Presentation on theme: "Developmental/Behavioral Screening:"— Presentation transcript:
1 Developmental/Behavioral Screening: HOW TO DO ITEFFICIENTLY AND COST-EFFECTIVELY AND WHYFrances Page GlascoeDept of Pediatrics Vanderbilt University
2 Screens: Identify the likelihood of a disability Do not provide a diagnosisCan 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 statusAAP Committee on Childrenwith Disabilities recommends routine standardized developmental and behavioral screening
4 Early Intervention Efficacy JAMA. 1990;263:Pediatric Care InterventionArkansasEinsteinHarvardMiamiPATexasWashingtonYaleTOTAL
5 Early Intervention Benefits: Rationale For Screening Individuals with Disabilities Education ActAvailability of servicesFamily interest in participationBetter outcomes for participants:Higher graduation rates, reduced teenpregnancy, higher employment rates,decreased criminality and violent crime$30,000 to >$100,000 benefit to society
6 Detection rates without screening tests70% of children with developmentaldisabilities not identified(Palfrey et al. J PEDS. 1994;111: )80% of children with mental healthproblems not identified(Lavigne et al. Pediatr. 1993;91: )
8 Sample ChecklistUses hungry, tired, thirstyClimbs stairs without holding onStacks 12 blocksKnows colorsDresses self completelyPlays games with rules
9 Effects of Psychosocial Risk Factors on Intelligence Percentiles84th75th50thIQ25th16thRISKS: < 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 behaviorNORMAL DEVELOPMENTminimal psychosocialrisk factorsBELOW AVERAGEDEVELOPMENTfrequent psychosocial risk factorsChildren need special education, speech-therapy, etc.DISABLEDsome psychosocial risk factorsand/or organicity
11 Detection rates WITH Screening Tests 70% to 80% of children with developmental disabilities correctly identifiedSquires et al, JDBP. 1996;17:80% to 90% of children with mental health problems correctly identifiedSturner, JDBP ; 12: 51-64Most over-referrals on standardized screens are children with below average development and psychosocial risk factorsGlascoe, APAM. 2001; 155:54-59.-
12 Reasons for limited use of screening tests at well visits: COMMON MYTHScommon screening tests too longmany difficult to administerchildren uncooperativereimbursement limitedreferral resources unfamiliar orseemly 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 completionand 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 methodsTests correct for the tendency of some parents to over-reportTests correct for the tendency of some parents to under-report.
16 Safety Word Inventory and Literacy Screener (SWILS ) 6 – 14 years Six Quality TestsParents’ Evaluation of DevelopmentalStatus (PEDS) 0 through 8 yearsChild Development Inventories(CDIs) 0 to 6 yearsAges and Stages (0 to 6 years)Pediatric Symptom Checklist(PSC) 4 through 18 yearsBrigance Screens 0 to 8 yearsSafety Word Inventory and Literacy Screener (SWILS ) 6 – 14 years
17 Early Screening Profile Early Screening Inventory Excluded Tests:PDQDenver-IIEarly Screening ProfileDIAL-IIIEarly Screening InventoryELMGesellDue to absence of validation, poor validation, norming on referred samples, and/or poor sensitivity/specificity
18 PARENTS’ EVALUATION OF DEVELOPMENTAL STATUS PEDSA Method for Detecting and AddressingDevelopmental and Behavioral ProblemsFor children 0 through 8 yearsIn English, Spanish and VietnameseTakes 2 minutes to scoreElicits parents’ concernsSorts children into high, moderate or low risk for developmental and behavioral problems4th – 5th grade reading level so > 90% can completeindependentlyScore/Interpretation form printed front and backand used longitudinally
19 Circle: Yes No A little Comment: PEDS Response Form1. 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 Form0 – 4 mos yrs yrs yrs1. Global/Cognitive - -2. Expressive Language3. Receptive Language4. Fine Motor5. Gross Motor Behavior7. Social-Emotional - -8. Self-Help9. Academic/Preacad
21 PEDS Interpretation Form Specific Decision0 - 3 mos:_____________4 - 5 mos:__mos:_mos:mos:__________4 - 4½yrs:___4½ - 6 yrs:__7 – 8 yrs_________________________PEDS Interpretation FormRefer for audiological and speech-language testing. Useprofessional judgment to decideif referrals are also needed forsocial work, occupational/physical therapy, mental healthservices, etc.Yes?2 or more concernsabout self-help, social, school, orreceptive languageskills?Yes?Path A: Two or More Predictive Concerns?No?Refer for intellectual/educational evaluations. Useprofessional judgment to decideif speech- language, or other evaluations are also neededNo?Path B: OneIf unsuccessful, screen foremotional/behavioralproblems and refer asindicated. Otherwise referfor parent training,behavioral intervention, etc.Counsel in areasof difficulty andfollow-up inseveral weeks.Path C: NonPredictiveConcerns?Yes?No?
22 PEDS’ Evidenced Based Decisions when and where to refer (e.g., mentalhealth services, speech-language ordevelopmental/school psychologists)when to screen further (or refer forscreening)when to offer developmental promotionwhen to provide behavioral guidancewhen to observe vigilantlywhen reassurance and routinemonitoring are sufficient
23 “Oh, by the way…..” Other PEDS Features Reduces “doorknob concerns” Shortens visit length/focuses visitFacilitates patient flowImproves parent satisfaction and positive parenting practicesIncreases provider confidence in decision-making
24 Child Development Inventories 3 screens for children years:Infant Development Inventory0 – 18 monthsEarly Child Development Inventory18 – 36 monthsPreschool Development Inventory36 – 72 months
25 Child Development Inventories Each screen:Has 60 items—all short descriptions of child behavior and developmentTakes about 10 minutes for parents to completeWritten at the 9th grade levelTakes about 2 minutes to scoreInfant Screen shows strengths and weaknesses in each domainScreens for older children provide a singlecutoff scoreAvailable 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 regularlyClinicians draw lines to represent child’s age, 30% below, and 30% abovePatterns of strength and weaknesses focus referralsAGESocialSelf-HelpGross MotorFine MotorLanguage6 mos.Reaches for familiar personsLooks for object after it disappearRolls from back to stomachTransfer objects from hand to handBabbles__Responds to name
27 Early Child Development InventoryParents mark YES or NO to 60 statementsClinicians count the number of YES statementsand compare to cutoff for ageOptional items address behavioral/emotionalconcerns but are not formally scoredSample Items:1. Y N Walks without help5. Y N Washes and dries hands4. Y N Feeds self a cracker or cookie24. Y N Kicks a ball
28 Preschool Development InventoryParents mark YES or NO to 60 statementsClinicians count the number of YES statements and compare to cutoff for ageOptional items address behavioral/emotional concerns but are not scoredEnter total scoreT____Enter cutoff for ageC
29 Ages and Stages Questionnaire (ASQ) 4 mos – 6 years A different 3 –4 page form for each well visit30 – 35 items per form describing skillsForms include helpful illustrationsCompleted by parent reportTaps major domains of developmentTakes about 15 minutes, and 5 to scoreASQ-Social-Emotional works similarly andmeasures behavior, temperament, etc.
30 ASQ Sample Items3. 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, withouttracing? 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 thesetotals in the space provided for area totals.Indicate the child’s total score for each area by filling inthe appropriate circle on the chart below.Scores in shaded areas, prompt a referral
32 ASQ Scoring - IIOPTIONAL: 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 – 18Screens for mental health and behavioral problemsPresents parents with a list of problematic behaviorsProduces four distinct factors:Internalizing (depressed, withdrawn, anxious)Externalizing (conduct, problem behavior, etc.)Attentional (impulsivity, distractibility, etc.)Academic/GlobalTakes about 7 minutes for parents to completeTakes 4 –5 minutes to score factorsAvailable in English, Spanish and Chinese
34 PSC Sample ItemsNEVER 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 ScoringAssign a value of 0 to Never, 1 to Sometimes, and 2 to often2. Add scores3. 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 domainsDetects children who are delayed as well as advanced9 separate forms across 0 – 8 year age range—similar format to Denver-IIEach produces 100 points and is comparedto an overall cutoffAvailable in multiple languagesWidely used by schools/practices with PNPsComputer scoring software, online version soonCurriculum 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 directelicitationSeparate form for 0 through 11 months, 12 through 23 monthsProvides scores for 6 developmental domains: fine/gross motor, receptive/expressive language, self-help,social-emotionalDetects children who are delayed as well as advancedCan plot progress over timeIncludes examiner observations of psychosocial riskIncludes 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 timeAll items require direct elicitationBlocks, crayons, providedSamples all developmental domains, with increasing emphasis on better predictorsof school success: language and academics
39 Brigance Screens Other features Strong predictive validity Good option for practices with NPsHas instructional videosSeparate 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 providersCurriculum 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 wordsChild given credit for correctpronunciationNumber correct is compared to a cutofffor agePerformance correlates with reading andmath6 – 14 years of agetakes 1 – 5 minutespublic domainMay serve as a springboard to injuryprevention counseling
41 Safety Word Inventory and Literacy Screener (SWILS) No TrespassingEMERGENCY FIRE ESCAPEHigh VoltagePOISON
42 Safety Word Inventory and Literacy Screener Age RangeYears--monthsDateCutoffResults< 6 – 66-7 to 6-106-11 to 7-2< 1< 2< 3Pass Fail7-2 to 7-67-7 to 7-107-11 to 8-3< 5< 128-3 to 8-68-7 to 8-108-11 to 9-2< 19
44 Organizing Offices for Efficient Screening Provide office staff a rationale for screening. Clearly state goals—screening at each well visitAllow staff some control over when and whereEnsure that staff ask families whether they would like to complete the measure on their own or be interviewedGive 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 billingSources for patient education materialsInformation about obtaining the various screensA guide to explaining test resultsInformation about the AAP’s Section on Developmental and Behavioral Pediatrics websiteInformation on organizing offices for efficient screening and developmental promotionInformation on referral resourcesHow to lead a screening initiative in a practice
46 Final Comments Developmental services are available and non-medical providers play a big roleMore detailed screening and developmental diagnostics can be provided by preschool IDEA and/or public schoolsIdeally, get to know key non-medical providers and establish a referral relationship:Head of school psych dept. or SELocal preschool IDEA coordinatorSupervisor of family and children’s services at mental health centers
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