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Screening for Childhood Developmental and Behavioral Problems. Developmental-Behavioral Pediatrics Lynne C. Huffman, MD. Screening for Childhood Developmental and Behavioral Problems. Overview Specific Screening Tools Referral Using Screeners in Continuity Clinic. Overview - AAP Policy.

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Screening for Childhood Developmental and Behavioral Problems

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Screening for Childhood Developmental and Behavioral Problems

Developmental-Behavioral Pediatrics

Lynne C. Huffman, MD


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Screening for Childhood Developmental and Behavioral Problems

Overview

Specific Screening Tools

Referral

Using Screeners in Continuity Clinic


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Overview - AAP Policy

AAP Committee on Children with Disabilities recommends routine standardized developmental and behavioral screening

Pediatrics Vol. 108 No. 1 July 2001


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Terminology

Surveillance

Vs.

Screening

Vs.

Assessment


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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


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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


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Differences among Surveillance, Screening, and Assessment

  • Assessment: In-depth, comprehensive examination of relevant domains


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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


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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


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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


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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)

Detection RatesWithout ToolsWith Tools


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Cost Effective

  • Benefits child

  • Reduces future health care costs (cost of early treatment is substantially lower than later treatment)

  • Saves medical resources


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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


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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


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11% - high risk of disabilities; need further evaluations

26% - moderate risk of disabilities; need 2nd level screening and vigilance

20% - low risk of disabilities; need behavioral guidance

43% - low risk of disabilities; need routine monitoring

What to Expect from Screening (Glascoe 2000)


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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


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Screening Challenges: Providers

  • Lack of time

  • Lack of staff

  • Inadequate reimbursement

  • Lack of parent acceptance of delay or problem


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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


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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


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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


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Overview Summary

Developmental/Behavioral Screening is:

  • Recommended by AAP

  • Different than surveillance

  • Beneficial to children and practices

  • Underutilized

  • Challenging but rewarding to implement


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Specific Screening Tools – Parent Reports

  • Features

  • Examples


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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


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Parent Report Screening Tools – Examples

  • Parents’ Evaluation of Developmental Status – PEDS (Glascoe)

  • Ages and Stages Questionnaires – ASQ (Bricker and Squires)


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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


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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


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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


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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


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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


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


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