Developmental Screening in the Primary Care Setting

Dr Kang Ying QiAssociate Consultant

Child Development UnitNational University Hospital

28 May 2016

Content

1. Overviewofterminologyandconcepts2. ImportanceofPrimaryCaresetting3. Importanceofdevelopmentalscreening4. SingaporeHealthBooklet5. MCHAT6. Vanderbiltassessmentscale7. PediatricSymptomChecklist

OverviewofConceptsandTerminology

Culture

CommunityChildren’s servicesSupport forparentingHousing Family

FamilyrelationshipsParentingstylesandvaluesFinancialsituationParent’slevelofeducation/occupationParent’sphysicalandmentalhealthSiblings

Factorsinfluencingachild’sdevelopment

ChildGeneticinheritanceTemperamentGenderPhysicalHealth

DevelopmentalDomains

Tervo R.RedFlagsandRulesofThumb:SortingOutDevelopmentalDelay.GilletteChildren’s SpecialtyHealthcare:APediatricPerspective2009;18:1.

DevelopmentalQuotient(DQ)=DevelopmentalAge x100ChronologicalAge

• DQ=100→average• DQ<70→significantdelay

>2 domain

WHYPrimaryCareSetting?

Ongoingrelationship

Agerelateddevelopmentalmanifestation

1– 2%

8 %

Familyfactorsandtrust

1in6childrenwithdevelopmentaldelayordisorder

LianWB,HoSKY, YeoCLetal.GeneralPractitioners’KnowledgeonChildhood DevelopmentalandBehavioural Disorders.SingaporeMedJ2003;44:397.

WHYDevelopmentalscreening?

DetectionMethods

DevelopmentalSurveillance

DevelopmentalEvaluation

http://www.medmerits.com/index.php/article/developmental_delay_in_children_evaluation_and_management/P2

Halfdetectedbefore5yearsold

HamiltonS.Screeningfordevelopmentaldelay:Reliable,easy-to-usetools.JFamPract 2006;55:415.

Developmentaldisordersexistasaspectrum

Language

DevelopmentalSurveillance

DevelopmentalEvaluation

DevelopmentalScreening

http://www.medmerits.com/index.php/article/developmental_delay_in_children_evaluation_and_management/P2

EarlyInterventionMatters.

DevelopmentalSurveillance

DevelopmentalScreening

Glascoe FP.ScreeningforDevelopmentalandBehavioralProblems.Ment RetardDevDisabil ResRev2005;11:173.HamiltonS.Screeningfordevelopmentaldelay:Reliable,easy-to-usetools.JFamPract 2006;55:415.

Toolsforscreeningfordevelopmentaldelays

DenverDevelopmentalScreeningTest(DDST)developedin1989

LimHC,ChanT,Yoong T.StandardisationandAdaptationoftheDenverDevelopmentalScreeningTest(DDST)andDenverIIforUseinSingaporeChildren.SingaporeMedJ 1994;35:156.LimHC,HoLY,GohLYetal.TheFieldTestingofDenverDevelopmentalScreeningTest,Singapore:ASingaporeVersionoftheDenver IIDevelopmentalScreeningTest.AnnAcad Med

• Objective:Theaimofthisstudywastoinvestigateparents'perceptionsofdevelopmental checklistsandthechilddevelopmentmonitoring scheduleintheSingaporehealthbooklet.

• Method:Parentsofchildrenaged2years6months to3years11monthswithorwithoutdevelopmentalconcerns(n=450)completedastructured interview,andtheirchild'shealthbookletswerereviewed.

• Results:Mostparentsreported readingandusing thedevelopmental checklists.However,onlyabouthalfofthemattemptedthechecklistswithminimalhelpfromprofessionals.Approximately7in10parentsofchildrenwithdevelopmental concernsfound thechecklistsuseful foridentifying concernsabouttheirchild.Despitepositivefeedbackfromparentsaboutthechecklists,onlyabout1in4parentsbrought theirchildfora2to3yearsdevelopmentalmonitoring visitatthetimeofthesurvey,andthecompletion ratesofthechecklistswerelessthandesirable.

• Conclusions:Further revisionstothechecklistscanincludesimplifying thewordsandsentencesandproviding relevantpicturestoaidunderstanding. Ifthechecklistsaretobeusedforscreening,standardizationofhowthechecklistsaretobecompletedandhowchildrenatriskofdevelopmentaldelayscanbeidentified onthechecklistsneedtobeprovided.Parents'awarenessoftheimportanceofevaluatingtheirchild'sdevelopmentat9months, 18months,andparticularlyat2.5years,needstoberaised.Developmental screeningforchildrenatthesecriticalagescanbemademandatory.Anelectronicversionofthehealthbookletislikelytofacilitateimplementation ofdevelopmental screeninginthehealthcaresystem.

Journal ofDevelopmentalandBehavioural Pediatrics:JDBP2016May5

11timepoints fordevelopmentsurveillanceandscreening

Othersimilarscreeningtoolsareyettobecomparable

PersonalCommunication.KKHDCDPhysiciansandPsychologists.April2014.Kiing J,LowPS,ChanYHetal.InterpretingParents’ConcernsaboutTheirChildren’sDevelopmentWithTheParentsEvaluationofDevelopmentalStatus:CultureMatters.JDevBehav Pediatr 2012;33:179.

https://www.m-chat.org

Nathan Mother

ScoringinstructionsforMCHAT

https://www.m-chat.org

Nathan Mother

16points

MCHAT

• 16– 30months• AAPguidelines:18and24months• Highfalsepositiverate->otherdevelopmentaldisorder

VanderbiltScoring

Hyperactive

Inattentive

ODD

CD

CDMood

Functio

n

9/9

9/9

0/8

>6/9=sig

>6/9=sig

>4/8=sig

>3/14=sig0/14

0/7 >3/7=sig

And anyscoreof4or5

VanderbiltAssessmentScale

• 6– 12yearsold• Togetherwiththeteacherassessmentscale,usedbypaediatriciansandpsychiatrists,toaidinthediagnosisofADHD

• ParentassessmentscalecanbeusedbyGPsasscreeningtoolinclinic

Toolforscreeningformental/emotionalhealthinchildren

http://www.massgeneral.org/psychiatry/services/psc_forms.aspx

MentalHealthismorethantheabsenceofmentalillness

• A stateofwell-beinginwhicheveryindividualrealizeshisorherownpotential,cancopewiththenormalstressesoflife,canworkproductivelyandfruitfully,andisabletomakeacontributiontoherorhiscommunity.

http://www.who.int/features/factfiles/mental_health/en/

Mentalwellness

Mentalhealthproblem

Mentalillness

Case

• 11yearoldboycomesforthe4th timein3monthstoyourclinicforaseriesofnonspecificcomplainslikeabdominalpainandheadache.Eachtimeaskingtobeexcusedfromschool.

• Thechildcomesalonetoyourconsulteachtime,whenquestionedifthereareanystressorsandaskedabouthismood,hegivesyounonchalantresponses.

• Whatdoyoudo?

0 1 2

0 1 2

PediatricSymptomChecklist

PediatricSymptomChecklist

• 3to18yearsold• Psychosocialscreen:cognitive,emotional,andbehavioralproblems

• Schoolagechildren:Scoresof28orgreater• Youngerkids:Scoresof24orgreater

• ->referralforfurthermentalhealthassessment

PediatricSymptomChecklist- 17

Difficultiesfaced

TimeCost

Literacy Knowledgeabouttools

Logistics

Parentsreceptivity

Followup

Responsibilityfortheresults

Competinghealthcarepriorities

Lackoftraining

Caution

• Positivescreeningdoesnotequaldiagnosis• Negativescreeningdoesnotmeanthereisnoissues• LackofstandardizedmeasuresforSingaporeanchildren• Caregiverreportsaresubjecttobiases• Confidentiality• Crisismanagement

Resources• HEALTHPROMOTIONBOARD

• HealthyStartForYourBabyhttp://www.hpb.gov.sg/HOPPortal/health-article/12206HealthyStartForYourGrowingChildhttp://www.hpb.gov.sg/HOPPortal/health-article/12294

• EARLYCHILDHOODDEVELOPMENTAGENCY

• GrowingwithYourChildbooklethttp://www.ecda.gov.sg/growatbeanstalk/Pages/articledetail.aspx?type=4&category=Growing+With+Your+Child+Booklet

• Care&Development:AResourceforParentsofChildrenwithDevelopmentalNeedshttp://www.ecda.gov.sg/growatbeanstalk/Pages/ArticleDetail.aspx?type=4&articleid=145http://www.childcarelink.gov.sg/ccls/uploads/MSF-ChildDevelopment-Booklet.pdf

• CENTERS FORDISEASECONTROLANDPREVENTIONUSALearntheSigns.Act Earlyhttp://www.cdc.gov/ncbddd/actearly/milestones/index.html

• MINISTRYOFHEALTH

• AMS-MOHClinicalPracticeGuidelineonAutismSpectrumDisordersinPreschoolChildren2010http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical/2010/cpgmed_autism_spectrum_dis orders_preschool_children.html

• Summary

• http://www.moh.gov.sg/content/dam/moh_web/HPP/Doctors/cpg_m edical/current/2010/ASD%20CPG(Card).pdf

• PatientVersionhttp://www.moh.gov.sg/content/dam/moh_web/HPP/Doctors/cpg _medical/current/2010/Autism%20Spectrum%20D.pdf

• http://www.mentalhealthamerica.net/every-child-needs

• RECOGNISINGCHILDRENWITHDEVELOPMENTALDELAYS:ASTRATEGY FORSURVEILLANCE.THESINGAPOREFAMILYPHYSICIANVOL40(2)APRIL-JUNE2014:18

• http://www.medmerits.com/index.php/article/developmental_delay_in_children_evaluation_and_management/P2