Developmental, Autism, and
Emotional Screening
Royann Mraz, MD
Clinical Associate Professor
Center for Disabilities and
Dec 10, 2014
• No conflicts of interest to disclose
• Review developmental, autism, and social
emotional screening
Why screen ?
• 16-20% of children have a developmental
or behavioral disorder
• 7-8% of children under 3 have delays
• Clinical judgment may only detect 30%
• Physician may be the only professional in
contact with young child and family
• Increases identification and referral
Benefits of early intervention
• Children with delays or environmental risk
benefit from early childhood programs
• Less grade retention, less need for special
education services, lower dropout rate,
improved health, improved income
• Early Childhood programs save money –
$30,000-100,000 per child
• Identify risk factors—medical and
• Elicit parental concerns
• Review milestones
• Skilled observation over time
• Selected screening
• Anticipatory guidance, monitoring and/or
Social smile
2 months
3 months
6-10 months
10-12 months
6-8 months
9 months
Early Pincer
8-10 months
12 months
Single words
11-15 months
18 months
11-15 months
18 months
Cooing – 2-3 months
Babbling – 6-10 months
Understands “No” – 9-10 months
“Mama” “Dada” – 10-12 months
1 step command without gesture – 12-14
• 3-10+ words – 18 months
• Combines 2 words – 21-24 months
• 50 Word vocabulary – 24 months
• Pronouns – 2 years old
• Average length of utterance one word for
each year of age from 2-4 years old
• Percentage of speech intelligible – 50% by
2 years, 75% by 3 years, 100% by 4 years
30 month old girl
Speech delay
15-20 words, can’t follow simple directions
Normal pregnancy and delivery
No major illnesses
What other history would you like?
Differential diagnoses?
Speech delay- most common delay
Speech/language disorder
Mild intellectual disability
Transient speech delay,
Autism spectrum disorder
Hearing impairment
Developmental Screening
• AAP recommends surveillance at every well
child visit
• AAP recommends formal screening at 9, 18,
and 30 months and whenever there is a
• Serial surveillance and screening is the most
• Screening may be recommended at 3 & 4 years
Trends in Use of Developmental
Screening 2002-2009
• 2002- less than 25% of AAP fellows used
formal developmental screening
• 2009 – 47% used one of more screening
• Most commonly used tools were ASQ,
Developmental Screening -2007
• Iowa- 19% of children receive formal
developmental screening
• Pennsylvania -11%, North Carolina -47%
• Increased screening for younger, minority, and
publicly insured children
• Based on National Survey of Children’s Health
• Higher rates of Early Intervention with higher
Developmental Screening
• Screening is not diagnostic or predictive
• Screening aims to identify those children
who need further evaluation
• If child is delayed in one area, check
development in all areas
• Screen development in children with
behavior problems
Developmental Screening – parent
completed questionnaires
• Involves the parents
• Stimulus for questions
• Educates parents about normal
• Time efficient for healthcare provider
• Sensitivity and specificity are as good
as most administered screening tools
Developmental Screening
• Sensitivity - % of children with delays
identified with the screener
• Specificity - % of typical children identified
as typical or low risk
• 70-80% sensitivity and specificity is
considered acceptable
Developmental Questionnaires
• Ages and Stages Questionnaires-3, 2-60
months, (Bricker and Squires) 2009
(endorsed by IDPH, CHSC,DHS)
• Parents’ Evaluation of Developmental Status
(PEDS) – 0-8 years, parental concerns,
(Glascoe)- (prescreener)
• Parents’ Evaluation of Developmental Status:
Developmental Milestones (PEDS-DM) – 0-8
years, (Glascoe)
• Child Development Inventories, 3-72 months,
(Ireton)- (Infant scale is very good)
Ages and Stages-3, 2009
2-60 months
Sensitivity 86%
Specificity 85%
25-35 items
10-20 min. for parent,
2-3 min. to score
• 21 forms, specific for
child’s age
Ages and Stages-3
• Communication,
FM,GM, problemsolving, personalsocial
• Identifies strengths
and weaknesses
• Forms can be
• On-line options
Ages and Stages-3
• Separate scores for Communication, GM,
FM, Problem-solving, Personal-Social
• Yes=10, Sometimes=5, Not yet=0
• Total scores recorded on chart
• Above the cutoff –on schedule (>-1SD)
• Close to the cutoff – monitor (-2 to -1SD)
• Below the cutoff – needs assessment
(below -2 SD)
• 10 Questions, also in
Spanish and online
• 5th grade reading level
• Elicits parent concern
about development and
• Same form for all ages,
• Sensitivity 74-79%,
Specificity 70-80%
• Glascoe recommends
evaluation if 2 or
more significant
concerns (11%)
• Screen if 1 concern
• Need second level
Developmental Screening
• Parent completed questionnaires make
• Remember to Refer – 50-80% of children
with at risk screens are not referred
• If child doesn’t qualify for Early
Intervention, consider Headstart, speech
therapy, etc.
Autistic Spectrum Disorders
• 1/68 children have autistic spectrum
• Group of neurodevelopmental disorders
• Early intervention improves outcome
DSM-5 Criteria for ASD
• Deficits in social communication and
social interactions
Social emotional reciprocity
Nonverbal communication
• Restricted, repetitive patterns of
behavior, interests, or activities
• Present in early childhood
• Limit and impair functioning
Joint Attention
• More specific to autism than speech delay
• Coordinate attention between an object
and a person in a social context –
responding to point or initiating point
• 8 mo Gaze monitoring
• 10 mo Follow a point
• 12 mo Point to request
• 14 mo Point to show
Autism Screening
• ASD is common
• Why screen? Better outcome with early
• First step- routine developmental
• AAP recommends use of autism
specific questionnaire at 18 and 24 mo
• Vigilance in siblings
Red Flags
• No back and forth sharing of sounds, smiles, and
other facial expressions by 9 months
• No babbling, pointing or other gestures by 12
• No single words by 16 months
• No spontaneous two word phrases by 24 months
• Any loss of language or social skills at any
Filipek, PA, Practice Parameter: Screening and Diagnosis of autism.
Neurology 2000;55:468-479
Autism Specific Questionnaires
• M-CHAT Modified Checklist for Autism in Toddlers
18-30 months -Parent questionnaire, Sens 85-87%,
Spec 93% - revised version 2012
• Pervasive Dev Disorders Screening Test PDDST-II –
Stage I 12-24 months, Sensitivity and specificity are
moderate to high
• CSBS Infant and Toddler Checklist- 6-24 mo, available
in AAP Autism toolkit. Sens 76-88%, spec 82-87%, also
identifies children with dd and speech disorders
• Social Communication Questionnaire - 4 years+, Sens
85%, Spec 75%
Modified Checklist for Autism in Toddlers
Please fill out the following about how your child usually is. Please try to answer
every question. If the behavior is rare (e.g., you've seen it once or twice), please
answer as if the child does not do it.
Does your child enjoy being swung, bounced on your knee, etc.?
Does your child take an interest in other children?
Does your child like climbing on things, such as up stairs?
Does your child enjoy playing peek-a-boo/hide-and-seek?
Does your child ever pretend, for example, to talk on the phone or take care of dolls, or
pretend other things?
6. Does your child ever use his/her index finger to point, to ask for something?
7. Does your child ever use his/her index finger to point, to indicate interest in
8. Can your child play properly with small toys (e.g. cars or bricks) without just
mouthing, fiddling, or dropping them?
9. Does your child ever bring objects over to you (parent) to show you something?
10. Does your child look you in the eye for more than a second or two?
11. Does your child ever seem oversensitive to noise? (e.g., plugging ears)
12. Does your child smile in response to your face or your smile?
13. Does your child imitate you? (e.g., you make a face-will your child imitate
14. Does your child respond to his/her name when you call?
15. If you point at a toy across the room, does your child look at it?
16. Does your child walk?
17. Does your child look at things you are looking at?
18. Does your child make unusual finger movements near his/her face?
19. Does your child try to attract your attention to his/her own activity?
20. Have you ever wondered if your child is deaf?
21. Does your child understand what people say?
22. Does your child sometimes stare at nothing or wander with no purpose?
23. Does your child look at your face to check your reaction when faced with
something unfamiliar?
 1999 Diana Robins, Deborah Fein, & Marianne Barton
Revised edition M-CHAT- R/F –
Simplified language and scoring,
Aim to decrease false positives,
Low, moderate, or high risk
If in moderate risk, Follow-up questions for
any failed item
• M-chat.org
Possible Autism
• Refer to Early Access for evaluation, therapy
and other services, Preschool at age 3,consult
Regional autism centers
• Consider additional therapy- behavioral, speech
• Refer for diagnostic evaluation – assessment
of cognitive and adaptive skills, receptive and
expressive language, hearing, medical
(Consider genetic testing)
• Parent support and information
Mental health screening in
• 20% of children and adolescents have a
mental health diagnosis
• Services need to be available
• Best evidence for benefit is for
depression screening in teens
Behavioral-Emotional Screening
• Brief broadband screeners ASQ-SE,
Pediatric symptom checklist
• Indepth broadband screeners – Child
Behavior checklist, others
• Narrow band – Vanderbilt, others
AAP Task Force on Mental Health
• Use validated social-emotional screening for
children 0-5 yr if risk factors, such as
Abnormal development screen, poor growth,
Poor attachment,
Excessive crying, clinging, fearfulness
Family psychosocial concerns
• Ages and Stages –Social Emotional 6-60 mo.
Older child and teen
• AAP - Use of validated screen for mental illness
at all well visits -5 years and up &
• Times of family disruption, poor school
performance, behavioral problems, recurrent
somatic complaints, involvement of DHS or
juvenile justice, and reported family
psychosocial concerns
• Pediatrics. June 2010 Supplement
Behavioral/Emotional Screening –
older child – initial screening
• Pediatric Symptom Checklist (Jellinek) –
6-16 yrs, 35 items, <5 min., Sens 80-95%,
Spec. 68%-100%, internalizing,
externalizing, and attention problems.
www.dbped.org, free, can be used as
young as 4 yrs
Depression Screening
• AAP/Bright Futures recommends
screening yearly at age 11 and up
• PHQ-2 Over the past 2 weeks, how often
have you been bothered by any of these
• Little interest or pleasure in doing things?
• Feeling down, depressed or hopeless?
• Several days (1), more than ½ (2), nearly
every day (3)
• Teens with scores of 3 or more should be
evaluated for possible depression
Substance Abuse Screening
• AAP/Bright Futures recommends
assessing all youth 11 years and up for
alcohol, tobacco, or drug use
• AAP/Bright Futures recommends asking
about experimentation/use
• Specific questionnaires to assess problem
use, such as the CRAFFT
Substance Use Screening
CRAFFT is a commonly used tool
Part A
During the past 12 months, did you:
Drink any alcohol (more than sip)?
Smoke marijuana?
Use anything to get high?
• If not to all questions in part A, ask CAR
question only. If yes in any in part A, ask all
• Have you ridden in a CAR driven by someone
high or using alcohol or drugs?
• Do you ever use to RELAX?
• Do you ever use ALONE?
• Do you ever FORGET while using?
• Do your FAMILY or FRIENDS tell you to cut
• Have you gotten into TROUBLE while using?
• Listen to parents’ concerns
• Developmental and autism screening
• Screen for teen depression and substance
• Social emotional screening
• Learn community resources
• Refer early
Education -Early Intervention
Birth to Three
In home services in
Iowa, teacher, OT,
org –good list of
resources in IA
• www.dbpeds.org Dev Behav Peds
website, articles and handouts
• www.pedstest.com PEDS, links
• www.firstsigns.org Development and
autism screening
• www.brookespublishing.com
• www.brightfutures.aap.org Guidelines for Health
Supervision Third Edition 2007
• AAP Medical Home website
• Developmental-Behavioral Pediatrics
(DBP): www.phoenixchildrens.com\dbpeds
• Developmental Screening Toolbox Boston
Children’s Hospital
ASD Resources
www.firstsigns.org videos, M-CHAT
www.autismspeaks.org videos
M-CHAT Information
AAP Autism Toolkit, including handouts for
• AAP Understanding Autism Spectrum
Disorders brochure for families
• AAP Policy Statement Identifying Infants and Young
Children with Developmental disorders in the medical
home Pediatrics: 118:405-420, 2006.
• LaRosa, A. Developmental and behavioral screening.
2014Up-To-Date, accessed 7.22.2014
• Kelly, N. Screening tests in Children and Adolescents.
Up-to-Date, accessed 7.22.2014
• Garg, A. Applying Surveillance and Screening to Family
Psychosocial Issues. JDBP: 32:418-426, 2011
• Robins, DL, Casagrande, K, Barton, M.
Validation of the M-CHAT-R/F. Pediatrics.
• Marks, KP, LaRosa, AC. Understanding
Developmental-Behavioral Screening
Measures. Pediatrics in Review.2012;448458.