An Update on Developmental Screeninghsc.ghs.org/wp-content/uploads/2016/02/An-Update... · and...

An Update on Developmental

Screening

Steven H. Ma, MD Fellow, Division of Developmental-Behavioral Pediatrics, GHS Children’s Hospital

Michelle M. Macias, MD Medical Director, Division of Developmental Pediatrics, Medical University of South Carolina

Lorraine J. Craigan-Sullivan, MA, LMSW, NCC Developmental Screening Coordinator, Help Me Grow South Carolina

Friday, February 26, 2016

2016 Nurturing Developing Minds Conference

Breakout Session 3

Conflicts and Disclosure

• Dr. Ma, Dr. Macias, and Ms. Craigan-

Sullivan have no conflicts of interest to

disclose.

• Housekeeping:

– Ask questions as they come up!

– Feel free to stand up, move about, etc.


Goals & Objectives

• Define developmental surveillance and

developmental screening and discuss their

importance.

• Discuss the current American Academy of Pediatrics

(AAP) algorithm for developmental surveillance and

screening at pediatric preventive care visits.

• Discuss recent updates to developmental

surveillance and screening.

• Discuss the purpose of Help Me Grow (HMG) and

their role in the screening process and new

screening initiatives.


Introduction

• Part C of IDEA (Individuals with Disabilities

Education Act)

– Establishes Early Intervention and assists with state

programs for infants and toddlers with disabilities.

– Birth to 2 years

– Goal: Proactively enhance development of infants

and toddlers with disabilities

• Part B of IDEA

– Establishes free and appropriate special education

services through school districts.

– 3 years to 21 years.

2016 Nurturing Developing Minds

Conference

Introduction

• Problem

– Gap exists, as children continue to fall

through the cracks and escape detection.

• Current detection rates of developmental disorders

are lower than their actual prevalence.

– Also, children with mild impairments may not

get identified until increased school demands

warrants further investigation.

• Only 20-30% of children with developmental

problems are identified prior to school entry.

• So what can be done? 2016 Nurturing Developing Minds

Conference

AAP Developmental Surveillance &

Screening Algorithm



Surveillance

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AAP Surveillance

Recommendations

• Flexible, longitudinal, continuous and

cumulative process integrated within

family’s medical home

• Should be incorporated at every well-child

visit by a knowledgeable health care

professional based on both observation

and family support


AAP Surveillance

Recommendations

• Surveillance confers risk, not a specific

diagnosis.

• Elicited developmental concerns or high

risk for developmental delays warrant

further screening.

• Be cautious with reassurance and temper

with closer monitoring


AAP Surveillance

Guidelines

• 5 Components:

– Eliciting and attending to the parents’

concerns about their child’s development

– Documenting and maintaining a

developmental history

– Making accurate observations of the child

– Identifying risk and protective factors

– Maintaining an accurate record of

documenting the process and finding


Attending to Parents’

Concerns

• Health care professional should elicit any

parental concern at each well child visit

– “Do you have any concerns about your child’s

development?”

• Absence of parental concern does not

preclude developmental delay.

– Think about minority groups, generational

differences or families from different cultural

backgrounds.


Maintaining a

Developmental History

• Make regular, periodic updates to a child’s

timeline for developmental milestones

• Identify age-specific milestones

• Presumes appropriate knowledge of the

usual temporal sequence of development

within primary domains:

– Speech/Language; Gross Motor; Fine Motor;

Cognitive; Social/Emotional


Making Observations of

the Child

• Imperative at every well-child visit

• Observe the parent-child interaction during

the visit.


Risk and Protective

Factors

• Risk Factors: – Adverse childhood experiences/toxic stress,

including: abuse, neglect, domestic violence, familial

substance abuse, parental divorce/separation,

caregiver incarceration, bullying, homelessness

• Protective Factors: – Nurturing and attachment, knowledge of parenting

and of child development, parental resilience, social

connections, concrete parental supports,

social/emotional competence of children


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Documenting Findings

• Creating a “paper trail” electronically

• Developmental analog to growth chart

• Leverage electronic medical records and

technology, especially with developmental

surveillance and screening



Screening

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://www.fotosearch.com/illustration/vision-test.html&ei=5GwUVaepGIiUNtvag7gI&bvm=bv.89381419,d.eXY&psig=AFQjCNGElGw9JVk0m4irCmK8Ni30j9Eqrg&ust=1427488320764234

Developmental Screening

• Should be performed if there is concern elicited

on surveillance AND at 9-, 18- and 24/30- month

visits

– Ages chosen based on major milestones within

domains

• Brief standardized tool aids in identification of

children at risk for developmental and/or

behavioral disorder.

• Does not result in a diagnosis or treatment plan!


Conference

Developmental Screening

• Normative: identifies areas in which a

child’s development differs from same-age

peers

• Effective: repeated and regular screening

is more likely to identify delays, as

development is dynamic

• Efficient: most common method is

through validated questionnaires


Conference

When NOT to Screen

• If a child is diagnosed with an identified

delay or disability AND connected to an

appropriate developmental service

– A child has a speech delay and is already

connected with speech therapy.


Developmental Screens

• Screening tests should:

– be reliable (consistent results)

– be valid (ability to discriminate risk stratification)

– have good sensitivity (accuracy in identifying delayed

development)

– have good specificity (accuracy in identifying non-

delayed individuals)

• Examples:

– PEDS (Parents’ Evaluation of Developmental Status)

– ASQ-3 (Ages and Stages Questionnaire-3)

– M-CHAT-R (Modified Checklist for Autism in Toddlers,

Revised) 2016 Nurturing Developing Minds Conference

M-CHAT-R & M-CHAT-R/F

• 16 to 30 months (not a valid measure for younger or older children)

• Complete initial M-CHAT-R (20 questions) – Score 0-2: not a positive screening

– Score 3-7: proceed with Follow-Up Questionnaire for positive questions

– Score 8-20: POSITIVE SCREENING

• Strongly recommend the child be referred for early intervention and further

evaluation/diagnostic testing (no need for Follow-Up Questionnaire)

• M-CHAT-R/F (Follow-Up Questionnaire) is pass/fail – only ask parent questions for which child failed

– POSITIVE SCREENING if child fails any two items of the Follow-Up Questionnaire

• Strongly recommended the child be referred for early intervention and further

evaluation/ diagnostic testing

• Note: A significant number (98%) of children who test positive on M-CHAT-

R/F will be diagnosed with developmental delay, but not all will be

diagnosed with autism.

• For more information or to use M-CHAT-R/F online scoring system, please

visit www.mchatscreen.com as this site is approved by the developer, Diana

L. Robins, PhD.


http://www.mchatscreen.com/

Screening Results Are

Concerning… Now What?

• Refer for a formal developmental and medical

evaluation with a simultaneous referral to early

developmental intervention/early childhood

services.

– Developmental/medical evaluation may be made by

neurodevelopmental pediatricians, developmental-

behavioral pediatricians, child neurologists, pediatric

physiatrists or child psychiatrists

– Medical evaluation may include: vision screening,

objective hearing evaluation, newborn metabolic

screening or growth charts


Summary

Recommendations • Perform developmental surveillance at every preventive visit throughout childhood,

and ensure that such surveillance includes eliciting and attending to parents’

concerns, obtaining a developmental history, making accurate and informed

observations of the child, identifying the presence of risk and protective factors, and

documenting the process and findings.

• Administer a standardized developmental screening tool for children who appear to

be at low risk of a developmental disorder at the 9-, 18-, and or 24/30-month visits

and for those whose surveillance yields concerns about delayed or disordered

development.

• Schedule early return visits for children whose surveillance raises concerns that are

not confirmed by a developmental screening tool.

• Refer children about whom developmental concerns are raised to early intervention

and early-childhood programs.

• Coordinate developmental and medical evaluations for children who have positive

screening results for developmental disorders.

• Document all surveillance, screening, evaluation, and referral activities in the child’s

health chart.

• Establish working relationships with state and local programs, services, and

resources. 2016 Nurturing Developing Minds

Conference

Updates on Developmental

Screening

Screening Initiatives

• One of 26 affiliates nationwide

• Serve families in Greenville, Pickens, Charleston, Dorchester, and Berkeley Counties with children birth to 8 years old

• Focused on child development, learning, and behavior

• Free developmental screening for children birth to 5 ½ years

• Connect families to existing community-based programs and supports

• Provide resources to professionals working with families where an additional need is identified

• Work to foster and enhance collaboration across systems


Screening Initiatives

LOCAL

• Universal screening program with ASQ-3 and ASQ:SE/SE-2 (online, paper)

• Maintaining Abstinence in Neonates (MAiN) Program through GHS

• Children entering foster care through Pendleton Place’s Assessment Center

• Children receiving Greenville County First Steps child care scholarships

SOUTH CAROLINA

• Technical assistance to Home Visiting programs through partnership with the Children’s Trust of SC

• Child Care Centers in partnership with DSS-Early Care and Education, SCPITC, SCIC, DHEC

• Read, Rattle, and Roll community-based developmental screening event


Ages and Stages

Questionnaires

• Educates parents about developmental

activities as they complete the screening

– Parent knowledge about child development

serves as a Protective Factor

• Written on a 3rd to 5th grade reading level

• Intervals are available for every age from 1

month to 5 ½ years (ASQ:SE-2 up to 6

years)

• High validity and reliability 2016 Nurturing Developing Minds

Conference

HMG SC’s Student Survey

Parents identified where they want to learn about child development

Pediatrician/Physician

Child Care Center/School

Prenatal OB Visits

Other

Government Agency

Newborn Nursery/NICU


HMG SC ASQ-3 SCREENING

RESULTS

Above the Cutoff

Monitoring

Below the Cutoff



RESULTS

Due to Physician Referral Column1

Above the Cutoff

Monitoring

Below the Cutoff



RESULTS

Child Care Scholarship

Recipients Column1

Above the Cutoff

Monitoring

Below the Cutoff


HMG SC ASQ:SE

SCREENING RESULTS

Above the Cutoff

Below the Cutoff


How Long Parents are

Concerned*


CONNECTION TO SERVICE

• Screening without connection to service is unethical

• National rate for connection to service for children already identified with a delay/disability by MD: 11%

(Halfon N, Regalado M. Assessing development in the pediatric office. Pediatrics 2004:113 (6 suppl)1926-1933; Kavanagh, J., Gerdes, M., Sell, K., Jimenes, M. and Guevara, J. SERIES: An Integrated Approach to Supporting Child Development. PolicyLab: Summer 2012.)

• HMG SC connection rate – 2014: 81%

– 2015: 79%


Conference

Case Scenario 1

• MD and parent concerned with child’s speech at 24 month well-visit

• MD referred mother to speech therapy program

• Child’s insurance not accepted by this specific speech therapy program

• 3 year old well-visit, MD and parent agreed speech had worsened significantly

On-going developmental screening would help identify this as a concern prior to 24 month well-visit

HMG SC could assist with connection to service


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Case Scenario 2

• Child was enrolled in HMG SC on-going developmental screening program at birth, screened at 2 months, 6 months prior; scores were above the cutoff

• Screening completed at 11 months and all scores were above the cutoff

• Three weeks later, mother completed additional screening and identified speech as a concern

• Mother provided consent to communicate and share results with pediatrician

• Child was referred to BabyNet and found eligible for speech therapy

• Pediatrician was informed of connection to service

On-going and repeated screening is effective in identifying later developing delays


Screening Scenario 3

• Mother heard about HMG SC through pediatrician’s office, wanted to know more about child development

– Initial ASQ-3 completed at 8 months • Scored below the cutoff in gross motor and mother identified this

as a concern

• Mother was not ready to be referred for evaluation with BabyNet

- Re-screened with ASQ-3 at 9 months • Score below the cutoff in gross motor again

• Mother spoke with friends, who advised her to “wait and see”

• Mother agreed to BabyNet services and child was connected within 1 month

On-going developmental screening could potentially identify this as a concern before parent recognized as a concern


Screening Scenario 4

• Mother heard about HMG SC through child care provider, as a result of concerns for her 16 month old who was not walking and did not want to eat solid food

• 16 month ASQ-3 completed and all scores were below the cutoff; concerns identified in gross motor, feeding issues – Recommended follow-up with Pediatrician

– Referred to BabyNet for further evaluation

On-going developmental screening could potentially identify this as a concern before parent recognized the concern


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