Estimating the cost of developmental and behavioral screening of preschool children in general pediatric practice

Mobile Device-Based Video Screening for Infant Head Lag: An Exploratory Study

INTRODUCTION

Video-based automatic motion analysis has been employed to identify infant motor development delays. To overcome the limitations of lab-recorded images and training datasets, this study aimed to develop an artificial intelligence (AI) model using videos taken by mobile phone to assess infants' motor skills.

METHODS

A total of 270 videos of 41 high-risk infants were taken by parents using a mobile device. Based on the Pull to Sit (PTS) levels from the Hammersmith Motor Evaluation, we set motor skills assessments. The videos included 84 level 0, 106 level 1, and 80 level 3 recordings. We used whole-body pose estimation and three-dimensional transformation with a fuzzy-based approach to develop an AI model. The model was trained with two types of vectors: whole-body skeleton and key points with domain knowledge.

RESULTS

The average accuracies of the whole-body skeleton and key point models for level 0 were 77.667% and 88.062%, respectively. The Area Under the ROC curve (AUC) of the whole-body skeleton and key point models for level 3 were 96.049% and 94.333% respectively.

CONCLUSIONS

An AI model with minimal environmental restrictions can provide a family-centered developmental delay screen and enable the remote monitoring of infants requiring intervention.

Preschoolers' Developmental Profiles and School-Readiness in a Low-Income Canadian City: A Cross-Sectional Survey

A joint initiative between community and public health stakeholders in a low-income Canadian city was created to describe the developmental profiles of children aged 2-5 years. A two-phase, cross-sectional design was used. Children's development was assessed using an online screening procedure. Those at risk of delays were invited for a school-readiness face-to-face brief assessment. Descriptive and exploratory analyses were conducted. In Phase 1, 223 families were screened; 100 children were at risk of delays (45%); 13% were at risk in ≥3 developmental domains; 26% were at risk in the fine motor domain. Risk of delay was associated with parental concerns, accessing more healthcare professionals, and using fewer public health/community programs. Lower incomes, and not attending day care showed trends towards an increased risk of delay. In Phase 2, 49 children were assessed; 69% were at risk of school-readiness delays; 22% had potential motor delays; 37% were at risk in the social domain. This study found a higher proportion of children at risk of delay than typically reported. Creating community partnerships could help identify all children needing developmental and school-readiness support. More research is needed to ensure these community-based partnerships are integrated into health/community programs responding to children's needs and parental concerns.

Comparative use of the Ages and Stages Questionnaires in the USA and Scandinavia: a systematic review

AIM

The aim of this systematic review was to investigate screening practices with the Ages and Stages Questionnaires (ASQ) and the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) in the USA and Scandinavia and to identify practical lessons and research opportunities.

METHOD

The review was performed for ASQ- and ASQ:SE-related studies in children from birth to 5 years. From nine databases and 1689 references (published from 1988-2018), 127 articles were included and categorized using Covidence online software. The Critical Appraisal Skills Programme Checklists were used before data synthesis.

RESULTS

US studies primarily use the ASQ/ASQ:SE to detect delays in general and at-risk populations in medical settings, which increases early detection, clinician-referral, and intervention rates. Scandinavian studies commonly use the ASQ/ASQ:SE to monitor developmental-behavioural differences in intervention/exposure-based cohorts. Pre-visit screening yields completion/return rates of 83% to more than 90% and fosters same-day interpretation. When referrals are indicated, systemwide care coordination or colocation with a developmental-behavioural specialist is beneficial.

INTERPRETATION

Practical implementation lessons are reviewed. Research opportunities include investigating and measuring the ASQ/ASQ:SE's 'overall' sections. Danish, Norwegian, and Swedish translations are available but up-to-date norming and validation studies are needed throughout Scandinavia. Randomized controlled trials are needed to investigate outcomes in screened versus unscreened cohorts.

WHAT THIS PAPER ADDS

General and at-risk populations broadly benefited from periodic Ages and Stages Questionnaires (ASQ) and/or Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) screening. Pre-visit ASQ and/or ASQ:SE screenining implementation systems work best. The ASQ and ASQ:SE 'overall' sections are not quantifiable and under-researched.

Physician Awareness of Developmental Screening and Referral in the State of Kuwait

OBJECTIVE

In the State of Kuwait, family physicians and pediatricians are responsible for identifying and referring children at risk of disability. The aims of this study were to better understand physician (1) use of developmental screening instruments, (2) referral practices for children at risk of developmental disability, (3) interpretation of screening results, and (4) anticipatory guidance topics prioritized over child screening.

METHODS

A nonprobability volunteer, self-selection sample of family physicians, general practitioners, and pediatricians (n = 398) completed a 60-item paper questionnaire. Items assessed included: (1) practitioner familiarity with, belief in, and use of screening instruments; (2) familiarity with early childhood intervention services; (3) perceived barriers to screening implementation; and (4) anticipatory topics prioritized over screening. Logistic regression was used to test a priori hypotheses.

RESULTS

In general, family doctors and pediatricians practicing in public hospitals and primary health care centers in the State of Kuwait do not use or know how to use a developmental screening instrument, while over half prioritized immunization counseling over child screening. Screening confidence and training on using screening instruments increased the likelihood of tool use. Staff shortages, time constraints, and a perceived lack of Arabic screening instruments were barriers to tool use.

CONCLUSION

Raising health care providers' awareness of standardized developmental screening instruments and establishment of an early identification system in the State of Kuwait are needed. Standardization and adaptation of technically sound Arabic-language screening tools for use in the State of Kuwait and physician training programs on screening are recommended.

Risk Assessment for Parents Who Suspect Their Child Has Autism Spectrum Disorder: Machine Learning Approach

Background

Parents are likely to seek Web-based communities to verify their suspicions of autism spectrum disorder markers in their child. Automated tools support human decisions in many domains and could therefore potentially support concerned parents.

Objective

The objective of this study was to test the feasibility of assessing autism spectrum disorder risk in parental concerns from Web-based sources, using automated text analysis tools and minimal standard questioning.

Methods

Participants were 115 parents with concerns regarding their child’s social-communication development. Children were 16- to 30-months old, and 57.4% (66/115) had a family history of autism spectrum disorder. Parents reported their concerns online, and completed an autism spectrum disorder-specific screener, the Modified Checklist for Autism in Toddlers-Revised, with Follow-up (M-CHAT-R/F), and a broad developmental screener, the Ages and Stages Questionnaire (ASQ). An algorithm predicted autism spectrum disorder risk using a combination of the parent's text and a single screening question, selected by the algorithm to enhance prediction accuracy.

Results

Screening measures identified 58% (67/115) to 88% (101/115) of children at risk for autism spectrum disorder. Children with a family history of autism spectrum disorder were 3 times more likely to show autism spectrum disorder risk on screening measures. The prediction of a child’s risk on the ASQ or M-CHAT-R was significantly more accurate when predicted from text combined with an M-CHAT-R question selected (automatically) than from the text alone. The frequently automatically selected M-CHAT-R questions that predicted risk were: following a point, make-believe play, and concern about deafness.

Conclusions

The internet can be harnessed to prescreen for autism spectrum disorder using parental concerns by administering a few standardized screening questions to augment this process.

Validation of a culturally adapted developmental screening tool for Australian Aboriginal children: Early findings and next steps

BACKGROUND

Early detection of developmental problems is important for facilitating access to targeted intervention and maximising its positive effects. The later problems are identified, the more likely that they will become increasingly difficult to ameliorate. Standardised developmental screening tools are known to improve detection rates of developmental problems compared to clinical judgement alone and are widely recommended for use with all children. The Ages and Stages Questionnaire (ASQ-3) is a tool that is widely used in Australia. However, mainstream screening tools may not be appropriate for remote-dwelling Australian Aboriginal children. While Australian Aboriginal children face multiple developmental risk factors, there are no developmental screening tools that have been validated for use in this population.

AIMS

To determine the concurrent validity of the culturally adapted ASQ-3 - the ASQ-TRAK - for Australian Aboriginal children compared to the Bayley Scales of Infant and Toddler Development (Bayley-III), a standardised, professionally administered developmental assessment.

SUBJECTS

The ASQ-TRAK and Bayley-III were administered cross-sectionally to 67 Central Australian Aboriginal children between 2 and 36months of age.

RESULTS

The ASQ-TRAK communication, gross motor, fine motor and problem-solving domains and the corresponding domains on the Bayley-III were moderately correlated. Overall sensitivity for the ASQ-TRAK was 71% (95% CI 29-96) and specificity was 92% (95% CI 88-99). Percentage agreement between the ASQ-TRAK and the Bayley-III was 90%.

CONCLUSIONS

The ASQ-TRAK shows promise as a tool that can be used to improve developmental monitoring for remote dwelling Australian Aboriginal children. Further research is necessary to build on the current findings.

Developmental Screening in the Primary Care Setting: A Qualitative Integrative Review for Nurses

Standardized developmental screening leads to the identification of children with developmental delays who may benefit from early intervention. Many children with developmental delays are not identified early in life. An integrative review was performed to synthesize and critically analyze qualitative studies on the developmental screening experiences of parents and providers to develop a deeper understanding of the developmental screening gaps in clinical practice and increase awareness among healthcare professionals who care for children.

ELIGIBILITY CRITERIA

Qualitative studies written in English that focused on developmental screening in children from birth to school age and that included registered nurses, advanced practice nurses, pediatric or family physicians, or parents were considered.

SAMPLE

Ten studies met the inclusion criteria.

RESULTS

The analysis resulted in four main themes: developmental screening behaviors, developmental screening barriers, developmental screening facilitators, and parent interactions.

CONCLUSIONS

Positive parent interactions and practice-wide engagement facilitated successful implementation of standardized developmental screening in primary care settings. Barriers associated with developmental screening included time, lack of reimbursement, poor communication with parents, and unfamiliarity with developmental screening instruments. A limited number of studies have examined developmental screening methods used by advanced practice nurses. Only two studies in the review included advanced practice nurses.

IMPLICATIONS

The developmental screening experiences of providers and parents increases awareness about the challenges associated with conducting developmental screening in primary care. Recommendations for future research are offered with a focus on advanced practice nurses in primary care.

Psychometric properties and validation of Portuguese version of Ages & Stages Questionnaires (3rd edition): 9, 18 and 30 Questionnaires

BACKGROUND

The essential underlying foundations of Early Intervention (EI), in which parents/family play a critical role in their child's development, leads us to conclude that their contribution assessing early detection of problems is fundamental. The Ages & Stages Questionnaires (ASQ) is a standardized screening instrument that has been successfully studied in different countries and cultures.

AIMS

Translate and study the psychometrics proprieties of the Portuguese version of the 9, 18 and 30month questionnaires of the Ages and Stages Questionnaires, 3rd edition (ASQ-3).

STUDY DESIGN

Cross-sectional study.

SUBJECTS

Validity and reliability were studied in a sample of 234 parents of children within 9, 18 and 30months.

RESULTS

The results indicated that the questionnaires had good internal consistency, strong agreement between observers and between observations with two weeks interval, and strong Pearson product-moment correlation coefficients between the overall and the total for each domain. The cutoff points (i.e. 2 standard deviations below the mean domain score), that identifies children who should receive further referral for more comprehensive assessment, were close to those determined in the original ASQ-3 psychometric studies. Cronbach's alpha ranging from .42 to .70 and Pearson's r values varies from .22 to .60.

CONCLUSIONS

Although some weaknesses were noted in psychometric qualities analysis, it can be concluded that the ASQ-PT of 9, 18 and 30months of age fulfills the requirements of a screening tool validated for the Portuguese population.

PRACTICE IMPLICATIONS

To allow the early identification of children with developmental problems.

Concurrent validity of the Ages And Stages Questionnaires and Bayley Developmental Scales in a general population sample

OBJECTIVE

Developmental delay is relatively common and produces serious impairment. Efforts to screen for delay often include parent-completed instruments. We evaluated the agreement between the most popular such instrument, the Ages and Stages Questionnaires (ASQ) and the third edition of the Bayley Scales of Infant Development (BSID-III).

METHODS

We analyzed a community sample of 587 children aged 1 month to 36 months who received both the ASQ and the BSID-III. We calculate sensitivity, specificity, and positive and negative predictive values. Because published BSID-III norms produced unexpectedly low prevalences, we also derived a set of distribution-based thresholds using quantile regression, and we repeated the validation analysis using these results.

RESULTS

BSID-III prevalence was 2.9% (95% confidence interval [CI] 1.7-4.6) with published norms and 7.7% (95% CI 5.6-10.1) with distribution-based thresholds, while 18.2% (95% CI 15.2-21.6) of children were positive on the ASQ. For published BSID-III norms, sensitivity was 41% (95% CI 18-67) and specificity 82% (95% CI 79-85). Results with distribution-based thresholds were essentially identical. Performance was somewhat better among children over 1 year (sensitivity 50%, specificity 87%). For subscales, sensitivities were generally lower (range 0-50%) and specificities higher (range 92-96%).

CONCLUSIONS

Agreement between the ASQ and BSID-III was relatively poor. Previous studies have reported somewhat better agreement. There are numerous possible explanations for differences, including the age ranges used, the risk profile of children, and differences in the ASQ administration. Results raise concerns about the performance of this instrument in primary care and community settings.

Should we consider alternatives to universal well-child behavioral-developmental screening?

The prevalence of developmental disabilities in the young age is of the order of 15%. When behavioral and social-emotional disorders, physical impairments, and sensory disorders are included, the need for special intervention increases to one out of four children. As the sensitivity and specificity of the best screening tests are in the range of 70-80%, their predictive value is controversial. The cost of conducting definitive tests and repeat screening for those who fail the screening tests is high. Children with severe disorders can be identified clinically without a screening test. The poor predictability, difficulty in implementation, and the high costs of developmental testing suggest that children, particularly those in high-risk communities, might be better served by implementing intervention programs for all, instead of trying to identify the outliers through screening.

Autism and developmental screening in a public, primary care setting primarily serving Hispanics: challenges and results

We implemented screening of children 16-30 months of age (n = 1,760) from a typically under-served, primarily Hispanic, population, at routine pediatric appointments using the modified checklist for autism in toddlers (M-CHAT) and Ages and Stages Questionnaire. Screen positive rates of 26 and 39%, respectively, were higher than previous reports. Hispanics were more likely to score M-CHAT positive than non-Hispanics (adjusted OR 1.7, 95% CI 1.2-2.4), as were those screened in Spanish. About 30% of screen-positive children were referred for further assessment, but only half were seen. Thus screening in this population is feasible, but may require additional resources. Attention to the cultural applicability of screening instruments, as well as to explaining the results or need for additional services to parents, is critical to serve the growing Hispanic population.

The Early Motor Questionnaire (EMQ): a parental report measure of early motor development

Children's early motor skills are critical for development across language, social, and cognitive domains, and warrant close examination. However, examiner-administered motor assessments are time consuming and expensive. Parent-report questionnaires offer an efficient alternative, but validity of parent report is unclear and only few motor questionnaires exist. In this report, we use cross-sectional and longitudinal data to investigate the validity of parent report in comparison to two examiner-administered measures (Mullen Scales of Early Learning, MSEL; Peabody Developmental Motor Scales, PDMS-2), and introduce a new parent-report measure called the Early Motor Questionnaire (EMQ). Results indicate strong correlations between parent report on the EMQ and a child's age, robust concurrent and predictive validity of parent report with both the MSEL and PDMS-2, and good test-retest reliability of parent report on the EMQ. Together, our findings support the conclusion that parents provide dependable accounts of early motor and cognitive development.

Incremental Validity in the Clinical Assessment of Early Childhood Development

The authors demonstrate the increment of clinical validity in early childhood assessment of physical impairment (PI), developmental delay (DD), and autism (AUT) using multiple standardized developmental screening measures such as performance measures and parent and teacher rating scales. Hierarchical regression and sensitivity/specificity analyses were used to identify the differential impact of each domain the scales measure. Significant findings include (a) self-help domains in either parent or teacher questionnaires are more significant contributors than social-emotional domains to early detection, (b) performance measures are stronger predictors than parent or teacher questionnaires in detecting physical impairment or developmental delay, and (c) parent questionnaires measuring self-help skills are a stronger predictor of autism than performance measures. These results support the combined use of parent and teacher rating scales and provide important implications in choosing instruments for different developmental disorders when time and resources are limited.

Effectiveness of developmental screening in an urban setting

OBJECTIVE

To determine the effectiveness of developmental screening on the identification of developmental delays, early intervention (EI) referrals, and EI eligibility.

METHODS

This randomized controlled, parallel-group trial was conducted from December 2008 to June 2010 in 4 urban pediatric practices. Children were eligible if they were <30 months old, term, without congenital malformations or genetic syndromes, not in foster care, and not enrolled in EI. Children were randomized to receive 1 of the following: (1) developmental screening using Ages and Stages Questionnaire-II (ASQ-II and Modified Checklist for Autism in Toddlers (M-CHAT) with office staff assistance, (2) developmental screening using ASQ-II and M-CHAT without office staff assistance, or (3) developmental surveillance using age-appropriate milestones at well visits. Outcomes were assessed using an intention-to-treat analysis.

RESULTS

A total of 2103 children were enrolled. Most were African-American with family incomes less than $30,000. Children in either screening arm were more likely to be identified with delays (23.0% and 26.8% vs 13.0%; P < .001), referred to EI (19.9% and 17.5% vs 10.2%; P < .001), and eligible for EI services (7.0% and 5.3% vs 3.0%; P < .001) than children in the surveillance arm. Children in the screening arms incurred a shorter time to identification, EI referral, and EI evaluation than children in the surveillance arm.

CONCLUSIONS

Children who participated in a developmental screening program were more likely to be identified with developmental delays, referred to EI, and eligible for EI services in a timelier fashion than children who received surveillance alone. These results support policies endorsing developmental screening.

Global perspective on early diagnosis and intervention for children with developmental delays and disabilities

Low- and middle-income countries are experiencing a significant reduction in mortality of children under 5 years of age. This reduction is bringing in its wake large numbers of surviving children with developmental delays and disabilities. Very little attention has been paid to these children, most of whom receive minimal or no support. Thus, there is an urgent need to recognize that improving the quality of life of the survivors must complement mortality reduction in healthcare practice and programs. The incorporation of early evaluation and intervention programs into routine pediatric care is likely to have the most impact on the quality of life of these children. We therefore call for leadership from practitioners, governments, and international organizations to prioritize regular childhood developmental surveillance for possible delays and disabilities, and to pursue early referral for intervention.

Developmental evaluation of preschool children: a service-learning experience for nursing students

Service-learning is a practice that is beneficial for both students and community participants. This article presents the service-learning experience of senior-level undergraduate nursing students at a southeastern U.S. university. Nursing students were taught how to administer the Denver II Developmental Screening Test (DDST-II), and they then evaluated high-risk preschool children during a clinical nursing experience. A total of 1,030 children were screened between 2008 and 2012. Early detection of developmental delays promotes earlier intervention for concerns, and the implementation of this service-learning project using a valid and sensitive screening tool aids in the cost-effective identification of preschool children who are at risk for developmental delays. Student evaluations of the experience were positive, and examples of the knowledge acquired are provided.

Validity of the fine motor area of the 12-month ages and stages questionnaire in infants following major surgery

The Ages and Stages Questionnaires (ASQ) are parent-report screening tools to identify infants at risk of developmental difficulties. The purpose of this study was to examine validity and internal reliability of the fine motor developmental area of the ASQ, 2nd edition (ASQ2-FM) for screening 12-month-old infants following major surgery. The ASQ2-FM was completed by caregivers of 74 infants who had cardiac surgery in the first 90 days of life, 104 infants who had noncardiac surgery in the first 90 days of life, and a control group of 154 infants. The Rasch item response analysis revealed that the ASQ2-FM had poor ability to discriminate among levels of fine motor ability. Sensitivity was poor (20%) and specificity was good (98%) when compared with the scores for the fine motor subscale of the Bayley Scales of Infant and Toddler Development. The ASQ2-FM under-identified infants at risk for fine motor delay; internal reliability and construct validity do not support use as a screening tool of fine motor development of infants aged 12 months who have undergone major surgery.

Screening in child health: studies of the efficacy and relevance of preventive care practices

BACKGROUND

Pediatric screening enables the prevention or early detection of diseases and developmental disturbances in infancy and childhood. Screening is a standard component of pediatric practice in many countries, but its scientific basis is not well known.

METHODS

The scientific justification for pediatric screening beyond the neonatal period is presented on the basis of a selective review of the literature on some aspects of pediatric screening.

RESULTS

The level of evidence varies highly among pediatric screening interventions and can be difficult to determine because of confounding variables. Parent counseling is associated with improvements in child-raising competence, accident prevention, and reading behavior. The early detection of abnormalities in a child's motor, linguistic, mental, or social development is possible and often leads to effective early interventions. Cyanotic congenital heart defects can be detected with 63% sensitivity and 99.8% specificity; cerebral palsy can be diagnosed with 33% to 100% sensitivity and 52.3% to 100% specificity (different figures from multiple studies). Physical therapy seems to improve some manifestations of cerebral palsy. Motor development at 90 days is correlated with motor development at 57 months (72% sensitivity, 91% specificity). A developmental quotient above 85 in a two-year-old child is correlated with an intelligence quotient above 85 when the child is 7 years old.

CONCLUSION

There is an increasing amount of scientific evidence in favor of pediatric screening. Nonetheless, further epidemiological studies are needed.

Application of neurodevelopmental screening to a sample of South American infants: the Bayley Infant Neurodevelopmental Screener (BINS)

OBJECTIVE

To evaluate the utility of the Bayley Infant Neurodevelopmental Screener (BINS), standardized in the US, for South American infants, 3-24 months of age.

METHODS

Thirty-five physicians administered the BINS to 2471 South American infants recruited during routine well-child visits, 578 (23%) from Brazil and 1893 (77%) from six other South American countries. The BINS was translated into Spanish and Portuguese and participating physicians were trained to administer the BINS. Physician inter-rater agreement with training tapes was 84.4%; test-retest reliability for age item sets ranged from 0.80 to 0.93 (Pearson's r). Infants were classified into being at low, moderate, or high risk for developmental delay or neurological impairment based on their total BINS score. The sample was stratified by infant's age, sex and language (Spanish and Portuguese). The BINS scores were compared to the scores of the US infant sample used to standardize the BINS.

RESULTS

Female infants performed higher than male at 16-20 months and 21-24 months; male infant scores were more variable at 5-6 months. Scores on only two items were significantly different between Spanish and Portuguese speaking participants. South American scores were typically significantly higher than the US sample, and a lower proportion of infants were classified as being at high risk in the South American sample than in the US standardization sample.

CONCLUSION

Overall, the results of this study indicate that the BINS is feasible and appropriate for neurodevelopmental screening in South America. Further studies are needed to confirm the BINS utility in South America, including its use with a clinical sample.

Office screening and early identification of children with autism

Autism spectrum disorders (ASDs), also called pervasive developmental disorders in the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revised), constitute a group of neurodevelopmental disorders that coalesce around a common theme of impairments in social functioning, communication abilities, and repetitive or rigid behaviors. The ASDs considered here include autism/autistic disorder, Asperger disorder/Asperger syndrome (AS), and pervasive developmental disorder not otherwise specified. This article focuses on autism/autistic disorder screening and its early identification, with a brief mention for AS screening, as there are limited tools and no recommendation for universal screening for AS.

The Impact of Household Investments on Early Child Neurodevelopment and on Racial and Socioeconomic Developmental Gaps - Evidence from South America

This paper assesses the effects of household investments through child educating activities on child neurodevelopment between the ages of 3 and 24 months, and evaluates whether investments explain racial and socioeconomic developmental gaps in South America. Quantile regression is used to evaluate the heterogeneity in investment effects by unobserved developmental endowments. The study finds large positive investment effects on early child neurodevelopment, with generally larger effects among children with low developmental endowments (children at the left margin of the development distribution). Investments explain part of the observed racial gaps and the whole socioeconomic developmental gap. Investments may compensate for low endowments and policy interventions to increase investments may reduce early development gaps and result in high social and economic returns.

Physician "costs" in providing behavioral health in primary care

OBJECTIVE

To examine pediatricians time spent, and resulting reimbursement payments for, addressing behavioral health concerns in a rural primary care pediatric practice.

METHODS

Research assistants observed 228 patient visits in a rural pediatric primary care office. The length of the visit (in minutes), content of visit, number and type of codes billed, and related insurance reimbursement amounts were recorded. Interrater reliability, scored for 22% of patient visits, was ≥90%.

RESULTS

Medical only visits lasted, on average, 8 minutes as compared with behavioral only visits that required nearly 20 minutes of physician time. Pediatricians billed up to 10 different billing codes for medical only visits but only billed 1 code for behavioral only visits. Consequently, pediatricians were reimbursed significantly less, per minute, for behavioral only visits as compared with those sessions addressing medical only or a combination of medical and behavior concerns.

CONCLUSION

Findings converge with previous research, demonstrating that behavioral health concerns dramatically affect the length of visit for primary care physicians. Moreover, this study is the first to document the specific impact of such concerns on pediatrician reimbursement for providing behavioral services. These results provide further support for integrating behavioral health services into pediatric primary care settings, thus allowing physicians to refer more difficult patients with behavioral issues to in-house collaborating behavioral health providers who can spend additional time necessary to address the behavioral health issue and who are licensed to receive mental health reimbursement.

Improving developmental screening in pediatric resident education

OBJECTIVE

Given that pediatricians cite low competency in developmental screening, this study aims to effectively teach screening to residents.

DESIGN

Using a quasi-experimental design, residents received an educational module and one-on-one teaching of 3 validated developmental screeners (Denver II, ASQ [Ages and Stages Questionnaire], and PEDS [Parents' Evaluation of Developmental Status]), with subsequent independent use with all 3 screeners with their own continuity patients. Outcome measures included changes in knowledge, skills, and preferences.

RESULTS

All residents achieved significantly increased skills with all screeners. They strongly preferred the ASQ (70%), citing that this taught them normal (30.2%) and pathological (27.9%) development while negatively noting time (72.1%), scheduling issues (30.2%), and difficulties with child cooperation (20.9%). Knowledge specifics did not significantly increase.

CONCLUSIONS

In-depth developmental screening education revealed marked improvement in skills and preferences. These evaluations led to full adoption of the ASQ in resident clinics. Future research must test if effective development teaching in residency leads to increased routine screenings in practice.

Concurrent validity of the parent-completed Ages and Stages Questionnaires, 2nd Ed. with the Bayley Scales of Infant Development II in a low-risk sample

Abstract Background This study assessed the concurrent validity of the Ages and Stages Questionnaire (ASQ) compared with Bayley Scales of Infant Development II (BSID II) amongst children aged 24 months. Methods Data were collected from 53 infants and mothers who participated in the New York State Angler Cohort Child Development Study. Parents completed the 24-month ASQ to assess communication, personal-social, problem-solving ability, and fine and gross motor control. The BSID II was administered by a clinical psychologist at the 24-month home visit for cognitive and psychomotor assessment. The ASQ was scored using age-specific norms of <2 SDs below any domain mean to define failure. A BSID II score of <85 indicated mild or severe delay, while a score of <70 suggested a severe delay. Results Scores on the ASQ communication and personal-social domains were moderately correlated with the BSID II Mental Scale (R= 0.52, P < 0.001; R= 0.45, P < 0.01) and ASQ gross motor with the BSID II Motor Scale (R= 0.46, P < 0.01), whereas ASQ problem-solving and fine motor domains were not significantly correlated with BSID II scores. The ASQ had a sensitivity of 100% and specificity of 87% at 24 months (n= 40) for severely delayed status. Conclusions Results suggest the ASQs provide a simple, valid, and cost-effective method for clinicians and field-based researchers to reduce the number of standardized assessments required to identify developmentally delayed infants at age 24 months. Future studies should further assess the validity of the ASQs in larger, more diverse populations of infants.

Developmental monitoring using caregiver reports in a resource-limited setting: the case of Kilifi, Kenya

Aim:

The main aim of the current study was to evaluate the reliability, validity and acceptability of developmental monitoring using caregiver reports among mothers in a rural African setting.

Methods:

A structured interview for parents of children aged 24 months and less was developed through both participant consultation and a review of literature. The reliability and validity of the schedule was evaluated through a 10-month monitoring programme of 95 children, aged 2–10 months. The acceptability of the process was evaluated by studying retention rates and by organizing focus group discussions with participating mothers.

Results:

The structured interview ‘Developmental Milestones Checklist’ consisted of 66 items covering three broad domains of child functioning: motor, language and personal–social development. The interview yielded scores of developmental achievements that showed high internal consistency and excellent test–retest reliability. The results were sensitive to maturational changes and nutritional deficiencies. In addition, acceptable retention rates of approximately 80% were found. Participating mothers reported that they found the procedures both acceptable and beneficial.

Conclusion:

Developmental monitoring using caregiver report is a viable method to identify and monitor at-risk children in Sub-Saharan Africa.

A longitudinal study of developmental and behavioral screening and referral in North Carolina's Assuring Better Child Health and Development participating practices

Screening children for developmental and behavioral delays is an important part of primary care practice. Well-child visits provide an ideal opportunity to engage parents and to do periodic screening. Screening identifies children who may be at risk and need further evaluation. In North Carolina's Assuring Better Child Health and Development project best-practices process, screening was incorporated as a routine part of well-child visits regardless of payor. The schedule of screenings, using the Ages and Stages Questionnaire, was 6, 12, 18 or 24, 36, 48, and 60 months. From the practices' population, a cohort of 526 children, screened from the age of 6 months during August 2001 through November 2003, was retrospectively reviewed. The main objectives of this descriptive study were to determine the number of children who were screened and whether this rate improved with time, observe patterns and trajectories for children identified at risk in 1 or more of the 5 developmental domains, and examine referral rates and physician referral patterns.

Healthy Steps: a systematic review of a preventive practice-based model of pediatric care

The preventive role of anticipatory guidance in pediatric practice has gained increasing importance over the last two decades, resulting in the development of competing models of practice-based care. Our goal was to systematically evaluate and summarize the literature pertaining to the Healthy Steps Program for Young Children, a widely cited and utilized preventive model of care and anticipatory guidance, Medline and the bibliographies of review articles for relevant studies were searched using the keywords: Healthy Steps, preventive care, pediatric practice and others. Other sources included references of retrieved publications, review articles, and books; government documents; and Internet sources. Relevant sources were selected on the basis of their empirical evaluation of some component of care (e.g., child outcomes, parent outcomes, quality of care). From 21 identified articles, 13 met the inclusion criteria of empirical evaluation. These evaluations were summarized and compared. Results indicated that the Healthy Steps program has been rigorously evaluated and shown to be effective in preventing negative child and parent outcomes and enhancing positive outcomes. Despite limited information concerning cost effectiveness, the Healthy Steps Program provides clear benefit through early screening, family-centered care, and evidence-based anticipatory guidance. It is recommended that the Healthy Steps program be more widely disseminated to relevant stakeholders, and further enhanced by improved linguistic and cultural sensitivity and long term evaluation of cost effectiveness.

PEDS: developmental milestones--an accurate brief tool for surveillance and screening

About 16% of children have developmental-behavioral disabilities but less than one-third of the children are detected by their health care providers, probably because of the use of informal milestones checklists. The goal of this study is to determine the reliability, validity, accuracy, and utility of a new tool, PEDS: Developmental Milestones (PEDS:DM). Data from a nationally representative sample of 1619 children administered developmental diagnostic measures were mined for items that best predicted performance in each developmental domain. A total of 112 met inclusion criteria, that is, sensitivity/specificity > or = 70%. For each domain/age level (birth to 8 years of age), sensitivity to performance less than or equal to the 16th percentile on diagnostic measures was 83% and specificity was 84%. Reliability was high (test-retest, .98 to .99; interrater, .82 to .96; kappa, .81). The readability level was 1.8 grades (range 1.1 to 2.6). The PEDS:DM appears to be a validated, accurate alternative to informal milestones checklists that are a probable contributor to underdetection of children with delays and disabilities.

Screening for risk factors of relational withdrawal behaviour in infants aged 14-18 months

OBJECTIVES

The objectives of this study were (1) to evaluate the prevalence of relational withdrawal behaviour in infants aged 14-18 months attending a public health centre in Paris, (2) to check some identified risk factors for relational withdrawal behaviour in this population.

METHODS

A cross-sectional study was conducted in infants aged 14-18 months attending a child health screening centre during the year 2005.

RESULTS

A total of 640 children were included in the study. Thirteen percent of the 640 infants (n=83, 95% CI [10.4%; 15.6%]) had an ADBB score at 5 and over 5 on the ADBB. There was a clear relationship between withdrawal behavior and having psychological difficulties as reported by parents, and between withdrawal and developmental delay. Withdrawal was also significantly associated with being a boy, with living in risk conditions (e.g. child being in joint custody, or with living in a foster family), with being adopted, or with being a twin. More withdrawn infants were taken care of at home.

CONCLUSION

Sustained relational withdrawal behaviour was linked with developmental disorders and psychopathology and not with SES, ethnical origin or rank of birth. The scale could be used in screening early psychopathology in infants aged 2-24 months of age.

Neonatal behaviour characteristics and psychological problems at 6 years

AIM

To examine the predictive capacity of the Neonatal Behavioral Assessment Scale (NBAS) on psychological problems at the age of 6 y.

METHODS

Eighty full-term infants of optimal health were evaluated at 3 d and 4 wk of age with the NBAS and at 6 y with the Child Behavior Checklist (CBCL) and the Inattention-Overactivity with Aggression Conners Teacher's Rating Scale (IOWA).

RESULTS

The NBAS clusters' predictive value was different at 3 d and at 4 wk. Orientation at 3 d and habituation at 4 wk were the best predictors of psychological problems. At 3 d, lower orientation scores and higher motor and habituation scores predicted higher scores in externalizing problems. Externalizing problems were least influenced by background variables. Only in girls were internalizing problems associated with lower orientation scores. At 4 wk, lower habituation cluster scores predicted higher scores in internalizing problems.

CONCLUSION

These findings suggest that the NBAS could be useful for identifying neonates at risk of later psychological problems.

Screening for developmental delay in the setting of a community pediatric clinic: a prospective assessment of parent-report questionnaires

OBJECTIVES

Our goal for this study was to prospectively test whether parent-completed questionnaires can be effectively used in the setting of a busy ambulatory pediatric clinic to accurately screen for developmental impairments. Specific objectives included (1) assessing the feasibility of using parent-report instruments in the setting of a community pediatric clinic, (2) evaluating the accuracy of 2 available screening tests (the Ages and Stages Questionnaire and Child Development Inventory), and (3) ascertaining if the pediatrician's clinical judgment could be used as a potential modifier.

METHODS

Subjects were recruited from the patient population of a community clinic providing primary ambulatory pediatric care. Subjects without previous developmental delay or concerns noted were contacted at the time of their routine 18-month-old visit. Those subjects who agreed to participate were randomly assigned to 1 of 2 groups and completed either the Ages and Stages Questionnaire or Child Development Inventory. The child's pediatrician also completed a brief questionnaire regarding his or her opinion of the child's development. Those children for whom concerns were identified by either questionnaire underwent additional detailed testing by the Battelle Development Inventory, the "gold standard" for the purposes of this study. An equal number of children scoring within the norms of the screening measures also underwent testing with the Battelle Development Inventory.

RESULTS

Of the 356 parents contacted, 317 parents (90%) agreed to participate. Most parents correctly completed the Ages and Stages Questionnaire (81%) and the Child Development Inventory (75%). Predictive values were calculated for the Ages and Stages Questionnaire and the Child Development Inventory (sensitivity: 0.67 and 0.50; specificity: 0.39 and 0.86; positive predictive value: 34% and 50%; negative predictive value: 71% and 86%, respectively). Incorporating the physician's opinion regarding the developmental status of the child did not improve the accuracy of the screening questionnaires.

CONCLUSIONS

Three important conclusions were reached: (1) parent-completed questionnaires can be feasibly used in the setting of a pediatric clinic; (2) the pediatrician's opinion had little effect in ameliorating the accuracy of either questionnaire; and (3) single-point accuracy of these screening instruments in a community setting did not meet the requisite standard for development screening tests as set by current recommendations. This study raises important questions about how developmental screening can be performed, and we recommend additional research to elucidate a successful screening procedure.

Setting the stage for success: implementation of developmental and behavioral screening and surveillance in primary care practice--the North Carolina Assuring Better Child Health and Development (ABCD) Project

Early identification of children with developmental and behavioral delays is important in primary care practice, and well-child visits provide an ideal opportunity to engage parents and perform periodic screening. Integration of this activity into office process and flow is necessary for making screening a routine and consistent part of primary care practice. In the North Carolina Assuring Better Child Health and Development Project, careful attention to and training for office process has resulted in a significant increase in screening rates to >70% of the designated well-child visits. The data from the project prompted a change in Medicaid policy, and screening is now statewide in primary practices that perform Early Periodic Screening, Diagnosis, and Treatment examinations. Although there are features of the project that are unique to North Carolina, there are also elements that are transferable to any practice or state interested in integrating child development services into the medical home. Included here are lessons learned and a listing of practical tools for implementation.

Follow up of infants following discharge from the neonatal unit: structure and process

Reviewing high risk infants after discharge to provide ongoing clinical care and to monitor later outcomes is an important role for neonatologists and paediatricians. Clinical need is the primary reason for such follow up but the process does provide additional opportunities, for example collecting information on later outcomes is vital for health care commissioning, and to determine the longer term effects of new medical treatments. Parents welcome the early identification of any problems in their infant and the opportunity for early intervention may improve outcomes in some circumstances. However, depending on the model adopted, follow up can be costly and this expenditure must be justified by considering the benefits obtained.

Developmental stages of developmental screening: steps to implementation of a successful program

Through the use of 2-stage screening strategies, research studies have shown that autism spectrum disorders and other developmental disabilities can now be detected reliably and with greater validity and in children as young as 18 months of age. Screening and diagnostic practices in the medical and educational arena lag far behind clinical research, however, with the average patient age at time of diagnosis being 3 to 6 years.We discuss the challenges of instituting universal developmental screening as part of pediatric care and present 2 models of existing or planned programs of early screening for autism spectrum disorder and developmental disability (1 in a community-based setting and 1 in a pediatric setting), and discuss the pros and cons of the different strategies.

The role of nurses in screening for autistic spectrum disorder in pediatric primary care

This article addresses the issue of integration of routine screening for autism spectrum disorder (ASD) in pediatric primary care. The relationship between screening and patient outcome is discussed. The ASD screening recommendations of the American Academy of Pediatrics and practical issues associated with their application are then reviewed. Finally, data from a pilot project to prepare nurses to conduct ASD screening during routine pediatric health visits are presented. The authors discuss the role of nurses in establishing systems within pediatric primary care to identify and refer children at risk for ASD.

Developmental screening

An estimated 5 to 10% of the pediatric population has a developmental disability. The current strategy to identify these children is through developmental surveillance, a continuous procedure in which the health professional observes the infant, takes a developmental history, and elicits any concerns that the caregiver might have. However, identification of delayed children is ineffective when based solely on routine surveillance. A necessary adjunct is developmental screening: the process of systematically identifying children with suspected delay who need further assessment. Screening tests greatly improve the rate of identification. With the advent of intervention programs and the support of organizations such as the American Academy of Pediatrics, the topic of developmental screening is a timely and essential one. This review aims to describe the properties of screening tests, to evaluate the available tools for developmental screening while providing a representative sample of the currently available developmental tests, and, finally, to evaluate the efficacy of intervention programs, a needed prerequisite to justify screening.

Early Diagnosis of Autism Spectrum Disorders

Autistic spectrum disorders (ASD) are an often-disabling continuum of disorders affecting two to four in 1000 children. These disorders have a core set of defining features including impaired verbal and nonverbal communication, impaired social interaction, and restricted or repetitive patterns of behavior. The cause of autism is unclear. The disorder can be defined only by related behaviors. Although there has been considerable improvement in standardized screening techniques for ASD in the past 10 years, screening and diagnostic practices in medicine and education lag far behind clinical research. Various studies have found the average age of diagnosis to be between 3 and 6 years, with significant differences as a function of ethnicity and socio-economic status. Preliminary research suggests that in some populations, missed diagnosis and misdiagnosis of ASD are common. This may be caused partly by inadequate screening practices. It also may reflect that presentation of symptoms varies from patient to patient. Lack of resources for appropriate referral, diagnosis, and treatment may play an important role. This article discusses recent progress in ASD screening, what is known of current screening and diagnostic practices, and future directions for research and practice improvement. The best practice model for the screening and early diagnosis of autism spectrum disorders and other developmental disabilities should include routine developmental surveillance as part of well-child pediatric care. General developmental screening should be followed by autism-specific screening for those children who fail the initial developmental screen, or whose parents report suspect behaviors.

Influences on participation rate in a national Norwegian child development screening questionnaire study

AIM

To describe the influence of demographic variables on participation rate in a child development screening questionnaire study, and to discuss the implications for data analysis and for the design of future similar studies.

METHODS

Appropriate Ages and Stages Questionnaires were mailed to 2392 mothers of children aged 4-60 mo. The bivariate and multivariate influence of demographic variables on responding was investigated.

RESULTS

The response rate decreased roughly linearly with the age of the child (ranging from 76% at 8 mo to 32% at 60 mo). Mother's educational level, civil status and (marginally) child's gender also contributed independently to the prediction of response.

CONCLUSION

Participation rate may be interpreted in terms of interest/saliency and time demands, if a mother's interest in her baby's normative development is assumed to be great, though decreasing as the child grows. Weighting for demographic variables seems to be a viable procedure in the present project; future studies may consider measures to increase the immediacy of questionnaire completion for mothers of children aged 3 y and older.