Developmental Screens in the Office Setting Nathaniel Beers

Developmental Screens in the Office Setting Nathaniel Beers, MD, MPA

OBJECTIVES z. Why to do developmental screen z. What types of screen tools are available y. How effective are they y. How are they administered z. What types of additional services are available

WHY SCREEN z 12 -22% of children in US have developmental or behavioral disorders z Many options now exist to tailor screening to what works in specific practice setting z Services available to children with developmental delays from birth on z Better outcomes for participants: yhigher graduation rates, delayed pregnancy, employment, decreased criminality z $30, 000 to >$100, 000 benefit to society

Why Screen (continued) z Without screening: y 70% of children with developmental disabilities not identified (Palfrey et al. J PEDS. 1994; 111: 651 -655) y 80% of children with mental health problems not identified (Lavigne et al. Pediatr. 1993; 91: 649=655) z With screening: y 70% to 80% of children with developmental disabilities correctly identified Squires et al, 1996, JDBP, 17: 420 - 427 y 80% to 90% of children with mental health problems correctly identified Sturner, 1991, JDBP; 12: 51 -64

Types of Screening Tools z. Two major categories y. Developmental y. Behavioral z. Two mechanisms of administration y. Parental y. Provider

Developmental Screening Tools z. Provider y. Denver y. CAT/CLAMS y. Bayley y. Brigance y. DIAL-R z. Parent y. Ages and Stages Questionnaire y. Parent’s Evaluations of Developmental Status

Denver Developmental Screening Test - 2 z. Very commonly used screening tool z. Birth to 6 years old z. Poor sensitivity and specificity (40 -60%) z 10 -20 minutes to administer z. Normed on diverse population sample z. Multiple languages z. Domains: fine and gross motor, language, and social skills

DDST (continued) z Identifies children at 25, 75, and 90% completion of task z Scored as concern if child completing task in shaded area (75 -90%) z Scored as failure if not completed by time 90% complete z Referrals warranted for one failure or two concerns z Correct for prematurity till 2 years old chronological age

CAT/CLAMS Clinical Adaptive Test/ Clinical Linguistic and Auditory Milestone Scale z Similar to Denver but more focused on screening language and better at catching MR z Some parental report, some direct observation by provider z Very high specificity and sensitivity (>90%) z Not standardized in Spanish z Quick to administer due to age categories

CAT/CLAMS (continued) z Start at chronological age or at last point z Credit given for completed tasks only z Basal age calculated at age where child completes all tasks at that age plus the value given to any additional tasks above that age z Basal age divided by chronological age then multiple by 100. This is the developmental quotient (DQ). z DQ<70 constitutes delays and should be referred for further evaluation

Bayley Screener z Ages 3 to 24 months z Direct observation of skills by provider z Assesses three domains (more neuro focused) z 11 -13 items at each age group (3 -6 month breaks) z Specificity and sensitivity 75 -86% z 10 -15 minutes to administer z Not standardized in Spanish

Bayley (continued) z. Neurologic processes (reflexes, tone) z. Neurodevelopmental skills (movement and symmetry) z. Developmental accomplishments (language, object permanence, imitation) z. Scored as low, medium and high risk for developmental disorders

Brigance z. Multiple age break downs y. Infants and Toddlers y. Early Preschool y. Pre-K y. K-1 st z. Assesses all domains z. Direct observation by provider

Brigance (continued) z. Standardized in English and Spanish z. Specificity and sensitivity 70 -82% z. Easy to administer z. Children almost always experience success z. Time to administer approximately 10 minutes, 20 minutes in a slow child y. Realistically after practice 5 minutes

Brigance (continued) z. Simple scoring z. Circle for correct, slash for incorrect z. Stop after 3 in a row incorrect z. Try to get 3 in a row correct as well z. Look up score for age to determine if normal or delayed z. Can show advanced skills

DIAL Developmental Indicators for Assessment of Learning z Screening tool to evaluate pre-school aged children y. Effective for evaluation of school readiness z Speed version: 10 questions (motor, concepts, language domains) z Spanish and English z Good specificity and sensitivity z 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) z Parent administered survey z Screens multiple domains (communication, gross and fine motor, problem solving and social) z Sensitivity 70 -90% Specificity 76 -91% z Validated in English, Spanish, Korean and French z Can be administered by provider or non-clinical person in cases of illiteracy z 5 minutes to administer when familiar, less if parents administer

ASK (continued) z. Pictures with some tasks to improve understanding of parents z. 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) z Parent administered survey z Identifies when to screen, refer, counsel, or monitor z Sensitivity 74 -79% Specificity 70 -80% z Available in Spanish z 2 minutes to administer, less if parents do alone z ONLY 10 QUESTIONS z Easy flow sheet to prompt when to refer, counsel or re-evaluate

Behavioral Screening z. Parent or teacher y. Connors y. Child Behavioral Checklist y. Pediatric Symptom Checklist y. Vanderbilt

Connor’s z Specific tool for ADHD with high sensitivity and specificity (>90%) z Breaks down into inattentive or hyperactive types z Not going to determine cause z Should never be used in isolation to make diagnosis y. Must rule out additional underlying conditions (MR, LD, hearing and vision abnormalities)

Connor’s (continued) z. Spanish versions available z. Teacher and parent forms z. Good for monitoring response to medications z. Scored by positives (2 or 3) on domains of inattention or hyperactivity

Child Behavioral Checklist (CBCL) z Multiple domains z Can help identify other mental health conditions z Available in Spanish as well z Teacher and parent forms, child forms for older children z Not as valuable for following child once on treatment z Scored in multiple areas (i. e. : internalizing, externalizing, somatic complaints, aggressive behaviors, attention z Scored by points in each of the domains. Cut off for significance given for raw or T-scores

Pediatric Symptom Checklist z Multiple domains of assessment y. Single score or subscales (attention, internalizing and externalizing) z Not standardized in Spanish z Not helpful once a child has been referred z Parent or child fills out form z Scored as 0, 1, or 2 z Significance if total score >24 in child 4 -5 YO or >28 in child 6 -16 YO z Attention: >7 points; Internalizing: >5; Externalizing: >7 points

NICHQ Vanderbilt Assessment z Sensitivity and specificity of >94% if both parent and teacher ratings used z Detailed questions about behavior to assess attention, opposition, conduct, anxiety and depression z Performance questions as well z Scored by number of 2 or 3 in behavior assessment and 4 or 5 in performance assessment z Break down given for diagnosis of ADHD (inattentive, hyperactive, or combined), Oppositional Defiant disorder, Conduct Disorder, and Anxiety/Depression

Additional Services z. Specialists y. Developmental Behavioral Pediatricians y. Speech Pathologists, PTs and OTs z. Other agencies doing evaluations z. Early Intervention z. Special Education

Specialists z. Huge backlogs to see specialists affiliated with Children’s (Nationwide issue) z. Constraints on types of testing they can do by insurance companies y. Medicaid does not allow Children’s to bill for psycho-educational evaluations z. Need to assess if patient actually needs this service

Other agencies z. Some are great and some are not y. Some are profit driven and have not invested in making sure the quality of evaluations is good z. WATS has been very reliable in both quality and speed y. No longer covered by HSCSN z. Additional agencies in handout

Early Intervention z. Zero to three years old z. Eligibility criteria vary by state and county y. DC requires delay of 2 SD z. Anyone can refer patient y. MD, RN, parent, childcare provider z. EI must complete evaluation and help parents transition to SPED when child is 3 yo

Special Education z 3 to 21 years old z. Every child has right to evaluation y. Anyone can request eval, but parent must consent y. Eval must be conducted in child’s primary language and in English y. DC requires eval started within 90 days of request (does not include summer or vacation) y. Repeat eval every 3 years

SPED (continued) z. Individualized Education Plan (IEP) y. Contains the services child will receive and goals for child y. Updated annually y. Parents do not need to sign at IEP meeting y. Quarterly report on progress z. Types of SPED y. Inclusion, pull-out, or self-contained class or school