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Developmental Screens in the Office Setting. Nathaniel Beers, MD, MPA. OBJECTIVES. Why to do developmental screen What types of screen tools are available How effective are they How are they administered What types of additional services are available. WHY SCREEN. - PowerPoint PPT Presentation
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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
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