Developmental Screens in

the Office Setting

OBJECTIVES

 Why to do developmental screen

 What types of screen tools are available
 How effective are they
 How are they administered
 What types of additional services are
available
WHY SCREEN
 12-22% of children in US have developmental or
behavioral disorders
 Many options now exist to tailor screening to what
works in specific practice setting
 Services available to children with developmental delays
from birth on
 Better outcomes for participants:
 higher graduation rates, delayed pregnancy,
employment, decreased criminality
 $30,000 to >$100,000 benefit to society
Why Screen (continued)
 Without screening:
 70% of children with developmental disabilities not identified
(Palfrey et al. J PEDS. 1994;111:651-655)
 80% of children with mental health problems not identified
(Lavigne et al. Pediatr. 1993;91:649=655)
 With screening:
 70% to 80% of children with developmental disabilities correctly
identified Squires et al, 1996, JDBP, 17:420 - 427
 80% to 90% of children with mental health problems correctly
identified Sturner, 1991, JDBP; 12: 51-64
Types of Screening Tools

 Two major categories

 Developmental
 Behavioral
 Two mechanisms of administration
 Parental
 Provider
Developmental Screening
Tools
 Provider
 Denver
 CAT/CLAMS
 Bayley
 Brigance
 DIAL-R
 Parent
 Ages and Stages Questionnaire
 Parent’s Evaluations of Developmental Status
Denver Developmental
Screening Test - 2
 Very commonly used screening tool
 Birth to 6 years old
 Poor sensitivity and specificity (40-60%)
 10-20 minutes to administer
 Normed on diverse population sample
 Multiple languages
 Domains: fine and gross motor, language, and
social skills
DDST (continued)
 Identifies children at 25,75, and 90% completion
of task
 Scored as concern if child completing task in
shaded area (75-90%)
 Scored as failure if not completed by time 90%
complete
 Referrals warranted for one failure or two concerns
 Correct for prematurity till 2 years old chronological
age
CAT/CLAMS
Clinical Adaptive Test/ Clinical Linguistic and
Auditory Milestone Scale

 Similar to Denver but more focused on

screening language and better at catching MR
 Some parental report, some direct observation
by provider
 Very high specificity and sensitivity (>90%)
 Not standardized in Spanish
 Quick to administer due to age categories
CAT/CLAMS (continued)
 Start at chronological age or at last point
 Credit given for completed tasks only
 Basal age calculated at age where child completes all
tasks at that age plus the value given to any additional
tasks above that age
 Basal age divided by chronological age then multiple by
100. This is the developmental quotient (DQ).
 DQ<70 constitutes delays and should be referred for
further evaluation
Bayley Screener
 Ages 3 to 24 months
 Direct observation of skills by provider
 Assesses three domains (more neuro focused)
 11-13 items at each age group (3-6 month
breaks)
 Specificity and sensitivity 75-86%
 10-15 minutes to administer
 Not standardized in Spanish
Bayley (continued)

 Neurologic processes (reflexes, tone)

 Neurodevelopmental skills (movement and
symmetry)
 Developmental accomplishments
(language, object permanence, imitation)
 Scored as low, medium and high risk for
developmental disorders
Brigance

 Multiple age break downs

 Infants and Toddlers
 Early Preschool
 Pre-K
 K-1st
 Assesses all domains
 Direct observation by provider
Brigance (continued)

 Standardized in English and Spanish

 Specificity and sensitivity 70-82%
 Easy to administer
 Children almost always experience success
 Time to administer approximately 10
minutes, 20 minutes in a slow child
 Realistically after practice 5 minutes
Brigance (continued)

 Simple scoring
 Circle for correct, slash for incorrect
 Stop after 3 in a row incorrect
 Try to get 3 in a row correct as well
 Look up score for age to determine if
normal or delayed
 Can show advanced skills
DIAL
Developmental Indicators for Assessment of
Learning

 Screening tool to evaluate pre-school aged children

 Effective for evaluation of school readiness
 Speed version: 10 questions (motor, concepts,
language domains)
 Spanish and English
 Good specificity and sensitivity
 Scored at norms for age with breakdown at 1.0,
1.3, 1.5, 1.7, 2.0 SD below
Ages and Stages
Questionnaire (ASK)
 Parent administered survey
 Screens multiple domains (communication, gross and
fine motor, problem solving and social)
 Sensitivity 70-90% Specificity 76-91%
 Validated in English, Spanish,Korean and French
 Can be administered by provider or non-clinical person
in cases of illiteracy
 5 minutes to administer when familiar, less if parents
administer
ASK (continued)

 Pictures with some tasks to improve

understanding of parents
 Scored as 10,5 or 0 points for each
question with norms in each domain for
each age level
Parents Evaluations of
Developmental Status (PEDS)

 Parent administered survey

 Identifies when to screen, refer, counsel, or monitor
 Sensitivity 74-79% Specificity 70-80%
 Available in Spanish
 2 minutes to administer, less if parents do alone
 ONLY 10 QUESTIONS
 Easy flow sheet to prompt when to refer, counsel or
re-evaluate
Behavioral Screening

 Parent or teacher
 Connors
 Child Behavioral Checklist
 Pediatric Symptom Checklist
 Vanderbilt
Connor’s
 Specific tool for ADHD with high sensitivity and
specificity (>90%)
 Breaks down into inattentive or hyperactive types
 Not going to determine cause
 Should never be used in isolation to make
diagnosis
 Must rule out additional underlying conditions
(MR, LD, hearing and vision abnormalities)
Connor’s (continued)

 Spanish versions available

 Teacher and parent forms
 Good for monitoring response to
medications
 Scored by positives (2 or 3) on domains of
inattention or hyperactivity
Child Behavioral Checklist
(CBCL)
 Multiple domains
 Can help identify other mental health conditions
 Available in Spanish as well
 Teacher and parent forms, child forms for older children
 Not as valuable for following child once on treatment
 Scored in multiple areas (i.e.:internalizing, externalizing,
somatic complaints, aggressive behaviors, attention
 Scored by points in each of the domains. Cut off for
significance given for raw or T-scores
Pediatric Symptom
Checklist
 Multiple domains of assessment
 Single score or subscales (attention, internalizing and
externalizing)
 Not standardized in Spanish
 Not helpful once a child has been referred
 Parent or child fills out form
 Scored as 0,1,or 2
 Significance if total score >24 in child 4-5 YO or >28 in child 6-
16 YO
 Attention: >7 points; Internalizing: >5; Externalizing: >7 points
NICHQ Vanderbilt
Assessment

 Sensitivity and specificity of >94% if both parent and

teacher ratings used
 Detailed questions about behavior to assess attention,
opposition, conduct, anxiety and depression
 Performance questions as well
 Scored by number of 2 or 3 in behavior assessment and
4 or 5 in performance assessment
 Break down given for diagnosis of ADHD (inattentive,
hyperactive, or combined), Oppositional Defiant
disorder, Conduct Disorder, and Anxiety/Depression
Additional Services

 Specialists
 Developmental Behavioral Pediatricians
 Speech Pathologists, PTs and OTs
 Other agencies doing evaluations
 Early Intervention
 Special Education
Specialists

 Huge backlogs to see specialists affiliated

with Children’s (Nationwide issue)
 Constraints on types of testing they can
do by insurance companies
 Medicaid does not allow Children’s to bill for
psycho-educational evaluations
 Need to assess if patient actually needs
this service
Other agencies

 Some are great and some are not

 Some are profit driven and have not invested
in making sure the quality of evaluations is
good
 WATS has been very reliable in both
quality and speed
 No longer covered by HSCSN
 Additional agencies in handout
Early Intervention

 Zero to three years old

 Eligibility criteria vary by state and county
 DC requires delay of 2 SD
 Anyone can refer patient
 MD, RN, parent, childcare provider
 EI must complete evaluation and help
parents transition to SPED when child is 3yo
Special Education

 3 to 21 years old
 Every child has right to evaluation
 Anyone can request eval, but parent must consent
 Eval must be conducted in child’s primary
language and in English
 DC requires eval started within 90 days of request
(does not include summer or vacation)
 Repeat eval every 3 years
SPED (continued)
 Individualized Education Plan (IEP)
 Contains the services child will receive and goals
for child
 Updated annually
 Parents do not need to sign at IEP meeting
 Quarterly report on progress
 Types of SPED
 Inclusion, pull-out, or self-contained class or school