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 children’s development
• 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

• 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
44

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 jhoube@cw.bc.ca
52

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
54

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.
55