Developmental Screening and Assessment What Are We Thinking

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Developmental Screening and Assessment: What Are We Thinking? Glen P. Aylward, Ph. D. ,

Developmental Screening and Assessment: What Are We Thinking? Glen P. Aylward, Ph. D. , ABPP Southern Illinois University School of Medicine Springfield, IL

Q 1: Is there a “Gold Standard” in Developmental Evaluation? • reference standard •

Q 1: Is there a “Gold Standard” in Developmental Evaluation? • reference standard • Flynn effect (. 3 -. 5 pt/year) • Bayley Scales (1969; 1993; 2006) • BSID—>BSID II (MDI 12 pts lower, PDI 7 • • • points) BSID-III (mental 6 pts higher; motor 8 pts higher) Mean 7 pt increase; comparability is limited Length/pragmatics

Q 2: Is There Agreement as to What Qualifies as a Developmental Delay? •

Q 2: Is There Agreement as to What Qualifies as a Developmental Delay? • “precision issue” • 20% delay ? • 2 standard deviations below the mean for a reference group? • Score compared to “local norms”? • A ratio/criterion measure? • Acceptance of psychometrically poor tests • Recommend SD cutoffs

Q 3: Does Development (DQ)= Intelligence (IQ)? • Neurologic motor sensorimotor cognitive • Skill

Q 3: Does Development (DQ)= Intelligence (IQ)? • Neurologic motor sensorimotor cognitive • Skill function integrated functional unit intelligence • Complexity increases in concert with age • Skill, function = potential • Different streams, different rates • Younger than age 2: simple cognitive functions —only after discrete functions are combined do we predict later “intelligence”

Canalized Behavior • Species-specific, prewired, self-righting • Fixed behavior pattern • Not highly complex

Canalized Behavior • Species-specific, prewired, self-righting • Fixed behavior pattern • Not highly complex • More canalized, less affected by adverse circumstances • Less canalized, weaker self-righting, greater likelihood of disruption • Sensorimotor behaviors are strongly canalized • Impact on test results/prediction

Integrated Functions • Individual developmental skill/ability is not most important • Integration of abilities

Integrated Functions • Individual developmental skill/ability is not most important • Integration of abilities into functional units that control these abilities • Ability to integrate functions information processing, memory, discrimination, attention • Musicians [skills] section of orchestra [function] integration of sections (conductor) concert

IQ/DQ Ambiguity • • BSID-III Mullen Scales SB-V K-ABC/2 • • WPPSI-III MSCA DAS

IQ/DQ Ambiguity • • BSID-III Mullen Scales SB-V K-ABC/2 • • WPPSI-III MSCA DAS Cattell Cognitive Composite Early Learning Composite NVIQ, FSIQ Mental Processing Composite; Mental Processing Index FSIQ General Cognitive Index (GCI) General Cognitive Ability (GCA) IQ

Q 4: Is a Ratio DQ useful? • Ratio DQ– MA/CA x 100 •

Q 4: Is a Ratio DQ useful? • Ratio DQ– MA/CA x 100 • Rate of development • Not comparable at different age levels b/c the standard deviation (variance) of the ratios does not remain constant • CI’s vary tremendously • Interpretation is difficult • “MA” is totally dependent on test used • Similar issues with “developmental age” • Better to use 1. 5, 2 SD < ‘average’

Q 5: Is Caretaker Report Sufficient for Developmental Screening? • AAP (2006) policy statement

Q 5: Is Caretaker Report Sufficient for Developmental Screening? • AAP (2006) policy statement regarding surveillance and screening • 1/3 of developmental screening instruments (excluding those targeting ASD) were parent completed • Earlier, parent report considered a Stage I or “prescreening” technique • Evolved to being considered comparable to hands-on screening • ? Evidence-based use

Caretaker Report • Little is known as to how parent completed • • questionnaires

Caretaker Report • Little is known as to how parent completed • • questionnaires are affected by: 1) child-related, or 2) environmental variables Accuracy depends on developmental area assessed, population ? Different tests for different populations How questions are answered (y/n, Likert, etc. ) Considerations: -- Length, detail -- Age range encompassed -- Presence/absence of examples of behavior -- Test behaviors or milestones

Caretaker Report • Diamond & Squires (1993): current behaviors, • • • recognition (vs

Caretaker Report • Diamond & Squires (1993): current behaviors, • • • recognition (vs recall), behaviors should occur frequently, parents need skills to be able to complete questionnaire Screening risk status of infant most predictive of agreement < 2 -years; at 2, race (marker of SES) predictive Camp (2007) spectrum bias: better/worse identification depends on base rates of problems Items most predictive often are those with poorer agreement (puzzle board, stacks 6 cubes)

Q 6: How Problematic Are Test Refusals? • Behaviors have an impact: frequently negative

Q 6: How Problematic Are Test Refusals? • Behaviors have an impact: frequently negative • More pronounced with younger children • Possibilities: a) Declines to respond to any item; • • • b) specific types of items, or c) stops when items become too difficult Occasional refusals— 41% of young children State of arousal, affect, motivation, temperament, physiological issues Score refusals as failures, prorate scores, or consider testing to be invalid?

Test Refusals • Potential causes: --Reaction to poor underlying skills/attempt to avoid failure --Oppositional

Test Refusals • Potential causes: --Reaction to poor underlying skills/attempt to avoid failure --Oppositional behavior --Shyness, anxiety --Temperament --Poor attentional skills/high activity level --Fatigue/malaise --Temper displays/crying --Parental behaviors

Test Refusals • Verbal production tasks, gross motor activities, end of testing • More

Test Refusals • Verbal production tasks, gross motor activities, end of testing • More in children born at biologic risk, low SES • Those who refuse any aspect of testing differ from those who refuse some items or who refuse more difficult items • High rates of refusal at one age associated with similar behaviors at later ages

Test Refusals--Implications • Those who refuse to comply often have decreased scores in several

Test Refusals--Implications • Those who refuse to comply often have decreased scores in several areas of function--untestable • Risk for lower test scores and higher rates of problems at ages 7 -8 years in many areas • Source of clinical information

Q 7: Is There a Role for Qualitative Information? • Not in place of

Q 7: Is There a Role for Qualitative Information? • Not in place of quantitative; rather, in • • • conjunction with Causes for + finding: cognitive impairment, emerging LD, language dysfunction, environmental risk, testing issues, combination Clinicians vs. technicians Play-based ‘assessment’ Examples: form board; naming pictures, stacking cubes Training to task

Quality Control Clinicians vs. Technicians • Quality of assessment may be compromised because of

Quality Control Clinicians vs. Technicians • Quality of assessment may be compromised because of the questionable proficiency of examiners • Not clear who is qualified – Conceptual and factual knowledge of normal development – Awareness of significance of pathognomonic indicators – Well versed in administration & scoring – (speed, best response, stop, eliciting report)

Q 8: What About Prediction? • Prediction tells us if early alarm or reassurance

Q 8: What About Prediction? • Prediction tells us if early alarm or reassurance • has any basis Prediction is difficult because: – – – – Rapid developmental change Intervening variables (environmental, biologic) Interventions (EI, medical, social) Testing itself has impact on developmental trajectory (observational effect) Emergent, latent, delayed, deficient, disordered Moving target Aspects of tests used at T 1 T 2 Tn Domain/area of development

Prediction • Stable performance: high risk>low risk> moderate risk • How does one define

Prediction • Stable performance: high risk>low risk> moderate risk • How does one define prediction (copositivity/co-negativity; ORs, correlations) • Time span/interval • What predicts what? – Single composite measure may not be appropriate; sub-domains of function

Q 9: Is There a Summary? • Consider tests as reference standards; be aware

Q 9: Is There a Summary? • Consider tests as reference standards; be aware of psychometric issues • Evaluation is a balance between concepts and pragmatics • Percent delay is not accurate; criterion based, > 1. 5, 2, 3 SDs below average • Consider what can be assessed at different ages (skill=capacity) • Ratio DQ’s not accurate • Serial screening/assessment

Summary • We need to better understand strengths, weaknesses, and variables that affect caretaker

Summary • We need to better understand strengths, weaknesses, and variables that affect caretaker report • Consensus on test refusals: should we include, prorate, or invalidate scores? • Clinicians need to test • Environment affects different skills and at different times • Wear sunscreen and eat fiber

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