A Comprehensive Model for Developmental-Behavioral Screening and Surveillance: Frances Page Glascoe, Ph.D. Nicholas S. Robertshaw Please use “Notes” view because there are comments below most slides in this show

Goals for this program: Explain the concept and value of developmental surveillance and how to conduct it with ease and accuracy Train participants in the administration and interpretation of a range of tools needed for comprehensive surveillance Ensure that participants understand and are ready to deploy developmental- behavioral surveillance in accordance with American Academy of Pediatrics 2006 recommendations

What is Developmental Surveillance? Eliciting and addressing parents’ concerns Ongoing monitoring of: Health family history developmental milestones mental health (parent/child) parent-child interactions risk and resilience factors Developmental promotion/parent education Periodic use of screening tests including autism screens at 18 and 24 months

Why is the combination of surveillance and screening a wise approach? Provides the “big” picture of children’s and families lives including how development is encouraged or deterred Encourages selection of a broader range of supporting services (e.g., parent education, social work, early intervention)

How can surveillance be provided efficiently? By making use of information from parents and enhancing your observations with quality measures (that parents can help complete)!

Getting Started You will need: Copies of Parents’ Evaluation of Developmental Status—Response Forms— and a PEDS Brief Guide A copy of PEDS: Developmental Milestones and its Recording Form (this includes a PEDS Score and Interpretation Form) To get familiar with Chapter 4 of the PEDS:DM manual (this has a comprehensive surveillance flow chart and tracking form) To view the 2nd Section of the PEDS:DM Family Book where the supplemental measures are found

Steps in Comprehensive Surveillance Step 1: Elicit Parents’ Concerns This involves using PEDS at each well- visit. Many providers serving at risk patients using PEDS “opportunistically” -- especially at return visits, even sick visits TIMING: every visit (can be completed in waiting or exam rooms

This is the PEDS Response Form showing the questions eliciting parents’ concerns (and positive comments)

The PEDS+PEDS:DM score form shows isssues raised at prior and current visits (shaded boxes are provided when a concern predicts developmental problems while unshaded boxes show concerns not predictive. These change by age. Guidance is given at the bottom of the form based on the type and frequeny of predictive and nonpredictive concerns.

Steps in Comprehensive Surveillance Step 2: Administer (either when indicated by PEDS or routinely) the PEDS:DM (to capture milestones and effectively address parents’ concerns TIMING: every visit or as indicated Note: Both measures are screens--and thus satisfy the AAP recommendations for periodic screening but the combination is best for a multi-dimensional view of both parents and children’s needs

PEDS:DM Combined Score and Interpretation Form This form Shows, if you’ve given PEDS first, When the PEDS:DM is needed and how its results inform decisions on developmental and behavioral needs. However, it is usually easier to give both at the same time.

Items at the to year level

Scoring Template: Failure in Fine Motor Fine Motor Receptive Language Expressive Language Reading Self-Help Social- Emotional Math

Steps in Comprehensive Surveillance Step 3: Administer the Modified Checklist of Autism in Toddlers (M-CHAT)--found in the 2nd section of the PEDS:DM Family Book Timing: all children at high-risk on PEDS, all children regardless of PEDS results at 18 and 14 months

Selected items from the Modified Checklist of Autism in Toddlers

Steps in Comprehensive Surveillance Step 4: Supplemental Screening for emotional and behavioral/mental health problems using the PPSC-17 Timing: ages years when parents raise concerns about behavior and social-emotional issues, otherwise at 9-18 years and at each visit (otherwise the PEDS:DM items capture this issue at younger ages

Clip from the PPSC- 17

Steps in Comprehensive Surveillance Step 5: Administer the Family Psychosocial Screen (for parental depression/substance abuse, hx of abuse as a child, and other risk factors such as homelessness, frequent household moves, limited education, etc. Timing: new patient with repeat screens for parental depression during the first two post-natal years. Otherwise, as needed.

Clip from the FPS

Steps in Comprehensive Surveillance Step 6: Assess parent-child interactions with the Brigance Parent-Child Interactions Scale Timing: As needed (especially in the presence of numerous psychosocial risk factors, or symptoms of autism spectrum disorder)

Clip of the parent- report version of the BPCIS

Steps in Comprehensive Surveillance Step 7: Review Child and Family Medical History Timing: Initial or pre-birth, with periodic probes, or as health or other issues arise.

Steps in Comprehensive Surveillance Step 8: Conduct Physical Examination Timing: Every well visit (although if adding a 30 month visit, this could be devoted only to development and behavior).

Steps in Comprehensive Surveillance Step 9: Promote Development and Identify Family or Child Interventions Timing: As indicated

Selecting Among Interventions Information handouts--for those with limited psychosocial risk and no delays Head Start, parent training, ROR, social work--for those with risk factors, few resilience features, and no or minor delays Early Intervention/SE--for those with delays without or with or psychosocial risk factors (also referring the later to social and other services EI or Special Ed/Subspecialty pediatricians - for those with delays and significant medical histories

Surveillance with children 8 years and older The PEDS:DM Family Book contains a measure of academic skill, The Safety Word Inventory and Literacy Screener (SWILS) that, in combination with the PPSC-17, the Family Psychosocial Screen (and clinical observation) provide a brief approach to surveillance for older children that could be expanded with Bright Futures trigger questions.

Case example Maria, age 19 months

Multiple psychosocial risk factors Parental depression Limited and problematic social support Problematic parenting/care-taking Autism Spectrum Disorder Any or all of the above Maria’s Differential

Service/Referral Plans Social Work Services, thus facilitating referrals to: Subsidized day care Food stamps/WIC Housing Assistance Job training/placement Mental health counseling Early Intervention for further assessment and monitoring

Downloadable referral letter template in the PEDS:DM

Follow-up: I

Follow-up: II

Guidance given Maria’s mother (Chapter 6 of the PEDS:DM manual/downloadable)

Maria: Summary A rich exploration of probable causes, using quality instruments, led to focused interventions

Longitudinal tracking within a comprehensive surveillance model