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Developmental/Behavioral Screening:. HOW TO DO IT EFFICIENTLY AND COST- EFFECTIVELY AND WHY. Frances Page Glascoe Dept of Pediatrics Vanderbilt University. Screens:. Identify the likelihood of a disability Do not provide a diagnosis

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Developmental/Behavioral Screening:




Frances Page Glascoe

Dept of Pediatrics Vanderbilt University

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  • Identify the likelihood of a disability

  • Do not provide a diagnosis

  • Can help identify a range of possible diagnoses that help focus referrals

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EPSDT benefit requires comprehensive health and developmental history, i.e., screening for developmental and mental health status

AAP Committee on Children

with Disabilities recommends routine standardized developmental and behavioral screening

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JAMA. 1990;263:3035-3042

Early Intervention Efficacy

Pediatric Care Intervention







Washington92 100

Yale91 103


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Early Intervention Benefits:

Rationale For Screening

Individuals with Disabilities Education Act

Availability of services

Family interest in participation

Better outcomes for participants:

Higher graduation rates, reduced teen

pregnancy, higher employment rates,

decreased criminality and violent crime

$30,000 to >$100,000 benefit to society

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Detection rates without

screening tests

70% of children with developmental

disabilities not identified

(Palfrey et al. J PEDS. 1994;111:651-655)

80% of children with mental health

problems not identified

(Lavigne et al. Pediatr. 1993;91:649 - 655)

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Sample Checklist

Uses hungry, tired, thirsty

Climbs stairs without holding on

Stacks 12 blocks

Knows colors

Dresses self completely

Plays games with rules

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Effects of Psychosocial Risk Factors on Intelligence








RISKS: < HS, > 3 children, stressful events, single parent,

parental mental health problems, < responsive parenting,

poverty, minority status, limited social support

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Parents often need training, and social services.

Children need enrichment tutoring, mentoring, mental health,


Parents often need advice about behavior


minimal psychosocial

risk factors



frequent psychosocial risk factors

Children need special education, speech-therapy, etc.


some psychosocial risk factors

and/or organicity

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Detection rates


Screening Tests

70% to 80% of children with developmental disabilities correctly identified

Squiresetal, JDBP. 1996;17:420 - 427

80% to 90% of children with mental health problemscorrectlyidentified

Sturner, JDBP .1991; 12: 51-64

Most over-referrals on standardized screens are children with below average development and psychosocial risk factors

Glascoe, APAM. 2001;155:54-59.


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Reasons for limited use of

screening tests at well visits:


common screening tests too long

many difficult to administer

children uncooperative

reimbursement limited

referral resources unfamiliar or

seemly unavailable

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So what should we do?

Use newer, brief, accurate tools

Make use of information from parents

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Can parents read well enough to fill out screens?

Usually! But first ask,

“Would you like to complete this on your own or have someone go through it with you?”

Also, double check screens for completion

and contradictions

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Can parents be counted upon to give accurate and good quality information?


Screens using parent report are as accurate as those using other measurement methods

Tests correct for the tendency of some parents to over-report

Tests correct for the tendency of some parents to under-report.

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Six Quality Tests

Parents’ Evaluation of Developmental

Status (PEDS) 0 through 8 years

Child Development Inventories

(CDIs) 0 to 6 years

Ages and Stages (0 to 6 years)

Pediatric Symptom Checklist

(PSC) 4 through 18 years

Brigance Screens 0 to 8 years

Safety Word Inventory and Literacy Screener (SWILS ) 6 – 14 years

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Excluded Tests:



Early Screening Profile


Early Screening Inventory



Due to absence of validation, poor validation, norming on referred samples, and/or poor sensitivity/specificity

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A Method for Detecting and Addressing

Developmental and Behavioral Problems

  • For children 0 through 8 years

  • In English, Spanish and Vietnamese

  • Takes 2 minutes to score

  • Elicits parents’ concerns

  • Sorts children into high, moderate or low risk for developmental and behavioral problems

  • 4th – 5th grade reading level so > 90% can complete

  • independently

  • Score/Interpretation form printed front and back

  • and used longitudinally

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Circle: Yes No A little Comment:

PEDS Response Form

1. Please list any concerns about your child’s learning, development, and behavior.

2. Do you have any concerns about how your child talks and makes speech sounds?

7. Do you have any concerns about how your child gets along with others?

Circle: Yes No A little Comment:

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PEDS Score Form

0 – 4 mos 2yrs 3yrs 4yrs 8

1. Global/Cognitive - -

2. Expressive Language

3. Receptive Language

4. Fine Motor - - - - - - -

5. Gross Motor - - - - - - 6. Behavior - - - - - - - -

7. Social-Emotional - -

8. Self-Help - - - - - - - - -

9. Academic/Preacad

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Specific Decision

0 - 3 mos:__



4 - 5 mos:__



6 - 11 mos:_



12 - 14 mos:




15 - 17 mos:




4 - 4½yrs:___




4½ - 6 yrs:__



7 – 8 yrs___


PEDS Interpretation Form

Refer for audiological and speech

-language testing. Use

professional judgment to decide

if referrals are also needed for

social work, occupational/

physical therapy, mental health

services, etc.


2 or more concerns

about self-help, social, school, or

receptive language



Path A:Two or More Predictive Concerns?


Refer for intellectual/

educational evaluations. Use

professional judgment to decide

if speech- language, or other evaluations are also needed


Path B: One

If unsuccessful, screen for


problems and refer as

indicated. Otherwise refer

for parent training,

behavioral intervention, etc.

Counsel in areas

of difficulty and

follow-up in

several weeks.

Path C: NonPredictive




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PEDS’ Evidenced Based Decisions

when and where to refer (e.g., mental

health services, speech-language or

developmental/school psychologists)

when to screen further (or refer for


when to offer developmental promotion

when to provide behavioral guidance

when to observe vigilantly

when reassurance and routine

monitoring are sufficient

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“Oh, by the way…..”

Other PEDS Features

Reduces “doorknob concerns”

Shortens visit length/focuses visit

Facilitates patient flow

Improves parent satisfaction and positive parenting practices

Increases provider confidence in decision-


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Child Development Inventories

3 screens for children 0 - 6 years:

Infant Development Inventory

0 – 18 months

Early Child Development Inventory

18 – 36 months

Preschool Development Inventory

36 – 72 months

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Child Development Inventories

  • Each screen:

  • Has 60 items—all short descriptions of child behavior and development

  • Takes about 10 minutes for parents to complete

  • Written at the 9th grade level

  • Takes about 2 minutes to score

  • Infant Screen shows strengths and weaknesses in each domain

  • Screens for older children provide a single

  • cutoff score

  • Available in English and Spanish

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Gross Motor

Fine Motor


6 mos.

Reaches for familiar persons

Looks for object after it disappear

Rolls from back to stomach

Transfer objects from hand to hand



Responds to name

Infant Development Inventory

Parents place a ‘B’ next to things their child is beginning to do and a  next to skills their child is doing regularly

Clinicians draw lines to represent child’s age, 30% below, and 30% above

Patterns of strength and weaknesses focus referrals

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Early Child Development


  • Parents mark YES or NO to 60 statements

  • Clinicians count the number of YES statements

  • and compare to cutoff for age

  • Optional items address behavioral/emotional

  • concerns but are not formally scored

  • Sample Items:

1. Y N Walks without help

5. Y N Washes and dries hands

4. Y N Feeds self a cracker or cookie

24. Y N Kicks a ball

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Preschool Development


Parents mark YES or NO to 60 statements

Clinicians count the number of YES statements and compare to cutoff for age

Optional items address behavioral/emotional concerns but are not scored

Enter total score



Enter cutoff for age


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Ages and Stages Questionnaire (ASQ) 4 mos – 6 years

A different 3 –4 page form for each well visit

30 – 35 items per form describing skills

Forms include helpful illustrations

Completed by parent report

Taps major domains of development

Takes about 15 minutes, and 5 to score

ASQ-Social-Emotional works similarly and

measures behavior, temperament, etc.

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ASQ Sample Items

3. Using the shapes below to look at, does your child copy at least three shapes onto a large piece of paper using a pencil or crayon, without

tracing? Your child’s drawings should look similar to the design of the shapes below, but they may be different in size.

Yes Sometimes Not Yet


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ASQ Scoring

  • Assign a value of 10 to yes, 5 to sometimes, 0 to never

  • Add up the item scores for each area, and record these

    totals in the space provided for area totals.

  • Indicate the child’s total score for each area by filling in

    the appropriate circle on the chart below.

  • Scores in shaded areas, prompt a referral

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ASQ Scoring - II

  • OPTIONAL: The specific answers to each item on the questionnaire can be recorded below on the summary chart.

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For children 4 – 18

Screens for mental health and behavioral problems

Presents parents with a list of problematic behaviors

Produces four distinct factors:

Internalizing (depressed, withdrawn, anxious)

Externalizing (conduct, problem behavior, etc.)

Attentional (impulsivity, distractibility, etc.)


Takes about 7 minutes for parents to complete

Takes 4 –5 minutes to score factors

Available in English, Spanish and Chinese

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NEVER SOMETIMES OFTEN1. Complains of aches or pains__ ___ __2. Spends more time alone__ ___ __3. Tires easily, little energy__ ___ __4. Fidgety, unable to sit still__ ___ __5. Has trouble with a teacher __ ___ __ . . . . . 35. Refuses to share__ ___ __

PSC Sample Items

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PSC Scoring

  • Assign a value of 0 to Never, 1 to Sometimes, and 2 to often

  • 2. Add scores

  • 3. If ages 4 & 5, omit items 5,6,17, and 18. If value is > 24 refer. For older children, > 28 indicates need for referral.

  • 4. View factor scores if scores are above cutoffs.

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Brigance Screens

  • Takes 10 – 15 minutes of professional time

  • Produces a range of scores across domains

  • Detects children who are delayed as well as advanced

  • 9 separate forms across 0 – 8 year age range—similar format to Denver-II

  • Each produces 100 points and is compared

  • to an overall cutoff

  • Available in multiple languages

  • Widely used by schools/practices with PNPs

  • Computer scoring software, online version soon

Curriculum Associates, Inc. | 153 Rangeway Road | North Billerica, MA 01862phone (800)225-0248 ext 219/978-667-8000 | fax 800-366-1158 /978-667-5706

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Brigance Infant and Toddler Screens

  • Can be administered by interview and/or direct

  • elicitation

  • Separate form for 0 through 11 months, 12 through 23 months

  • Provides scores for 6 developmental domains: fine/gross motor, receptive/expressive language, self-help,

  • social-emotional

  • Detects children who are delayed as well as advanced

  • Can plot progress over time

  • Includes examiner observations of psychosocial risk

  • Includes a small materials kit (you’ll add crackers)

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Brigance Screens

For children 2 – 8 years

1 form per each year of age

Takes 10 – 15 minutes of professional time

All items require direct elicitation

Blocks, crayons, provided

Samples all developmental domains, with increasing emphasis on better predictors

of school success: language and academics

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Brigance Screens

  • Other features

  • Strong predictive validity

  • Good option for practices with NPs

  • Has instructional videos

  • Separate cutoffs for children at psychosocial risk who have just entered intervention programs (to minimize unnecessary referrals for dx services)

  • Test forms come in triplicate for ease of sharing with other providers

Curriculum Associates, Inc. | 153 Rangeway Road | North Billerica, MA 01862phone (800)225-0248 ext 219/978-667-8000 | fax 800-366-1158 /978-667-5706

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Safety Word Inventory and Literacy Screener (SWILS)

29 common signs and safety words

Child given credit for correct


Number correct is compared to a cutoff

for age

Performance correlates with reading and


6 – 14 years of age

takes 1 – 5 minutes

public domain

May serve as a springboard to injury

prevention counseling

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No Trespassing

Safety Word Inventory and Literacy Screener (SWILS)


High Voltage


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Age Range





< 6 – 6

6-7 to 6-10

6-11 to 7-2

< 1

< 2

< 3

Pass Fail

Pass Fail

Pass Fail

7-2 to 7-6

7-7 to 7-10

7-11 to 8-3

< 5

< 5

< 12

Pass Fail

Pass Fail

Pass Fail

8-3 to 8-6

8-7 to 8-10

8-11 to 9-2

< 12

< 12

< 19

Pass Fail

Pass Fail

Pass Fail

Safety Word Inventory and Literacy Screener

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Screen Selection Flow Chart:

Age Range

0 – 44 – 6 6 – 8 8 – 18


CDIs or

ASQ or


( + PSC)






( + PSC)





CDIs or




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Organizing Offices for Efficient Screening

Provide office staff a rationale for screening. Clearly state goals—screening at each well visit

Allow staff some control over when and where

Ensure that staff ask families whether they would like to complete the measure on their own or be interviewed

Give office staff the option of administering an interview version when needed and scoring the measure.

Keep a list of referral contact information handy

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in the handout for this talk you will find:

Procedures and diagnosis codes for billing

Sources for patient education materials

Information about obtaining the various screens

A guide to explaining test results

Information about the AAP’s Section on Developmental and Behavioral Pediatrics website

Information on organizing offices for efficient screening and developmental promotion

Information on referral resources

How to lead a screening initiative in a practice

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Final Comments

Developmental services are available and

non-medical providers play a big role

More detailed screening and developmental diagnostics can be provided by preschool IDEA and/or public schools

Ideally, get to know key non-medical providers and establish a referral relationship:

Head of school psych dept. or SE

Local preschool IDEA coordinator

Supervisor of family and children’s services at mental health centers

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