Improving Preschool Developmental Screening and Follow-Up Services

1. Innovative Approaches to Preschool Developmental and Behavioral Screening and Follow-up ServicesFrances Page GlascoeProfessor of PediatricsVanderbilt University

2. Disclosures • Dr. Glascoe is the author of several developmental-behavioral screens may receive royalties on those not in the public domain • She assures you that this is not a get rich quick scheme! • She is from the United States and may have vocabulary lapses!

3. Outline • Why early intervention is vital • Why we have such trouble finding kids with delays • Why it is important for non-medical providers to understand the challenges of early detection in health care settings • How we need to work together

4. Early Intervention Benefits: Rationale For Screening Family interest in participation Better outcomes for participants: Higher graduation rates, reduced teen pregnancy, higher employment rates, decreased criminality and violent crime $30,000 to >$100,000 benefit to society (1992 $$s) For every 1$ spent on EI, society saves 17$

5. Early Detection Problems!! 16% - 18% of children have developmental-behavioral difficulties and need special servicespossibly 13% by age 2!only about 30% are detected by their health care provider before school entranceonly 2% - 3% are enrolled in early interventionEnrollment rates should be closer to 8% in the 0 - 2 age range

6. Why is it so hard to detect children with problems? 8 major challenges

7. Challenge #1: CLINICAL JUDGMENT Why Are Detection Rates So Low?

12. Challenge #2: MILESTONES CHECKLISTS Why Are Detection Rates So Low?

13. Sample Checklist Uses hungry, tired, thirsty Climbs stairs without holding on Stacks 12 blocks Knows colors Dresses self completely Plays games with rules

14. Quality Measures Define Scoring Criteria For example, “Knows Colors”-- What exactly does this mean? Match? Points to when named? Names when pointed to? How many colors?

15. Quality Measures Select Items that Best Predict Actual Developmental Status X O C A Z B T K

16. Challenge #3: DEVELOPMENT ITSELF: Development Develops. Developmental Problems Do Too! Why Are Detection Rates So Low?

18. Quotients Developmental Status by parent's verbal behavior and positive perceptions(Leew & Glascoe, in press) Age in Months * Talks at meals, helps child learn new things, reads aloud, able to soothe, enjoys child, perceives child as interested in conversing 6 - 11

19. Effects of Psychosocial Risk Factors on Intelligence Percentiles 84th 75th 50th IQ 25th 16th RISKS: < HS, > 3 children, stressful events, single parent, parental mental health problems, < responsive parenting, poverty, minority status, limited social support

20. Parents often need training, and social services. Children need enrichment tutoring, mentoring, mental health, etc. Parents often need advice about behavior TYPICAL DEVELOPMENT minimal psychosocial risk factors BELOW AVERAGE DEVELOPMENT frequent psychosocial risk factors Children need special education, speech-therapy, etc. DISABLED some psychosocial risk factors and/or organicity

23. Challenge #4: DEALING WITH THE RESULTS OF A SCREENING TEST Why Are Detection Rates So Low?

24. 50% - 80% of children who fail screens are not referred (Rushton et al, APAM, 2002) > 80% of referrals from primary care providers made only to familiar services (Glade, Forrest et al Amb Peds, 2002) Nonmedical providers may not respond like the ideal subspecialist (Forrest et al APAM, 1999) REFERRAL CHALLENGES

25. Challenge #5: Providers Don't Get Much Feedback Why Are Detection Rates So Low?

26. What’s your referral rate? 1 out of 400 1 out of 200 1 out of 100 1 out of 25 1 out of 10 1 out of 6

27. PREVALENCE BY AGE 8 % of 0 - 2 year olds 10% of 0 - 3 year olds 12% of 0 - 4 year olds 16%+ of 0 - 8 year olds

28. Challenge #6: FAILURE TO USE A HIGH QUALITY SCREENING TEST Why Are Detection Rates So Low?

29. Standards for screening tests Standardized on a national samploe Proof of reliability Evidence of validity Accuracy, i.e.: Sensitivity of 70% to 80% Specificity of 70% to 80%

30. Standards for screening tests Accuracy of the Denver-II Developmental DX NO YES PASS 77 69 8 Denver-II FAIL 27 17 10 86 18 Sensitivity = 10/18 = 56% Specificity = 69/86 = 80%

31. Screening is a BRIEF process that sorts those who probably have problems from those who probably don’tScreening is for the asymptomatic

32. Challenge #7: COMMUNICATING WITH FAMILIES Why Are Detection Rates So Low?

33. “Your teacher wishes me to delineate those watershed occasions in your life that have led you to become, slowly and inexorably,a loose cannon.”

35. Sample questions to parents that don’t work well Do you think he has any problems…..? Do you have any worries about her development?

36. Challenge #8: IMPLEMENTATION! Why Are Detection Rates So Low?

37. Reasons for limited use of screening tests at well visits: COMMON YET SURMOUNTABLE MYTHS Common screening tests too long Tests difficult to administer Children uncooperative Reimbursement and time limited Challenges of giving difficult news Staff reluctant to take on new tasks Referral resources unfamiliar or seemly unavailable

38. “Looking Good”

39. So what should we do? Use newer, brief, accurate tools Make use of information from parents

40. Screens using parent report are as accurate as those using other measurement methods Parents of all socioeconomic backgrounds and education are equally accurate Can parents be counted upon to give accurate and good quality information? YES!

41. 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

42. Detection rates WITH Screening Tests 70% to 80% of children with developmental disabilities correctly identified Squiresetal, JDBP. 1996;17:420 - 427 80% to 90% of children with mental health problemscorrectlyidentified Sturner, JDBP .1991; 12: 51-64 Most over-referrals on standardized screens are children with below average development and psychosocial risk factors Glascoe, APAM. 2001;155:54-59. -

43. Detection/Enrollment Successes WITH Screening Tests 70% increased in ASD dx in ages 0 - 3 Minnesota Dept of Education, Pediatrics, 2004 244% increase in referrals to EI Pediatrics, 2007 40% increase in referrals to behavioral specialists Pediatrics, 2008 -

44. But…. are we identifying kids who aren’t eligible for services?

46. Enrollment Rates in Early Intervention in States Requiring Use of Quality Screens: National Average: 2.53% in the 0 – 2 year age range Broad Eligibility Criteria Hawaii: 6.9% Moderate Eligibility Criteria: Rhode Island: 4.61% Narrow Eligibility Criteria: Connecticut: 3.35% *Source: https://www.ideadata.org/

47. Enrollment Rates in Early Intervention in States NOT Requiring Use of Quality Screens* Broad Eligibility Criteria: Florida: 1.7% Moderate Eligibility Criteria: Alaska: 2.0% Narrow Eligibility Criteria: Washington, DC: 1.2% *Source: https://www.ideadata.org/

48. Three Examples of Brief Quality Screens

49. Providers Have Preferences for Measurement Methods Comfortable with parents' concerns? Prefer parent report of children's skills? Wish to elicit skills directly from children?

50. Ages & Stages Questionnaire-3: Screening by Parental Report of Children's Skills