Developmental Screens in the Office Setting

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Developmental Screens in the Office Setting

• Nathaniel Beers, MD, MPA

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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

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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 gt100,000 benefit to society

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Why Screen (continued)

• Without screening
• 70 of children with developmental disabilities
  not identified (Palfrey et al. J PEDS.
  1994111651-655)
• 80 of children with mental health problems not
  identified (Lavigne et al. Pediatr.
  199391649655)
• With screening
• 70 to 80 of children with developmental
  disabilities correctly identified Squires et al,
  1996, JDBP, 17420 - 427
• 80 to 90 of children with mental health
  problems correctly identified Sturner, 1991,
  JDBP 12 51-64

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Types of Screening Tools

• Two major categories
• Developmental
• Behavioral
• Two mechanisms of administration
• Parental
• Provider

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Developmental Screening Tools

• Provider
• Denver
• CAT/CLAMS
• Bayley
• Brigance
• DIAL-R
• Parent
• Ages and Stages Questionnaire
• Parents Evaluations of Developmental Status

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Denver Developmental Screening Test - 2

• Very commonly used screening tool
• Birth to 6 years old
• Poor sensitivity and specificity (40-60)
• 10-20 minutes to administer
• Normed on diverse population sample
• Multiple languages
• Domains fine and gross motor, language, and
  social skills

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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

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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 (gt90)
• Not standardized in Spanish
• Quick to administer due to age categories

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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).
• DQlt70 constitutes delays and should be referred
  for further evaluation

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Bayley Screener

• Ages 3 to 24 months
• Direct observation of skills by provider
• Assesses 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 administer
• Not standardized in Spanish

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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

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Brigance

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

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Brigance (continued)

• Standardized in English and Spanish
• Specificity and sensitivity 70-82
• Easy to administer
• Children almost always experience success
• Time to administer approximately 10 minutes, 20
  minutes in a slow child
• Realistically after practice 5 minutes

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Brigance (continued)

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

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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 English
• Good specificity and sensitivity
• Scored at norms for age with breakdown at 1.0,
  1.3, 1.5, 1.7, 2.0 SD below

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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

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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

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Parents Evaluations of Developmental Status (PEDS)

• Parent administered survey
• Identifies when to screen, refer, counsel, or
  monitor
• Sensitivity 74-79 Specificity 70-80
• Available in Spanish
• 2 minutes to administer, less if parents do alone
• ONLY 10 QUESTIONS
• Easy flow sheet to prompt when to refer, counsel
  or re-evaluate

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Behavioral Screening

• Parent or teacher
• Connors
• Child Behavioral Checklist
• Pediatric Symptom Checklist
• Vanderbilt

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Connors

• Specific tool for ADHD with high sensitivity and
  specificity (gt90)
• Breaks down into inattentive or hyperactive types
• Not going to determine cause
• Should never be used in isolation to make
  diagnosis
• Must rule out additional underlying conditions
  (MR, LD, hearing and vision abnormalities)

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Connors (continued)

• Spanish versions available
• Teacher and parent forms
• Good for monitoring response to medications
• Scored by positives (2 or 3) on domains of
  inattention or hyperactivity

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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

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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 gt24 in child 4-5 YO
  or gt28 in child 6-16 YO
• Attention gt7 points Internalizing gt5
  Externalizing gt7 points

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NICHQ Vanderbilt Assessment

• Sensitivity and specificity of gt94 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

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Additional Services

• Specialists
• Developmental Behavioral Pediatricians
• Speech Pathologists, PTs and OTs
• Other agencies doing evaluations
• Early Intervention
• Special Education

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Specialists

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

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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

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Early Intervention

• Zero to three years old
• Eligibility 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

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Special Education

• 3 to 21 years old
• Every child has right to evaluation
• Anyone can request eval, but parent must consent
• Eval must be conducted in childs 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

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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