1. Pediatric Screening Stacey Cobb, MD Developmental-Behavioral Pediatrics Assistant Professor of Pediatrics University of South Carolina School of Medicine

2. Disclosures No actual or potential conflicts of interest in relation to this program or presentation. No discussion of off-label pharmacotherapy or devices.

3. Objectives Discuss the role of the Primary Care Provider in developmental surveillance and screening Review the administration and interpretation of the most widely used screening tools Develop action steps for positive screen results Discuss barriers in various practice settings

4. Leading Causes of Limitation due to Chronic Conditions in US Children 1.Speech problems 2.Learning disability 3.ADHD 4.Other emotional, mental and behavioral problems 5.Other developmental problems 6.Asthma or breathing problems

5. Developmental Delay 12-16% of U.S. children About half will not be identified before kindergarten Association between disabilities and poorer health status

6. The Mandate Mandate for early identification and intervention for children with developmental disabilities Social Security Act, Title V Individuals with Disabilities Education Improvement Act (IDEA)

7. Impact of Early Intervention Increased academic achievement Increased adult employment rates Decreased criminality

8. Definitions Surveillance – Process of recognizing children who may be at risk Screening – Use of standardized tools to identify and refine that recognized risk Evaluation – Complex process aimed at identifying specific developmental disorders

9. Surveillance Parental concern – Developmental and behavioral concerns Documenting developmental history – Delayed milestones and deviations or dissociation, regression Accurate provider observations Identifying risk and protective factors – Environmental, genetic, biological, social and demographic factors Recording the process and findings

10. Surveillance Clinical judgment alone inadequate and insensitive Checklists and clinical observation has poor sensitivity Aylward showed that physician impression alone would have missed 45% of children eligible for early intervention

11. AAP Recommendations American Academy of Pediatrics – Surveillance at well-child visits – Standardized screening at 9, 18, and 24 or 30 month visits – Standardized screening when delay is suspected Based on substantial evidence demonstrating accuracy of several tools in research settings

12. Additional Organizational Statements USPSTF and AAFP – Insufficient or inconsistent evidence to recommend for or against routine use of brief, formal screening instruments (evidence rating C) Study design issues – Limited studies with general population samples – Lack of use of a criterion measure – Small sample sizes – Conflicting results between studies

13. Broad Screening Tools Address all developmental domains – Motor skills: fine and gross – Language & communication – Problem solving/adaptive behavior – Personal-social skills Should be culturally and linguistically sensitive Sensitivity and specificity levels of 70-80% are acceptable for developmental screening

14. Screening Tools A variety of screening tools to choose from Parent completed questionnaires most widely used –Ages and Stages Questionnaire –Parents Evaluation of Developmental Status

15. Ages & Stages Questionnaire (ASQ-3) Parent report questionnaire 5 developmental domains – 6 questions per domain Response options: yes, sometimes, not yet Provides total score and domain subscale scores

16. ASQ-3 Concerns Validated in mostly high risk populations Validity varies widely between populations – Age, language, country, sample size, risk status Poorer sensitivity in recent Canadian community sample – Very high SES sample

17. Parents’ Evaluation of Developmental Status (PEDS) Parent report questionnaire 10 questions – 2 general questions – 8 developmental domain questions Single form for all ages Responses: no, yes, a little Overall risk based on predictive versus non- predictive items

18. Limbos et al 334 children aged 12-60 months Recruited from 80 primary care providers Completed screening with ASQ and PEDS Completed evaluation with adaptive, speech- language, and cognitive functioning scales

19. Findings From Limbos et al

20. Comparison Ages and StagesPEDS Cost$275 starter kit with photocopy rights $36 starter kit for 50 ($0.72 initial, $0.36/visit) # of Items3010 Parent time10-20 minutes5 minutes Provider time1-5 minutes2 minutes Sensitivity72%74-79% Specificity86%70-80% Age range4 mo – 5 yo0-8 years Variety of survey forms21 age-based formsSingle form, all ages Year of validation1991-19981997 LanguagesEnglish, Spanish, FrenchEnglish, Spanish, Chinese, Hmong, Somali & more

21. 9 Month Well Visit No scheduled vaccines Rapid development – Motor skills – Early language skills – Social and nonverbal communication If practices have eliminated this visit, screen at 12 months

22. 18 Month Well Visit No new vaccines Communication & language delays typically evident by this visit Mild motor delays undetected at 9 months typically are apparent Early intervention available for all domains at this age

23. 30 Month Well Visit Goal of a focused visit on development Still time for state early intervention programs Now part of Bright Futures recommendations

24. Autism Screening Recommended schedule – 18 months – 24 months Modified Checklist for Autism in Toddlers (M-CHAT-R/F) – For use from 16-30 months – 20 questions 0-2  continued surveillance, re-screen at 24 months 3-7  follow-up interview 8-20  refer for evaluation

25. Importance of the Follow-up Interview Follow-up interview – Follow-up questions for those items missed on the M-CHAT-R – 2 items of concern prompts referral Increased specificity from 95.5% to 99.3%

26. Are Separate Screening Tools Needed? Pinto-Martin et al. – 2-step screen with PEDS then M-CHAT – Positive PEDS  16% with positive M-CHAT – Negative PEDS  14% with positive M-CHAT YES! – ASD-specific tool for all children in conjunction with regular standardized developmental screening

27. Results of Screening Does not result in diagnosis Identifies variances from same-age norms Repeated and regular screening more sensitive that a single screening If surveillance or screening indicate developmental concern, sooner follow up and/or referral is indicated

28. Action Steps Early intervention services – BabyNet and ChildFind Referral for evaluation – Developmental-Behavioral Pediatrics, Psychology – Specific therapies – Audiology – Referral for STAT for autism concerns (24-36 mo)

29. Early Intervention Services Diagnosis not needed for referral Can be referred while awaiting evaluation Provide limited evaluation services – Further developmental & medical evaluation is typically needed Provide in-home therapies

30. Barriers Only 23% of primary care clinicians use standardized screening tools Time constraints – Cited by 82% of providers in a recent study Competing clinical demands Cost burden Staff requirements Lack of consensus on tools Insufficient training and expertise

31. Implementation AAP Task Force on Mental Health – Toolkit to aid implementation efforts Implementation steps – Ready the practice – Identify resources – Establish office routines for screening – Track referrals – Seek payment – Foster collaboration

32. Reimbursement 96110 – developmental testing, limited – Multiple units can be billed – Not covered by some private insurance providers Reimburses for review and interpretation of the screening tool

33. The Take Away Surveillance alone is not enough Screening is feasible in the primary care setting Repeated and regular screening is more likely than a single screening to identify problems Early intervention can significantly improve outcomes

34. Resources Developmental screening implementation – www.developmentalscreening.org/screening_tool s/choosing_a_tool.htm www.developmentalscreening.org/screening_tool s/choosing_a_tool.htm M-CHAT-R online – www.m-chat.org/mchat.php www.m-chat.org/mchat.php AAP Mental Health Resources – www.aap.org/en-us/advocacy-and-policy/aap- health-initiatives/Mental-Health/Pages/Key- Resources.aspx www.aap.org/en-us/advocacy-and-policy/aap- health-initiatives/Mental-Health/Pages/Key- Resources.aspx

35. References Aylward GP. Developmental screening and assessment: what are we thinking? J Dev Behav Pediatr. 2009;30(2):169-173. Council on Children With Disabilities; Section on Developmental Behavioral Pediatrics; Bright Futures Steering Committee; Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening [published correction appears in Pediatrics. 2006; 118(4): 1808-1809]. Pediatrics. 2006; 118(1): 405-420. Limbos MM. Comparison of the ASQ and PEDS in Screening for Developmental Delay in Children Presenting for Primary Care. J Dev Behav Pediatr. 2011;32:499-511. Mackrides PS. Screening for Developmental Delay. Am Fam Physician. 2011;84(5):544-549. Pinto-Martin, JA. Screening strategies for autism spectrum disorders in pediatric primary care.J Dev Behav Pediatr. 2008;29:345-350. Robins, DL. Validation of the Modified Checklist for Autism in Toddlers, Revised With Follow-up (M- CHAT-R/F). Pediatrics. 2014;133:37-45. Slomski A. Chronic mental health issues in children now loom larger than physical problems. JAMA. 2012;308(3):223-225. Veldhuizen S. Concurrent Validity of the Ages and Stages Questionnaires and Bayley Developmental Scales in a General Population Sample. Acad Pediatr. 2014; Epub ahead of print 9/12/14 Weitzman C. Section on Developmental and Behavioral Pediatrics, Committee on Psychosocial Aspects of Child and Family Health, Council on Early Childhood, Society of Developmental and Behavioral Pediatrics. Promoting Optimal Development: Screening for Behavioral and Emotional Problems. Pediatrics. 2015;135: 384-395.