Beyond the Assessment Score: What Else Can We Learn from an Assessment?

1. Beyond the Assessment Score: What Else Can We Learn from an Assessment? Barbara Fitzgerald M.D. FRCP(C) Developmental Pediatrician, Sunny Hill bfitzgerald@cw.bc.ca Clinical Associate Professor U.B.C. Assistant Dean, Student Affairs

2. The Role of the Frontline Worker: Identifying Children With Developmental Problems Observation • Over time • In a variety of settings • Ready comparison group • Interactions with other children and with their parents • Response to interventions You may be the only developmental specialist to ever appraise this child.

3. Role of the Frontline Worker Screening: Ages and Stages Questionnaire Nippissing

4. Role of the Frontline Worker Recommendations • Communication to parents of concerns Suggestions for: Assessment Intervention Advocacy Follow-up

5. Developmental/Behavioural Presentations • Speech and Language Delay • “Odd” behaviour • Withdrawn, quiet child • Developmental delay • Hyperactive/disruptive/inattentive behaviour

6. Why “Early Diagnosis”? • Early treatment/support results in improved outcome e.g. hearing impairment Fetal Alcohol Syndrome • Family planning e.g. in genetic conditions • Understanding of the child from a disability perspective • Economic “preschool interventions are cheaper than jail!”

7. But which kids need assessment/intervention?

8. General Concepts • Children can exhibit delays in one domain of development or in many (Global Developmental Delay) • Speech development is most predictive of cognitive development • Gross motor skills are the least predictive of cognitive outcome e.g. (35% of profoundly mentally handicapped children walk by 15 months) • Things which are typical (normal) at one age may be cause for concern at another age

9. General Concepts (cont.) • Approximately 16% of children have disabilities such as speech-language impairments, intellectual impairment (mental retardation), learning disabilities, and emotional/behavioural disturbance. • Only 20-30% are detected prior to school entry. courtesy Francis P. Glascoe

10. Biopsychosocial Approach to Child Development • Child development is multifactorial • Occurs in the context of a genetic background, prenatal exposures and influences, postnatal environmental influences, familial factors and health conditions • Must assess child in context of these varied influences to arrive at an appropriate diagnosis and to plan effective intervention

11. Ages and Stages Questionnaire • Economical screening tool devised from questions on other assessment tools to screen for developmental delay in infants and young children up to age 5 yrs. • Each questionnaire has 3 parts: demographic items, 30 developmental items, and 7 open ended questions about the child’s behaviour and development

12. Ages and Stages Questionnaire 5 Domains for items: Gross Motor Fine Motor Communication Problem Solving Personal-social Cut off scores identify whether that domain is an area of potential delay

13. Ages and Stages Questionnaire Sensitivity (proportion of children with delays who will be identified by ASQ): 75% Specificity (proportion of children without delays who have a negative test): 86%

14. Case 1: J.S. Jacqueline is a 12 month old baby who has been referred to IDP. She has been in the same foster home since her discharge from the Fir Square ward of Women’s Hospital at one month of age. Her foster mother is very experienced and asks that the child be seen by IDP. She was not given much information about the baby, other than that her mother used crack cocaine. You are her IDP consultant.

15. Foster Mother’s Concerns • Constant crying until 6 months of age, very difficult to soothe • Hard to cuddle, very “stiff” • Wasn’t secure sitting until 8 months of age because she would arch and fall over • No words yet but is babbling

16. What information is important so far?

17. Jacqueline is a 12 month old baby who has been referred to IDP. She has been in the same foster home since her discharge from the Fir Square ward of Women’s Hospital at one month of age. Her foster mother is very experienced. She was not given much information about the baby, other than that her mother used crack cocaine.

18. Foster Mother’s Concerns • Constant crying until 6 months of age, very difficult to soothe • Hard to cuddle, very “stiff” • Wasn’t secure sitting until 8 months of age because she would arch and fall over • No words yet but is babbling • A relative has said that because she isn’t cuddly and is not talking she might have autism

19. Your Observations • Home is set up well for children • Foster mother’s interactions are loving and age appropriate • Jacqueline is a beautiful little girl who is a little slender • She is playing with a pot and dumping things out of it • You put the things back in and she looks at you, laughs and dumps then out again, clearly waiting for you to put them back in • You don’t hear any vocalizations

21. What are the areas of concern?

22. Communication: • Mild delay • No concerns about hearing, but still needs to be checked

23. Concerns Re: Language Development Speech & Language Delay Expressive onlyExpressive & Receptive unusual or delays in many hearing test atypical social areas behaviour refer to SLP consider Autism refer for Spectrum Disorder developmental intervention and investigate for *hearing assessments in all underlying etiology (global developmental delay)

24. Concerns Re: Language Development Speech & Language Delay Expressive onlyExpressive & Receptive hearing test unusual or delays in many hearing test atypical social areas behaviour refer to SLP consider Autism refer for Spectrum Disorder developmental assessment and investigation for underlying etiology

25. Do you think that Autism Spectrum Disorder is a likely possibility? • What features would make you suspicious of Autism? • How could you screen for it?

26. You have observed typical social interactions • You could look for more evidence of social communication (pointing, interactive games) • You could consider doing the CHAT at 18 months when you would expect imaginary play

29. Pointing

30. Sharing/Giving

31. Autism Autism is a disorder of brain development with a strong genetic component. It is characterized by qualitative impairment in: • Reciprocal social interaction • Communication • And: restricted, repetitive and stereotypic patterns of behaviours, interests and activities.

32. Autism Autism is a disorder of brain development with a strong genetic component. It is characterized by qualitative impairment in: • Reciprocal social interaction • Communication • And: restricted, repetitive and stereotypic patterns of behaviours, interests and activities.

33. Gross Motor • History of arching • Not using hands equally • Not walking What might be the reason for the gross motor delays?

34. Prenatal Cocaine Exposure • Usually doesn’t cause intellectual delay • May predispose to learning disabilities • Children tend to be more hyperactive and inattentive • In infancy, babies can present with stiffness and unequal use of hands/lower limbs which usually resolves by age 2 yrs • Higher incidence of speech and language delay • Outcome may be more related to home environment than prenatal exposure to cocaine

35. Fine Motor • Mildly delayed, may be related to effects of cocaine • May be related to prolonged withdrawal

36. What should you do next?

37. Consider referral for hearing assessment and possible speech pathology evaluation • Consider physiotherapy referral • Remind foster parent that child will be at higher risk for behaviour and learning problems in school • Child should be followed by a pediatrician • May need full developmental assessment pre-kindergarten

38. Case 2: S.K. Sierra is a 2 ½ year old girl who is attending your daycare. She is brought to daycare every day by her single mom who is 18 years old. She has been in the daycare for 6 months; prior to that a neighbour looked after her while her mother was at work. You have made the following observations:

39. Sierra has had trouble learning the routines • She forgets new concepts easily but then can do them again later • She is overly friendly with strangers at the daycare • She is unduly distressed by loud noises • She is aggressive with other children • Tantrums are a problem • She is very active and loves gross motor activities • She doesn’t ever choose fine motor activities, gives up easily with any fine motor tasks • She speaks mainly in single words • She is disruptive at story time • Safety is a concern as she always runs away at outside play time

40. Is this emotional/behavioural, environmental or developmental? • How would you proceed?

42. What does the ASQ tell you?

43. Communication • Delays in both receptive and expressive communication

44. Do the tantrums relate to the communication skills?

45. Gross Motor How do you reconcile the differences in your observation of gross motor skills being a preferred activity and the fact that they are delayed on the ASQ?

46. Hyperactivity and impulsivity are often confused with good gross motor skills • She can’t stand on one foot to kick a ball or to balance. What might that mean?

47. Fine Motor Does she have fine motor delay? How do you put your observations together with the ASQ?

48. Her fine motor skills are just into the area of concern on the ASQ • Could be part of a picture of global delay • Fits with your observation of her never choosing fine motor activities • May be related to her short attention span

49. Problem Solving • The problem solving tasks on the ASQ rely quite heavily on language. Do you have any other indicators that problem solving and/or learning is a concern for Sierra?

50. Personal-Social On the ASQ, there was no indication of concern in this area. Do your observations lead you to any concerns?