1. Developmental Screening: Putting It In Practice
William Lewis MD, FAAFP
Jane Holt DO
Cheryl Shaw DO
West Virginia University School of Medicine - Eastern Division
Harpers Ferry Family Medicine

2. Harpers Ferry Family Medicine
Founded in 1982 as NHSC site
Site for Tri-State Children’s Health Improvement Consortium
Multi-specialty group with 14 providers plus residents
36,000 visits annually
12,000 pediatric visits (60% seen by family med)

3. WVU Rural Family Medicine Residency
First resident started in 1996
44 graduates
5-5-5 residency
75% of graduates for past five years practice in West Virginia

4. Background United States Preventive Task Force
Insufficient or inconsistent evidence to recommend for or against use of brief, formal screening instruments in primary care to detect speech and language delay in children up to 5 years of age
AAFP agrees with USPSTF
AAP has their own recommendations

5. Background Individuals with Disabilities Education Act
Mandates the early identification of and intervention for developmental disabilities through development of community based systems
All states receive federal funding for early intervention programs
Jfponline IDEA mandates the early identification of and intervention for developmental disabilities through the development of community based systems
This law
requires physicians to refer children with
suspected developmental delays to appropriate
early intervention services in a
timely manner. All states receive federal
funding to provide appropriate intervention
through infant and child-find programs
for children with developmental
delays.

6. Early Intervention
Evidence behind early intervention, though limited, shows long term improvement in outcomes
Early Intervention has been shown to
Improve IQ
Higher academic achievement
Increased adult employment
Decreased criminality

7. A Common Problem
Twelve to 16% of children in the United States have at least 1 delay
Half of these children will not be detected by the time they enter kindergarten
AAFP SFDD
½ not detected despite the fact that most will display mild developmental delays by 2 years of age (aafp)

8. Morbidity Developmental delays are associated with
Poorer overall health status
Higher rates of school failure
Increased in-grade retention
Increased special education placement

9. Screening Screening tools are reasonably accurate
Less than 25% of primary care physicians use a standardized screening tool
82% of PCPs cite time constraints as the most prominent barrier

10. Screening Milestone checklists and clinical judgment are not enough
Less than 30% identified by clinician judgment
Surveillance methods such as checklists and clinical observation have poor sensitivity (AAFP)

11. Recommendations Physician surveillance at all well child visits
Identification of children at risk
Use of validated screening tools at regular, repeated intervals and when delay suspected
Parent-completed tools rather than directly administered tools
AAFP SFDD

12. Recommendations
Prompt referral for comprehensive developmental assessment
Prompt referral to early intervention services

13. Screening Instruments
Directly Administered
Combination of parent report and direct observation
Provides in-depth information
Requires time to complete
Most useful as second stage screening tool
Examples
Denver Developmental Screening Test II
Child Development Inventory

14. Screening Instruments
Parent Completed
Parent report alone
Time efficient
Completed in waiting room or at home
Valid
Similar sensitivity and specificity to directly administered
Less expensive
Meet elements of the Patient Centered Medical Home
Examples
Ages and Stages Questionnaire (ASQ)
Parents’ Evaluation of Development Status (PEDS)
Valid, with sensitivity and specificity similar to those of directly administered tools (AAFP)
Practical and time efficient
Less expensive for both positive and negative screening results ($12 (negative)-16(positive))
Medical home elements-1) Engage parents as active participants in their child’s health
2) Facilitate the parent-child-physician relationship

15. Parents’ Evaluation of Development Status Child Development
Ages and Stages
Parents’ Evaluation of Development Status
Child Development
Inventories
Denver II
Cost
$199, CD unlimited downloads
$60/100 survey forms and score sheets then $0.30/survey
$72/25 forms to start, then $1/screen
$114/100 forms and 1 kit
Time: Parent Completion
10-20 minutes
5 minutes
30 minutes
Time: Provider Score and Interpret
1-5 minutes
2 minutes
10 minutes
20 minutes
Sensitivity
72%
74-79%
80%
56-83%
Specificity
86%
70-80%
96%
43-80%
Estimated Administrative Cost Per Visit
$13-17
$12-16 NR
$56-60
Talk about acceptable sensivity and specificity (70-80% sensitivity and approximately 80% specificity)-AAFP
Sensitivity being children who truly have delays that are identified as delayed by the tool and specificity is the percentage of kids without delays who were appropriately identified as not having a delay (the more specific a test, the fewer overreferrals)
Because no tool is great at identifying kids with and without delay, about 1 in 3 referred children actually have a delay
Point out the similar sensitivity and specificity of parent completed and directly administered tools

16. What barriers do you see to screening?

17. What were we doing? We had inconsistent screening
I’ll know if there is a problem with the kid
The screen that came in the EMR
Full Denver Developmental Screening
We had unclear plan for problems
Who gets referred
We did know who we would refer to

18. What did we want? Consistent screening
Clear decision on who needed referral

19. What did we want to avoid?
Increasing physician time
Increased costs
Decreasing patient satsifaction

20. ASQ Uniform screening Parent engaged Limited physician time Cost
Pro’s
Con’s
Uniform screening
Parent engaged
Limited physician time
Both training and during exam
Cost
Used by local birth to three program
Increased staff time

21. Implementation Identify Champions Not physicians
Work at key points of process
Nursing director
Pediatric Care Coordinator

22. Implementation Screen all children at 9,18 & 24 month well visits
1 week prior to visit ASQ mailed to up coming well visit
Day of visit
Well visit are identified in huddle
Front desk gives ASQ to parents who forgot form
Parents of toddlers never do this
Parent fills out prior to visit

23. Implementation Nursing staff scores the form
Physician then conducts visit and makes recommendation
Normal ASQ – regular well visit
Borderline ASQ – repeat ASQ in two months
Abnormal ASQ – refer
Pediatric care coordinator collects all ASQs and tacks follow up

24. The research Objective
To assess parent and providers views on the impact of implementing ASQ screening in a family medicine office.

25. Methods
IRB approval ✔
Thank you Eastern panhandle developmental screening champion !

26. Methods ASQ’s were distributed Convenience survey Groups
In mail prior to their 9,18,24 month visits.
Or given at office if parents left form at home
Convenience survey
Parents with children ages 5-24 months at well child check
July and August at Harpers Ferry Family Medicine.
Groups
those who completed an ASQ and those who did not as control.
those who saw a Pediatrician, Family Medicine Attending, or resident.
The survey assessed for parents views on
usefulness of ASQ
time to complete form or perform ASQ
concern about child’s development
how informed parents feel about their child’s development.

27. Methods Cont. Physicians at Harpers Ferry Family Medicine
survey was distributed by
Returned to anonymous mailbox
Survey assessed
preferred method of development screening
usefulness of ASQ
time to complete well child visit
if the plan of action changed due to ASQ use.
Survey questions were likert scale, yes/no and fill in for time taken to complete.

28. Results
85 parent surveys were returned out of ___ visits with ASQ’s over 2 month period
15 of 30 physician surveys were obtained over the 2 month period.

29. Results Parental Data
No significant difference in how informed parents felt about their childs development p = 0.07

30. Results Parental Data (cont.)
No significant difference in parents concern for childs development. P = 0.27
All parents felt as though their child had been developmentally screened during their visit
All 85 parents answered yes to if their child had been developmentally screened at that days visit.

31. Results Parental Data (cont.)
usefulness of survey
40.5 percent felt the ASQ was useful

32. Results Physician Data (cont.)
No significant difference in time to complete their exam compared to their screening t test p = 0.39.
Average time to complete the exam with asq was 28 min.
with preferred method of screening 30 minutes.

33. Results Physicians (cont.)
Significant difference in providers for well child visits between 5-24 months between pediatrician vs. attending vs. resident vs. physician assistant
With pediatricians seeing 70.5 % of patients.
A chi square p = E-14.

34. Questions?

35. References
Council on Children with Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee and Medical Home Initiatives for Children With Special Needs Project Advisory Committee (2006). Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening. Pediatrics 2006; 118;405.

36. References
Hamilton S. Screening for Developmental Delay: Reliable, Easy-To-Use tools. J Family Practice. 2006; 55(5):
Mackrides P, Ryherd S. Screening for Developmental Delay. American Family Physician. 2011;84(5):

37. Nutting P. , Miller, W. , Crabtree, B. , Jaen, C. , Stewart, E
Nutting P., Miller, W., Crabtree, B., Jaen, C., Stewart, E., Stange, K. (2009). Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Annals of Family Medicine Vol 7, No. 3, May/June 2009