Surveillance and Screening

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Surveillance and Screening

• Partnerships and Advocacy
• Integrated Services in the Early Years

Jill Houbé, MD, MPhil, FAAP, FRCP(C)
2
Surveillance and Screening

• Current child health status
• Definition of terms
• Tools and experience
• Partnerships and advocacy

3
BC Child Health Status

• Outcome measures
• Process measures
• Social determinants

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Healthy Child Development

• Domains directly related to adult well-being
• Socio-emotional
• Language/cognitive
• Physical health

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Early Development Instrument (EDI)

• Kindergarten year
• 5 scales
• Vulnerable if below BC cut-offs 10

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BC EDI Results

• No neighbourhood is immune
• Vulnerability ranges from 13.4 to 39.6

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Corrected EverRiskMap
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Why Does Early Identification Matter?

• Documentation of benefits
• for physical handicaps, mental retardation
• improved family functioning
• for environmental risk (e.g., Head Start)
• decreased likelihood of grade repetition
• less need for special education services
• fewer dropping out of school
• Clearer delineation of adverse influences
• low-level lead exposure
• adverse parent-infant interaction

9
Why Does Early Identification Matter?

• Legal Mandate
• Canadian Charter of Rights and Freedoms (1985)
• Section 7 Legal rights
• Section 15 Equality Rights
• BC Human Rights Code (1996)
• BC School Act (revised 1989)
• Guralnick 1987

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Child Health Status

• 16 of children have disabilities
• 20 30 detected before school entrance
• There are known risk factors for delay and
  disability

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NORMAL
Guidance
BELOW AVERAGE

• Parenting
• Mental health
• Enrichment

DISABLED

• Therapy
• Special Ed

Glascoe, 1997
12
Effects of Psychosocial Risk Factors on
Intelligence
Percentiles 84th 75th
50th
IQ
25th
16th
Risk Factors Poor health status, gt 3 children,
stressful events, single parent, parental
mental health problems, less responsive
parenting, poverty, minority status, limited
social support
Glascoe, 1997
13
Surveillance and Screening

• Current child health status
• Definition of terms
• Tools and experience
• Partnerships and advocacy

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Surveillance and Screening

• Hand in Hand

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Developmental Surveillance

• flexible, continuous process in which
• knowledgeable professionals perform skilled
• observations of children ...

With proper techniques, surveillance is
family-focused, accurate, efficient,
Dworkin, 2004
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Developmental Surveillance

• Eliciting/attending to parents concerns
• Obtaining a relevant developmental history
• Skillfully observing childrens development
• Sharing opinions with other professionals

Dworkin, 2004
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Developmental Surveillance

• Childrens developmental competencies are best
  determined over time
• spurts and pauses
• variable rate across domains
• longitudinal aspect of health supervision

Dworkin, 2004
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Attending to Parents Concerns

• There is a strong relationship between parents
  concerns and childs developmental status
• Parents have high levels of sensitivity for
  problems regarding fine motor, language,
  cognitive and school skills
• Parental concerns about gross motor, hearing and
  medical status are highly related to
  developmental problems

Dworkin, 2001
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DEVELOPMENTAL SURVEILLANCEParents Appraisals

• In 87 of children with ADHD, parents have
  concerns related to impulsiveness, inattention or
  over activity
• Absence of parental concerns or concerns in other
  areas (self-help or socialization) correlates
  with children without developmental disorders

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DEVELOPMENTAL SURVEILLANCEElicit Parents
Opinions and Concerns

• Information available from parents
• Appraisals (opinions of childrens development)
• concerns
• estimations
• predictions
• Descriptions
• recall
• report

Dworkin, 2004
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DEVELOPMENTAL SURVEILLANCEParents Appraisals

• Concerns
• accurate indicators of true problems
• speech and language
• fine motor
• general functioning (hes just slow)
• self-help skills, behavior less sensitive
• Please tell me any concerns about the way your
  child is behaving, learning, and developing
• Any concerns about how she

Dworkin, 2004
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DEVELOPMENTAL SURVEILLANCEParents Appraisals

• Estimations
• Compared with other children, how old would you
  say your child now acts?
• correlate well with developmental quotients
• cognitive, motor, self-help, academic skills
• less accurate for language abilities
• Predictions
• likely to overestimate future function
• if delayed, predict average functioning
• if average, presidential syndrome

Dworkin, 2004
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DEVELOPMENTAL SURVEILLANCEParents Descriptions

• Recall of developmental milestones
• notoriously unreliable
• reflect prior conceptions of childrens
  development
• accuracy improved by records, diaries
• even if accurate, age of achievement of limited
  predictive value

Dworkin, 2004
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DEVELOPMENTAL SURVEILLANCEParents Descriptions

• Report
• accurate contemporaneous descriptions of current
  skills and achievements
• importance of format of questions
• recognition Does your child use any of the
  following words
• identification What words does your child
  say?
• produces higher estimates than assessment
• child within a familiar environment
• skills inconsistently demonstrated

Dworkin, 2004
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Developmental Surveillance Eliciting Parents
Opinions and Concerns
Caveat Detection without referral/intervention
is ineffective and may be judged unethical
Dworkin, 2004
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Developmental Surveillance

• An appropriate response to parents behavioral
  concerns is to seek additional information about
  childrens development
• important indicators of childrens status
• need for cautious interpretation

Dworkin, 2004
27
Developmental Surveillance

• Opinions of other professionals offer valuable
  information regarding children's developmental
  functioning
• input from preschool teachers, child care
  providers, visiting nurses
• preschool teachers predictions of school
  readiness, kindergarten success

Dworkin, 2004
28
Screening

• Identify the likelihood of a disability
• Do not provide a diagnosis
• Can help identify a range of possible diagnoses
  that help focus referrals

Prieto 2004
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Screening

• Brief
• Standardized administration
• Proven valid reliable
• For the asymptomatic

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Detection rates No risk factors and no screening

• 30 of developmental disabilities
• 20 of mental health problems

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Detection rates No risk factors and screening

• 7080 dev disabilities
• 8090 mental health problems
• Over referrals related to psychosocial risk

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Surveillance and Screening

• Current child health status
• Definition of terms
• Tools and experience
• Partnerships and advocacy

33
PDQ Denver-II Early Screening Profile DIAL-III Ear
ly Screening Inventory ELM Gesell
Due to absence of validation, poor validation,
norming on referred samples, and/or poor
sensitivity/specificity
Glascoe, 1997
34
Six Quality Tests

• Parents Evaluation of Developmental Status
  (PEDS) (0 through 8 years)
• Child Development Inventories (CDIs) (0
  to 6 years)
• Ages and Stages (0 to 6 years)
• Pediatric Symptom Checklist (PSC) (4
  through 18 years)
• Brigance Screens (0 to 8 years)
• Safety Word Inventory and Literacy Screener
  (SWILS ) (6 14 years

Glascoe, 1997
35
Screen Selection Flow Chart
Age Range 04 yrs 46 yrs 68 yrs
818 yrs
PEDS or Brigance or SWILS ( PSC)
SWILS and/or PSC
PEDS or CDIs or ASQ or Brigance
PEDS or CDIs or ASQ or Brigance ( PSC)
Glascoe, 1997
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Behavioral/Emotional Screening

• Pediatric Symptom Checklist (PSC)
• Eyberg Child Behavior Inventory
• Family Psychosocial Screening

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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

Glascoe, 1997
38
Can parents be counted upon to give accurate and
good quality information?
YES!

• 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.

Glascoe, 1997
39
When Should You Ask for Further Evaluation?

• Sudden Unexpected Change
• In Developmental Trajectory
• Unexplained regression
• Sudden change in personality
• Change in mood or emotional well-being
• May be due to disease or illness
• May reflect important events occurring at home

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When Should You Ask for Further Evaluation?

• Global Developmental Delay
• Persistent significant delay in all domains that
  cannot be attributed to other known factors
• Delays in a sphere of development that
  adversely impact the childs functioning
• At home
• Daycare
• School
• Significant Emotional Concerns

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What Do You Ask For?

• Community health unit and GP
• Hearing screen
• Vision screen
• Speech and language evaluation
• Paediatrician referral
• Infant Development Program
• Child Development Centre
• Sunny Hill Health Centre
• BC Childrens Hospital Child Psychiatry
• School Principal and Individual Education Plan

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Sunny Hill Health Centre Outpatient Clinics

• School Consults SERT Team (Substance Exposure
  Resource Team)
• Brain Injury
• Craniofacial Clinic, Downtown Eastside Clinic
  SERT Team
• Visually Impaired Program
• Preschool and Developmental-Genetics Clinic
• Hearing Loss Team
• SERT Team
• Neuromotor/Spasticity/Feeding
• Provincial Autism Program

http//www.sunny-hill.bc.ca/sunnyhill/shhcc/defaul
t.asp
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Alan Cashmore Centre

• Child-Family Therapy Centre [phone]
• Under umbrella of services provided by Vancouver
  Coastal Health
• Parent Infant Program home based therapy for
  mother/family/infant having difficulties in the
  initial stage of their relationship (birth to 30
  months of age)
• Parent Child Therapy Program therapy services
  for families finding it challenging to care for
  their young child (21/2 to 7 years of age)
• Parent Child Day Program intensive services for
  families experiencing a significant social,
  emotional and/or behavioral difficulties in
  parenting their young child (2 ½ to 6 years)
• Childcare Centre Outreach program consultation
  and support to childcare staff in their own
  centres in managing children with social,
  emotional and/or behavioral challenges.

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Mental Health Services

• Alan Cashmore Centre Child-Family Therapy Centre
• [phone]
• BC Psychological Association - www.psychologists.b
  c.ca
• UBC Psychology Clinic - http//www.psych.ubc.ca/cl
  inic/
• SFU Psychology Clinic 604-291-4720
• New Westminster Counselling
• Tel [phone]
• Treatment is free and patients can self-refer

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Other Sources of Information

• MCFD website - http//www.mcf.gov.bc.ca/
• Redbook - http//www2.vpl.vancouver.bc.ca/dbs/redb
  ook/htmlpgs/home.html
• Community Brain Injury Program coordinated by
  Center for Abilities

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Psychiatry Clinics At BC Children's Hospital

• Psychiatry
• Mood Disorders Clinic
• Neuropsychiatry Clinic
• Attention Deficit Hyperactivity Disorder Clinic
• Infant Psychiatry
• Urgent Assessment

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Surveillance and Screening

• Current child health status
• Definition of terms
• Tools and experience
• Partnerships and advocacy

48
Who does what?

• Look where children are found
• Use a valid, reliable tool
• Talk to other people
• Document

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Current practices

• Local initiatives
• Targeted clinical risk
• Only 1 in 3 BC children with developmental
  disorder receive screening/ assessment/interventio
  n
• IDP/CDC

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Research and Experience

• CHILD
• Neonatal Follow-Up Program
• Early Hearing Program
• BC Healthy Child Development Alliance

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Advocacy

• Public awareness
• Training
• Policy
• Wait lists
• Database
• Public Health Act 2007?

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Acknowledgements

• Hillel Goelman and Clyde Hertzman CHILD and HELP
• BC Healthy Child Development Alliance
• Neonatal Follow-Up Program
• Dana Brynelsen and IDP
• Sunny Hill Foundation
• CFRI

jhoube_at_cw.bc.ca
53
References

• Glascoe, Peds In Rev 2000. Chis, Peds Rev 2000
• Glascoe, Peds 95, 97 Glascoe, Ped 91. Diamond ,
  J Div Early Childhood 87
• Glascoe, Clin Pediatr 91, 94
• Mulhern et al, Am J Dis Child. 93
• Glascoe FP, Am J Dis Child 89
• Perrin E. J Dev Behav Pediatr 1998 19 350-352
• Palfrey et al. J PEDS. 1994111651-655
• Lavigne et al. Pediatr. 199391649 655
• Sturner, JDBP . 1991 12 51-64
• Glascoe, APAM. 2001 15554-59
• http//cshcnleaders.ichp.edu/Presentations/screeni
  ng.htmPowerPoint20Presentations
• http//www.aap.org/catch/6
• www.dbpeds.org

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References

• American Academy Of Pediatrics. Committee on
  Children With Disabilities Developmental
  Surveillance and Screening of Infants and Young
  Children Pediatrics. 2001108192-196.
  http//www.aap.org/policy/re0062.html
• Dworkin PH. British and American Recommendations
  for Developmental Monitoring The Role of
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• Dworkin PH. Detection of behavioral,
  developmental, and psychosocial problems in
  pediatric primary care practice. Curr Opin
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• Dworkin PH. Detection of behavioral,
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  Pediatr. 1993 5 531-536.
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• Glascoe FP. Toward a Model for An Evidenced-Based
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• Meisels SJ, Provence S. Screening and Assessment.
  Guidelines for Identifying Young Disabled and
  Developmentally Vulnerable Children and Their
  Families. Washington, DC National Center for
  Clinical Infant Programs 1989

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References

• Dobos AE, Dworkin PH, Bernstein B
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• Dworkin PH, Glascoe FP Early detection of
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