Windows to Success:
Developmental Screening In the
Early Years
Jane Squires, Ph.D.
Chile Grows With You
November, 2008
Santiago, Chile
Jsquires@uoregon.edu
Objectives
What is risk in early
development?
What is the
importance of early
identification?
Why screen young
children?
Risk factors
Factors that hamper typical development in
young children
 Environmental
• Poverty
• Teen parents
• Abuse/neglect
 Biological
• Low birth weight
 Identified/established delays
• Down syndrome
Cumulative Effects of Risk
Sameroff et al, 1987
Poverty
How does poverty affect developmental
outcomes?
 Is not a direct cause of poor outcomes
 Parents in poverty are not “poor parents”
 Produces a constellation of stresses and risks
Poverty
Lack of food
 Iron deficiency
• Anemia
• Problems with problem-solving, concentration, lower
IQ
Housing Problems
 Homelessness
• Infant mortality, asthma, delayed immunizations
• Frequent moving
• Not completing high school
Poverty
Family stress
• Perceived financial
hardship
• Parent stress and
depression
• Family conflict, less
effective parenting behavior
• Child behavior problems,
aggressiveness, learning
problems
Poverty
Fewer resources for learning
 Inferior child care
• Less exposure to print, learning materials
• More child stress--anxious, aggressive, less active
 Financial barriers for school, college
• Less educational attainment
Meaningful Differences
in the Everyday Experiences of
Young American Children
Hart & Risley, 1995, Brookes Publishing
Meaningful Differences
in the Everyday Experiences of
Young American Children
Hart & Risley, 1995, Brookes Publishing
How can we improve child outcomes?
Early Child Development
Series of interactions
between child and
environment
Series of qualitative
reorganizations among
and within biological
systems stimulated by
environmental
interactions
Transactional Model of Development
Reciprocal, ongoing exchanges between the
child and environment serve as the foundation
of development.
Child is active participant in development.
Outcomes depend upon quality of caregiving
environment as well as the child’s
characteristics.
Plasticity of Young Brain
Brain imaging research shows affects of
stimulating environment on young children
Children of depressed mothers show 40% less
brain activity (Shore, 1997)
With rich interactions from the environment,
brain develops in optimal way
Differential genetic susceptibility to effects of
caregiving environment
Genes + caregiving environment = adult
outcomes
Early Identification
 On going monitoring
of young children’s
development
 Identifying children
with delays in
development
 Providing
enrichment activities
and/or special
education
Early Intervention
Early intervention provides continuum of supports
to children and families
Intervening early is necessary to compensate
Continued intervention and support are often
necessary to sustain gains
Early intervention makes a substantial difference in
the lives of young children and families
Evidence for Early Intervention
 Intelligence is enhanced in some children.
 Substantial gains are made in all developmental
areas
 Secondary handicapping conditions are inhibited
or prevented.
 Family support is provided.
Evidence for Early Intervention
 Dependency is reduced
 Need for special education services at school age
is reduced.
 Substantial cost savings in health care and
education costs.
Incidence of children identified as
having a disability by age
2.3%
5.9%
11.6 %
Prevention Triangle
Tertiary
Level
Special education, OT/PT
Secondary
Prevention
Targeted interventions with
risk population
Primary Prevention
Building Positive Relationships for Families
Screening, education, health
Early childhood programs
save money
 3 to 1 benefit-cost ratio
 Better health and academic outcomes
 $3-9 for every dollar invested
 16% annual return
• http://epinet.org
• http://brookings.edu
• http://minneapolisfed.org/
Heckman, J. (2006). Skill formation and the economics of investing in disadvantaged children.
Science 312(5782), pp. 1900-1902.
Risk Factors and Development:
Review
• Environmental, medical, and combination risk
factors affect development
• Quality of caregiving environment can mitigate
effects of risk
• Poverty presents most devastating risk factors for
young children
• Prevention is cost-efficient and effective
WHAT IS SCREENING?
Screening
A brief assessment procedure designed to
identify children who should receive more
intensive diagnosis or evaluation from local
education, health, mental health agencies
Screening
Beyond Cutoff
Professional
Assessment
Eligible
Not Eligible
Near Cutoff
Not near cutoff
Continue to monitor
(re-screen) & use
curriculum-based
assessment to
develop learning
plans
WHY SCREEN YOUNG CHILDREN?
Why use screening tests?
Clinical judgment is not accurate
Increases identification rates of children with
delays
If used system-wide, increase
communication, collaboration
among agencies
Why screen?
Increased rates of poverty for families
with young children
 Poverty associated with increased medical,
developmental, and social-emotional problems
Medical interventions increasing numbers
of children with delays
 Children born below 1500 grams have greatly
increased chance for developmental delays
Increased use of illegal substances by
stressed families
Why screen?
Early childhood time for
brain plasticity and growth
 Neurons to Neighborhoods,
http://www4.nationalacademies.org/
Early intervention is effective
 For low-birth weight children


 McCormick et al. 2006
Ecological focus on family and child
 Bronfenbrenner, 1977; Sameroff & Fiese, 2000
Home and center based programs effective
 Olds, 1997; Ramey & Ramey, 2000
Identification by pediatricians
In U.S. 60-80% with delays not identified
early
American Academy of Pediatrics 2006:
Pediatricians recommended screening at

9, 18-24, 30 months
Referral rates in 1 practice increased
224% in one year with formal screening
test (Hix-Small, Marks, Squires & Nickel, 2007)
What are effective screening
measures?
Qualities of assessment tools to
consider
Validity
Reliability
Adequate normative
population
Cultural sensitivity
Comprehensiveness
Attractiveness to children
Types of screening instruments
Professionally-administered
Parent-completed
Information on screening tools
 http://www.dbpeds.org/
 http://www.fpnotebook.com
 http://www.cimh.org
 Individual publishers
Professionally-administered
Battelle Developmental Inventory Screen, 2nd
(http://www.assess.nelson.com)
Bayley Scales of Infant Development Screen, 3rd
(http://harcourtassessment.com)
Brigance Screens
(http://www.curriculumassociates.com)
Denver II
(http://www.denverii.com/DenverII.html)
Early Screening Inventory
(www.pearsonearlylearning.com)
Parent-Completed
 Pediatric Evaluation of Developmental


Status PEDS--Glascoe
• www.pedstest.com
MacArthur Communicative Development
Inventory--Fenson et al.
Minnesota Child Development Inventories
•
http://www.childdevrev.com/cdi.html
 Ages & Stages Questionnaires
• http://www.brookespublishing.com
• http://agesandstages.com
Assessment
“the science of examining the strange
behaviors of children in a strange
situation with strange adults for the
briefest possible periods of time”
(Bronfenbrenner, 1979)
Advantages of Parent-Completed
Screening Measures
Engaging families in the
assessment of their child
Parents are reservoirs of rich
information about their
children
Parental involvement reduces
cost
Screening structures
observations, reports and
communications about child
development
Engaging families in the
assessment of their child
Screening may become a teaching tool for
parents and teaching staff
Information/communication can be useful
for primary health care providers and
communication based rehabilitation center
Effective and efficient method of early
identification
Research on parent report of
child developmental level
As accurate as formal measures for identifying cognitive
delay (Glascoe, 1989, 1990; Pulsifer, 1994)
As accurate as formal measures for identifying language
delay (Tomblin, 1987)
As accurate as formal measures for identifying symptoms
of ADHD and school related problems (Mulhern, 1994)
More accurate than Denver for predicting school-age
learning problems (Diamond, 1987)
Accuracy of low and middle
income parents
Agreement between parent-completed ASQ and
professionally administered standardized




assessment:
Low income parents
.85
(below federal poverty level)
Middle income parents
.89
No statistical significance between groups
(Squires, Potter, & Bricker, (1998) Early Childhood Research
Quarterly,13, 2, 345-354.)
Advantages of parent-completed
screening tests
Parents/caregivers can provide rich
information about child across settings
Parent involvement reduces cost
• 3-5 times less
Screening structures observations, reports,
communications about child development
Cost Effective
Parent-completed assessments
range between $3-10 per assessment
(U.S. interview/mail models)
Professionally-administered cost 3-5
times more
(Chan & Taylor, 1998; Dobrez Lo Sasso, Holl et
al., 2001; Glascoe, Foster, & Wolraich, 1997)
Factors that may affect the
accuracy of parental report
Characteristics of parents
Impaired mental functioning
Mental health issues
Cultural and language differences
Involvement with child protective
agencies
Low literacy
PARENTS’ EVALUATION OF
DEVELOPMENTAL STATUS
A Method for Detecting and Addressing
Developmental and Behavioral Problems
• For children 0 through 8 years
• In English, Spanish and Vietnamese
• Takes 2 minutes to score
• Elicits parents’ concerns/family-focused/culturally
competent
• Sorts children into high, moderate or low risk
• 4th – 5th grade reading level
• Score/Interpretation form printed front and back
•
and used longitudinally
• Screens for developmental and behavioral/mental
health problems
PEDS Response Form
1. Please list any concerns about your child’s learning,
development, and behavior.
2. Do you have any concerns about how your child talks and
makes speech sounds?
Circle: Yes No A little
Comment:
7. Do you have any concerns about how your child gets along
with others?
Circle: Yes No A little
Comment:
What are the ASQ and ASQ:SE?
 Series of parent- completed developmental
questionnaires
 Screen children for possible developmental
delays, difficulties
 Monitor the development of young children from
1 month to 5 years
 Enlist parents and caregivers in assessment
process
ASQ Communication
 12 month ASQ
• Does your baby follow one simple command, such as
Come here, Give it to me, Put it back, without your
using gestures?
Yes
Sometimes
Not Yet
• Does your baby say one word in addition to Mama and
Dada?
Yes
Sometimes
Not Yet
ASQ Fine motor
 24-month ASQ
• Does your child turn the
pages of a book by himself?
(He may turn more than one
page at a time.)
Yes
Sometimes
Not Yet
• Does your child flip switches
off and one?
Yes
Sometimes
Not Yet
12 month ASQ:Social Emotional
• Does your baby laugh or smile at you and other
family members?
(z)Most of the time
(v) Sometimes
(x) Rarely or never
• Does your baby like to be picked up and held?
(z)Most of the time
(v) Sometimes
(x) Rarely or never
24 month ASQ:Social Emotional
• Does your child seem too friendly with
strangers?
(x)Most of the time
(v) Sometimes
(z) Rarely or never
• Do you and your child enjoy mealtimes
together?
(z)Most of the time
(v) Sometimes
(x) Rarely or never
ASQ & ASQ:SE for autism
ASQ identified 76/76 children in retrospective
study (Nickel, 2006)
70/76 parents made comments in overall
section
ASQ:SE in clinical settings is identifying children
with autism
Two studies just beginning using ASQ and
ASQ:SE
ASQ Office Study
 12 and 24 months
 20 pediatric practitioners
 76% agreement between ASQ and pediatrician
estimate of development (OK, at risk)
 Pediatricians referred mostly for communication,
gross motor delays
 Referrals for further assessment increased 224%
in one year
Control and screening year
referrals
70
60
50
40
control year
screening year
30
20
10
0
12-months
24-months
Control and screening year
referrals
45
40
35
doc control
year
doc screening
year
asq screening
30
25
20
15
10
5
0
12-months
24-months
Recommendations for
a screening system
Best practices in screening
Use formal, validated screening measures
Include parents in decision making
Consider cultural adaptations
Develop systematic screening and referral
procedures
Include personnel and agency training
Evaluate screening system
 Cost
 Efficacy
 Utility
Include social-emotional areas
 Links between earliest emotional development
and later social behavior. (Cicchetti & Cohen
1995; Reynolds et al., 2001)
 Behaviors, even in infancy, signal the need for
intervention (Shonkoff & Phillips, 2000)
 Links between early risk factors, poor outcomes
& violence (Conroy & Brown, 2004)
 By third grade, programs for children with antisocial behavior are mostly ineffective (Walker,
2004; Greenberg et al., 2003)
21st Century Screening Programs
 Short, effective screening tests
 Increased use of parent report
 Internet-based
 Touch screens at health and educational
centers
 Follow-up through health and educational
outreach staff
In Summary
Early identification is critical for improving
developmental outcomes
Valid and reliable screening tests are central to
early identification efforts
Several parent-completed screening tests assist in
early identification efforts
 Early identification and intervention have
extensive cost savings as well as improving
child and family outcomes
To make change, we must have
unwarranted optimism about our
children and our future
• “All this will not be finished in the first 100 days..
Nor will it be finished in the life of this
Administration, nor even perhaps in our lifetime on
this planet. But let us begin.”
 John F. Kennedy, 1961
• “We must become the change we seek to create.”
 Gandhi
Thank you