Early Detection of
Developmental and
Behavioral Problems in
Primary Care
Frances Page Glascoe
Adjunct Professor of Pediatrics
Vanderbilt University
Medicaid EPSDT requires
screening for developmental and
mental health status
AAP recommends routine
standardized developmental and
behavioral screening
IDEA requires child-find in every
state
Early Intervention Efficacy
JAMA. 1990;263:3035-3042
Pediatric Care
Arkansas
85
Einstein
74
Harvard
96
Miami
66
U of PA
92
Texas
80
Washington
92
Yale
91
TOTAL
85
Intervention
99
85
97
81
95
87
100
103
94
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 13$
Detection rates without
screening tests
only 30% of children with developmental
disabilities identified before K
(Palfrey et al. J PEDS. 1994;111:651-655)
only 20% of children with mental health
problems identified
(Lavigne et al. Pediatr. 1993;91:649 - 655)
Challenge #1:
CHECKLISTS
Sample Checklist
Uses hungry, tired, thirsty
Climbs stairs without holding on
Stacks 12 blocks
Knows colors
Dresses self completely
Plays games with rules
Challenge #2:
COMMUNICATING
WITH FAMILIES
“Your teacher wishes me to delineate those
watershed occasions in your life that have led you
to become,
slowly and inexorably,
a loose cannon.”
Challenge #3:
CLINICAL
JUDGMENT
Challenge #4:
DEVELOPMENT
ITSELF
Effects of Psychosocial Risk
Factors on Intelligence
Percentiles
125
120
84th
75th
115
110
105
IQ
50th
100
95
90
25th
16th
85
80
0
1
2
3
4
5
6
7+
RISKS: < HS, > 3 children, stressful events, single parent,
parental mental health problems, < responsive parenting,
poverty, minority status, limited social support
TYPICAL DEVELOPMENT
minimal psychosocial
Parents
risk factors
often need
training,
and social
services.
BELOW AVERAGE
Children
DEVELOPMENT
need
frequent psychosocial risk
enrichment
tutoring,
factors
mentoring,
DISABLED
mental
health, some psychosocial risk factors
etc.
and/or organicity
Parents
often need
advice
about
behavior
Children
need special
education,
speechtherapy, etc.
Challenge #5:
DEALING WITH THE
RESULTS OF A
SCREENING TEST
REFERRAL CHALLENGES
• 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)
Challenge #6:
FAILURE TO USE A
HIGH QUALITY
SCREENING TEST
Screening sorts those
who probably have
problems from those
who probably don’t
Standardized on a national samploe
Proof of reliability
Evidence of validity
Accuracy, i.e.:
Sensitivity of 70% to 80%
Specificity of 70% to 80%
Accuracy of the Denver-II
Developmental DX
NO
Denver-II
YES
PASS
69
8
86
FAIL
17
10
27
86
18
Sensitivity = 10/18 = 56%
Specificity = 69/86 = 80%
Detection rates
WITH Screening Tests
70% to 80% of children with developmental
disabilities correctly identified
Squires et al, JDBP. 1996;17:420 - 427
80% to 90% of children with mental health problems
correctly identified
Sturner, JDBP . 1991; 12: 51-64
Most over-referrals on standardized screens are
children with below average development and
psychosocial risk factorsGlascoe, APAM. 2001; 155:54-59.
Reasons for limited use of
screening tests at well visits:
COMMON MYTHS
common screening tests too long
many difficult to administer
children uncooperative
reimbursement and time limited
referral resources unfamiliar or
seemly unavailable
challenges of giving difficult news
“Looking Good”
So what
should we
do?
Use newer, brief, accurate tools
Make use of information from
parents
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.
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
Three Quality Parent Report Screens
Parents’ Evaluation of Developmental
Status (PEDS) 0 to 8 years
At this point we are
going to talk about three brief parent-based screening tools
Ages and Stages (0 to 6 years)
Modified Checklist of Autism in
Toddlers (M-CHAT) 18 mos to 4 yrs.
PARENTS’ EVALUATION OF
DEVELOPMENTAL STATUS
A Method for Detecting and Addressing
Developmental and Behavioral Problems
• For children 0 to 8 years
• In English, Spanish, Vietnamese, Somali, Chinese,
and many other languages
• Takes about 5 minutes for parents to complete
• Takes 2 minutes to score
• Elicits parents’ concerns
•Uses same 10 questions at each visit
• Sorts children into high, moderate or low risk for
developmental and behavioral problems
• 4th – 5th grade reading level so > 90% can complete
PEDS’ Evidenced Based Decisions
when and where to refer (e.g., mental
health services, speech-language or
developmental/school psychologists)
when to screen further (or refer for
screening)
when to offer developmental promotion
when to provide behavioral guidance or
refer for mental health services
when to observe vigilantly
when reassurance and routine
monitoring are sufficient
“Oh, by the way…..”
Reduces “doorknob concerns”
Focuses visit and facilitates patient flow
Improves parent satisfaction and positive
parenting practices
Increases provider confidence in decisionmaking
Increases attendance at well-child visits
Electronic PEDS
• Automated scoring, generates parent summaries,
and referral letters
• www.forepath.org
• Web accessible PEDS for
– Licensed PEDS users
– Self-selected parents
• PEDS scoring Web service for EMR/EHR and
other electronic systems
Subject Information
Parent Information
PEDS Questions
M-CHAT (optional)
Results (record)
Results (parent information)
Letter of Referral
Resources for Parents
Data Resources
• All demographics
captured
• De-identified datasets
available for research
(subject to IRB and HIPPA)
• Multiple formats
available (SQL, text,
Excel, etc)
• Raw or aggregated
data
Flexible
• Works with several workflow approaches
• Adaptable to licensee’s level of automation
– Faster screening and analysis for paper-based organizations
– Can be fully integrated with licensee’s electronic systems
– – or anything in between
• Referral letters and parent information sheets are fully
customizable for each licensee or locale
• Many options for collection of research data
Ages and Stages Questionnaire
(ASQ) 4 months to 6 years
19 color-coded questionnaires, each 6 –7 pages
long 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 15 minutes, and 5 to score
ASQ-Social-Emotional works similarly and
measures behavior, temperament, etc.
ASQ Sample Items
3. Using the shapes below to look at, does your
child copy at least three shapes onto a large
piece of paper using a pencil or crayon, without
tracing? Your child’s drawings should look similar
to the design of the shapes below, but they may
be different in size.
Yes

Sometimes Not Yet


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.
Communication
Gross Motor
Fine Motor
Problem solving
Personal-social
Scores in shaded areas, prompt a referral
Other Features
Instructional video
Curriculum linkage guide
Multiple language translations
CD-ROM scoring
May be online in the near
future
Modified Checklist
of Autism in Toddlers
(M-CHAT)
 23 yes-no questions
 Measures social reciprocity, language, some
motor
 18 months to 4 years of age
 Detects ASD, language impairment, MR
M-CHAT Sample Items
 Does your child ever use his/her index finger to po
to ask for something
 Can your child play properly with small toys witho
just mouthing, fiddling, or dropping them?
 Does your child take an interest in other children?
M-CHAT Details
 failing score if 2 or more critical items or any 3 ite
are failed
 free download or online (after purchase of PEDS)
www.forepath.org
 2 page scoring guide
 takes 7 - 10 minutes to complete
 recommended by AAN for use after a broad-band
screen is failed
Three Quality Parent Report Screens
Ages and Stages (0 to 6 years)
Parents’ Evaluation of Developmental
Status (PEDS) 0 to 8 years
Modified Checklist of Autism in
Toddlers (M-CHAT) 16 mos to 4 yrs.
At this point we are
going to talk about three brief parent-based screening tools
in the handout for this talk you
will find:
Procedures and diagnosis codes for billing
Sources for patient education materials
Information about obtaining the various
screens
A guide to explaining test results
Information on organizing offices for efficient
screening and developmental promotion
Information on referral resources
How to lead a screening initiative in a
practice
www.dbpeds.org
Implementing Screens in Primary Care
Educate staff on importance of
screening
Allow input into workflow
Be creative in tool selection
Locate and get to know referral
resources
Organize patient education and
referral materials
Take Home Messages
Screening tests are workable in primary
care
Quality screens improve detection rates , 3 4-fold
Developmental services are available
Non medical providers need guidance on
how best to work with medical providers
Office Staff need to be engaged
Parent education and referral materials are
essential
PEDIATRIC SYMPTOM
CHECKLIST (PSC)
For children 4 – 18
Screens for mental health and behavioral problems
Presents parents with a list of problematic behaviors
Produces four distinct factors:
Internalizing (depressed, withdrawn, anxious)
Externalizing (conduct, problem behavior, etc.)
Attentional (impulsivity, distractibility, etc.)
Academic/Global
Takes about 7 minutes for parents to complete
Takes 4 –5 minutes to score factors
Available in English, Spanish and Chinese
PEDIATRIC SYMPTOM
CHECKLIST (PSC)
NEVER SOMETIMES OFTEN
1. Complains of aches or pains
2. Spends more time alone
3. Tires easily, little energy
4. Fidgety, unable to sit still
5. Has trouble with a teacher
__
__
__
__
__
___
___
___
___
___
__
__
__
__
__
__
___
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.....
35. Refuses to share
PSC Scoring
1. Assign a value of 0 to Never, 1 to
Sometimes, and 2 to often
2. Add scores
3. If ages 4 & 5, omit items 5,6,17, and
18. If value is > 24 refer. For older
children, > 28 indicates need for
referral.
4. View factor scores if scores are
above cutoffs.
Safety Word Inventory and
Literacy Screener (SWILS)
22 common signs and safety words
Number correct is compared to a
cutoff for age
6 – 14 years of age
May serve as a springboard to
injury prevention counseling
Safety Word Inventory and
Literacy Screener (SWILS)
No Trespassing
EMERGENCY FIRE ESCAPE
High Voltage
POISON
Safety Word Inventory and Literacy Screener
Age Range
Years--months
<6–6
6-7 to 6-10
6-11 to 7-2
Date
Cutoff
Results
<1
<2
<3
Pass
Pass
Pass
Fail
Fail
Fail
/\ /\ 8-3
/\ /\to/\8-6/\ /\ /\ /\ /\ /\ /\ /\ /\ </\12/\ /\ /\ /\ /\Pass
/\ /\ /\Fail
/\ /\ /\ /\
8-7 to 8-10
8-11 to 9-2
9-3 to 9-7
9-8 to 10- 4
< 12
< 14
Pass
Pass
Fail
Fail
< 15
< 16
Pass Fail
Pass Fail
Safety Word Inventory and
Literacy Screener (SWILS)
public domain
longitudinal form can remain in chart
takes 1 - 5 minutes
requires direct elicitation
high correlations with reading
comprehension, basic reading and math
recent publication so no utilization
studies
•Conforms to Head Start Framework
• Takes 10 – 15 minutes of professional time
• Produces a range of scores across domains
•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 and online version
for
data aggregation
•Items linked to IED for initial instructional planning
•Can be administered by interview and/or direct
elicitation
•Separate form for 0 through 11 months, 12 through 23 months
•Provides scores for 6 developmental domains: fine/gross
motor, receptive/expressive language, self-help,
social-emotional
•Detects children who are delayed as well as advanced
•Can plot progress over time
•Includes examiner observations of psychosocial risk
•Includes a small materials kit (you’ll add crackers)
For children 2 – 7 years
1 form per each year of age
Takes 10 – 15 minutes of
professional time
All items require direct elicitation
Blocks, crayons, provided
Samples all developmental domains, with
increasing emphasis on better predictors
of school success: language and academics
Addressing Psychosocial Risk
on the Brigance Screens
The majority of children at-risk fail screens
If recently enrolled in programs, children need a
chance to learn before making referral
decisions
Programs need to be able to identify the subset in
need of immediate referral
Risk impact becomes visible by 6 months of age
Associated with limited verbalization from parent
(developmental skills at 60th versus 21st
percentiles)
Separate cutoffs and risk indicators included
Screens of behavior, mental health and
emotional well-being
Pediatric Symptoms Checklist (4 – 18
years)
Eyberg Child Behavior Inventory (2 –
11)
Ages and Stages Questionnaire SocialEmotional (4 months to 60 months)
Parents Evaluation of Developmental
Status (ages 0 – 8)