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Setting the Stage for Success…. Marian Earls, MD, FAAP Guilford Child Health, Inc., Greensboro, North Carolina June 6, 2007. I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity.

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Setting the stage for success

Setting the Stage for Success…

Marian Earls, MD, FAAPGuilford Child Health, Inc., Greensboro, North CarolinaJune 6, 2007

Setting the stage for success

I have no relevant financial relationships with the manufacturers

of any commercial products and/or provider of commercial

services discussed in this CME activity.

I do not intend to discuss an unapproved/investigative use of a

commercial product/device in my presentation.

Integrating screening surveillance in primary care practice

Integrating Screening & Surveillance in Primary Care Practice

Marian Earls, MD, FAAP

June 6,2007

What we know
What We Know Practice

  • Impact of experience on brain development.

  • Growth, development, and behavior are inextricably linked.

  • Emotional development occurs in the context of a relationship (bonding, attachment, reading cues).

Prevalence and risk
Prevalence and Risk Practice

About 16% of children have disabilities including speech

and language delays, mental retardation, learning

disabilities and emotional/behavioral problems.


(Only 30% are detected prior to school entrance.)


Prevalence and risk1

13% of preschool children have mental health problems. Practice

This rate increases with the co-occurrence of other risk factors:


Maternal depression

Substance abuse

Domestic Violence

Foster care

Prevalence and Risk

Are we looking
Are we looking? Practice

Poor rates of screening in PCP’s office for:

  • Development and behavior

  • Maternal depression

  • Family risk factors

Setting the stage for success

PracticeUnder-detection …Eliminates the Possibility of Early Intervention...”


  • No point in waiting to screenuntil

  • the problem is observable.

  • Don’t ignore screening results;

  • there is no value to “wait and see.”

  • Informalchecklists haveno

  • validated criteriafor referral.

Setting the stage for success

Limited use of screening Practiceat well visits because…


  • Takes too long

  • Difficult to administer

  • Children may not cooperate

  • Reimbursement is limited

Setting the stage for success

So…. Practice

What Should We Do?

  • Use new,brief,accurate tools

  • Use parents

  • Use Family Centered principles

Setting the stage for success

Using Effective Screens: Practice

Accuracy, meaningspecificity(at least 70% of normal children correctlydetected) andsensitivity (at least 70% of children with disabilities correctly detected)

Setting the stage for success

Does Screening Mean Becoming an Expert in Evaluating a Child’s Development?NO…

Screening is looking at the whole population to identify those at risk.Identifiedchildren are referredfor assessment. Assessment determinestheexistence of delay or disability which generates a decision regarding intervention.

Screening is optimized bySurveillance……periodic screening gives a longitutidinal perspective of a child’s developmental progress.

Excluded tests

Excluded Tests: Child’s Development?



Early Screening Profile


Early Screening Inventory



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

Strengths of tools using parent report

Strengths of Tools Using Parent Report Child’s Development?

Give parents and providers information on children’s actual skillsHelp parents learn important developmental milestonesIllustrate strengths and weakness in developmentFree professional time for more important things… like helping familiesGive providers confidence in decision-making

Strengths of tools relying on parents concerns

Strengths of Tools Relying on Parents’ Concerns Child’s Development?

Help focus encounters on issues of importance to familiesCreate a “teachable moment”Enhance parents’ sense of a true collaboration with professionalsIncrease positive parenting practicesMake it easier to give difficult newsReduce “oh by the way” concernsIncrease attendance at well-visits…and perhaps parent-teacher conferences

Family psychosocial screens
Family Psychosocial Screens Child’s Development?

  • Variety of tools ranging from very brief to multi-item.

  • Most screen for maternal depression, domestic violence, substance abuse: individual area or several.

  • Considered best practice, but limited validation data, etc.

  • Examples are Kemper&Kelleher, Edinburgh

Setting the stage for success

Child’s Development?Oh, by the


Reduces “doorknob concerns”

Shortens visit length/focuses visit

Facilitates patient flow

Improves parent satisfaction and positive parenting practices

Increases provider confidence in decision-


The office process
The Office Process Child’s Development?

  • Assess Current Protocols

  • Identify Physician Champion

  • Select a Screening Tool

  • “Map the Workflow”

  • Identify System Supports

    Networking is key

  • Conduct Staff Orientations

Setting the stage for success

Creativity a Key…… Child’s Development?

  • Use growth tool for developmental surveillance;

  • Some tools can be photocopied so laminate a set for each exam room;

  • Use lab labels on the screening tool to eliminate handwriting of demographic information;

  • Measure performance and offer feedback to staff.

Setting the stage for success

Creativity a Key…… Child’s Development?

  • Use posters in your waiting room to explain the developmental screening process to families;

  • Use a combination of tools for different ages. (e.g.. 0-24 months use ASQ; older children use PEDS);

  • Obtain free stuff, e.g. “ABCD” anticipatory guidance brochures, for families to promote healthy development

Setting the stage for success

The Creativity continues… Child’s Development?

  • Invite your community partners, (EI Specialists, etc.) to your office for a social or open house (Talk about your respective goals and align goals wherever possible.)

  • Immerse yourself into community/state meetings where policy issues affecting families are discussed

  • Sponsor family events with your community partners, e.g. health dept.- health fairs

Partner with parents to do screening surveillance
Partner with Parents to Do Screening & Surveillance Child’s Development?

  • Primary Care Medical Home

  • Head Start

  • Child Care

  • Preschools

Assuring better child health development abcd the north carolina experience
Assuring Better Child Child’s Development?Health & Development “ABCD”the North Carolina Experience

DEVELOPMENTAL & BEHAVIORAL SCREENING:AQuality Improvement Initiative in Primary Care Practice

Setting the stage for success

Developmental Screening: Child’s Development?

Percentage of 0-24 Month Health Checks

with a Screening during a 6 Month Period

Setting the stage for success

Practice/Parent Surveys Summary Child’s Development?

  • Instrument:Questionnaires were disseminated to Guilford Child Health staff (three sites) in 2001 and Moses Cone Family staff in 2002. Questions were designed to yield qualitative information. A 27% and 26% response rate was achieved respectively.

  • ConclusionsStaff….

  • agree the ASQ is an effective assessment tool and would

  • recommend it to other providers;

  • generally use the ASQ as a guide for discussing

  • developmental issues with parents;

  • agree it “somewhat” impacts office workflow so attention

  • needs to be given to where and when parents complete the

  • questionnaire;

  • parents appreciate the additional time staff spend assessing

  • their child’s development

Setting the stage for success

Policy Change Child’s Development?

  • Public Health system (Child Health) transitioned

    clinics to a menu of standardized, valid,

    developmental screening tools in 2003

  • Medicaid changed EPSDT policy (Health Check),

    effective 7/1/2004, requiring avalid, standardized

    developmental screening tool when screening

    children at the 6, 12, 18 or 24months and

    3, 4, & 5 year old visit. The medical record

    should contain results & 96110-EP should

    be on the claim.

Lessons learned
Lessons Learned Child’s Development?

  • Keep it “tops” on the provider, family,

    and state agenda

  • Build on existing infrastructures and align goals with partners who invest in quality improvement

  • Optimize funding by sharing activities with partners

  • Evaluate and report data

  • Develop and change policy

Setting the stage for success

Screening & Surveillance Resources Child’s Development?


Anticipatory guidance resources
Anticipatory Guidance Resources Child’s Development?

  • NC ABCD disk

  • Bright Futures

  • AAP

  • CDC

  • Zero to Three

  • Parents as Teachers

  • Family Voices

  • Kids Growth