Developmental Screening Tools

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

• Understand properties of good screening tools
• Review the screening tool grid

3
What is screening?

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

4
Why Screen?

• Most obvious problems are the least prevalent
• New morbidities
• 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
• Needs additional evaluation - Did not pass screen
• Needs close monitoring/surveillance- Passed
  screen but has risk factors
• Needs ongoing monitoring in the context of
  well-child care - Passed screen and has no known
  risk factors

7
Screening Challenges

• Use of informal checklists of developmental
  skills
• Lack proof that they predict developmental status
• Lack criteria to indicate when a referral is
  indicated
• Informally eliciting parents concerns (Are you
  worried about your childs development?)
• Parents often not sure if they are worried
• The word development is understood by only 50
  of parents
• Accuracy of clinical judgment
• detects fewer than 30 of children who have
  developmental disabilities

8
Developmental Screening Tools

• 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

• Standardized on national sample
• Proof of reliability
• ability of a measure to produce consistent
  results
• 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

• 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
false positives
Normal test result
Cutoff
12
High Specificity Trade-off
Abnormal test result
cutoff
false negatives
Normal test result
13
Standards for Screening TestsAccuracy of the
Denver-II
Developmental Diagnosis NO
YES
PASS 86
69 8
Denver-II
FAIL 27
17 10
86 18
Sensitivity 10/18 56
Specificity 69/86 80
14
Screening Pitfalls

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

15
Screening PitfallsThe Damage

• Relying on informal methods
• ignores the asymptomatic who are those most in
  need of screening
• 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
Lets Review the Developmental Screening Tools
Grid!
17
Developmental Screening Tools Grid Components

• Organized from general screening tools to
  domain/disorder specific screening tools
• General Screens
• Language and cognitive screens
• Motor screens
• Autism screens

• 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

• 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
• 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
Examples Parent Report Screens

• Ages and Stages Questionnaire (ASQ) 4 months to 6
  years
• Parents Evaluation of Developmental Status
  (PEDS) 0 to 8 years

22
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

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

24
(No Transcript)
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
• 30 35 items per form describing skills
• Completed by parent report
• Taps most domains of development
• Takes about 10-15 minutes, and 3 to score
• ASQ-Social-Emotional works similarly and measures
  behavior, temperament, etc.
• 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 childs 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
PEDS

• 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
• 4th 5th grade reading level
• Score/Interpretation form printed front and
  back
• and used longitudinally

29
(No Transcript)
30
(No Transcript)
31
Two Directly Administered Screening Tools

• Bayley Infant Neurodevelopmental Screener (BINS)
• Brigance Screens-II

32
Bayley Infant Neurodevelopmental Screener (BINS)

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

33
(No Transcript)
34
BINS Risk Scores
35
Brigance Screens

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

36
How to Explain Screening Test Results

• Use language that encourages follow-up
• Avoid negative and meaningless words
• Be sensitive to cultural meanings of words

37
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

38
Developmental Screening Recommendations

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

39
(No Transcript)