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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

Screening for Childhood Developmental and Behavioral Problems

Developmental-Behavioral Pediatrics

Lynne C. Huffman, MD

screening for childhood developmental and behavioral problems2

Screening for Childhood Developmental and Behavioral Problems

Overview

Specific Screening Tools

Referral

Using Screeners in Continuity Clinic

overview aap policy
Overview - AAP Policy

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

Pediatrics Vol. 108 No. 1 July 2001

terminology
Terminology

Surveillance

Vs.

Screening

Vs.

Assessment

differences among surveillance screening and assessment
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
differences among surveillance screening and assessment6
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
differences among surveillance screening and assessment7
Differences among Surveillance, Screening, and Assessment
  • Assessment: In-depth, comprehensive examination of relevant domains
current practices in developmental behavioral screening
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
screening strategies and goals
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
why screen and refer
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
detection rates without tools with 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)

Detection RatesWithout Tools With Tools
cost effective
Cost Effective
  • Benefits child
  • Reduces future health care costs (cost of early treatment is substantially lower than later treatment)
  • Saves medical resources
good patient care
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
federal legal requirements
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
what to expect from screening glascoe 2000
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)
screening challenges providers
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
screening challenges providers17
Screening Challenges: Providers
  • Lack of time
  • Lack of staff
  • Inadequate reimbursement
  • Lack of parent acceptance of delay or problem
screening challenges parents
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
pitfalls of screening
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
rewards of screening
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
overview summary
Overview Summary

Developmental/Behavioral Screening is:

  • Recommended by AAP
  • Different than surveillance
  • Beneficial to children and practices
  • Underutilized
  • Challenging but rewarding to implement
parent report screening tools features
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
parent report screening tools examples
Parent Report Screening Tools – Examples
  • Parents’ Evaluation of Developmental Status – PEDS (Glascoe)
  • Ages and Stages Questionnaires – ASQ (Bricker and Squires)
ex parents evaluations of developmental status peds glascoe 1997
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
ex ages stages questionnaires asq bricker and squires 1999
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
management after screening evidence based decision making
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
referral options
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
concluding messages
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
ad