Transcript AAP Screening-ScreenMaterials

Developmental Screens in
the Office Setting
Nathaniel Beers, MD, MPA
OBJECTIVES
Why to do developmental screen
What types of screen tools are available
How effective are they
How are they administered
What types of additional services are
available
WHY SCREEN
 12-22% of children in US have developmental or
behavioral disorders
 Many options now exist to tailor screening to what
works in specific practice setting
 Services available to children with developmental delays
from birth on
 Better outcomes for participants:
higher graduation rates, delayed pregnancy,
employment, decreased criminality
 $30,000 to >$100,000 benefit to society
Why Screen (continued)
Without screening:
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)
With screening:
70% to 80% of children with developmental disabilities correctly
identified Squires et al, 1996, JDBP, 17:420 - 427
80% to 90% of children with mental health problems correctly
identified Sturner, 1991, JDBP; 12: 51-64
Types of Screening Tools
Two major categories
Developmental
Behavioral
Two mechanisms of administration
Parental
Provider
Developmental Screening
Tools
Provider
Denver
CAT/CLAMS
Bayley
Brigance
DIAL-R
Parent
Ages and Stages Questionnaire
Parent’s Evaluations of Developmental Status
Denver Developmental
Screening Test - 2
Very commonly used screening tool
Birth to 6 years old
Poor sensitivity and specificity (40-60%)
10-20 minutes to administer
Normed on diverse population sample
Multiple languages
Domains: fine and gross motor, language,
and social skills
DDST (continued)
Identifies children at 25,75, and 90%
completion of task
Scored as concern if child completing task in
shaded area (75-90%)
Scored as failure if not completed by time 90%
complete
Referrals warranted for one failure or two
concerns
Correct for prematurity till 2 years old
chronological age
CAT/CLAMS
Clinical Adaptive Test/ Clinical Linguistic and
Auditory Milestone Scale
Similar to Denver but more focused on
screening language and better at catching MR
Some parental report, some direct observation
by provider
Very high specificity and sensitivity (>90%)
Not standardized in Spanish
Quick to administer due to age categories
CAT/CLAMS (continued)
 Start at chronological age or at last point
 Credit given for completed tasks only
 Basal age calculated at age where child completes all
tasks at that age plus the value given to any additional
tasks above that age
 Basal age divided by chronological age then multiple by
100. This is the developmental quotient (DQ).
 DQ<70 constitutes delays and should be referred for
further evaluation
Bayley Screener
Ages 3 to 24 months
Direct observation of skills by provider
Assesses three domains (more neuro focused)
11-13 items at each age group (3-6 month
breaks)
Specificity and sensitivity 75-86%
10-15 minutes to administer
Not standardized in Spanish
Bayley (continued)
Neurologic processes (reflexes, tone)
Neurodevelopmental skills (movement
and symmetry)
Developmental accomplishments
(language, object permanence, imitation)
Scored as low, medium and high risk for
developmental disorders
Brigance
Multiple age break downs
Infants and Toddlers
Early Preschool
Pre-K
K-1st
Assesses all domains
Direct observation by provider
Brigance (continued)
Standardized in English and Spanish
Specificity and sensitivity 70-82%
Easy to administer
Children almost always experience
success
Time to administer approximately 10
minutes, 20 minutes in a slow child
Realistically after practice 5 minutes
Brigance (continued)
Simple scoring
Circle for correct, slash for incorrect
Stop after 3 in a row incorrect
Try to get 3 in a row correct as well
Look up score for age to determine if
normal or delayed
Can show advanced skills
DIAL
Developmental Indicators for Assessment of
Learning
Screening tool to evaluate pre-school aged
children
Effective for evaluation of school readiness
Speed version: 10 questions (motor, concepts,
language domains)
Spanish and English
Good specificity and sensitivity
Scored at norms for age with breakdown at 1.0,
1.3, 1.5, 1.7, 2.0 SD below
Ages and Stages
Questionnaire (ASK)
 Parent administered survey
 Screens multiple domains (communication, gross and
fine motor, problem solving and social)
 Sensitivity 70-90% Specificity 76-91%
 Validated in English, Spanish,Korean and French
 Can be administered by provider or non-clinical person
in cases of illiteracy
 5 minutes to administer when familiar, less if parents
administer
ASK (continued)
Pictures with some tasks to improve
understanding of parents
Scored as 10,5 or 0 points for each
question with norms in each domain for
each age level
Parents Evaluations of
Developmental Status (PEDS)
Parent administered survey
Identifies when to screen, refer, counsel, or
monitor
Sensitivity 74-79% Specificity 70-80%
Available in Spanish
2 minutes to administer, less if parents do alone
ONLY 10 QUESTIONS
Easy flow sheet to prompt when to refer,
counsel or re-evaluate
Behavioral Screening
Parent or teacher
Connors
Child Behavioral Checklist
Pediatric Symptom Checklist
Vanderbilt
Connor’s
Specific tool for ADHD with high sensitivity and
specificity (>90%)
Breaks down into inattentive or hyperactive
types
Not going to determine cause
Should never be used in isolation to make
diagnosis
Must rule out additional underlying
conditions (MR, LD, hearing and vision
abnormalities)
Connor’s (continued)
Spanish versions available
Teacher and parent forms
Good for monitoring response to
medications
Scored by positives (2 or 3) on domains
of inattention or hyperactivity
Child Behavioral Checklist
(CBCL)
 Multiple domains
 Can help identify other mental health conditions
 Available in Spanish as well
 Teacher and parent forms, child forms for older children
 Not as valuable for following child once on treatment
 Scored in multiple areas (i.e.:internalizing, externalizing,
somatic complaints, aggressive behaviors, attention
 Scored by points in each of the domains. Cut off for
significance given for raw or T-scores
Pediatric Symptom
Checklist
 Multiple domains of assessment
Single score or subscales (attention, internalizing and
externalizing)
 Not standardized in Spanish
 Not helpful once a child has been referred
 Parent or child fills out form
 Scored as 0,1,or 2
 Significance if total score >24 in child 4-5 YO or >28 in
child 6-16 YO
 Attention: >7 points; Internalizing: >5; Externalizing:
>7 points
NICHQ Vanderbilt
Assessment
 Sensitivity and specificity of >94% if both parent and
teacher ratings used
 Detailed questions about behavior to assess attention,
opposition, conduct, anxiety and depression
 Performance questions as well
 Scored by number of 2 or 3 in behavior assessment and
4 or 5 in performance assessment
 Break down given for diagnosis of ADHD (inattentive,
hyperactive, or combined), Oppositional Defiant disorder,
Conduct Disorder, and Anxiety/Depression
Additional Services
Specialists
Developmental Behavioral Pediatricians
Speech Pathologists, PTs and OTs
Other agencies doing evaluations
Early Intervention
Special Education
Specialists
Huge backlogs to see specialists affiliated
with Children’s (Nationwide issue)
Constraints on types of testing they can
do by insurance companies
Medicaid does not allow Children’s to bill for
psycho-educational evaluations
Need to assess if patient actually needs
this service
Other agencies
Some are great and some are not
Some are profit driven and have not invested
in making sure the quality of evaluations is
good
WATS has been very reliable in both
quality and speed
No longer covered by HSCSN
Additional agencies in handout
Early Intervention
Zero to three years old
Eligibility criteria vary by state and county
DC requires delay of 2 SD
Anyone can refer patient
MD, RN, parent, childcare provider
EI must complete evaluation and help
parents transition to SPED when child is
3yo
Special Education
3 to 21 years old
Every child has right to evaluation
Anyone can request eval, but parent must
consent
Eval must be conducted in child’s 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
SPED (continued)
Individualized Education Plan (IEP)
Contains the services child will receive and
goals for child
Updated annually
Parents do not need to sign at IEP meeting
Quarterly report on progress
Types of SPED
Inclusion, pull-out, or self-contained class or
school