Developmental Screens in the Office Setting

Nathaniel Beers, MD, MPA

OBJECTIVES

Why to do developmental screenWhat 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 toolBirth to 6 years oldPoor sensitivity and specificity (40-60%)10-20 minutes to administerNormed on diverse population sampleMultiple languagesDomains: 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/CLAMSClinical 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 SpanishQuick 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 monthsDirect observation of skills by providerAssesses 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 administerNot 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 domainsDirect observation by provider

Brigance (continued)

Standardized in English and SpanishSpecificity and sensitivity 70-82%Easy to administerChildren almost always experience

successTime to administer approximately 10

minutes, 20 minutes in a slow child Realistically after practice 5 minutes

Brigance (continued)

Simple scoringCircle for correct, slash for incorrectStop after 3 in a row incorrectTry to get 3 in a row correct as wellLook up score for age to determine if

normal or delayedCan show advanced skills

DIALDevelopmental 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 EnglishGood specificity and sensitivityScored 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

monitorSensitivity 74-79% Specificity 70-80%Available in Spanish2 minutes to administer, less if parents do aloneONLY 10 QUESTIONSEasy 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 causeShould 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 availableTeacher and parent formsGood for monitoring response to

medicationsScored 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 evaluationsEarly InterventionSpecial 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 evaluationsNeed 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 oldEligibility 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 oldEvery 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