1. Developmental Screening Tools Michelle M. Macias, 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. Learning Objectives u Understand properties of good screening tools u Review the screening tool grid

3. What is screening? u Use of a brief, objective, and validated instrument u Goal to help differentiate children that are “probably ok” vs. those “needing additional investigation”- those with unsuspected deviations from normal u Performed at a set point in time –9, 18,(24), 30 months u Objective vs. subjective impressions u Results always interpreted in context –Never in isolation –Aid to ongoing surveillance

4. Why Screen? u Most obvious problems are the least prevalent u “New morbidities” u Cannot rely solely on clinical judgment for identification of developmental problems

5. WHY SCREEN? CLEARLY NORMAL CLEARLY ABNORMAL ?

6. Benefits of Screening Assists in sorting children into 3 categories: u Needs additional evaluation - Did not pass screen u Needs close monitoring/surveillance- Passed screen but has risk factors u Needs ongoing monitoring in the context of well-child care - Passed screen and has no known risk factors

7. Screening Challenges u Use of informal checklists of developmental skills –Lack proof that they predict developmental status –Lack criteria to indicate when a referral is indicated u Informally eliciting parents’ concerns (Are you worried about your child’s development?) –Parents often not sure if they are worried –The word “development” is understood by only ~50% of parents u Accuracy of clinical judgment –detects fewer than 30% of children who have developmental disabilities

8. Developmental Screening Tools u Developmental screening tools are used to enhance the surveillance process and increase detection rates –Parent-completed questionnaires –Directly administered instruments

9. Standards for Screening Tests u Standardized on national sample u Proof of reliability –ability of a measure to produce consistent results u Evidence of validity –ability of a measure to discriminate between a child at a determined level of risk for delay (i.e. high, moderate) from the rest of the population (low risk)

10. Standards for Screening Tests u Accuracy in ability to categorize is measured by: –Sensitivity: accuracy of the test in identifying delayed development –Specificity: accuracy of the test in identifying individuals who are not delayed For developmental screening tests, Sensitivity and Specificity of 70-80% are acceptable

11. High Sensitivity Trade-off Abnormal test result Normal test result Cutoff false positives

12. High Specificity Trade-off Abnormal test result Normal test result cutoff false negatives

13. Denver-II PASS 86 FAIL 27 698 Specificity = 69/86 = 80% 17 10 86 18 Developmental Diagnosis NO YES Sensitivity = 10/18 = 56% Standards for Screening Tests Accuracy of the Denver-II

14. Screening Pitfalls u Relying on informal methods –Checklists! –provide no validated criteria for referral –have unknown reliability u Using a measure not suitable for primary care (i.e. too long) –results in two things F using tests only with selected patients, usually those with observable problems F nonstandard administrations

15. Screening Pitfalls: The Damage u Relying on informal methods –ignores the asymptomatic who are those most in need of screening u Using a measure too time consuming for primary care –reduces screens to the status of checklists with their inherent lack of criteria and unproven sensitivity and specificity

16. Let’s Review the Developmental Screening Tools Grid!

17. Developmental Screening Tools Grid: Components u Organized from general screening tools to domain/disorder specific screening tools –General Screens –Language and cognitive screens –Motor screens –Autism screens u Information provided –Description –Age Range –Number of Items –Administration Time –Psychometric Properties –Scoring Method –Languages available –How to obtain –Key references

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

19. u Gross motor –Early Motor Pattern Profile (EMPP) –Motor Quotient (MQ) u 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) Developmental Screening Instruments: Domain-specific

20. Autism and pervasive developmental disorders –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) Developmental Screening Instruments: Disorder-specific

21. Examples: Parent Report Screens u Ages and Stages Questionnaire (ASQ) 4 months to 6 years u Parents’ Evaluation of Developmental Status (PEDS) 0 to 8 years

22.  Screens using parent report are as accurate as those using other measurement methods  Tests correct for the tendency of some parents to over-report  Tests correct for the tendency of some parents to under-report Can parents be counted upon to give accurate and good quality information? YES!

23. Can parents read well enough to fill out screens? Usually! But first ask, “Would you like to complete this on your own or have someone go through it with you?” Also, double check screens for completion and contradictions

25. Ages and Stages Questionnaire (ASQ) 4 months to 6 years 19 color-coded questionnaire for use at 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, 24, 27, 30, 33, 36, 42, 48, 54, and 60 months 19 color-coded questionnaire for use at 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, 24, 27, 30, 33, 36, 42, 48, 54, and 60 months 30 – 35 items per form describing skills 30 – 35 items per form describing skills Completed by parent report Completed by parent report Taps most domains of development Taps most domains of development Takes about 10-15 minutes, and 3 to score Takes about 10-15 minutes, and 3 to score ASQ-Social-Emotional works similarly and measures behavior, temperament, etc. ASQ-Social-Emotional works similarly and measures behavior, temperament, etc. Can be photocopied Can be photocopied

26. ASQ Sample Items 1. When your child wants something, does she tell you by pointing to it? Yes Sometimes Not Yet    4. Does your child say eight or more words in addition to “Mama” and “Dada”? Yes Sometimes Not Yet   

27. ASQ Scoring  Assign a value of 10 to yes, 5 to sometimes, 0 to never  Add up the item scores for each area, and record these totals in the space provided for area totals  Indicate the child’s total score for each area by filling in the appropriate circle on the chart below  Scores in shaded areas prompt a referral Communication Gross Motor Fine Motor Problem solving Personal-social

28. PARENTS’ EVALUATION OF DEVELOPMENTAL STATUS For children 0 to 8 years In English, Spanish, Vietnamese, Somali, Chinese Takes 2 minutes to score Elicits parents’ concerns Sorts children into high, moderate or low risk for developmental and behavioral problems 4 th – 5 th grade reading level Score/Interpretation form printed front and back and used longitudinally

31. Two Directly Administered Screening Tools u Bayley Infant Neurodevelopmental Screener (BINS) u Brigance Screens-II

32. Bayley Infant Neurodevelopmental Screener (BINS) u Takes 10 - 15 minutes u Assesses neurological processes (reflexes, and tone); neurodevelopmental skills (movement, and symmetry) and developmental accomplishments (object permanence, imitation, and language) u Uses 10 - 13 directly elicited items per 3 - 6 month age range u Categorizes performance into low, moderate or high risk via cut scores. Provides subtest cut scores for each domain u For use from 3 - 24 months

34. BINS Risk Scores

35. Brigance Screens u Takes 10 – 15 minutes of professional time u Produces a range of scores across developmental domains u Relies primarily on observation and elicitation of skills (0-2 year age range can be administered by parent report) u Detects children who are delayed as well as advanced u 9 separate forms across 0 – 7 years of age u Each produces 100 points and is compared to an overall cutoff u Available in multiple languages u Computer scoring software

36. How to Explain Screening Test Results u Use language that encourages follow-up u Avoid negative and meaningless words u Be sensitive to cultural meanings of words

37. Developmental Screening Principles (AAP 2006) u 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 u 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 u When results are concerning: –Schedule developmental evaluations –Schedule medical evaluations

38. Developmental Screening: Recommendations u Infants and young children should be screened for developmental delays using reliable and valid screening techniques at 9,18,(24), 30 months u Use of standardized developmental screening tools at periodic intervals will increase accuracy u Use parent-report questionnaires or directly administered tools with sensitivity and specificity of at least 70-80%