INTRODUCTION. 9 March Hartford, Connecticut New England s s Rising Star. Connecticut Children s s Medical Center

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1 EARLY DETECTION OF DEVELOPMENTAL PROBLEMS Evolution of the Concept and Current Practice-A A US Perspective Early Detection of Health and Developmental Problems in Young Children Centre for Community Child Health 9 March 2010 Hartford, Connecticut New England s s Rising Star Connecticut Children s s Medical Center INTRODUCTION More than 4 decades since identification of developmental problems as component of new morbidity of US child health practice Profound societal change has influenced pediatric practice Deinstitutionalization Mainstreaming Medical Home 9 March

2 INTRODUCTION High prevalence of developmental problems within pediatric practice setting specific learning disability attention-deficit/hyperactivity disorder speech/language impairment mental retardation cerebral palsy hearing impairment serious emotional disturbance Dobos et al., J Dev Behav Pediatr 1994;15:348 Prevalence of Parent-Reported Diagnosis of Autism Spectrum Disorder Among Children in the US, 2007 Michael D. Kogan,, PhD, Stephen J. Blumberg, PhD, Laura A. Schieve,, PhD, Coleen A. Boyle, PhD, James M. Perrin, MD, Reem M. Ghandour, DrPH, Gopal K. Singh, PhD, Bonnie B. Strickland, PhD, Edwin Trevathan,, MD, MPH, Peter C. van Dyck, MD, MPH GOALS Review the evolution of the concept of developmental surveillance and screening in the US Describe the US context for the use of such specific strategies as parent-completed questionnaires and professionally-administered administered tools to facilitate early recognition Emphasize the critical importance of linking at- risk children and their families to programs and services DEVELOPMENTAL PROBLEMS Rationale for Early Detection Critical influence of early childhood years Less-differentiated brain of younger child amenable to intervention Neural plasticity Critical periods of development Sequential development of brain structures Activity-dependent neural differentiation Role of experience in brain development DEVELOPMENTAL PROBLEMS Options for Early Detection How to best promote such early recognition controversial Variety of techniques currently in use reviewing developmental milestones informal collection of age-appropriate appropriate tasks clinical judgment based on history, exam detects <30% of children with disabilities formal screening with parent-completed questionnaire formal screening with professionally-administered administered standardized test (e.g., Denver II) employed by only 30% of pediatricians reliability, validity, logistical issues 9 March

3 Health for All Children by Joint Working Party on Child Health Surveillance DMB Hall, Editor Dworkin PH. British and American recommendations for developmental monitoring: the role of surveillance. Pediatrics 1989;84: Elicit Parents Opinions and Concerns Information available from parents Appraisals (opinions of children s development) concerns estimations predictions Descriptions recall report Parents Appraisals Concerns accurate indicators of true problems speech and language fine motor general functioning ( he( he s 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 Oberklaid F, Dworkin PH, Levine MD. Developmental- behavioral dysfunction in preschool children. Descriptive analysis of a pediatric consultative model. Am J Dis Child 1979;133: Children Referred for Non-developmental Concerns Area of Concern Social-emotional Social-emotional/ hyperactive Hyperactive TOTAL N No. (%) With Unsuggested Developmental Concern 3 (30) 7 (33) 3 (50) 13 (35) 9 March

4 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 Parents Descriptions Recall of 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 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 DEVELOPMENTAL SCREENING Parent-Completed Questionnaires Advantages ease of administration do not require child s s cooperation broad sampling of skills flexible administration methods mailed prior to visit complete in waiting room waiting room or telephone interview by staff combination DEVELOPMENTAL SCREENING Professionally-Administered Tools Strengthen observations of children s development selective administration to prevent children eluding detection impracticality of routine, regular administration administration at select visit(s) confirmation of parental, professional concerns second-stage screening Always interpreted within context of surveillance (i.e., growth chart analogy) DEVELOPMENTAL MONITORING Developmental Surveillance and Screening (AAP Policy Statement, July 2006) Definition of surveillance Flexible, longitudinal, continuous process Knowledgeable practitioners perform skilled observations during child health encounters 9 March

5 DEVELOPMENTAL MONITORING Developmental Surveillance and Screening (AAP Policy Statement, July 2006) Components of surveillance: eliciting/attending to parents concerns obtaining a relevant developmental history making accurate observations of children identifying risk and resiliency factors maintaining record of process and findings [sharing opinions with other professionals] View child within context of overall well-being DEVELOPMENTAL MONITORING Developmental Surveillance and Screening (AAP Policy Statement, July 2006) Use of screening tools at periodic intervals to strengthen surveillance Types parent-completed questionnaires professionally-administered administered tests Frequency 9, 18, months when concerns arise ( second-stage ) AND SCREENING Expert opinion and research evidence support developmental surveillance as optimal clinical practice for monitoring children s development ( (Arch Arch Pediatr Adolesc Med 2001;155: ) 1322) Effectiveness is enhanced by incorporating valid measures of parents appraisals and descriptions (i.e., parent questionnaires) and objective measures of children s s development (i.e., professionally-administered administered tools) surveillance and screening screening at 9-, 9, 18-,, and months AND SCREENING Caveat: : Detection without referral/intervention is ineffective and may be judged unethical (Perrin E. Ethical questions about screening. J Dev Behav Pediatr 1998;19: ) 352) NATIONAL DISSEMINATION King TM, Tandon SD, Macias M, et al. Implementing developmental screening and referrals: Lessons learned from a national project. Pediatrics published online Jan 25, 2010; DOI: /peds FINDINGS Monthly referral rates among children with failed screens ranged from a high of 78% in September 2006 to a low of 48% in January 2007, averaging 61% over the entire study. 9 March

6 DISCUSSION Implementation systems for referrals.have received far less attention.than implementation of screening instruments. SUMMARY Variety of strategies merit consideration by child health providers to recognize developmental problems elicit parents opinions and concerns perform relevant history skillfully observe parent-child interactions SUMMARY (Continued) Additional screening techniques worthy of implementation structured parent questionnaires professionally-administered administered tools Successful early detection requires useful techniques, appropriate training of child health providers, resolution of reimbursement issues SUMMARY (Continued) Children, families at risk for developmental problems require outreach and support key role of public health programs in assuring linkages 9 March

7 REFERENCES American Academy of Pediatrics Council on Children with Disabilities: Developmental surveillance and screening in the medical home. Pediatrics 2006; 118: Dobos AE, Dworkin PH, Bernstein B: Pediatricians approaches to developmental problems: Has the gap been narrowed? J Dev Behav Pediatr 1994;15: Dworkin PH: Historical overview: from ChildServ to Help Me Grow.. J Dev Behav Pediatr 2006;27:S Dworkin PH, Glascoe FP: Early detection of developmental delays. Contemp Pediatr 1997;14: Glascoe FP, Dworkin PH: The role of parents in the detection of developmental and behavioral problems. Pediatrics 1995;95: March

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