Developmental Screening

Slides adapted from the American Academy of Pediatrics and Ages and Stages

Objectives
Discuss the importance of developmental screening Differentiate between surveillance and screening Identify components of a good screening instrument Define and discuss benefits of developmental screening Describe features of the Ages and Stages Questionnaire (ASQ) Implement and score the ASQ

How common are developmental disabilities?

17% of children have developmental disabilities Less than 50% are detected prior to school entrance

EARLY DETECTION = EARLY INTERVENTION

Why is early detection of developmental problems so critical?

Children involved in Early Intervention programs are more likely: To live independently Graduate from high school Save society $30,000-$100,000 per child

Preterm Births United States, 1983-2003

Percent

28 Percent Increase

Healthy People Objective

Preterm is less than 37 completed weeks gestation. Source: National Center for Health Statistics, 2003 final natality data. Prepared by March of Dimes Perinatal Data Center, 2006.

Preterm births

US, 1999-2009

Preterm is less than 37 completed weeks gestation. Very preterm is less than 32 completed weeks gestation. Moderately preterm is 32-36 completed weeks of gestation. Source: National Center for Health Statistics, final natality data. Retrieved March 29, 2012, from www.marchofdimes.com/peristats.

Preterm births by maternal race/ethnicity

US, 2009

All race categories exclude Hispanics. Preterm is less than 37 completed weeks gestation. Very preterm is less than 32 completed weeks gestation. Moderately preterm is 32-36 completed weeks of gestation. Source: National Center for Health Statistics, final natality data. Retrieved March 29, 2012, from www.marchofdimes.com/peristats.

Infant mortality rates by maternal age

US, 2007

An infant death occurs within the first year of life. Source: National Center for Health Statistics, period linked birth/infant death data. Retrieved March 29, 2012, from www.marchofdimes.com/peristats.

The key to early detection of disabilities is quality surveillance and screening

WHAT IS SURVEILLANCE VS. SCREENING?

Surveillance: Ongoing and systematic collection, analysis, and interpretation of health data for the purpose of planning, implementing, and evaluating public health interventions. Surveillance is a continuous process

What is surveillance involving children?

A flexible, continuous process, in which knowledgeable professionals perform skilled observations of children (in consultation w/families, specialists, child care providers, etc).

SM Dworkin, A Shannon, and P Dworkin. ChildServ Curriculum. Center for Childrens Health and Development, St Francis Hospital and Medical Center; 1999; Hartford, CT

Surveillance techniques:

LISTEN
Think
Talk

Components of Effective Surveillance

Elicit and/or attend to parents' concerns Obtain a relevant history Skillful observation of the child Share opinions with other professionals

What are some good open-ended questions to ask parents about their childs development?

What is screening?
Screening identifies individuals with unrecognized health risk factors or asymptomatic disease conditions in populations. Screening tools are used to enhance the surveillance process.

CLEARLY TYPICAL

CLEARLY ATYPICAL

Importance of Being Objective

TOUCH OR TAKE TEMP?

Clinical judgment detects fewer than 30% of children with developmental disabilities

Benefits of Screening
Sorts children into 3 categories: Needs additional evaluation - Did not pass screening Needs close monitoring- Passed screening but has risk factors (e.g. premature infant) Needs ongoing monitoring in the context of well-child assessment - Passed screening and has no known risk factors

Standards for Screening Tools

Standardized on a national sample Proof of reliability
ability of a measure to produce consistent results

Evidence of validity
ability of a measure to discriminate between a child at a determined level of risk for delay (i.e. high, moderate) from the rest of the population (low risk)

Standards for Screening Tools

Accuracy in ability to categorize is measured by:
Sensitivity: accuracy in identifying delayed development. True positive proportion. Specificity: accuracy in identifying individuals who are not delayed or typically developing children.

For developmental screenings, Sensitivity and Specificity of 70-80% are acceptable

Developmental Screening Instruments: General

Ages and Stages Questionnaire Battelle Developmental Inventory (BDI) Screening Test Bayley Infant Neurodevelopmental Screener (BINS) Brigance Screens-II Infant Development Inventory Child Development Review Child Development Inventory (CDI) Parents' Evaluation of Developmental Status (PEDS)

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

YES!
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

Prescreening Activities
Obtain consent from parent or caregiver and encourage parent to be involved. Check your agency for specific consent form, if required. Explain purpose of screening to parents and review questionnaire content. Make sure parents know that a screening is not the same as a diagnosis. Provide appropriate questionnaire (if child is premature, correct for prematurity).

ASQ Screens 5 Domains

Communication Gross Motor Fine Motor Problem solving Personal-social
Overall sensitivity = 72%, specificity = 86%

Ages and Stages Questionnaire (ASQ) 4 months to 6 years

19 color-coded questionnaire for use at 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, 24, 27, 30, 33, 36, 42, 48, 54, and 60 months 30 35 items per form describing skills Completed by nurse and parent during home visit,
preferred method. Can also be completed by parent alone.

Takes about 10-15 minutes, and 3 to score Reading level of tool is 4-6th grade

Which ASQ to give?

Use a questionnaire that is within a 2 month window of the childs age (or corrected age if premature) If child is exactly in between, then give the lower interval and then follow up with the next interval. Questions are hierarchical, easy to difficult Questions are answered: Yes, Sometimes, Not yet

ASQ Sample Items

1. When your child wants something, does she tell you by pointing to it?
Yes Sometimes Not Yet

4. Does your child say eight or more words in addition to Mama and Dada?

Yes

Sometimes

Not Yet

Scoring the ASQ

Step 1: Total the points in each area. yes= 10, sometimes= 5, not yet= 0. Step 2: Transfer the area totals to the information summary page. Fill in the matching circle in the space provided. Step 3: Read the answers to overall section questions carefully and respond appropriately. Step 4: Any score falling near or into the shaded area

Bell curve used to determine cutoff point

68% ASQ cutoff
13.5% 13.5%
Percentage of Population

2.5%

2.5%

-2 SD

-1 SD

+1 SD

+2 SD

Follow-up Criteria:
Well above cut-off points. Provide follow up activities for developmental promotion
Continue to monitor (surveillance). Rescreen in 4-6 months.

Close to cutoffs: Provide follow up activities to practice specific skills. Make community referrals as appropriate. Re screen later, interval based on age

Referral Criteria for ASQ

Below cutoff in one or more areas: Refer for developmental evaluation Parent concern: Respond to all concerns Refer if necessary Your own concern

Communication tips when there are concerns:

Avoid terms such as test, passor fail. Review the screening tool and explain area scores. Emphasize child and family strengths. Provide specific examples of concerns.

Use language that encourages follow-up Avoid negative and meaningless words

Be sensitive to cultural meanings of words

People-first language!

Early Intervention
Zero to three years - Early Start Program.
Services are provided through Regional Centers (21 in state). Emphasis is in the natural home setting

3 21 years Special Education

Individual Education Plan Free and Appropriate Education (FAPE) in the Least Restrictive Environment (LRE)

Special Education
3 to 21 years old Anyone can request eval, but parent must consent
Eval must be conducted in childs primary language and in English DC requires eval started within 90 days of request (does not include summer or vacation) Repeat eval every 3 years

IMPORTANT RESOURCE
Learn the Signs. Act Early http://www.cdc.gov/ncbddd/actearl y/index.html