1. Screening for Childhood Developmental and Behavioral Problems Developmental-Behavioral Pediatrics Lynne C. Huffman, MD

2. Screening for Childhood Developmental and Behavioral Problems Overview Specific Screening Tools Referral Using Screeners in Continuity Clinic

3. Pediatrics Vol. 108 No. 1 July 2001 Overview - AAP Policy AAP Committee on Children with Disabilities recommends routine standardized developmental and behavioral screening

4. Terminology Surveillance Vs. Screening Vs. Assessment

5. Differences Among Surveillance, Screening, and Assessment Surveillance: A flexible, continuous process whereby professionals performed skilled observations of children during provision of health care –Eliciting and attending to parental concerns –Obtaining relevant developmental history –Making accurate and informative observations of children –Sharing opinions and concerns with other relevant professionals

6. Differences Among Surveillance, Screening, and Assessment Screening: Dependable, quick, flexible, and brief ‘sorting’ strategy that distinguishes those children who probably have difficulties from those who probably do not Screening applied to asymptomatic children to preemptively identify problems that would not otherwise be detected

7. Differences among Surveillance, Screening, and Assessment Assessment: In-depth, comprehensive examination of relevant domains

8. Current Practices in Developmental/Behavioral Screening Nearly all providers use surveillance Many providers use developmental checklists Many providers use trigger questions to promote discussion –Guidelines for Health Supervision (AAP) –Bright Futures (MCHB/AAP) 15-20% of pediatricians use screening tests routinely

9. Screening Strategies and Goals Screening strategies –Clinician questions; parent-completed screening questionnaire; physician-completed check sheet –Condition under consideration must be important, common, diagnosable, treatable Screening goals –Use of multiple sources of information –Result should be concern, but not conclusions; a path to more in-depth assessment –Consider family and environmental contexts

10. Why Screen and Refer? Facilitates access to intervention services Benefits patients - Studies of impact of interventions reveal –better intellectual, social, and adaptive behavior –increased HS graduation, employment rates –decreased criminality and teen pregnancy Improves patient/family satisfaction Satisfies federal/legal requirements

11. Detection Rates Without ToolsWith Tools 20% of mental health problems identified (Lavigne et al. Pediatr. 1993; 91:649-655) 30% of developmental disabilities identified (Palfrey et al. JPEDS. 1994; 111:651-655) 80-90% with mental health problems identified (Sturner, JDBP 1991; 12:51-64) 70-80% with developmental disabilities correctly identified (Squires et al., JDBP 1996; 17:420- 427)

12. Cost Effective Benefits child Reduces future health care costs (cost of early treatment is substantially lower than later treatment) Saves medical resources

13. Good Patient Care Parents want and expect support on child development –Commonwealth Fund survey –Parents are least satisfied with extent to which their children’s regular doctors helps them understand their children’s care and development Screening can encourage parent involvement and investment in child’s health care

14. Federal/Legal Requirements Individuals with Disabilities Education Act (IDEA) 1975 (Amended in 1997 and 2004) IDEA secures patients’ right to appropriate early intervention services, which state agencies must provide Healthy People 2000 & 2010 Goals Ensure that children enter kindergarten ready to learn Use screeners to identify delays and refer for services

15. What to Expect from Screening (Glascoe 2000) 11% - high risk of disabilities; need further evaluations 26% - moderate risk of disabilities; need 2 nd level screening and vigilance 20% - low risk of disabilities; need behavioral guidance 43% - low risk of disabilities; need routine monitoring

16. Screening Challenges: Providers Lack of education on tools and their use High expectations for normal development The “wait and see” approach Continued reliance on observations Failure to trust screening tests or results Reliance on poor quality or homemade tools

17. Screening Challenges: Providers Lack of time Lack of staff Inadequate reimbursement Lack of parent acceptance of delay or problem

18. Screening Challenges: Parents Parent recall is often inaccurate Parent reports rely on current descriptions of child’s behavior and skills Parents may face personal challenges

19. Pitfalls of Screening Not screening until a problem is observable –If the problem is obvious, referring is the correct response Ignoring screening results –Good screens make correct decision >70 - 80% of time Relying on informal screening methods –Discriminating between adequately developed and problematic levels of skills requires careful measurement Using a screening measure not suitable for primary care Assuming services are limited or nonexistent

20. Rewards of Screening Parents are reservoirs of rich information Screening becomes a teaching tool for parents and health care professionals Screening improves relationships Screening structures observations, reports, and communication about child development Using well-tested, standardized screening tools reduces unreliability of parent reports

21. Overview Summary Developmental/Behavioral Screening is: Recommended by AAP Different than surveillance Beneficial to children and practices Underutilized Challenging but rewarding to implement

22. Specific Screening Tools – Parent Reports Features Examples

23. Parent Report Screening Tools – Features Easier than other measures for pediatricians to use Can be administered to parents in the waiting room, sent home with appointment reminders, or conducted by telephone or during an in-office interview

24. Parent Report Screening Tools – Examples Parents’ Evaluation of Developmental Status – PEDS (Glascoe) Ages and Stages Questionnaires – ASQ (Bricker and Squires)

25. Ex: Parents’ Evaluations of Developmental Status (PEDS; Glascoe 1997) Detects range of developmental issues, including behavioral, mental health problems Respondent: Parent (can be performed as interview) Child age: Birth – 8 years Requires 2-3 minutes to complete and score Scores: High, moderate, and low risk scores Sensitivity 74% - 79%; specificity 70% - 80% Available in English, Spanish, Vietnamese

26. Ex: Ages & Stages Questionnaires (ASQ; Bricker and Squires, 1999) Indicates child skills in language, personal-social, fine and gross motor, and cognition Respondent: Parent (can be performed as interview) Child age: 4 months – 5 years Requires 10 - 15 minutes to complete and score Scores: Single pass/fail score Sensitivity 70% - 90%; specificity 76% - 91% Available in English, Spanish, French and Korean ASQ SE: Social and emotional development

27. Management After Screening: Evidence-based Decision-Making When and where to refer When to screen further When to provide behavioral/ developmental guidance and promotion When to observe vigilantly When reassurance and routine monitoring are sufficient

28. Referral Options General Prevention Programs and Resources Early Intervention – for suspected delay or qualifying condition –Birth to age 3 Education - educational and therapeutic services mandated by Individuals with Disabilities Education Act (IDEA) –Age 3 to 21

29. Concluding Messages "Flu model" does not apply to developmental and behavioral problems Screen and screen again Refer, refer, refer –Err in direction of referral rather than deferral –Children who are over-referred have below- average performance, increased psychosocial risk

30. Concluding Question: How would a developmental screener work in our clinics?