Developmental/Behavioral Screening:

Frances Page GlascoeDept of Pediatrics Vanderbilt University

Screens:

• Identify the likelihood of a disability

• Do not provide a diagnosis

• Can help identify a range of possible diagnoses that help focus referrals

EPSDT benefit requires comprehensive health and developmental history, i.e.,

screening for developmental and mental health status

AAP Committee on Children

with Disabilities recommends routine standardized

developmental and behavioral screening

Early Intervention EfficacyPediatric Care Intervention

Arkansas 85 99

Einstein 74 85

Harvard 96 97

Miami 66 81

PA 92 95

Texas 80 87

Washington 92 100

Yale 91 103

TOTAL 85 94

JAMA. 1990;263:3035-3042

Early Intervention Benefits: Rationale For Screening

Individuals with Disabilities Education ActAvailability of servicesFamily interest in participationBetter outcomes for participants: Higher graduation rates, reduced teen pregnancy, higher employment rates, decreased criminality and violent crime$30,000 to >$100,000 benefit to society

Detection rates without screening tests

70% of children with developmental disabilities not identified

(Palfrey et al. J PEDS. 1994;111:651-655)

80% of children with mental health problems not identified

(Lavigne et al. Pediatr. 1993;91:649 - 655)

Sample Checklist

Uses hungry, tired, thirsty

Climbs stairs without holding on

Stacks 12 blocks

Knows colors

Dresses self completely

Plays games with rules

Effects of Psychosocial Risk Factors on Intelligence

80

85

90

95

100

105

110

115

120

125

0 1 2 3 4 5 6 7+

IQ

RISKS: < HS, > 3 children, stressful events, single parent, parental mental health problems, < responsive parenting, poverty, minority status, limited social support

50th

25th

16th

Percentiles

84th 75th

NORMAL DEVELOPMENT

minimal psychosocial risk factors

BELOW AVERAGE DEVELOPMENT

frequent psychosocial risk factors

DISABLED

some psychosocial risk factors

and/or organicity

Parents often need

advice about

behavior

Parents often need training,

and social services. Children

need enrichment tutoring, mentoring,

mental health,

etc.

Children need special education,

speech-therapy, etc.

Detection rates WITH Screening Tests

70% to 80% of children with developmental disabilities correctly identified

Squires et al, JDBP. 1996;17:420 - 427

80% to 90% of children with mental health problems correctly identified

Sturner, JDBP . 1991; 12: 51-64

Most over-referrals on standardized screens are children with below average development and psychosocial risk factors

Glascoe, APAM. 2001; 155:54-59. -

Reasons for limited use of screening tests at well visits:

COMMON MYTHS

common screening tests too long

many difficult to administer

children uncooperative

reimbursement limited referral resources unfamiliar or

seemly unavailable

So what should we do?

Use newer, brief, accurate toolsMake use of information from parents

Can parents read well enough to fill out screens?

Usually! But first ask, “Would you like to complete this on your own or have someone go through it with

you?”

Also, double check screens for completion

and contradictions

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.

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

YES!

Six Quality Tests

Parents’ Evaluation of Developmental Status (PEDS) 0 through 8 yearsChild Development Inventories (CDIs) 0 to 6 years

Pediatric Symptom Checklist (PSC) 4 through 18 yearsBrigance Screens 0 to 8 years

Ages and Stages (0 to 6 years)

Safety Word Inventory and Literacy Screener (SWILS ) 6 – 14 years

Excluded Tests:

PDQ

Denver-II

Early Screening Profile

DIAL-III

Early Screening Inventory

ELM

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

PARENTS’ EVALUATION OF DEVELOPMENTAL STATUS

A Method for Detecting and Addressing Developmental and Behavioral Problems

• For children 0 through 8 years• In English, Spanish and Vietnamese• Takes 2 minutes to score• Elicits parents’ concerns• Sorts children into high, moderate or low risk for

developmental and behavioral problems• 4th – 5th grade reading level so > 90% can complete

independently• Score/Interpretation form printed front and back

and used longitudinally

7. Do you have any concerns about how your child gets along with others?

PEDS Response Form 1. Please list any concerns about your child’s

learning, development, and behavior.

2. Do you have any concerns about how your child talks and makes speech sounds?Circle: Yes No A little Comment:

Circle: Yes No A little Comment:

PEDS Score Form

1. Global/Cognitive

- -

2. Expressive

Language

3. Receptive

Language

4. Fine Motor - - - -

- - -

5. Gross Motor - - -

- - - 6. Behavior - -

- - - - - -

7. Social-

Emotional - -

8. Self-Help - - - - -

- - - -

9.

Academic/Preacad

0 – 4 mos 2yrs 3yrs 4yrs 8

Counsel in areas of difficulty and follow-up in several weeks.

Path A: Two or More Predictive Concerns?

2 or more concernsabout self-help, social, school, or receptive languageskills?

PEDS Interpretation Form

Yes?

Refer for audiological and speech -language testing. Use professional judgment to decide if referrals are also needed for social work, occupational/ physical therapy, mental health services, etc.

Refer for intellectual/ educational evaluations. Use professional judgment to decide if speech- language, or other evaluations are also needed

No?

No?

Path C: NonPredictive Concerns?

If unsuccessful, screen for emotional/behavioral problems and refer as indicated. Otherwise refer for parent training, behavioral intervention, etc.

No?

Yes?

Specific Decision 0 - 3 mos:________________________ 4 - 5 mos:________________________ 6 - 11 mos:_______________________ 12 - 14 mos:_________________________________ 15 - 17 mos:_____________________ ___________4 - 4½yrs:___________________________________ 4½ - 6 yrs:____________ ___________7 – 8 yrs_________________________

Yes?

Path B: One

PEDS’ Evidenced Based Decisions

when and where to refer (e.g., mental health services, speech-language or developmental/school psychologists)

when to screen further (or refer for screening)

when to offer developmental promotionwhen to provide behavioral guidancewhen to observe vigilantlywhen reassurance and routine monitoring are sufficient

“Oh, by the way…..”

Other PEDS FeaturesReduces “doorknob concerns”Shortens visit length/focuses visitFacilitates patient flowImproves parent satisfaction and positive parenting practicesIncreases provider confidence in decision- making

3 screens for children 0 - 6 years:

Infant Development Inventory 0 – 18 months

Early Child Development Inventory 18 – 36 months

Preschool Development Inventory 36 – 72 months

Each screen:o Has 60 items—all short descriptions of child behavior and developmento Takes about 10 minutes for parents to completeo Written at the 9th grade levelo Takes about 2 minutes to scoreo Infant Screen shows strengths and weaknesses in each domaino Screens for older children provide a single

cutoff scoreo Available in English and Spanish

Parents place a ‘B’ next to things their child is beginning to do and a next to skills their child is doing regularlyClinicians draw lines to represent child’s age, 30% below, and 30% abovePatterns of strength and weaknesses focus referrals

 

AGESocial Self-Help Gross

MotorFine Motor

Language

6 mos.

Reaches for familiar persons

Looks for object after it disappear

Rolls from back to stomach

Transfer objects from hand to hand

Babbles__Responds to name

• Parents mark YES or NO to 60 statements

• Clinicians count the number of YES statements

and compare to cutoff for age• Optional items address behavioral/emotional

concerns but are not formally scored Sample Items:

1. Y N Walks without help5. Y N Washes and dries hands4. Y N Feeds self a cracker or cookie24. Y N Kicks a ball

Parents mark YES or NO to 60 statements

Clinicians count the number of YES statements and compare to cutoff for age

Optional items address behavioral/emotional concerns but are not scored

____

T

C

Enter total score

Enter cutoff for age

Ages and Stages Questionnaire (ASQ) 4 mos – 6 years

A different 3 –4 page form for each well visit

30 – 35 items per form describing skills

Forms include helpful illustrations

Completed by parent report

Taps major domains of development

Takes about 15 minutes, and 5 to score

ASQ-Social-Emotional works similarly and

measures behavior, temperament, etc.

ASQ Sample Items

3. Using the shapes below to look at, does your child copy at least three shapes onto a large piece of paper using a pencil or crayon, withouttracing? Your child’s drawings should look similar to the design of the shapes below, but they may be different in size.

Yes Sometimes Not Yet

ASQ Scoring

Assign a value of 10 to yes, 5 to sometimes, 0 to never

Add up the item scores for each area, and record these totals in the space provided for area totals.

Indicate the child’s total score for each area by filling in the appropriate circle on the chart below.

Scores in shaded areas, prompt a referral

ASQ Scoring - II

OPTIONAL: The specific answers to each item on the questionnaire can be recorded below on the summary chart.

PEDIATRIC SYMPTOM CHECKLIST (PSC)

For children 4 – 18Screens for mental health and behavioral problemsPresents parents with a list of problematic behaviorsProduces four distinct factors:

Internalizing (depressed, withdrawn, anxious)Externalizing (conduct, problem behavior, etc.)Attentional (impulsivity, distractibility, etc.)Academic/Global

Takes about 7 minutes for parents to completeTakes 4 –5 minutes to score factorsAvailable in English, Spanish and Chinese

NEVER SOMETIMES OFTEN

1. Complains of aches or pains __ ___ __2. Spends more time alone __ ___ __3. Tires easily, little energy __ ___ __4. Fidgety, unable to sit still __ ___ __5. Has trouble with a teacher __ ___ __

. . . . . 35. Refuses to share __ ___ __

PSC Sample Items

PSC Scoring

1. Assign a value of 0 to Never, 1 to Sometimes, and 2 to often

2. Add scores

3. If ages 4 & 5, omit items 5,6,17, and 18. If value is > 24 refer. For older children, > 28 indicates need for referral.

4. View factor scores if scores are above cutoffs.

• Takes 10 – 15 minutes of professional time• Produces a range of scores across domains•Detects children who are delayed as well as advanced• 9 separate forms across 0 – 8 year age range—similar format to Denver-II• Each produces 100 points and is compared

to an overall cutoff•Available in multiple languages•Widely used by schools/practices with PNPs•Computer scoring software, online version soon

Curriculum Associates, Inc. | 153 Rangeway Road | North Billerica, MA 01862phone (800)225-0248 ext 219/978-667-8000 | fax 800-366-1158 /978-667-5706

•Can be administered by interview and/or direct

elicitation•Separate form for 0 through 11 months, 12 through 23 months•Provides scores for 6 developmental domains: fine/gross

motor, receptive/expressive language, self-help,

social-emotional•Detects children who are delayed as well as advanced•Can plot progress over time•Includes examiner observations of psychosocial risk•Includes a small materials kit (you’ll add crackers)

For children 2 – 8 years

1 form per each year of age

Takes 10 – 15 minutes of professional time

All items require direct elicitation

Blocks, crayons, provided

Samples all developmental domains, with increasing emphasis on better predictors

of school success: language and academics

Curriculum Associates, Inc. | 153 Rangeway Road | North Billerica, MA 01862phone (800)225-0248 ext 219/978-667-8000 | fax 800-366-1158 /978-667-5706

Other features

•Strong predictive validity

•Good option for practices with NPs

•Has instructional videos

•Separate cutoffs for children at psychosocial risk who have just entered intervention programs (to minimize unnecessary referrals for dx services)

•Test forms come in triplicate for ease of sharing with other providers

Safety Word Inventory and Literacy Screener (SWILS)

29 common signs and safety words Child given credit for correct

pronunciationNumber correct is compared to a cutoff

for agePerformance correlates with reading and

math 6 – 14 years of age takes 1 – 5 minutes public domain May serve as a springboard to injury

prevention counseling

No Trespassing

EMERGENCY FIRE ESCAPE

High Voltage POISON

Safety Word Inventory and Literacy Screener (SWILS)

Age RangeYears--months

Date Cutoff Results

< 6 – 66-7 to 6-106-11 to 7-2

< 1< 2< 3

Pass FailPass FailPass Fail

7-2 to 7-67-7 to 7-107-11 to 8-3

< 5< 5< 12

Pass FailPass FailPass Fail

8-3 to 8-68-7 to 8-108-11 to 9-2

< 12< 12< 19

Pass FailPass FailPass Fail

Safety Word Inventory and Literacy Screener

Screen Selection Flow Chart:Age Range

0 – 4 4 – 6 6 – 8 8 – 18

PEDS orCDIs or ASQorBrigance

PEDS orCDIs orASQ orBrigance( + PSC)

PEDS orBrigance or SWILS( + PSC)

SWILSand/or PSC

Organizing Offices for Efficient Screening

Provide office staff a rationale for screening. Clearly state goals—screening at each well visit

Allow staff some control over when and where

Ensure that staff ask families whether they would like to complete the measure on their own or be interviewed

Give office staff the option of administering an interview version when needed and scoring the measure.

Keep a list of referral contact information handy

in the handout for this talk you will find:

Procedures and diagnosis codes for billingSources for patient education materialsInformation about obtaining the various screensA guide to explaining test resultsInformation about the AAP’s Section on

Developmental and Behavioral Pediatrics websiteInformation on organizing offices for efficient

screening and developmental promotionInformation on referral resourcesHow to lead a screening initiative in a practice

Final CommentsDevelopmental services are available and non-medical providers play a big roleMore detailed screening and developmental diagnostics

can be provided by preschool IDEA and/or public schools

Ideally, get to know key non-medical providers and establish a referral relationship: Head of school psych dept. or SE Local preschool IDEA coordinatorSupervisor of family and children’s services at mental

health centers