Pretest questionsThe recommended ages for routine developmental screening tests are: 12m, 24m, 36m *9m, 18m, 24/30m 6m, 18m, 24/30m 6m, 12m, 24m

The prevalence for developmental disabilities in children is approximately: 1% 5% *15% 30%

Developmental Surveillance and Screening

Craig D. Boreman, MD, FAAP21 February 2015

Disclosures

I did not, do not, and likely will not have any financial relationships with proprietary entities that produce goods or services

I am the medical director for the new Dayton Autism Center and have a vested interest in seeing children receive the best health care

Objectives

Understand the reasons for developmental/behavioral monitoring

Learn the importance of Surveillance vs Screening

Experience specific tools (examples) for screening

Did You Know?● Prevalence of developmental disabilities 1 in 7

children (~14%)● Most developmental disabilities are

● Learning disabilities – 7.6%● ADHD – 6.7%● Intellectual disability – 0.7%● Autism – 0.47%

Blumberg SJ. Trends in the Prevalence of DD in US Children, 1997-2008. Presented at National Conference on Health Statistics, August 2012

Over the 12 years, increase of

------------17%

------------33%

------------290%

A little more on autism

– 1975, 1 in 5000: 0.2/1000– 1985, 1 in 2500: 0.4/1000– 1995, 1 in 500: 2/1000– 2001, 1 in 250: 4/1000– 2006, 1 in 110: 9/1000 (CDC)– 2008, 1 in 88: 11/1000 (CDC)– 2013, 1 in 50: 20/1000 (CDC)*

* Health Resources and Services Administration and Centers for Disease Control report – Mar13

Autism• There has been a 600% increase in prevalence in

the past 20 years

• One in 50

What’s causing the rise? Many factors

Diagnostic change Substitution (X → Y)

Accretion (X → X + Y) Broadening (x → X)

Advanced parental age Social influence and increased awareness

Better education/Increased information dissemination Spatial clustering Advocacy interest groups National/International coverage

Other factors?

2009 Amer J Epidemiology2009 Oct Int J Epidemiol 2010 Mar Amer J Sociology

WHY SCREEN??

Benefits of Monitoring

• Screening works• Results in access to services• Cost effective• Improves patient/family satisfaction• Because we are told to!

Early Intervention EfficacyPediatric Care Intervention

Arkansas 85 99

Einstein 74 85

Harvard 96 97

Miami 66 81

PA 92 95

Texas 80 87

Washington92 100

Yale 91 103

TOTAL 85 94

JAMA. 1990;263:3035-3042

Effects of Psychosocial Risk Factors on Intelligence

0 1 2 3 4 5 6 7+80

85

90

95

100

105

110

115

120

125

IQ

RISKS: < HS parental education, > 3 children, > stressful life events, single parent, parental mental health problems, < responsive parenting,

poverty, minority status, < social support

Cost Effective• The cost of treating developmental problems early

is substantially lower than treating a patient who is diagnosed late.

• May save society $30,000-$100,000 per child

Patient and Family Satisfaction• Parents want and expect support on child

development.• Screening can encourage parent involvement and

investment in child’s health care.

Because we said so…• AAP Council on Children with Disabilities

recommends routine surveillance and standardized developmental and behavioral screening. • Pediatrics 2006 Jul

• Policy reinforced in American Academy of Family Physicians AFP journal article. • Am Fam Physician. 2011 Sep

Guidelines

Developmental surveillance at every well-child preventative care visit

Developmental screening tests if:– Concerns exist, OR– Regularly at the 9-, 18-, 30-month visits

Children identified with developmental disorders should be identified with a special health care need, and chronic-condition management should be initiated

AAP

Policy

Statement -

2006

Definitions

Surveillance

vs

Screening

What is Surveillance?

A flexible, continuous process, in which knowledgeable professionals perform skilled observations of children during child health care (in consultation w/families,

specialists, child care providers, etc).  

SM Dworkin, A Shannon, and P Dworkin. ChildServ Curriculum. Center for Children’s Health and Development, St. Francis Hospital and Medical Center; 1999; Hartford, CT.

Surveillance: 5 Components

• Eliciting and attending to the parent’s concerns

• Maintaining a developmental history

• Identifying the presence of risk and protective factors

• Making accurate and informed observations of the child

• Documenting the process and findings

AAP Policy - Pediatrics 2006; 118; 405-420

What is Screening?

• Brief procedure using a standardized and validated developmental tool at pre-determined times

• Goal to differentiate children that are "probably ok" vs. "needing additional investigation”

• Performed at set points (eg. 9, 18, 24/30 months) OR if a specific concern arises*

*AAP Policy - Pediatrics 2006; 118; 405-420

Importance of Being Objective

TOUCH OR TAKE TEMP?

Developmental SurveillanceVersus

Developmental Screening

Courtesy of Paul Lipkin MD FAAP: D-PIP Training Workshop

9 Months

18 Months24/30 Months

A Typical Challenge

• Roger, new pt well visit, 2 years old

• Upset and crying when he checks in

• Mother reports he has limited words, does not listen, and has “temper tantrums” when he does not get his way

How is this currently handled in your clinic?How would you like to handle it?

Screening’s Role

• In the optimal setting, primary care physicians have good surveillance skills - BUT

• Screening compliments continuous surveillance

• Research indicates effective screening is not always being done

Pediatrician Recognition of Developmental and Behavioral Problems

8.7

13

5.7

11

0

2

4

6

8

10

12

14

Preschool BehavioralProblems

School-Age BehaviorProblems

Identified

Prevalence

Per

cent

of

Chi

ldre

n

Costello et al. Pediatrics. 1988;82:415-424

Sources: J. V. Lavigne et al, Pediatrics, Mar. 1993 91(3):649–55; E. J. Costello et al., “Pediatrics, Sept. 1988 82(3 Pt. 2):415–24. Slide thanks to: Edward L. Schor, MD

Detection RatesWithout Tools With Tools

• 20% of mental health problems identified (Lavigne et al. Pediatrics. 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)

Past PracticesDuring Primary Care Visits

• Only 15-20% of pediatricians routinely use screening tests

• Most rely on developmental milestones or prompting for parental concern

• Only half of physicians in a national survey have a validated developmental screening instrument in their offices

• The Denver-II continues to be the predominant choice

JDBP 24:409–417, 2003

The bad news…

Practices that do not regularly screen for developmental, behavioral and emotional problems may miss opportunities for early referral and treatment.

Barriers to Screening• Time

• Knowledge of tools and methods

• Familiarity with coding and billing procedures

• Referral resources

JDBP 2003; 24:409–417

Challenges for Providers

• Resistance from within

• Lack of education on tools and their use

• Expectations about children’s development

• The “wait and see” approach

• Continued reliance on observations

• Failure to trust screening tests or results

• Reliance on poor quality or homemade tools

Challenges to Evaluating Children

• Development exists on a continuum

• Children manifest skills variably, inconsistently

• Developmental/behavioral problems increase with age– 2-3% of 0-18 month olds– 10% of 24-72 month olds– 16% of 0-21 year olds

The good news…

The use of standardized screening tools increased significantly between 2002-2009.

According to AAP periodic survey of fellows:• 2002: 23% used one or more tools (always/almost always)• 2009: 47% used one or more tools (always/almost always)

• Tools used: BINS, Denver II, ASQ, PEDS

Pediatrics 2011; 128: 14-19

Summary/Intermission

Developmental Screening is:

• Recommended by AAP & AAFP

• Different than surveillance

• Beneficial to children and practices

• Underutilized

• Challenging but rewarding to implement

Questions?

Tool TimeTool Ages Admin time Psychometrics Comments

Ages and Stages Questionnaire

B-66m 10-15m,1-3m scoring

Normed, broad population

$225Unlimited copy

Battelle Dev Inventory

B-95m 10-30m direct

Normed, broad population

$1280

Bayley Infant Screen

3-24m 10-15m direct

Normed, broad population

$225

Brigance B-90m 10-15m direct

Normed, broad population

$299 + data sheets

Denver 0-6y 10-20m direct

Normed, narrow population

Parents’ Eval of Dev Status

0-8y 2-10m,1-2m scoring

Standardized, broad population

$36/ 50 copies

I do not have any financial ties to any of these products (or any other ties!)

• Time required: • Parent 10-15 minutes to

complete• 3 minutes to score

• Cost: One time purchase; photocopying permitted or print from CD

• Features: Age-appropriate sensitivity and specificity; comes with suggestions for parents

• Adapted from: Michelle Macias MD FAAP, D PIP Training

Ages and Stages Questionnaire (ASQ) 2 Months to 5 Years

• 21 questionnaires from 1-66 months

• 30 - 35 items per form describing skills

• Taps 5 domains of development

• Validity is .82-.88; Test-retest reliability is .91 and inter-rater reliability is .92

• ASQ-Social-Emotional (ASQ-SE) works similarly and measures behavior, temperament, etc.

What’s new in ASQ-3?

2 and 9 month old questionnaire “Anytime screening” – ages 1-66 months Larger standardization population (15,138) Improved sensitivity (.86) and specificity (.85) Revised illustrations, wording, examples to

improve accuracy

Ages & Stages™ Sample Items

1. When your child wants something, does she tell you by pointing to it?

Yes Sometimes Not Yet

4. Does your child say eight or more words in addition to “Mama” and “Dada”?

Yes Sometimes Not Yet

Ages & Stages™ Sample Item 48 months

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, without tracing? 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

Communication

Gross Motor

Fine Motor

Problem Solving

Personal-Social

• Assign a value of 10 to yes, 5 to sometimes, 0 to not yet.• Be sure each item has been answered• The scoring grid below shows the cutoff score for each

domain, indicated by the dark bar• Any score touching or in the dark bar requires further

evaluation

ASQ Scoring

Questions so far?

Autism Spectrum DisordersThere has been a 600% increase in prevalence

in the past 20 years1 in 50 children*

* Health Resources and Services Administration and Centers for Disease Control report – Mar13

Modified Checklist for Autism in Toddlers (M-CHAT)

• Administered at 16-30 months• 23 questions expanded and adapted from earlier CHAT

(English or Spanish) – 1999• Modified to update/clarify language – 2009 • Free: www.m-chat.org • Available in >25 languages (including Icelandic)• Can be scored in 2-5 minutes by a professional or

paraprofessional• Yes/No responses convert to Pass/Fail responses

M-CHAT

• Considered “High-risk” if fails 8 or more items• Recommended to refer directly for diagnostic

evaluation

• Considered “Medium-risk” if fails 3 to 7 items• Recommended to administer follow-up (second

stage) questions

• Considered “Low-risk” if fails 2 or less items• Recommended to continue routine surveillance and

screening.

• Not all children who fail the checklist will meet all criteria for diagnosis on the autism spectrum

M-CHATR Follow-up

Question/interview algorithm designed to further validate M-CHATR results

Failure of any 2 items is considered significant– Refer for diagnostic testing

SummaryConduct surveillance at every pediatric health

supervision visitConduct screening when concerns arise OR at

set intervals (9, 18, 24/30 months) If failure/concerns noted on screening tools

– Refer family to Early Intervention/Help-Me-Grow services

– Begin evaluation process (hearing, speech evaluation, etc)

– Consider referral for full diagnostic evaluation (developmental pediatrics, child psychology, neurology, etc)

Questions??