Screening for Childhood Developmental and Behavioral Problems

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

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. 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

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. 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)

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?