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

Pediatrics Vol. 108 No. 1 July 2001

Overview - AAP Policy

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

Terminology

Surveillance

Vs.

Screening

Vs.

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 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 Assessment

• Assessment: In-depth, comprehensive examination of relevant domains

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– 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?• 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 RatesWithout 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)

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

• 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

• 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

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: Providers

• Lack of time

• Lack of staff

• Inadequate reimbursement

• Lack of parent acceptance of delay or problem

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

• 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

• 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

Developmental/Behavioral Screening is:

• Recommended by AAP

• Different than surveillance

• Beneficial to children and practices

• Underutilized

• Challenging but rewarding to implement

Specific Screening Tools – Parent Reports

• Features

• Examples

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

• Parents’ Evaluation of Developmental Status – PEDS (Glascoe)

• Ages and Stages Questionnaires – ASQ (Bricker and Squires)

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)

• 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

• 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

• 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• "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

Concluding Question:

How would a developmental screener work in our

clinics?