1. Developmental/Behavioral Screening:
HOW TO DO IT
EFFICIENTLY AND COST-
EFFECTIVELY AND WHY
Frances Page Glascoe
Dept of Pediatrics Vanderbilt University

2. Screens: Identify the likelihood of a disability
Do not provide a diagnosis
Can help identify a range of possible diagnoses that help focus referrals

3. AAP Committee on Children
EPSDT benefit requires comprehensive 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

4. Early Intervention Efficacy
JAMA. 1990;263:
Pediatric Care Intervention
Arkansas
Einstein
Harvard
Miami PA
Texas
Washington
Yale
TOTAL

5. Early Intervention Benefits: Rationale For Screening
Individuals with Disabilities Education Act
Availability of services
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

6. Detection rates without
screening tests
70% of children with developmental
disabilities not identified
(Palfrey et al. J PEDS. 1994;111: )
80% of children with mental health
problems not identified
(Lavigne et al. Pediatr. 1993;91: )

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

9. Effects of Psychosocial Risk Factors on Intelligence
Percentiles
84th
75th
50th IQ
25th
16th
RISKS: < HS, > 3 children, stressful events, single parent,
parental mental health problems, < responsive parenting,
poverty, minority status, limited social support

10. frequent psychosocial risk factors
Parents often need training, and social services.
Children need enrichment tutoring, mentoring, mental health,
etc.
Parents often need advice about behavior
NORMAL DEVELOPMENT
minimal psychosocial
risk factors
BELOW AVERAGE
DEVELOPMENT
frequent psychosocial risk factors
Children need special education, speech-therapy, etc.
DISABLED
some psychosocial risk factors
and/or organicity

11. Detection rates WITH Screening Tests
70% to 80% of children with developmental disabilities correctly identified
Squires et al, JDBP. 1996;17:
80% to 90% of children with mental health problems correctly identified
Sturner, JDBP ; 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. -

12. 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

13. So what should we do? Use newer, brief, accurate tools
Make use of information from parents

14. 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

15. 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.

16. Safety Word Inventory and Literacy Screener (SWILS ) 6 – 14 years
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

17. Early Screening Profile Early Screening Inventory
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

18. PARENTS’ EVALUATION OF DEVELOPMENTAL STATUS
PEDS
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 developmental and behavioral problems
4th – 5th grade reading level so > 90% can complete
independently
Score/Interpretation form printed front and back
and used longitudinally

19. Circle: Yes No A little Comment:
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:

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

21. PEDS Interpretation Form
Specific Decision
0 - 3 mos:__
___________
4 - 5 mos:__
mos:_
mos:
mos:
__________
4 - 4½yrs:___
4½ - 6 yrs:__
7 – 8 yrs___
______________________
PEDS Interpretation Form
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.
Yes?
2 or more concerns
about self-help, social, school, or
receptive language
skills?
Yes?
Path A: Two or More Predictive Concerns?
No?
Refer for intellectual/
educational evaluations. Use
professional judgment to decide
if speech- language, or other evaluations are also needed
No?
Path B: One
If unsuccessful, screen for
emotional/behavioral
problems and refer as
indicated. Otherwise refer
for parent training,
behavioral intervention, etc.
Counsel in areas
of difficulty and
follow-up in
several weeks.
Path C: NonPredictive
Concerns?
Yes?
No?

22. 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

23. “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

24. Child Development Inventories
3 screens for children years:
Infant Development Inventory
0 – 18 months
Early Child Development Inventory
18 – 36 months
Preschool Development Inventory
36 – 72 months

25. Child Development Inventories
Each screen:
Has 60 items—all short descriptions of child behavior and development
Takes about 10 minutes for parents to complete
Written at the 9th grade level
Takes about 2 minutes to score
Infant Screen shows strengths and weaknesses in each domain
Screens for older children provide a single
cutoff score
Available in English and Spanish

26. Infant Development Inventory
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
AGE
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

27. Early Child Development
Inventory
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

28. Preschool Development
Inventory
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

29. 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.

30. 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
  

31. 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

32. ASQ Scoring - II
OPTIONAL: The specific answers to each item on the questionnaire can be recorded below on the summary chart.

33. 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

34. 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 __ ___ __ Refuses to share __ ___ __

35. PSC Scoring
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.

36. Brigance Screens Takes 10 – 15 minutes of professional time
Produces a range of scores across domains
Detects children who are delayed as well as advanced
9 separate forms across 0 – 8 year age range—similar format to Denver-II
Each produces 100 points and is compared
to an overall cutoff
Available in multiple languages
Widely used by schools/practices with PNPs
Computer scoring software, online version soon
Curriculum Associates, Inc. | 153 Rangeway Road | North Billerica, MA 01862phone (800) ext 219/ | fax /

37. Brigance Infant and Toddler Screens
Can be administered by interview and/or direct
elicitation
Separate form for 0 through 11 months, 12 through 23 months
Provides scores for 6 developmental domains: fine/gross motor, receptive/expressive language, self-help,
social-emotional
Detects children who are delayed as well as advanced
Can plot progress over time
Includes examiner observations of psychosocial risk
Includes a small materials kit (you’ll add crackers)

38. Brigance Screens 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

39. Brigance Screens Other features Strong predictive validity
Good option for practices with NPs
Has instructional videos
Separate cutoffs for children at psychosocial risk who have just entered intervention programs (to minimize unnecessary referrals for dx services)
Test forms come in triplicate for ease of sharing with other providers
Curriculum Associates, Inc. | 153 Rangeway Road | North Billerica, MA 01862phone (800) ext 219/ | fax /

40. 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

41. Safety Word Inventory and Literacy Screener (SWILS)
No Trespassing
EMERGENCY FIRE ESCAPE
High Voltage
POISON

42. Safety Word Inventory and Literacy Screener
Age Range
Years--months
Date
Cutoff
Results
< 6 – 6
6-7 to 6-10
6-11 to 7-2
< 1
< 2
< 3
Pass Fail
7-2 to 7-6
7-7 to 7-10
7-11 to 8-3
< 5
< 12
8-3 to 8-6
8-7 to 8-10
8-11 to 9-2
< 19

43. Screen Selection Flow Chart:
Age Range
0 – – – – 18
PEDS or
CDIs or
ASQ or
Brigance
( + PSC)
PEDS or
Brigance
SWILS
( + PSC)
SWILS
and/or
PSC
PEDS or
CDIs or
ASQ or
Brigance

44. 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

45. 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

46. 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