Developmental Surveillance and Screening

1. Developmental Surveillance and Screening Paul H. Lipkin, MD D-PIP Training Workshop June 16, 2006 I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity.

2. Motor Gross motor Fine motor Adaptive Communication Speech Language Expressive Receptive Social pragmatics Social-emotional Blend of fine motor, adaptive, communication, cognition Cognition Language Visual-motor/ problem solving Domains of Development

3. Definitions: Developmental surveillance • “A flexible, longitudinal, continuous, and cumulative process whereby knowledgeable health care professionals identify children who may have developmental problems” (AAP 2006) • Longitudinal • Continuous • Cumulative

4. Definitions: Developmental screening • “The administration of a brief standardized tool aiding the identification of children at risk of a developmental disorder” (AAP 2006) • Brief • Standardized • Identification of risk • NOT DIAGNOSTIC

5. Developmental Surveillance Developmental Screening

6. Definitions: Developmental evaluation • “Aimed at identifying the specific developmental disorder or disorders affecting the child ” (AAP 2006) • Synonym: Developmental Assessment • Completed in children who do not pass developmental screening • Coupled with medical evaluation • Diagnostic

7. Developmental Surveillance and ScreeningAAP Policy Statement 2006 Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening

9. Developmental SurveillanceAAP 2006 Surveillance can be useful for determining appropriate referrals, providing patient education and family-centered care in support of healthy development, and monitoring the effects of developmental health promotion through early intervention and therapy

10. Components of Surveillance- IAAP 2006 • Eliciting and attending to the parents’ concerns about their child’s development • “Do you have any concerns about your child’s development? Behavior? Learning?” • Documenting and maintaining a developmental history • “What changes have you seen in your child’s development since our last visit?” • Age-specific queries, such as whether the child is walking or pointing

11. Components of Surveillance- IIAAP 2006 • Making accurate observationsof the child • A careful physical and developmental examination within the context of the preventive care visit • Observation of the parent-child interaction • Identifying risk and protective factors • Environmental, genetic, biologic,social, and demographic factors • Children with established risk factors may be referred directly for evaluation or more frequent developmental surveillance • Identify protective factors

12. Components of Surveillance- IIIAAP 2006 • Maintaining an accurate record of documenting the process and findings • Document all surveillance and screening activities during preventive care visits • Document specific actions taken or planned • Scheduling an earlier follow-up visit • Scheduling a visit to discuss developmental concerns more fully • Referrals to medical specialists or early childhood programs and specialists • “Developmental growth chart”

13. Developmental Screening • Cross sectional analysis • Tests administered to whole population to identify those not meeting standard expectations of development • Results of periodic screens must be interpreted within the context of the practitioner’s knowledge of environment, social, biological and historical risks to the individual child

14. Developmental ScreeningAAP 2006 • All children, most of whom will not have identifiable risks or whose development appears to be proceeding typically, should receive periodic developmental screening using a standardized test

15. Developmental ScreeningAAP 2006 • In the absence of established risk factors or parental or provider concerns: • 9 months • 18 months • 30-months*

16. Developmental Screening: The Asterisk * AAP 2006 • Because the 30-month visit is not yet a part of the preventive care system and is often not reimbursable by third-party payers at this time, developmental screening can be performed at 24 months of age • In addition, because the frequency of regular pediatric visits decreases after 24 months of age, a pediatrician who expects that his or her patients will have difficulty attending a 30-month visit should conduct screening during the 24-month visit.

17. Choosing an test:Key screening instrument qualities • Reliability: The ability of a measure to produce consistent results • Validity: The ability to discriminate between a child at a determined level of risk for delay from the rest of the population • Sensitivity: The accuracy of the test in identifying delayed development • Specificity: The accuracy of the test in identifying individuals who are not delayed If a test incorrectly identifies a child as delayed, this practice will result in over-referrals If a test incorrectly identifies a child as normal, this practice results in under-referrals

18. Developmental Screening Instruments: General • Ages and Stages Questionnaire • Battelle Developmental Inventory (BDI) Screening Test • Bayley Infant Neurodevelopmental Screener (BINS) • Brigance Screens-II • Infant Development Inventory • Child Development Review • Child Development Inventory (CDI) • Denver-II Developmental Screening Test • Parents' Evaluation of Developmental Status (PEDS)

19. Developmental Screening Instruments: Domain-specific • Gross motor • Early Motor Pattern Profile (EMPP) • Motor Quotient (MQ) • Communication/Cognition • Capute Scales (aka Cognitive Adaptive Test/Clinical Linguistic Auditory Milestone Scale-CAT/CLAMS) • Communication and Symbolic Behavior Scales- Developmental Profile (CSBS-DP): Infant Toddler Checklist • Early Language Milestone Scale (ELMS -2)

20. Developmental Screening Instruments: Disorder-specific • Autism and pervasive developmental disorders:Perform at 18 month visit • Autism Behavior Checklist (ABC) • Checklist for Autism in Toddlers (CHAT) • Modified Checklist for Autism in Toddlers (M-CHAT) • Modified Checklist for Autism in Toddlers-23 (CHAT-23) • Pervasive Developmental Disorders Screening Test-II (PDDST-II) - Stage 1-Primary Care Screener • Pervasive Developmental Disorders Screening Test-II (PDDST-II) - Stage 2-Developmental Clinic Screener • Screening Tool for Autism in Two-Year-Olds (STAT) • Social Communication Questionnaire (SCQ) (formerly Autism Screening Questionnaire-ASQ)

21. Developmental Screening Principles (AAP 2006) • When the results are normal: • Inform the parents and continue with other aspects of the preventive visit • Provide an opportunity to focus on developmental promotion • When administered due to concerns: • Schedule early return visit for additional surveillance, even if the screening tool results do not indicate a risk of delay • When results are concerning: • Schedule developmental evaluations • Schedule medical evaluations

22. Surveillance and Screening Guidelines: AAP 2006 … the bottom line…

23. Surveillance and Screening Guidelines: AAP 2006 • Perform developmental surveillance at every well-child visit • Perform developmental screening using a standardized screening tool at 9, 18, and 30* months or when concern is expressed • If screening results are concerning, refer to developmental and medical evaluations and early intervention services • Follow up on referrals made and continually track child’s developmental status