Windows to Success: Developmental Screening In the Early Years

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Windows to Success Developmental Screening In
the Early Years

• Jane Squires, Ph.D.
• Chile Grows With You
• November, 2008
• Santiago, Chile
• Jsquires_at_uoregon.edu

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Objectives

• What is risk in early development?
• What is the importance of early identification?
• Why screen young children?

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Risk factors

• Factors that hamper typical development in young
  children
• Environmental
• Poverty
• Teen parents
• Abuse/neglect
• Biological
• Low birth weight
• Identified/established delays
• Down syndrome

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Cumulative Effects of RiskSameroff et al, 1987
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Poverty

• How does poverty affect developmental outcomes?
• Is not a direct cause of poor outcomes
• Parents in poverty are not poor parents
• Produces a constellation of stresses and risks

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Poverty

• Lack of food
• Iron deficiency
• Anemia
• Problems with problem-solving, concentration,
  lower IQ
• Housing Problems
• Homelessness
• Infant mortality, asthma, delayed immunizations
• Frequent moving
• Not completing high school

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Poverty

• Family stress
• Perceived financial hardship
• Parent stress and depression
• Family conflict, less effective parenting
  behavior
• Child behavior problems, aggressiveness, learning
  problems

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Poverty

• Fewer resources for learning
• Inferior child care
• Less exposure to print, learning materials
• More child stress--anxious, aggressive, less
  active
• Financial barriers for school, college
• Less educational attainment

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Meaningful Differencesin the Everyday
Experiences of Young American ChildrenHart
Risley, 1995, Brookes Publishing
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Meaningful Differencesin the Everyday
Experiences of Young American ChildrenHart
Risley, 1995, Brookes Publishing
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How can we improve child outcomes?
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Early Child Development

• Series of interactions between child and
  environment
• Series of qualitative reorganizations among and
  within biological systems stimulated by
  environmental interactions

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Transactional Model of Development

• Reciprocal, ongoing exchanges between the child
  and environment serve as the foundation of
  development.
• Child is active participant in development.
• Outcomes depend upon quality of caregiving
  environment as well as the childs
  characteristics.

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Plasticity of Young Brain

• Brain imaging research shows affects of
  stimulating environment on young children
• Children of depressed mothers show 40 less brain
  activity (Shore, 1997)
• With rich interactions from the environment,
  brain develops in optimal way
• Differential genetic susceptibility to effects of
  caregiving environment
• Genes caregiving environment adult outcomes

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Early Identification

• On going monitoring of young childrens
  development
• Identifying children with delays in development
• Providing enrichment activities and/or special
  education

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Early Intervention

• Early intervention provides continuum of supports
  to children and families
• Intervening early is necessary to compensate
• Continued intervention and support are often
  necessary to sustain gains
• Early intervention makes a substantial difference
  in the lives of young children and families

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Evidence for Early Intervention

• Intelligence is enhanced in some children.
• Substantial gains are made in all developmental
  areas
• Secondary handicapping conditions are inhibited
  or prevented.
• Family support is provided.

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Evidence for Early Intervention

• Dependency is reduced
• Need for special education services at school
  age is reduced.
• Substantial cost savings in health care and
  education costs.

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Incidence of children identified as having a
disability by age
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Prevention Triangle
Tertiary Level
Special education, OT/PT
Secondary Prevention
Targeted interventions with risk population
Primary Prevention Building Positive
Relationships for Families
Screening, education, health
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Early childhood programs save money

• 3 to 1 benefit-cost ratio
• Better health and academic outcomes
• 3-9 for every dollar invested
• 16 annual return
• http//epinet.org
• http//brookings.edu
• http//minneapolisfed.org/

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Risk Factors and DevelopmentReview

• Environmental, medical, and combination risk
  factors affect development
• Quality of caregiving environment can mitigate
  effects of risk
• Poverty presents most devastating risk factors
  for young children
• Prevention is cost-efficient and effective

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WHAT IS SCREENING?
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Screening

• A brief assessment procedure designed to identify
  children who should receive more intensive
  diagnosis or evaluation from local education,
  health, mental health agencies

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Screening
Not near cutoff
Near Cutoff
Beyond Cutoff
Professional Assessment
Continue to monitor (re-screen) use
curriculum-based assessment to develop learning
plans
Eligible
Not Eligible
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WHY SCREEN YOUNG CHILDREN?
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Why use screening tests?

• Clinical judgment is not accurate
• Increases identification rates of children with
  delays
• If used system-wide, increase
• communication, collaboration
• among agencies

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Why screen?

• Increased rates of poverty for families with
  young children
• Poverty associated with increased medical,
  developmental, and social-emotional problems
• Medical interventions increasing numbers of
  children with delays
• Children born below 1500 grams have greatly
  increased chance for developmental delays
• Increased use of illegal substances by stressed
  families

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Why screen?

• Early childhood time for
• brain plasticity and growth
• Neurons to Neighborhoods,
• http//www4.nationalacademies.org/
• Early intervention is effective
• For low-birth weight children
• McCormick et al. 2006
• Ecological focus on family and child
• Bronfenbrenner, 1977 Sameroff Fiese, 2000
• Home and center based programs effective
• Olds, 1997 Ramey Ramey, 2000

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Identification by pediatricians

• In U.S. 60-80 with delays not identified early
• American Academy of Pediatrics 2006
  Pediatricians recommended screening at
• 9, 18-24, 30 months
• Referral rates in 1 practice increased 224 in
  one year with formal screening test (Hix-Small,
  Marks, Squires Nickel, 2007)

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What are effective screening measures?
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Qualities of assessment tools to consider

• Validity
• Reliability
• Adequate normative population
• Cultural sensitivity
• Comprehensiveness
• Attractiveness to children

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Types of screening instruments

• Professionally-administered
• Parent-completed
• Information on screening tools
• http//www.dbpeds.org/
• http//www.fpnotebook.com
• http//www.cimh.org
• Individual publishers

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Professionally-administered

• Battelle Developmental Inventory Screen, 2nd
• (http//www.assess.nelson.com)
• Bayley Scales of Infant Development Screen, 3rd
• (http//harcourtassessment.com)
• Brigance Screens
• (http//www.curriculumassociates.com)
• Denver II
• (http//www.denverii.com/DenverII.html)
• Early Screening Inventory
• (www.pearsonearlylearning.com)

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Parent-Completed

• Pediatric Evaluation of Developmental Status
  PEDS--Glascoe
• www.pedstest.com
• MacArthur Communicative Development
  Inventory--Fenson et al.
• Minnesota Child Development Inventories
• http//www.childdevrev.com/cdi.html
• Ages Stages Questionnaires
• http//www.brookespublishing.com
• http//agesandstages.com

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Assessment

• the science of examining the strange behaviors
  of children in a strange situation with strange
  adults for the briefest possible periods of
  time
• (Bronfenbrenner, 1979)

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Advantages of Parent-Completed Screening Measures
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Engaging families in the assessment of their
child

• Parents are reservoirs of rich information about
  their children
• Parental involvement reduces cost
• Screening structures observations, reports and
  communications about child development

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Engaging families in the assessment of their child

• Screening may become a teaching tool for parents
  and teaching staff
• Information/communication can be useful for
  primary health care providers and communication
  based rehabilitation center
• Effective and efficient method of early
  identification

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Research on parent report of child developmental
level

• As accurate as formal measures for identifying
  cognitive delay (Glascoe, 1989, 1990 Pulsifer,
  1994)
• As accurate as formal measures for identifying
  language delay (Tomblin, 1987)
• As accurate as formal measures for identifying
  symptoms of ADHD and school related problems
  (Mulhern, 1994)
• More accurate than Denver for predicting
  school-age learning problems (Diamond, 1987)

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Accuracy of low and middle income parents

• Agreement between parent-completed ASQ and
• professionally administered standardized
  assessment
• Low income parents .85
• (below federal poverty level)
• Middle income parents .89
• No statistical significance between groups
• (Squires, Potter, Bricker, (1998) Early
  Childhood Research Quarterly,13, 2, 345-354.)

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Advantages of parent-completed screening tests

• Parents/caregivers can provide rich information
  about child across settings
• Parent involvement reduces cost
• 3-5 times less
• Screening structures observations, reports,
  communications about child development

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Cost Effective

• Parent-completed assessments range between 3-10
  per assessment (U.S. interview/mail models)
• Professionally-administered cost 3-5 times more
• (Chan Taylor, 1998 Dobrez Lo Sasso, Holl et
  al., 2001 Glascoe, Foster, Wolraich, 1997)

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Factors that may affect the accuracy of parental
report

• Characteristics of parents
• Impaired mental functioning
• Mental health issues
• Cultural and language differences
• Involvement with child protective agencies
• Low literacy

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PARENTS EVALUATION OF DEVELOPMENTAL STATUS
PEDS
A Method for Detecting and Addressing
Developmental and Behavioral Problems

• For children 0 through 8 years
• In English, Spanish and Vietnamese
• Takes 2 minutes to score
• Elicits parents concerns/family-focused/cultura
  lly competent
• Sorts children into high, moderate or low risk
• 4th 5th grade reading level
• Score/Interpretation form printed front and back
• and used longitudinally
• Screens for developmental and behavioral/mental
  
• health problems

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PEDS Response Form
1. Please list any concerns about your childs
learning, development, and behavior.
2. Do you have any concerns about how your child
talks and makes speech sounds?
7. Do you have any concerns about how your child
gets along with others?
Circle Yes No A little Comment
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What are the ASQ and ASQSE?

• Series of parent- completed developmental
  questionnaires
• Screen children for possible developmental
  delays, difficulties
• Monitor the development of young children from 1
  month to 5 years
• Enlist parents and caregivers in assessment
  process

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ASQ Communication

• 12 month ASQ
• Does your baby follow one simple command, such as
  Come here, Give it to me, Put it back, without
  your using gestures?
• ?Yes ?Sometimes ?Not Yet
• Does your baby say one word in addition to Mama
  and Dada?
• ?Yes ?Sometimes ?Not Yet

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ASQ Fine motor

• 24-month ASQ
• Does your child turn the pages of a book by
  himself? (He may turn more than one page at a
  time.)
• ?Yes ?Sometimes ?Not Yet
• Does your child flip switches off and one?
• ?Yes ?Sometimes ?Not Yet

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12 month ASQSocial Emotional

• Does your baby laugh or smile at you and other
  family members?
• (z)Most of the time (v) Sometimes (x)
  Rarely or never
• Does your baby like to be picked up and held?
• (z)Most of the time (v) Sometimes (x)
  Rarely or never

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24 month ASQSocial Emotional

• Does your child seem too friendly with strangers?
• (x)Most of the time (v) Sometimes (z)
  Rarely or never
• Do you and your child enjoy mealtimes together?
• (z)Most of the time (v) Sometimes (x)
  Rarely or never

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ASQ ASQSE for autism

• ASQ identified 76/76 children in retrospective
  study (Nickel, 2006)
• 70/76 parents made comments in overall section
• ASQSE in clinical settings is identifying
  children with autism
• Two studies just beginning using ASQ and ASQSE

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ASQ Office Study

• 12 and 24 months
• 20 pediatric practitioners
• 76 agreement between ASQ and pediatrician
  estimate of development (OK, at risk)
• Pediatricians referred mostly for communication,
  gross motor delays
• Referrals for further assessment increased 224
  in one year

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Control and screening year referrals
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Control and screening year referrals
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Recommendations for a screening system
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Best practices in screening

• Use formal, validated screening measures
• Include parents in decision making
• Consider cultural adaptations
• Develop systematic screening and referral
  procedures
• Include personnel and agency training
• Evaluate screening system
• Cost
• Efficacy
• Utility

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Include social-emotional areas

• Links between earliest emotional development and
  later social behavior. (Cicchetti Cohen 1995
  Reynolds et al., 2001)
• Behaviors, even in infancy, signal the need for
  intervention (Shonkoff Phillips, 2000)
• Links between early risk factors, poor outcomes
  violence (Conroy Brown, 2004)
• By third grade, programs for children with
  anti-social behavior are mostly ineffective
  (Walker, 2004 Greenberg et al., 2003)

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21st Century Screening Programs

• Short, effective screening tests
• Increased use of parent report
• Internet-based
• Touch screens at health and educational centers
• Follow-up through health and educational outreach
  staff

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In Summary

• Early identification is critical for improving
  developmental outcomes
• Valid and reliable screening tests are central to
  early identification efforts
• Several parent-completed screening tests assist
  in early identification efforts
• Early identification and intervention have
  extensive cost savings as well as improving child
  and family outcomes

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To make change, we must have unwarranted optimism
about our children and our future

• All this will not be finished in the first 100
  days.. Nor will it be finished in the life of
  this Administration, nor even perhaps in our
  lifetime on this planet. But let us begin.
• John F. Kennedy, 1961
• We must become the change we seek to create.
• Gandhi

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Thank you