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Title: Developmental Screening and Assessment: What Are We Thinking?


1
Developmental Screening and AssessmentWhat Are
We Thinking?
  • Glen P. Aylward, Ph.D., ABPP
  • Southern Illinois University
  • School of Medicine
  • Springfield, IL

2
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Q 1 Is there a Gold Standard in Developmental
Evaluation?
  • reference standard
  • Flynn effect (.3-.5 pt/year)
  • Bayley Scales (1969 1993 2006)
  • BSIDgtBSID II (MDI 12 pts lower, PDI 7 points)
  • BSID-II?BSID-III (mental 6 pts higher motor 8
    pts higher)
  • Mean 7 pt increase comparability is limited
  • Length/pragmatics

5
Q2 Is There Agreement as to What Qualifies as a
Developmental Delay?
  • precision issue
  • 20 delay ?
  • 2 standard deviations below the mean for a
    reference group?
  • Score compared to local norms?
  • A ratio/criterion measure?
  • Acceptance of psychometrically poor tests
  • Recommend SD cutoffs

6
Q3 Does Development (DQ) Intelligence (IQ)?
  • Neurologic?motor?sensorimotor? cognitive
  • Skill?function?integrated functional unit?
    intelligence
  • Complexity increases in concert with age
  • Skill, function potential
  • Different streams, different rates
  • Younger than age 2 simple cognitive
    functionsonly after discrete functions are
    combined do we predict later intelligence

7
Canalized Behavior
  • Species-specific, prewired, self-righting
  • Fixed behavior pattern
  • Not highly complex
  • More canalized, less affected by adverse
    circumstances
  • Less canalized, weaker self-righting, greater
    likelihood of disruption
  • Sensorimotor behaviors are strongly canalized
  • Impact on test results/prediction

8
Integrated Functions
  • Individual developmental skill/ability is not
    most important
  • Integration of abilities into functional units
    that control these abilities
  • Ability to integrate functions?information
    processing, memory, discrimination, attention
  • Musicians skills?section of orchestra
    function?integration of sections (conductor)?
    concert

9
IQ/DQ Ambiguity
  • BSID-III Cognitive Composite
  • Mullen Scales Early Learning Composite
  • SB-V NVIQ, VIQ, FSIQ
  • K-ABC/2 Mental Processing Composite Mental
    Processing Index
  • WPPSI-III FSIQ
  • MSCA General Cognitive Index (GCI)
  • DAS General Cognitive Ability (GCA)
  • Cattell IQ

10
Q4 Is a Ratio DQ useful?
  • Ratio DQ MA/CA x 100
  • Rate of development
  • Not comparable at different age levels b/c the
    standard deviation (variance) of the ratios does
    not remain constant
  • CIs vary tremendously
  • Interpretation is difficult
  • MA is totally dependent on test used
  • Similar issues with developmental age
  • Better to use 1.5, 2 SD lt average

11
Q5 Is Caretaker Report Sufficient for
Developmental Screening?
  • AAP (2006) policy statement regarding
    surveillance and screening
  • 1/3 of developmental screening instruments
    (excluding those targeting ASD) were parent
    completed
  • Earlier, parent report considered a Stage I or
    prescreening technique
  • Evolved to being considered comparable to
    hands-on screening
  • ? Evidence-based use

12
Caretaker Report
  • Little is known as to how parent completed
    questionnaires are affected by 1) child-related,
    or 2) environmental variables
  • Accuracy depends on developmental area assessed,
    population
  • ? Different tests for different populations
  • How questions are answered (y/n, Likert, etc.)
  • Considerations
  • -- Length, detail
  • -- Age range encompassed
  • -- Presence/absence of examples of behavior
  • -- Test behaviors or milestones

13
Caretaker Report
  • Diamond Squires (1993) current behaviors,
    recognition (vs recall), behaviors should occur
    frequently, parents need skills to be able to
    complete questionnaire
  • Screening risk status of infant most predictive
    of agreement lt 2-years at 2, race (marker of
    SES) predictive
  • Camp (2007) spectrum bias better/worse
    identification depends on base rates of problems
  • Items most predictive often are those with poorer
    agreement (puzzle board, stacks 6 cubes)

14
Q6 How Problematic Are Test Refusals?
  • Behaviors have an impact frequently negative
  • More pronounced with younger children
  • Possibilities a) Declines to respond to any
    item b) specific types of items, or c) stops
    when items become too difficult
  • Occasional refusals41 of young children
  • State of arousal, affect, motivation,
    temperament, physiological issues
  • Score refusals as failures, prorate scores, or
    consider testing to be invalid?

15
Test Refusals
  • Potential causes
  • --Reaction to poor underlying skills/attempt to
    avoid failure
  • --Oppositional behavior
  • --Shyness, anxiety
  • --Temperament
  • --Poor attentional skills/high activity level
  • --Fatigue/malaise
  • --Temper displays/crying
  • --Parental behaviors

16
Test Refusals
  • Verbal production tasks, gross motor activities,
    end of testing
  • More in children born at biologic risk, low SES
  • Those who refuse any aspect of testing differ
    from those who refuse some items or who refuse
    more difficult items
  • High rates of refusal at one age associated with
    similar behaviors at later ages

17
Test Refusals--Implications
  • Those who refuse to comply often have decreased
    scores in several areas of function--untestable
  • Risk for lower test scores and higher rates of
    problems at ages 7-8 years in many areas
  • Source of clinical information

18
Q7 Is There a Role for Qualitative Information?
  • Not in place of quantitative rather, in
    conjunction with
  • Causes for finding cognitive impairment,
    emerging LD, language dysfunction, environmental
    risk, testing issues, combination
  • Clinicians vs. technicians
  • Play-based assessment
  • Examples form board naming pictures, stacking
    cubes
  • Training to task

19
Quality ControlClinicians vs. Technicians
  • Quality of assessment may be compromised because
    of the questionable proficiency of examiners
  • Not clear who is qualified
  • Conceptual and factual knowledge of normal
    development
  • Awareness of significance of pathognomonic
    indicators
  • Well versed in administration scoring
  • (speed, best response, stop, eliciting report)

20
Q8What About Prediction?
  • Prediction tells us if early alarm or reassurance
    has any basis
  • Prediction is difficult because
  • Rapid developmental change
  • Intervening variables (environmental, biologic)
  • Interventions (EI, medical, social)
  • Testing itself has impact on developmental
    trajectory (observational effect)
  • Emergent, latent, delayed, deficient, disordered
  • Moving target
  • Aspects of tests used at T1 T2 Tn
  • Domain/area of development

21
Prediction
  • Stable performance high riskgtlow riskgt moderate
    risk
  • How does one define prediction (co-positivity/co-n
    egativity ORs, correlations)
  • Time span/interval
  • What predicts what?
  • Single composite measure may not be appropriate
    sub-domains of function

22
Q9 Is There a Summary?
  • Consider tests as reference standards be aware
    of psychometric issues
  • Evaluation is a balance between concepts and
    pragmatics
  • Percent delay is not accurate criterion based, gt
    1.5, 2, 3 SDs below average
  • Consider what can be assessed at different ages
    (skillcapacity)
  • Ratio DQs not accurate
  • Serial screening/assessment

23
Summary
  • We need to better understand strengths,
    weaknesses, and variables that affect caretaker
    report
  • Consensus on test refusals should we include,
    prorate, or invalidate scores?
  • Clinicians need to test
  • Environment affects different skills and at
    different times
  • Wear sunscreen and eat fiber
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