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Developmental Screens in the Office Setting Nathaniel Beers, MD, MPA.

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Presentation on theme: "Developmental Screens in the Office Setting Nathaniel Beers, MD, MPA."— Presentation transcript:

1 Developmental Screens in the Office Setting Nathaniel Beers, MD, MPA

2 OBJECTIVES zWhy to do developmental screen zWhat types of screen tools are available yHow effective are they yHow are they administered zWhat types of additional services are available

3 WHY SCREEN z12-22% of children in US have developmental or behavioral disorders zMany options now exist to tailor screening to what works in specific practice setting zServices available to children with developmental delays from birth on zBetter outcomes for participants: yhigher graduation rates, delayed pregnancy, employment, decreased criminality z$30,000 to >$100,000 benefit to society

4 Why Screen (continued) zWithout screening: y70% of children with developmental disabilities not identified (Palfrey et al. J PEDS. 1994;111:651-655) y80% of children with mental health problems not identified (Lavigne et al. Pediatr. 1993;91:649=655) zWith screening: y70% to 80% of children with developmental disabilities correctly identified Squires et al, 1996, JDBP, 17:420 - 427 y80% to 90% of children with mental health problems correctly identified Sturner, 1991, JDBP; 12: 51-64

5 Types of Screening Tools zTwo major categories yDevelopmental yBehavioral zTwo mechanisms of administration yParental yProvider

6 Developmental Screening Tools zProvider yDenver yCAT/CLAMS yBayley yBrigance yDIAL-R zParent yAges and Stages Questionnaire yParent’s Evaluations of Developmental Status

7 Denver Developmental Screening Test - 2 zVery commonly used screening tool zBirth to 6 years old zPoor sensitivity and specificity (40-60%) z10-20 minutes to administer zNormed on diverse population sample zMultiple languages zDomains: fine and gross motor, language, and social skills

8 DDST (continued) zIdentifies children at 25,75, and 90% completion of task zScored as concern if child completing task in shaded area (75-90%) zScored as failure if not completed by time 90% complete zReferrals warranted for one failure or two concerns zCorrect for prematurity till 2 years old chronological age

9 CAT/CLAMS Clinical Adaptive Test/ Clinical Linguistic and Auditory Milestone Scale zSimilar to Denver but more focused on screening language and better at catching MR zSome parental report, some direct observation by provider zVery high specificity and sensitivity (>90%) zNot standardized in Spanish zQuick to administer due to age categories

10 CAT/CLAMS (continued) zStart at chronological age or at last point zCredit given for completed tasks only zBasal age calculated at age where child completes all tasks at that age plus the value given to any additional tasks above that age zBasal age divided by chronological age then multiple by 100. This is the developmental quotient (DQ). zDQ<70 constitutes delays and should be referred for further evaluation

11 Bayley Screener zAges 3 to 24 months zDirect observation of skills by provider zAssesses three domains (more neuro focused) z11-13 items at each age group (3-6 month breaks) zSpecificity and sensitivity 75-86% z10-15 minutes to administer zNot standardized in Spanish

12 Bayley (continued) zNeurologic processes (reflexes, tone) zNeurodevelopmental skills (movement and symmetry) zDevelopmental accomplishments (language, object permanence, imitation) zScored as low, medium and high risk for developmental disorders

13 Brigance zMultiple age break downs yInfants and Toddlers yEarly Preschool yPre-K yK-1st zAssesses all domains zDirect observation by provider

14 Brigance (continued) zStandardized in English and Spanish zSpecificity and sensitivity 70-82% zEasy to administer zChildren almost always experience success zTime to administer approximately 10 minutes, 20 minutes in a slow child yRealistically after practice 5 minutes

15 Brigance (continued) zSimple scoring zCircle for correct, slash for incorrect zStop after 3 in a row incorrect zTry to get 3 in a row correct as well zLook up score for age to determine if normal or delayed zCan show advanced skills

16 DIAL Developmental Indicators for Assessment of Learning zScreening tool to evaluate pre-school aged children yEffective for evaluation of school readiness zSpeed version: 10 questions (motor, concepts, language domains) zSpanish and English zGood specificity and sensitivity zScored at norms for age with breakdown at 1.0, 1.3, 1.5, 1.7, 2.0 SD below

17 Ages and Stages Questionnaire (ASK) zParent administered survey zScreens multiple domains (communication, gross and fine motor, problem solving and social) zSensitivity 70-90% Specificity 76-91% zValidated in English, Spanish,Korean and French zCan be administered by provider or non-clinical person in cases of illiteracy z5 minutes to administer when familiar, less if parents administer

18 ASK (continued) zPictures with some tasks to improve understanding of parents zScored as 10,5 or 0 points for each question with norms in each domain for each age level

19 Parents Evaluations of Developmental Status (PEDS) zParent administered survey zIdentifies when to screen, refer, counsel, or monitor zSensitivity 74-79% Specificity 70-80% zAvailable in Spanish z2 minutes to administer, less if parents do alone zONLY 10 QUESTIONS zEasy flow sheet to prompt when to refer, counsel or re-evaluate

20 Behavioral Screening zParent or teacher yConnors yChild Behavioral Checklist yPediatric Symptom Checklist yVanderbilt

21 Connor’s zSpecific tool for ADHD with high sensitivity and specificity (>90%) zBreaks down into inattentive or hyperactive types zNot going to determine cause zShould never be used in isolation to make diagnosis yMust rule out additional underlying conditions (MR, LD, hearing and vision abnormalities)

22 Connor’s (continued) zSpanish versions available zTeacher and parent forms zGood for monitoring response to medications zScored by positives (2 or 3) on domains of inattention or hyperactivity

23 Child Behavioral Checklist (CBCL) zMultiple domains zCan help identify other mental health conditions zAvailable in Spanish as well zTeacher and parent forms, child forms for older children zNot as valuable for following child once on treatment zScored in multiple areas (i.e.:internalizing, externalizing, somatic complaints, aggressive behaviors, attention zScored by points in each of the domains. Cut off for significance given for raw or T-scores

24 Pediatric Symptom Checklist zMultiple domains of assessment ySingle score or subscales (attention, internalizing and externalizing) zNot standardized in Spanish zNot helpful once a child has been referred zParent or child fills out form zScored as 0,1,or 2 zSignificance if total score >24 in child 4-5 YO or >28 in child 6-16 YO zAttention: >7 points; Internalizing: >5; Externalizing: >7 points

25 NICHQ Vanderbilt Assessment zSensitivity and specificity of >94% if both parent and teacher ratings used zDetailed questions about behavior to assess attention, opposition, conduct, anxiety and depression zPerformance questions as well zScored by number of 2 or 3 in behavior assessment and 4 or 5 in performance assessment zBreak down given for diagnosis of ADHD (inattentive, hyperactive, or combined), Oppositional Defiant disorder, Conduct Disorder, and Anxiety/Depression

26 Additional Services zSpecialists yDevelopmental Behavioral Pediatricians ySpeech Pathologists, PTs and OTs zOther agencies doing evaluations zEarly Intervention zSpecial Education

27 Specialists zHuge backlogs to see specialists affiliated with Children’s (Nationwide issue) zConstraints on types of testing they can do by insurance companies yMedicaid does not allow Children’s to bill for psycho-educational evaluations zNeed to assess if patient actually needs this service

28 Other agencies zSome are great and some are not ySome are profit driven and have not invested in making sure the quality of evaluations is good zWATS has been very reliable in both quality and speed yNo longer covered by HSCSN zAdditional agencies in handout

29 Early Intervention zZero to three years old zEligibility criteria vary by state and county yDC requires delay of 2 SD zAnyone can refer patient yMD, RN, parent, childcare provider zEI must complete evaluation and help parents transition to SPED when child is 3yo

30 Special Education z3 to 21 years old zEvery child has right to evaluation yAnyone can request eval, but parent must consent yEval must be conducted in child’s primary language and in English yDC requires eval started within 90 days of request (does not include summer or vacation) yRepeat eval every 3 years

31 SPED (continued) zIndividualized Education Plan (IEP) yContains the services child will receive and goals for child yUpdated annually yParents do not need to sign at IEP meeting yQuarterly report on progress zTypes of SPED yInclusion, pull-out, or self-contained class or school

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