Integrated Services in Early Years

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Surveillance and Screening

Partnerships and Advocacy:

Integrated Services in the Early Years

Jill Houb

é, MD, MPhil, FAAP, FRCP(C)

Surveillance and Screening

• Current child health status

• Definition of terms

• Tools and experience

• Partnerships and advocacy

2

BC Child Health Status

• Outcome measures

• Process measures

• Social determinants

3

Healthy Child Development

Domains directly related to adult well-being:

–Socio-emotional

–Language/cognitive

–Physical health

4

Early Development

Instrument (EDI)

• Kindergarten year

• 5 scales

• Vulnerable if below “BC cut-offs” 10%

5

BC EDI Results

• No neighbourhood is immune

• Vulnerability ranges from

13.4% to 39.6%

6

Corrected EverRiskMap

7

Why Does Early Identification Matter?

• Documentation of benefits

– for physical handicaps, mental retardation

• improved family functioning

– for environmental risk (e.g., Head Start)

• decreased likelihood of grade repetition

• less need for special education services

• fewer dropping out of school

• Clearer delineation of adverse influences

• low-level lead exposure

• adverse parent-infant interaction

8

Why Does Early Identification Matter?

Legal Mandate

• Canadian Charter of Rights and

Freedoms (1985)

Section 7 Legal rights

Section 15 Equality Rights

• BC Human Rights Code (1996)

• BC School Act (revised 1989)

Guralnick 1987

9

Child Health Status

• 16% of children have disabilities

• 20 – 30% detected before school entrance

• There are known risk factors for delay and disability

10

NORMAL

BELOW AVERAGE

Guidanc e

•Parenting

•Mental health

•Enrichment

DISABLED

•Therapy

•Special

Ed

Glascoe, 1997

11

IQ

125

120

115

110

105

100

95

90

85

80

Effects of Psychosocial Risk

Factors on Intelligence

Percentiles

84th

75th

50 th

25 th

16 th

0 1 2 3 4 5 6 7+

Glascoe, 1997

Risk Factors

Poor health status, > 3 children, stressful events, single parent, parental mental health problems, less responsive parenting, poverty, minority status, limited social support

12

Surveillance and Screening

• Current child health status

Definition of terms

• Tools and experience

• Partnerships and advocacy

13

Surveillance and Screening

Hand in Hand

Developmental Surveillance

“… flexible, continuous process in which knowledgeable professionals perform skilled observations of children ...

With proper techniques, surveillance is familyfocused, accurate, efficient, …”

Dworkin, 2004

15

Developmental Surveillance

• Eliciting/attending to

parents’ concerns

• Obtaining a relevant

developmental history

• Skillfully

observing

development children’s

• Sharing opinions with other

professionals

Dworkin, 2004

16

Developmental Surveillance

Children’s developmental competencies are best determined

over time

– “spurts” and pauses

– variable rate across domains

– longitudinal aspect of health supervision

Dworkin, 2004

17

Attending to Parents’ Concerns

• There is a strong relationship between parents’ concerns and child’s developmental status

• Parents have high levels of sensitivity for problems regarding fine motor, language, cognitive and school skills

• Parental concerns about gross motor, hearing and medical status are highly related to developmental problems

Dworkin, 2001

18

DEVELOPMENTAL SURVEILLANCE

Parents’ Appraisals

• In 87% of children with ADHD, parents have concerns related to impulsiveness, inattention or over activity

• Absence of parental concerns or concerns in other areas (self-help or socialization) correlates with children without developmental disorders

19

DEVELOPMENTAL SURVEILLANCE

Elicit Parents’ Opinions and Concerns

• Information available from parents

Appraisals (opinions of children’s development)

• concerns

• estimations

• predictions

Descriptions

• recall

• report

Dworkin, 2004

20

DEVELOPMENTAL SURVEILLANCE

Parents’ Appraisals

Concerns

– accurate indicators of true problems

• speech and language

• fine motor

• general functioning (“he’s just slow”)

– self-help skills, behavior less sensitive

• “Please tell me any concerns about the way your child is behaving, learning, and developing”

– “Any concerns about how she…”

Dworkin, 2004

21

DEVELOPMENTAL SURVEILLANCE

Parents’ Appraisals

Estimations

– “Compared with other children, how old would you say your child now acts?”

– correlate well with developmental quotients

• cognitive, motor, self-help, academic skills

• less accurate for language abilities

Predictions

– likely to overestimate future function

• if delayed, predict average functioning

• if average, “presidential syndrome”

22

Dworkin, 2004

DEVELOPMENTAL SURVEILLANCE

Parents’ Descriptions

Recall of developmental milestones

– notoriously unreliable

– reflect prior conceptions of children’s development

– accuracy improved by records, diaries

– even if accurate, age of achievement of limited predictive value

Dworkin, 2004

23

DEVELOPMENTAL SURVEILLANCE

Parents’ Descriptions

Report

– accurate contemporaneous descriptions of current skills and achievements

– importance of format of questions

recognition: “Does your child use any of the following words…”

identification: “What words does your child say?”

– produces higher estimates than assessment

• child within a familiar environment

• skills inconsistently demonstrated

24

Dworkin, 2004

Developmental Surveillance

Eliciting Parents’ Opinions and Concerns

Caveat: Detection without referral/intervention is ineffective and may be judged unethical

Dworkin, 2004

25

Developmental Surveillance

An appropriate response to parents’ behavioral concerns is to seek additional information about children’s development

– important indicators of children’s status

– need for cautious interpretation

Dworkin, 2004

26

Developmental Surveillance

Opinions of other professionals offer valuable information regarding children's developmental functioning

– input from preschool teachers, child care providers, visiting nurses

– preschool teachers’ predictions of school readiness, kindergarten success

Dworkin, 2004

27

Screening

• Identify the likelihood of a disability

• Do not provide a diagnosis

• Can help identify a range of possible diagnoses that help focus referrals

Prieto 2004

28

• Brief

Screening

• Standardized administration

• Proven valid & reliable

• For the asymptomatic

29

Detection rates:

No risk factors and no screening

• 30% of developmental disabilities

• 20% of mental health problems

30

Detection rates:

No risk factors and screening

• 70–80% dev disabilities

• 80–90% mental health problems

• Over referrals related to psychosocial risk

31

Surveillance and Screening

• Current child health status

• Definition of terms

Tools and experience

• Partnerships and advocacy

32

PDQ

Denver-II

Early Screening Profile

DIAL-III

Early Screening Inventory

ELM

Gesell

Due to absence of validation, poor validation, norming on referred samples, and/or poor sensitivity/specificity

33

Glascoe, 1997

Six Quality Tests

1. Parents’ Evaluation of Developmental Status

(PEDS)

(0 through 8 years)

2. Child Development Inventories (CDIs)

(0 to 6 years)

3. Ages and Stages

(0 to 6 years)

4. Pediatric Symptom Checklist (PSC)

(4 through 18 years)

5. Brigance Screens

(0 to 8 years)

6. Safety Word Inventory and Literacy Screener

(SWILS ) ( 6 – 14 years

Glascoe, 1997

34

Screen Selection Flow Chart

Age Range

0–4 yrs 4–6 yrs 6–8 yrs 8–18 yrs

PEDS or

CDIs or

ASQ or

Brigance

PEDS or

CDIs or

ASQ or

Brigance

( + PSC)

PEDS or

Brigance or

SWILS

( + PSC)

SWILS and/or

PSC

35

Glascoe, 1997

Behavioral/Emotional Screening

• Pediatric Symptom Checklist (PSC)

• Eyberg Child Behavior Inventory

• Family Psychosocial Screening

36

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

Glascoe, 1997

37

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.

38

Glascoe, 1997

When Should You Ask for

Further Evaluation?

Sudden Unexpected Change

In Developmental Trajectory

• Unexplained regression

• Sudden change in personality

• Change in mood or emotional well-being

– May be due to disease or illness

– May reflect important events occurring at home

39

When Should You Ask for

Further Evaluation?

Global Developmental Delay

– Persistent significant delay in all domains that cannot be attributed to other known factors

Delays in a sphere of development that adversely impact the child’s functioning

– At home

– Daycare

– School

Significant Emotional Concerns

40

What Do You Ask For?

• Community health unit and GP

– Hearing screen

– Vision screen

– Speech and language evaluation

– Paediatrician referral

• Infant Development Program

• Child Development Centre

• Sunny Hill Health Centre

• BC Children’s Hospital Child Psychiatry

• School Principal and Individual Education Plan

41

Sunny Hill Health Centre

Outpatient Clinics

• School Consults & SERT Team (Substance

Exposure Resource Team)

• Brain Injury

• Craniofacial Clinic, Downtown Eastside Clinic &

SERT Team

• Visually Impaired Program

• Preschool and Developmental-Genetics Clinic

• Hearing Loss Team

• SERT Team

• Neuromotor/Spasticity/Feeding

• Provincial Autism Program http://www.sunny-hill.bc.ca/sunnyhill/shhcc/default.asp

42

Alan Cashmore Centre

• Child-Family Therapy Centre (604) 454-1676

• Under umbrella of services provided by Vancouver Coastal

Health

• Parent Infant Program – home based therapy for mother/family/infant having difficulties in the initial stage of their relationship (birth to 30 months of age)

• Parent Child Therapy Program – therapy services for families finding it challenging to care for their young child

(21/2 to 7 years of age)

• Parent Child Day Program – intensive services for families experiencing a significant social, emotional and/or behavioral difficulties in parenting their young child (2 ½ to 6 years)

• Childcare Centre Outreach program – consultation and support to childcare staff in their own centres in managing children with social, emotional and/or behavioral challenges.

43

Mental Health Services

• Alan Cashmore Centre

Child-Family Therapy

Centre

(604) 454-1676

• BC Psychological Association www.psychologists.bc.ca

• UBC Psychology Clinic http://www.psych.ubc.ca/clinic/

• SFU Psychology Clinic

604-291-4720

• New Westminster Counselling

– Tel: (604) 525-6651

– T reatment is free and patients can self-refer

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Other Sources of Information

• MCFD website http://www.mcf.gov.bc.ca/

• Redbook http://www2.vpl.vancouver.bc.ca/dbs/r edbook/htmlpgs/home.html

• Community Brain Injury Program coordinated by Center for Abilities

45

Psychiatry Clinics At

BC Children's Hospital

• Psychiatry

• Mood Disorders Clinic

• Neuropsychiatry Clinic

• Attention Deficit Hyperactivity

Disorder Clinic

• Infant Psychiatry

• Urgent Assessment

46

Surveillance and Screening

• Current child health status

• Definition of terms

• Tools and experience

Partnerships and advocacy

47

Who does what?

• Look where children are found

• Use a valid, reliable tool

• Talk to other people

• Document

48

Current practices

• Local initiatives

• Targeted clinical risk

• Only 1 in 3 BC children with developmental disorder receive screening/ assessment/intervention

• IDP/CDC

49

Research and Experience

• CHILD

• Neonatal Follow-Up

Program

• Early Hearing Program

• BC Healthy Child

Development Alliance

50

Advocacy

• Public awareness

• Training

• Policy

Wait lists

–Database

• Public Health Act 2007?

51

Acknowledgements

• Hillel Goelman and Clyde

Hertzman: CHILD and HELP

• BC Healthy Child Development

Alliance

• Neonatal Follow-Up Program

• Dana Brynelsen and IDP

• Sunny Hill Foundation

• CFRI [email protected]

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References

Glascoe, Peds In Rev 2000. Chis, Peds Rev 2000

Glascoe, Peds 95, 97; Glascoe, Ped 91. Diamond , J Div Early Childhood 87

Glascoe, Clin Pediatr 91, 94

Mulhern et al, Am J Dis Child. 93

Glascoe FP, Am J Dis Child 89

Perrin E. J Dev Behav Pediatr 1998; 19: 350-352

Palfrey et al. J PEDS. 1994;111:651-655

Lavigne et al. Pediatr. 1993;91:649 – 655

Sturner, JDBP . 1991; 12: 51-64

Glascoe, APAM. 2001; 155:54-59 http://cshcnleaders.ichp.edu/Presentations/screening.htm#PowerPoint%20Presenta tions http://www.aap.org/catch/6 www.dbpeds.org

53

References

American Academy Of Pediatrics. Committee on Children With Disabilities

Developmental Surveillance and Screening of Infants and Young Children

Pediatrics. 2001;108:192-196. http://www.aap.org/policy/re0062.html

Dworkin PH. British and American Recommendations for Developmental

Monitoring: The Role of Surveillance. Pediatrics. 1989;84:1000 1010

Dworkin PH. Detection of behavioral, developmental, and psychosocial problems in pediatric primary care practice. Curr Opin Pediatr. 1993; 5: 531-536.

Dworkin PH. Detection of behavioral, developmental, and psychosocial problems in pediatric primary care practice. Curr Opin Pediatr. 1993; 5: 531-536.

Frankenburg WK. Selection of diseases and tests in pediatric screening. Pediatrics.

1974;54:1-5.

Glascoe FP, Dworkin PH. Obstacles to Effective Developmental Surveillance: Errors in Clinical Reasoning. Journal of Developmental and Behavioral Pediatrics.

1993;14:344-349.

Glascoe FP. Toward a Model for An Evidenced-Based Approach to

Developmental/Behavioral Surveillance, Promotion and Patient Education.

Ambulatory Child Health, 1999, 5; 197-208

Glascoe, F.P. (2000). Early detection of developmental and behavioral problems.

Pediatrics in Review, 21, 272-280.

Meisels SJ, Provence S. Screening and Assessment. Guidelines for Identifying

Young Disabled and Developmentally Vulnerable Children and Their Families.

Washington, DC: National Center for Clinical Infant Programs; 1989

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References

• Dobos AE, Dworkin PH, Bernstein B: Pediatricians’ approaches to developmental problems: Has the gap been narrowed? J Dev

Behav Pediatr 1994;15:34-38.

• Dworkin PH, Glascoe FP: Early detection of developmental delays. Contemp Pediatr 1997;14:158-168.

• Dworkin PH: Prevention Health Care and Anticipatory Guidance, in: Shonkoff JP, Meisels, SJ, eds. Handbook of Early Childhood

Intervention. Second Edition. Cambridge, Cambridge University

Press, 2000.

• Frankenburg WK, Dodds J, Archer P, et al: A major revision and restandardization of the Denver Developmental Screening Test.

Pediatrics 1992;89:91-97.

• Glascoe FP, Dworkin PH: The role of parents in the detection of developmental and behavioral problems. Pediatrics

1995;95:829-836.

• Squires J, Nickel RE, Eisert D: Early detection of developmental problems: strategies for monitoring young children in the practice setting. J Dev Behav Pediatr 1996; 17:420-427.

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