Pediatric Developmental Surveillance Program Putting principles into practice for children’s health and development

Developmental Surveillance: Why do it & why so early? High prevalence High prevalence ~16% of children have disabilities Speech and language delays, mental retardation, learning disabilities, and emotional/behavioral problems Early intervention is critical Early intervention is critical ~50% of children with disabilities are detected prior to school entrance.

Developmental Surveillance Is it ‘doable’? Where do we start?

Importance of Being Objective TOUCH OR TAKE TEMP?

Objective Developmental Screening Tools Good sensitivity and specificity Good sensitivity and specificity Ideal for use in primary care settings Ideal for use in primary care settings

Where do we start? Where infants and young children seen on a regular basis – Well Child Visits

Educating medical providers Increasing knowledge and skills and changing practice patterns - Is that ‘doable’?

Improving Clinical Practice – Some ways it’s been done Academic mentoring – Soumerai & Avorn: Principles of Educational Outreach (‘Academic Detailing’) to Improve Clinical Decision Making. JAMA 263:449, Academic mentoring – Soumerai & Avorn: Principles of Educational Outreach (‘Academic Detailing’) to Improve Clinical Decision Making. JAMA 263:449, Process planning – Ploof & Hammel: Originally printed in Developmental and Behavioral News, published by the AAP Section on Developmental and Behavioral Pediatrics Publication date: Jan 4, 2005 Process planning – Ploof & Hammel: Originally printed in Developmental and Behavioral News, published by the AAP Section on Developmental and Behavioral Pediatrics Publication date: Jan 4, 2005

PDSP Phases of Training What did we actually do? Implementation/Training Implementation/Training Mentoring/Consultation Mentoring/Consultation Surveillance/Support Surveillance/Support Continuous Quality Improvement Continuous Quality Improvement

Outcomes – What is getting done? Medical Homes – Work directly in over 30 practices Work directly in over 30 practices Over 200 staff trained in screening tools Over 200 staff trained in screening tools More than 95% ‘pass’ CQI More than 95% ‘pass’ CQI Community and Families – Streamline referrals to preschool and early intervention services Streamline referrals to preschool and early intervention services Provide developmental information to over 1400 families each year Provide developmental information to over 1400 families each year Provide additional secondary developmental screens to over 800 children each year Provide additional secondary developmental screens to over 800 children each year

Barriers – What made it hard(er) to do? Selling the idea Identifying and sustaining funding

Lessons learned – Making it easier to do in the future Flexibility - Tailor implementation and training to each practice Flexibility - Tailor implementation and training to each practice Practices own the process - Help practices identify the problem for themselves Practices own the process - Help practices identify the problem for themselves Secure funding - allow Program staff to productively focus energy and time Secure funding - allow Program staff to productively focus energy and time

Monitoring Child Development: Is it something Public Health should be doing? Nutrition/safe water supply Infection control/immunization Development

Developmental Surveillance - What Public Health Agencies CAN DO Educate community and medical providers Educate community and medical providers Provide consultation and technical assistance Provide consultation and technical assistance Monitor for continuous quality improvement Monitor for continuous quality improvement

Pediatric Developmental Surveillance Program

REFERENCES

References Boyle CS, Decoufle P, Yeargin-Allsoop MY. Prevalence and healh impact of developmental disabilities. Pediatrics 93:863, Boyle CS, Decoufle P, Yeargin-Allsoop MY. Prevalence and healh impact of developmental disabilities. Pediatrics 93:863, Committee on Children and Disabilities, American Academy of Pediatrics. Developmental surveillance and screening for infants and young children. Committee on Children and Disabilities, American Academy of Pediatrics. Developmental surveillance and screening for infants and young children. Pediatrics 108:192, Dworkin PH. Detection of behavioral, developmental, and psychosocial problems in pediatric primary care practice. Curr Opin Pediatr. 5:531, Dworkin PH. Detection of behavioral, developmental, and psychosocial problems in pediatric primary care practice. Curr Opin Pediatr. 5:531, 1993.

References Glascoe FP, Dworkin PH. The role of parents in the detection of developmental and behavioral problems. Pediatrics 95:828, Glascoe FP, Dworkin PH. The role of parents in the detection of developmental and behavioral problems. Pediatrics 95:828, Palfrey JS, Singer JD, Walker DK, Butler JA. Early identification of children’s special needs: A study in five metropolitan communities. J of Pediatr 11:651, Palfrey JS, Singer JD, Walker DK, Butler JA. Early identification of children’s special needs: A study in five metropolitan communities. J of Pediatr 11:651, RegaladoM, Halfon N. Primary care services promoting optimal dhild development from birth to age 3 years. Arch of Pediatr & Adol Med 155:1311, RegaladoM, Halfon N. Primary care services promoting optimal dhild development from birth to age 3 years. Arch of Pediatr & Adol Med 155:1311, 2001.

References From Neurons to Neighborhoods: The science of early child development. Shonkoff & Phillips, eds. Washington, D. C., National Academy Press, From Neurons to Neighborhoods: The science of early child development. Shonkoff & Phillips, eds. Washington, D. C., National Academy Press, 2000.

“Developmental” History of the PDSP Two previous projects in Wake County from the mid 1990’s: Healthy Start project - providing PE’s and developmental assessments in child care settings with funding by Wake County Smart Start. Healthy Start project - providing PE’s and developmental assessments in child care settings with funding by Wake County Smart Start. NC Health Choice enrollment initiative – a collaborative between Wake County Human Services and NC Pediatric Society for Wake County practices. NC Health Choice enrollment initiative – a collaborative between Wake County Human Services and NC Pediatric Society for Wake County practices.

“Developmental” History – Why was developmental surveillance chosen? AAP Committee on Children with Disabilities recommends the use of standardized screening tests periodically at well visits. AAP Committee on Children with Disabilities recommends the use of standardized screening tests periodically at well visits. North Carolina Division of Public Health mandated new screening guidelines. North Carolina Division of Public Health mandated new screening guidelines.

“Developmental” History - Lessons learned about working with primary care practices Assessing and monitoring children’s developmental status is a priority for the primary practices. Assessing and monitoring children’s developmental status is a priority for the primary practices. Practices welcome assistance to provide quality care IF it can be integrated into their individual office setting. Practices welcome assistance to provide quality care IF it can be integrated into their individual office setting.

Costs of NOT screening Society saves between $30,000 & $100,000 for every 2 years o needed intervention prior to kindergarten. Society saves between $30,000 & $100,000 for every 2 years o needed intervention prior to kindergarten. Glascoe FP, Foster M, Wolraich ML. An economic analysis of developmental detection methods. Pediatrics 99: 830, 1997.

Cost considerations Advocates of earlier & more intervention have an obligation to measure their impacts & costs. Advocates of earlier & more intervention have an obligation to measure their impacts & costs. Skeptics, in turn, must acknowledge the massive scientific evidence that early childhood development is influenced by the environments in which children live. Skeptics, in turn, must acknowledge the massive scientific evidence that early childhood development is influenced by the environments in which children live. From Neurons to Neighborhoods

Parents have abundant opportunities to Parents have abundant opportunities to observe and compare their children to others. observe and compare their children to others. Tests correct for tendency of some Tests correct for tendency of some parents to over-report and some parents parents to over-report and some parents to under-report. to under-report. YES! Can parents be counted upon to give accurate and quality information? Can parents be counted upon to give accurate and quality information?

Where are children seen? Early Child Development in Social Context: A Chartbook, The Commonwealth Fund, Sept 2004 In 2002, 84% of children < 6 years of age had a well- child visit in past year. In 2002, 84% of children < 6 years of age had a well- child visit in past year. In 2000, almost on half of parents had concerns about young child’s speech, social development, or behavior, but only about 45% of parents recalled any developmental assessment being done. In 2000, almost on half of parents had concerns about young child’s speech, social development, or behavior, but only about 45% of parents recalled any developmental assessment being done. Improvement, in part physician training, tracking quality of care, and changes in health care plans, and work with other community services to improve primary care, identify problems, and facilitate interventions on behalf of children’s development. Improvement, in part physician training, tracking quality of care, and changes in health care plans, and work with other community services to improve primary care, identify problems, and facilitate interventions on behalf of children’s development.