outline
• Why early intervention is vital
• Why we have such trouble finding kids
with delays
• Why it is important for non-medical
providers to understand the challenges of
early detection in health care settings
• How we need to work together
Early Intervention Benefits:
Rationale For Screening
Family interest in participation
Better outcomes for participants:
Higher graduation rates, reduced teen
pregnancy, higher employment rates,
decreased criminality and violent crime
$30,000 to >$100,000 benefit to society
(1992 $$s)
For every 1$ spent on EI, society saves 17$
Early Detection Problems!!
16% - 18% of children have developmental-behavioral
difficulties and need special services
possibly 13% by age 2!
only about 30% are detected by their health care
provider before school entrance
only 2% - 3% are enrolled in early intervention
Enrollment rates should be closer to 8% in the 0 - 2 age
range
Why is it so hard to detect
children with problems?
8 major challenges
Challenge #1:
CLINICAL
JUDGMENT
Challenge #2:
MILESTONES
CHECKLISTS
Sample Checklist
Uses hungry, tired, thirsty
Climbs stairs without holding on
Stacks 12 blocks
Knows colors
Dresses self completely
Plays games with rules
Quality Measures Define Scoring Criteria
For example, “Knows Colors”-- What exactly
does this mean?
Match?
Points to when named?
Names when pointed to?
How many colors?
Quality Measures Select Items that Best
Predict Actual Developmental Status
Challenge #3:
DEVELOPMENT
ITSELF:
Development Develops.
Developmental Problems
Do Too!
Developmental Status by parent's verbal
behavior and positive perceptions
(Leew & Glascoe, in press)
Quotients
110
105
100
95
90
85
80
75
Age in Months
0-5
06 --11
11
12 - 17
18 - 24
* Talks at meals, helps child learn new things, reads aloud,
able to soothe, enjoys child, perceives child as interested in
conversing
Effects of Psychosocial Risk
Factors on Intelligence
Percentiles
125
120
84th
75th
115
110
105
IQ
50th
100
95
25th
16th
90
85
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
TYPICAL DEVELOPMENT
minimal psychosocial
Parents
risk factors
often need
training,
and social
services.
BELOW AVERAGE
Children
DEVELOPMENT
need
frequent psychosocial risk
enrichment
tutoring,
factors
mentoring,
DISABLED
mental
health, some psychosocial risk factors
etc.
and/or organicity
Parents
often need
advice
about
behavior
Children
need special
education,
speechtherapy, etc.
Challenge #4:
DEALING WITH THE
RESULTS OF A
SCREENING TEST
REFERRAL CHALLENGES
• 50% - 80% of children who fail screens
are not referred
(Rushton et al, APAM, 2002)
• > 80% of referrals from primary care
providers made only to familiar
services
(Glade, Forrest et al Amb Peds, 2002)
• Nonmedical providers may not
like the ideal subspecialist
(Forrest et al APAM, 1999)
respond
Challenge #5:
Providers Don't Get Much
Feedback
What’s your referral rate?
1 out of 400
1 out of 200
1 out of 100
1 out of 25
1 out of 10
1 out of 6
PREVALENCE BY AGE
8 % of 0 - 2 year olds
10% of 0 - 3 year olds
12% of 0 - 4 year olds
16%+ of 0 - 8 year olds
Challenge #6:
FAILURE TO USE A HIGH
QUALITY SCREENING
TEST
Standardized on a national samploe
Proof of reliability
Evidence of validity
Accuracy, i.e.:
Sensitivity of 70% to 80%
Specificity of 70% to 80%
Accuracy of the Denver-II
Developmental DX
NO
Denver-II
YES
PASS
69
8
77
FAIL
17
10
27
86
18
Sensitivity = 10/18 = 56%
Specificity = 69/86 = 80%
Screening is a BRIEF process that
sorts those who probably have
problems from those who probably
don’t
Screening is for the asymptomatic
Challenge #7:
COMMUNICATING
WITH FAMILIES
“Your teacher wishes me to delineate those
watershed occasions in your life that have led
you to become, slowly and inexorably,
a loose cannon.”
Sample questions to parents
that don’t work well
Do you think he has any
problems…..?
Do you have any worries
about her development?
Challenge #8:
IMPLEMENTATION!
Reasons for limited use of
screening tests at well visits:
COMMON YET SURMOUNTABLE MYTHS
Common screening tests too long
Tests difficult to administer
Children uncooperative
Reimbursement and time limited
Challenges of giving difficult news
Staff reluctant to take on new tasks
Referral resources unfamiliar or
seemly unavailable
“Looking Good”
So what
should we
do?
Use newer, brief, accurate tools
Make use of information from
parents
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
Parents of all socioeconomic backgrounds
and education are equally accurate
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
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
Glascoe, APAM. 2001; 155:54-59.
Detection/Enrollment Successes
WITH Screening Tests
70% increased in ASD dx in
ages 0 - 3
Minnesota Dept of Education, Pediatrics, 2004
244% increase in referrals to EI
Pediatrics, 2007
40% increase in referrals to
behavioral specialists
Pediatrics, 2008
But…. are we identifying kids who
aren’t eligible for services?
Enrollment Rates in Early Intervention in
States Requiring Use of Quality Screens:
National Average: 2.53% in the 0 – 2 year age range
Broad Eligibility Criteria
Hawaii: 6.9%
Moderate Eligibility Criteria:
Rhode Island: 4.61%
Narrow Eligibility Criteria:
Connecticut: 3.35%
*Source: https://www.ideadata.org/
Enrollment Rates in Early Intervention in
States NOT Requiring Use of Quality Screens*
Broad Eligibility Criteria:
Florida: 1.7%
Moderate Eligibility Criteria:
Alaska: 2.0%
Narrow Eligibility Criteria:
Washington, DC: 1.2%
*Source: https://www.ideadata.org/
Three Examples of Brief
Quality Screens
Providers Have Preferences for
Measurement Methods
Comfortable with parents' concerns?
Prefer parent report of children's skills?
Wish to elicit skills directly from children?
Ages & Stages
Questionnaire-3:
Screening by
Parental Report of
Children's Skills
Ages and Stages Questionnaire
4 months to 6 years
19 color-coded questionnaires, each 6 –7 pages long
for use at 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, 24, 27, 30,
33, 36, 42, 48, 54, and 60 months
30 – 35 items per form describing skills
Completed by parent report
Taps most 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.
Communication
Gross Motor
Fine Motor
Problem solving
Personal-social
Scores in shaded areas, prompt a referral
ASQ: Additional Materials
Scoring CD-ROM
Training
videos
Online ASQ coming soon:
at www.patienttools.com
Same 10 parents' concerns questions, 0 to 8 years
For example, “Please list any concerns about how
your child uses hands and fingers to do things?”
Sorts children into 5 paths offering decision
support
PEDS’ Evidenced Based Decisions
Path A: high risk of developmental disabilities, refer
Path B: moderate risk of disabilities, screen further,
promote development, monitor
Path C: low risk of developmental disabilities but elevated
risk for mental health problems, need for parent education,
monitoring, and/ or additional behavioral screening
Path D: moderate risk of developmental disabilities,
problems with parental communication and need for handson screening
Path E: low risk of disability, reassure
“Oh, by the way…..”
PEDS, by eliciting concerns in advance:
Reduces “doorknob concerns”-- the
"grenades of the day"!
Focuses visits and facilitates patient
flow
Subsequent PEDS Findings
Alerts parents that db issues are a part of well-care and
better focuses visit on issues of importance to families
Teaches parents think about development as a range of
domains
Increases positive parenting practices
Makes it easier to give difficult news
Reduces “oh by the way” concerns--contains visit
length
Increases attendance at well-visits
Over-referrals are children performing in the belowaverage range on the better predictors of school success
and who have psychosocial risk factors
Electronic PEDS
Online PEDS with (optional) Modified
Checklist of Autism in Toddlers (M-CHAT)
EHR interface
Automated scoring
Generates parent summary and referral
letters
Produces ICD-9 and procedure codes
PEDS: Developmental
Milestones (PEDS:DM)
Screening by parent report
or hands-on
How does the PEDS:DM work?
Measures development in 7 domains:
expressive and receptive language, fine and
gross motor, social-emotional, self-help,
academic/pre-academic
One item per domain at each age level
6 - 8 items per encounter
Includes developmental promotion and
evidenced-based surveillance measures
Provides longitudinal monitoring
PEDS:DM
Family
Book
(English
and
Spanish)
laminated,
one page
with 6 - 8
questions
per visit
How does the PEDS:DM work
(continued)?
Includes training guides/case
examples
Has parent education materials
Available in English and Spanish
For NICU follow-up, EI, and
research, the Assessment Level
PEDS:DM offers more items at once
and produces age-equivalent scores
Take Home Messages
 Screening tests are essential and workable in all
settings where we encounter children
 Quality screens improve detection rates 3 - 4-fold
 Office staff need to be engaged
 Parent education and referral materials are essential
 Screening improves quality of care, provider and
parent satisfaction
Take Home Messages-II
Early Intervention takes many forms:
Parent education is critical but monitoring and
continued guidance is essential
For children with more substantial or growing
difficulty, intervention needs to be intensive
Ideally intervention continues throughout the
school years
Take Home Messages-III
Non medical providers need to reach out to
medical providers:
Work through Clinic Coordinators
Visit offices
Describe services
Offer training on tools
Provide laminated lists of services for each
exam rooms
Bring pizzas!
Take Home Messages-IV
Government and other funding agencies need to:
 Offer “carrots” and “sticks” to “do the right thing.”
For example,
A menu of acceptable tools/diverse methods
Economic incentives and proscriptions
Collaborative training opportunities
Feedback on performance
 Organize Services (e.g., directories), centralize
referrals (e.g., single toll-free number)
Locating Professional
Support/Guidance:
 AAP's Section on Developmental-Behavioral
Pediatrics (www.dbpeds.org)
(info on conditions, medications, treatments)
 Early Detection discussion list (www.pedstest.com)
(to post how-to questions and get info on use of tools)
 Harvard's www.developmentalscreening.org
(decision support and implementation research)
Questions?