Supporting & Related Research

OBJECTIVES To assess the degree to which a national sample of pediatric practices could implement American Academy of Pediatrics (AAP) recommendations for developmental screening and referrals, and to identify factors that contributed to the successes and shortcomings of these efforts.

BACKGROUND In 2006, the AAP released a policy statement on developmental surveillance and screening that included an algorithm to aid practices in implementation. Simultaneously, the AAP launched a 9-month pilot project in which 17 diverse practices sought to implement the policy statement’s recommendations.

METHODS Quantitative data from chart reviews were used to calculate rates of screening and referral. Qualitative data on practices’ implementation efforts were collected through semi-structured telephone interviews and inductively analyzed to generate key themes.

RESULTS Nearly all practices selected parent-completed screening instruments, and half chose PEDS. Instrument selection was frequently driven by concerns regarding clinic flow. At the project’s conclusion, practices reported screening more than 85% of patients presenting at recommended screening ages. They achieved this by dividing responsibilities among staff and actively monitoring implementation. Despite these efforts, many practices struggled during busy periods and times of staff turnover. Most practices were unable or unwilling to adhere to 3 specific AAP recommendations: to implement a 30-month visit; to administer a screen after surveillance suggested concern; and to submit simultaneous referrals both to medical subspecialists and local early-intervention programs. Overall, practices reported referring only 61% of children with failed screens. Many practices also struggled to track their referrals. Those that did found that many families did not follow through with recommended referrals.

CONCLUSIONS A diverse sample of practices successfully implemented developmental screening as recommended by the AAP. Practices were less successful in placing referrals and tracking those referrals. More attention needs to be paid to the referral process, and many practices may require separate implementation systems for screening and referrals.

Comment by Dr. Glascoe: Implementing quality screens in primary care is a challenge. But referral coordination with non-medical services is even more problematic in terms of actually getting a child with apparent problems to services. Both medical and non-medical providers need to collaborate in making this process easier for families. Non-medical providers, in particular, need to provide health care clinicians feedback about outcomes (e.g., when a referral is received, when appointments are scheduled, AND send the results to providers). When children don’t qualify for IDEA, clinics need to know so they can refer to Head Start or other services, i.e., most non-qualifying children remain at risk and careful monitoring of progress is essential.

Background: The American Academy of Neurology together with other professional societies recommend the use of a broad-band developmental screen to be followed, if results are problematic, by an autism-specific screen. Given that only 30% of health care providers use a broad-band screen, let alone a secondstage narrow-band one, and that most rely instead on informal methods, a reasonable research question is whether parents’ concerns alone can detect children who need to be seen by an autism specialist.

Method: Links from various autism focused sites and from ad words on search engines, lead parents to www.forepath.org, a site that interfaces with electronic health records but is also offered directly to families for a small fee. The site provides for children between 18 and 60 months, two online screens: Parents’ Evaluation of Developmental Status (PEDS), a ten item tool eliciting parents’ concerns across each developmental domains, and the Modified Checklist of Autism in Toddlers (M-CHAT). Parents were provided a privacy policy notice that included consent to use anonymized results in research studies.

Results: Of 593 individuals who engaged the website from January, 2005 to January 2006, 135 (22.8%) did not fully complete both measures and were excluded from analysis. Of the remaining 458, 302 were mothers (65.9%), 32 were fathers (7%), 22 were grand- or foster-parents (4.8%), 22 were relatives/friends/teachers (4.8%) and 80 (17.8%) did not disclose their relationship. When compared to US Census Bureau data, respondents (who disclosed this information) were highly educated; 208 (61.5%) held college degrees and were disproportionately white; 292 (77.7%). Of their target children, the mean age was 34.7 months (sd = 11.39) and 302 (69%) were boys. On the M-CHAT, 289 children had failing scores (63.1%) while 169 (36.9%) passed. On PEDS, 427 (93.2%) received high or moderate risk scores (indicating the need for additional assessment or screening). At-risk PEDS scores identified 98% (283/289) of MCHAT failures but low-risk PEDS scores were only 15% specific (25/169) to M-CHAT passes. Thus PEDS alone would have resulted in excessive over-referrals to autism specialists. To discern whether unique constellations of parental concerns offered more parsimonious referral decisions, logistic regression was deployed to predict M-CHAT performance from the 10 kinds of concerns onPEDS. Because children’s ages are associated with different kinds of concerns (parents of older children tend to have more worries about expressive language and school performance), two regression analyses were run: one on children between 18 and 35 months of age, and a second on children 36 to 59 months of age.

In the youngest age group (N = 249), five types of concerns were associated with M-CHAT performance: behavior (OR = 2.9, CI = 2.10 – 3.97), fine motor (OR = 4.2, CI = 2.11 – 8.20), gross motor (OR = 4.4, CI = 1.23 – 8.68), receptive language (OR = 3.4, CI = 2.28 – 5.05), and social-emotional skills (OR = 2.4, CI = 1.71 – 3.39). The presence of three or more of these predictive concerns identified 131 of the 168 MCHAT failures (sensitivity = 78%) while fewer than three such concerns, identified 61 of the 81 M-CHAT passes (specificity = 75%). In the older age group (N = 209) concerns identified by logistic regression included receptive language (OR = 2.3, CI = 1.69 – 3.12), school performance (OR = 2.1, CI = 1.50 – 3.04), social-emotional (OR = 1.9, CI = 1.42 – 2.56), and expressive language concerns (OR = 2.0, CI = 1.48 – 2.63). The presence of three or more such concerns identified 81% of M-CHAT failures (98/121) while fewer than three was 70% specific to M-CHAT passes (62/88). When comparing respondents whose concerns accurately predicted M-CHAT results to those whose concerns did not, there were no differences on any demographic variable: child’s gender, language spoken at home, prior diagnosis, race, relationship to the child, child’s age or respondent’s level of education.

Conclusions: The results reinforce the value of carefully eliciting parents’ concerns because these provide a reasonable indicator of the probable presence or absence of autism spectrum disorder. Replication is needed on a more typical pediatric sample and preferably with diagnostic measures of autism in order to confirm the generalizability and validity of the findings. If confirmed, it may be advisable to modify the PEDS scoring paradigm so that it optimally identifies children with and without features of ASD. Nevertheless, adherence to the American Academy of Neurology recommendations for broad-band screening followed by an autism-specific tool yields far greater accuracy in determining the need for referral to an autism specialist.

Purpose/Background: The increasing prevalence of Autism Spectrum Disorders (ASD) has generated increased interest in identifying children with ASD at a young age. There is much discussion in the literature regarding best practices for screening and early identification. Some argue that at a young age, a general developmental screening tool at a first level (and then autism specific screening if the child fails) is as effective as using an ASD-specific tool at selected intervals to screen all young children.

Objective: Determine the utility of using a general developmental screening tool compared to an autism specific tool when screening for ASD.

Methods: An ongoing study to improve Developmental Delay (DD) and ASD screening practices in an urban pediatric primary care practice is underway. Data has been collected on the use and results of a standardized general developmental screening tool, the PEDS (Parents’ Evaluation of Developmental Status) and an autism-specific screening tool, the Modified Checklist for Autism in Toddlers (M-CHAT) in children ages 15 to 30 months. Assessments are complete for 66 children (55% male, mean age 23 months, 41% African American, 30% Caucasian, 15% Biracial, 14% Asian). The sensitivity, specificity, and positive predictive value of the PEDS compared to the M-CHAT in identifying young children at risk for ASD was computed. While the sensitivity of the PEDS compared to the M-CHAT was 77.8%, the specificity was only 26.3% and the positive predictive value was just 14.3%.

Results: Preliminary analysis indicates that in this urban pediatric population the PEDS as a first line screen is not a good substitute for the MCHAT when screening for ASD, as children who screen negative for general developmental concerns may score positive on the M-CHAT.

Conclusions: Specific red flag items for autism, included in ASDspecific screening tools, may not be adequately examined in a this specific general developmental screening tool. These findings should be replicated in a larger population with greater ethnic diversity. Sponsor: Centers for Disease Control and Prevention.

Comment from Dr. Glascoe: The results of both papers show that the majority of children who fail the M-CHAT also receive moderate or at-risk scores on PEDS. But problematic PEDS results alone do little to identify which children need referrals to autism specialists, because PEDS, like any other quality broad-band screening tool is also designed to identify other problems such as language impairment, learning disabilities, and mental retardation.

In my paper, patterns of concerns helped identify which children were likely to need referring to an autism specialist (and the latest print run of the PEDS Brief Guide includes this information and guidance). That said, it is clear from both papers that we can do better at early detection of autism spectrum disorders if we routinely use a measure like the M-CHAT. Indeed, the American Academy of Pediatrics is now recommending administration of an ASD screen at 18 and 14 months. Although this is wise, it is critical for those involved in early detection to note that measures like the M-CHAT do not identify with much regularity, the more common disabilities of childhood. So both a broad-band screen and an ASD specific one should be deployed at these an other visits, and otherwise, an ASD screen should be administered whenever PEDS results fall into moderate to high risk categories.

Many US State-wide screening initiatives (e.g., TN AAP, Iowa DoE) focus on detecting social-emotional/behavioral health problems (SEBH). Many health care providers and other professionals use broad-band screens for early identification, particularly measures focused on children’s skills/milestones. For SEBH-focused initiatives, should professionals view all domains of development or just SEBH risk? The goals of this study are to: a) Determine SEBH risk rates on PEDS: Developmental Milestones®(PEDS:DM®); b) Identify whether developmental delays are associated with SEBH risk; and c) Evaluate family psychosocial risk factors correlated with SEBH risk. The results should assist professionals with decisions about types of further assessment and interventions.

Many US State-side screening initiatives (e.g., TN AAP, Iowa DoE) focus on detecting social-emotional/behavioral health problems (SEBH). While a worthy goal, interening with children at risk for social-emotional/behavioral health problems (SEBH) may require a thoughtful view of overall development. Symptoms of SEBH (e.g., emotional distress, acting out) may be due to communication or motor deficits (e.g., when children do not understand what they are asked to do; if frustrated by difficulties expressing themselves; in the presence of motor delays that make it hard to execute self-help or academic tasks). Family psychosocial risk factors may also contribute to SEBH problelms. The goals of this study are to identify child and family characteristics associated with SEBH and to assist professionals in assessment, referral, and intervention decisions.

Objective: Parents’ Evaluation of Developmental Status (PEDS) is a validated tool used to assess child development that has not previously been tested in Australian general practice. We examined the effect of a Quality-Improvement intervention in a single general practice in Melbourne, Australia, that aimed to use this tool to improve the documented assessment of child developmental surveillance during vaccination visits.

Methods: Mixed methods incorporated audits of clinical records of children aged 1-5 years, before and after intervention, written questionnaires and a focus group (informed by the theoretical domains framework and Capability, Opportunity, Motivation-Behaviour (COM-B model)) with clinical and non-clinical staff.

Results: After 6 months, developmental surveillance more than doubled and was documented in more than one in three visits (34.1%). Almost one in five (18.6%) vaccination visits included the PEDS tool. Overall, the tool was positively received with staff expressing high levels of comfort asking parents to complete it (92.8%), increasing development of professional skills (71.4% staff) and confidence (55% clinicians) detecting developmental delays. Thematic analysis of the focus group transcript revealed underlying barriers arising from the practice environment, staff capabilities and motivation.

Conclusions: In a whole of practice Quality-Improvement intervention that applied PEDS training and implementation, including the receptionist in the medical team more than doubled documented rates of child developmental surveillance during vaccination visits. Solutions to underlying barriers could be incorporated into a revised training module. Future studies need to test the tool in more methodologically robust studies that include analysis of the outcomes of developmental surveillance.

Background:Only 30% of parents of children aged 9-35 months report that their child received a developmental screening in the previous year. Screening rates are even lower in low-income households, where the rates of developmental delays are typically higher than those in high-income households. Seeking to evaluate ways to increase developmental screening, Text4baby, a national perinatal texting program, created an interactive text message-based version of a validated developmental screening tool for parents.

Objective: This study aimed to assess whether a text message-based developmental screening tool is usable and acceptable by low-income mothers.

Methods: Low-income mothers of infants aged 8-10 months were recruited from the Women, Infants and Children Program clinics in Prince George’s County, MD. Once enrolled, participants used text messages to receive and respond to six developmental screening questions from the Parents’ Evaluation of Developmental Status: Developmental Milestones. After confirming their responses, participants received the results and feedback. Project staff conducted a follow-up phone survey and invited a subset of survey respondents to attend focus groups. A representative of the County’s Infants and Toddlers Program met with or called participants whose results indicated that their infants may be behind.

Results: Eighty-one low-income mothers enrolled in the study, 93% of whom reported that their infants received Medicaid (75/81). In addition, 49% of the mothers were Hispanic/Latina (40/81) and 42% were African American (34/81). A total of 80% participated in follow-up surveys (65/81), and 14 mothers attended focus groups. All participants initiated the screening and responded to all six screening questions. Of the total, 79% immediately confirmed their responses (64/81), and 21% made one or more changes (17/81). Based on the final responses, 63% of participants received a text that the baby was “doing well” in all six developmental domains (51/81); furthermore, 37% received texts listing domains where their baby was “doing well” and one or more domains where their baby “may be behind” (30/81). All participants received a text with resources for follow-up. In a follow-up survey reaching 65 participants, all respondents said that they would like to answer screening questions again when their baby was older. All but one participant would recommend the tool to a friend and rated the experience of answering questions and receiving feedback by text as “very good” or “good.”

Conclusions: A mobile text version of a validated developmental screening tool was both usable and acceptable by low-income mothers, including those whose infants “may be behind.” Our results may inform further research on the use of the tool at older ages and options for a scalable, text-based developmental screening tool such as that in Text4baby.

Background: Developmental delays are more prevalent in low-income countries and access to developmental screening is severely limited.

Introduction: This study evaluated an m-Health version of a standard developmental screening tool, Parents Evaluation Developmental Status (PEDS) and PEDS: Developmental Milestones (PEDS:DM) for use by community health workers (CHWs) in terms of

1. correspondence with conventional paper-based testing by a speech language pathologist (SLP) and
2. interrater reliability compared to an SLP.

Method: CHWs were trained in a primary healthcare (PHC) setting to administer the newly developed smartphone application version of the PEDS tools. One SLP and two CHWs recruited 207 caregivers who were attending a baby wellness clinic. Caregivers were tested by one CHW using the smartphone application of the PEDS tools; a qualified SLP simultaneously recorded and scored the PEDS tools on the same participants.

Results: High positive (100%) and nega- tive correspondence (96%) was found between the paper- based PEDS tools and the smartphone application PEDS tools and between the SLP and CHW. Almost perfect (Cohen’s Kappa) inter-rater agreement between conditions was dem- onstrated (j = 0.873 to j = 0.961).

Conclusions: Outcomes of the smartphone application, operated by a CHW, corre- sponded closely to the gold standard PEDS tools operated by a health professional. Trained CHWs can conduct accurate developmental screening using the smartphone version of the PEDS tools.

Background: Developmental delays are more prevalent in low-income countries and access to developmental screening is severely limited. Introduction: This study evaluated an m-Health version of a standard developmental screening tool, Parents Evaluation Developmental Status (PEDS) and PEDS: Developmental Milestones (PEDS:DM) for use by community health workers (CHWs) in terms of

1. correspondence with conventional paper-based testing by a speech language pathologist (SLP) and
2. interrater reliability compared to an SLP.

Method: CHWs were trained in a primary healthcare (PHC) setting to administer the newly developed smartphone application version of the PEDS tools. One SLP and two CHWs recruited 207 caregivers who were attending a baby wellness clinic. Caregivers were tested by one CHW using the smartphone application of the PEDS tools; a qualified SLP simultaneously recorded and scored the PEDS tools on the same participants. Results: High positive (100%) and nega- tive correspondence (96%) was found between the paper- based PEDS tools and the smartphone application PEDS tools and between the SLP and CHW. Almost perfect (Cohen’s Kappa) inter-rater agreement between conditions was dem- onstrated (j = 0.873 to j = 0.961).

Conclusions: Outcomes of the smartphone application, operated by a CHW, corre- sponded closely to the gold standard PEDS tools operated by a health professional. Trained CHWs can conduct accurate developmental screening using the smartphone version of the PEDS tools.

By 2014, 59.5 million people worldwide were forcibly displaced from their homes and living as refugees or stateless people. Over 50% of these individuals were children.

1. Of the nearly 70 000 refugees annually resettled to the United States, ∼30% are children.
2. The United Nations High Commissioner for Refugees reports that refugee and resettlement experiences may impact critical stages of intellectual, social, emotional, and physical child development.
3. Disruption to families and education and witnessed traumatic events impact the presentation of development concerns.

By 2014, 59.5 million people worldwide were forcibly displaced from their homes and living as refugees or stateless people. Over 50% of these individuals were children.

1. Of the nearly 70 000 refugees annually resettled to the United States, ∼30% are children.
2. The United Nations High Commissioner for Refugees reports that refugee and resettlement experiences may impact critical stages of intellectual, social, emotional, and physical child development.
3. Disruption to families and education and witnessed traumatic events impact the presentation of development concerns.

This large-scale longitudinal population study provided a rare opportunity to consider the interface between multilingualism and speech-language competence on children’s academic and social-emotional outcomes and to determine whether differences between groups at 4–5 years persist, deepen, or disappear with time and schooling. Four distinct groups were identified from the Kindergarten cohort of the Longitudinal Study of Australian Children (LSAC)

1. English-only + typical speech and language (n = 2012);
2. multilingual + typical speech and language (n = 476);
3. English-only + speech and language concern (n = 643); and
4. multilingual + speech and language concern (n = 109).

Two analytic approaches were used to compare these groups. First, a matched case-control design was used to randomly match multilingual children with speech and language concern (group 4, n = 109) to children in groups 1–3 on gender, age, and family socio-economic position in a cross-sectional comparison of vocabulary, school readiness, and behavioral adjustment. Next, analyses were applied to the whole sample to determine longitudinal effects of group membership on teachers’ ratings of literacy, numeracy, and behavioral adjustment at ages 6–7 and 8–9 years. At 4–5 years, multilingual children with speech and language concern did equally well or better than English-only children (with or without speech and language concern) on school readiness tests but performed more poorly on measures of English vocabulary and behavior. At ages 6–7 and 8–9, the early gap between English-only and multilingual children had closed. Multilingualism was not found to contribute to differences in literacy and numeracy outcomes at school; instead, outcomes were more related to concerns about children’s speech and language in early childhood. There were no group differences for socio-emotional outcomes. Early evidence for the combined risks of multilingualism plus speech and language concern was not upheld into the school years.

This large-scale longitudinal population study provided a rare opportunity to consider the interface between multilingualism and speech-language competence on children’s academic and social-emotional outcomes and to determine whether differences between groups at 4–5 years persist, deepen, or disappear with time and schooling. Four distinct groups were identified from the Kindergarten cohort of the Longitudinal Study of Australian Children (LSAC)

1. English-only + typical speech and language (n = 2012);
2. multilingual + typical speech and language (n = 476);
3. English-only + speech and language concern (n = 643); and
4. multilingual + speech and language concern (n = 109).

Two analytic approaches were used to compare these groups. First, a matched case-control design was used to randomly match multilingual children with speech and language concern (group 4, n = 109) to children in groups 1–3 on gender, age, and family socio-economic position in a cross-sectional comparison of vocabulary, school readiness, and behavioral adjustment. Next, analyses were applied to the whole sample to determine longitudinal effects of group membership on teachers’ ratings of literacy, numeracy, and behavioral adjustment at ages 6–7 and 8–9 years. At 4–5 years, multilingual children with speech and language concern did equally well or better than English-only children (with or without speech and language concern) on school readiness tests but performed more poorly on measures of English vocabulary and behavior. At ages 6–7 and 8–9, the early gap between English-only and multilingual children had closed. Multilingualism was not found to contribute to differences in literacy and numeracy outcomes at school; instead, outcomes were more related to concerns about children’s speech and language in early childhood. There were no group differences for socio-emotional outcomes. Early evidence for the combined risks of multilingualism plus speech and language concern was not upheld into the school years.

To assess whether age of initial parent developmental concern differs between children with autism spectrum disorder (ASD) vs other developmental conditions, and to assess whether provider response to initial parent concerns is associated with earlier diagnosis.

To assess whether age of initial parent developmental concern differs between children with autism spectrum disorder (ASD) vs other developmental conditions, and to assess whether provider response to initial parent concerns is associated with earlier diagnosis.

211 is a national telephone helpline focused on non-medical emergencies, i.e., addressing the challenges of people with unstable housing, food insufficiency, lack of money to pay for utilities or health care, etc. With help from the Robert Wood Johnson Foundation, 211LA added a screening and referral service for young children with autism and other developmental disabilities. After addressing the immediate issues raised by callers, 211LA staff asked parents if they would also like to discuss and assess their children’s development and behavior. Almost all parents were interested. Since its beginning in September 2009, the program has screened nearly eight thousand children under the age of five; nearly half were found to be at moderate to high risk of a development delay—rate much greater than found in general pediatric samples including low-income, Medicaid eligible families. 211LA’s referral coordination efforts (e.g., live call transfers to early intervention providers) ensures that this vulnerable population actually received services: 211LA’s families are ~ twice as likely to be enrolled in early intervention than are families screened in primary care. Thus 211LA serves as a national and replicable model for detecting and addressing the needs of high risk families and for supporting early identification efforts in primary care.This link provides more information on the Robert Wood Johnson Foundations efforts with 211LA and contact information for the program.

211 is a national telephone helpline focused on non-medical emergencies, i.e., addressing the challenges of people with unstable housing, food insufficiency, lack of money to pay for utilities or health care, etc. With help from the Robert Wood Johnson Foundation, 211LA added a screening and referral service for young children with autism and other developmental disabilities. After addressing the immediate issues raised by callers, 211LA staff asked parents if they would also like to discuss and assess their children’s development and behavior. Almost all parents were interested. Since its beginning in September 2009, the program has screened nearly eight thousand children under the age of five; nearly half were found to be at moderate to high risk of a development delay—rate much greater than found in general pediatric samples including low-income, Medicaid eligible families. 211LA’s referral coordination efforts (e.g., live call transfers to early intervention providers) ensures that this vulnerable population actually received services: 211LA’s families are ~ twice as likely to be enrolled in early intervention than are families screened in primary care. Thus 211LA serves as a national and replicable model for detecting and addressing the needs of high risk families and for supporting early identification efforts in primary care.This link provides more information on the Robert Wood Johnson Foundations efforts with 211LA and contact information for the program.

The goals of this study are to (a) inform clinicians embarking on evidence-based screening initiatives about what to expect when using quality tools, including provision of information on identification rates by age, patient mix, and well-visit uptake, and (b) describe the various implementation methods used by other clinics. Participants were professionals in 79 clinics across 20 U.S. states and elsewhere in North America, collectively serving 20,941 families via a Web-based screening ervice, PEDS Online, which offers developmental-behavioral/mental health and autism screens with automated scoring, report writing, and a mineable database. Problematic screening results were found in more than 1 out of 5 children, and rates of screening test failures increased with children’s ages. Children screened outside the well-child visit schedule were more likely to have screening test failures. Personnel at 22 of the 79 clinics were either interviewed or observed in person to identify implementation strategies. Clinics, even those serving families with limited education or lack of facility with English, found a variety of ways to make use of online screening services.

The goals of this study are to (a) inform clinicians embarking on evidence-based screening initiatives about what to expect when using quality tools, including provision of information on identification rates by age, patient mix, and well-visit uptake, and (b) describe the various implementation methods used by other clinics. Participants were professionals in 79 clinics across 20 U.S. states and elsewhere in North America, collectively serving 20,941 families via a Web-based screening ervice, PEDS Online, which offers developmental-behavioral/mental health and autism screens with automated scoring, report writing, and a mineable database. Problematic screening results were found in more than 1 out of 5 children, and rates of screening test failures increased with children’s ages. Children screened outside the well-child visit schedule were more likely to have screening test failures. Personnel at 22 of the 79 clinics were either interviewed or observed in person to identify implementation strategies. Clinics, even those serving families with limited education or lack of facility with English, found a variety of ways to make use of online screening services.

Drs. Cleave et al viewed the impact of the 2007 Mass Medicaid’s requirement for use of quality screening tools in primary care in order to best identify children with developmental-behavioral/mental health problems. Providers were motivated to comply with the mandate and most practices reported implementing screens routinely, whether for Medicaid patients or not, i.e., practices found it easiest to establish a consistent process across well-visits regardless of insurance). PEDS together with the M-CHAT were the most commonly selected measures due to their brevity and numerous translations (both are included in PEDS Online). The authors conclude that mandates are an effective way to improve evidence-based practice but that: a) physician champions are needed to promote solutions to implementation; and b) referral coordination and service capacity building are needed to make sure that children identified by screens receive intervention.

Drs. Cleave et al viewed the impact of the 2007 Mass Medicaid’s requirement for use of quality screening tools in primary care in order to best identify children with developmental-behavioral/mental health problems. Providers were motivated to comply with the mandate and most practices reported implementing screens routinely, whether for Medicaid patients or not, i.e., practices found it easiest to establish a consistent process across well-visits regardless of insurance). PEDS together with the M-CHAT were the most commonly selected measures due to their brevity and numerous translations (both are included in PEDS Online). The authors conclude that mandates are an effective way to improve evidence-based practice but that: a) physician champions are needed to promote solutions to implementation; and b) referral coordination and service capacity building are needed to make sure that children identified by screens receive intervention.

PEDS has been re-standardized and validated and its technical manual, Collaborating with Parents includes an enormous range of studies on PEDS.

PEDS has been re-standardized and validated and its technical manual, Collaborating with Parents includes an enormous range of studies on PEDS.

Objective: To study the relationship between parent concerns about development in the first year and a half of life and later autism diagnostic outcomes.

Method: Parent concerns about development were collected (via PEDS) for infants at high and low risk for autism, using a prospective, longitudinal design. Parents were asked about developmental concerns at study intake and when their infant was 6, 12, and 18 months. Infants were then followed up until 36 months, when diagnostic status was determined.

Results: By the time their child was 12 months, parents who have an older child with autism reported significantly more concerns in autism spectrum disorders-related areas than parents of children with typical outcomes. These concerns were significantly related to independent measures of developmental status and autism symptoms and helped predict which infants would later be diagnosed with autism or autism spectrum disorders. At 6 months, however, the concerns of parents who have an older child with autism do not predict outcome well.

Conclusion: Explicitly probing for parent concerns about development is useful for identifying children in need of closer monitoring and surveillance, as recommended by the American Academy of Pediatrics.

Comment: This invaluable study shows that parents may worry unnecessarily about their young children when an older child has an ASD diagnosis. That seems totally understandable and worth attending to with vigilant monitoring. Risk of ASD, just as with any developmental-behavioral problem increases as children age and the genetic correlates of ASD are high. Thus parents should be worried early on and it is our job as providers to address those worries, dispel when needed and watch carefully the development of all children at risk.

Objective: To study the relationship between parent concerns about development in the first year and a half of life and later autism diagnostic outcomes.

Method: Parent concerns about development were collected (via PEDS) for infants at high and low risk for autism, using a prospective, longitudinal design. Parents were asked about developmental concerns at study intake and when their infant was 6, 12, and 18 months. Infants were then followed up until 36 months, when diagnostic status was determined.

Results: By the time their child was 12 months, parents who have an older child with autism reported significantly more concerns in autism spectrum disorders-related areas than parents of children with typical outcomes. These concerns were significantly related to independent measures of developmental status and autism symptoms and helped predict which infants would later be diagnosed with autism or autism spectrum disorders. At 6 months, however, the concerns of parents who have an older child with autism do not predict outcome well.

Conclusions: Explicitly probing for parent concerns about development is useful for identifying children in need of closer monitoring and surveillance, as recommended by the American Academy of Pediatrics.

Comment: This invaluable study shows that parents may worry unnecessarily about their young children when an older child has an ASD diagnosis. That seems totally understandable and worth attending to with vigilant monitoring. Risk of ASD, just as with any developmental-behavioral problem increases as children age and the genetic correlates of ASD are high. Thus parents should be worried early on and it is our job as providers to address those worries, dispel when needed and watch carefully the development of all children at risk.

Background: The Parental Evaluation of Developmental Status (PEDS) questionnaire is a validated 10-item questionnaire that elicits parental concerns in multiple developmental areas. Little is known about how caretakers in minority populations perceive this tool to assess normal development.

Objective: To survey caretaker’s perceptions about the usefulness of the PEDS questionnaire to assess child development and self-evaluation regarding child development knowledge.

Design/Methods: We conducted a cross-sectional survey of a convenience sample at a resident’s continuity clinic at an academic community center in Philadelphia, PA. Inclusion criteria were: 1) Caretaker aged 18years 2) Child aged 2m-8years 3) Caretaker completed at least one PEDS survey at a previous visit. Data were analyzed with Pearson Chi-square. The study was approved for exempt status by the IRB.

Results: A total of 421 caretakers were approached, 269 met criteria, 231 were enrolled and 38 refused. Most caretakers felt confident with their level of knowledge about child development (36% average, 51% enough, 5% experts). The educational level of the caretakers was significantly associated with their self-assessment of child development knowledge (p=0.006). The majority (79%) reported the purpose of the PEDS was explained to them, and 78% felt that completing the PEDS form was easy/ very easy. Two thirds (65%) felt the PEDS was helpful to identify problems in their child’s development and 30% felt it was somewhat helpful. Half (53%) reported concerns in the PEDS, but a third (29%) of these reported the concerns were not addressed by the provider. Most (74%) caretakers were satisfied with the PEDS. Many parents commented that the PEDS questions were too broad and should be age specific . The majority (90%) agreed that, in addition to PEDS, a checklist could be helpful in understanding their child’s development.

Conclusions: Overall caretakers felt the PEDS was an easy tool to assess child development. However, a third felt the PEDS alone was not enough to identify problems in their child’s development and another third felt that their concerns had not been adequately addressed. These findings should encourage healthcare providers to address parental developmental concerns and provide additional tools to improve parental understanding about normal development. An additional developmental checklist may help address this need.

Comment: Complementing PEDS with an accurate milestones screens addresses AAP policy, helps parents learn more about expected developmental skills, and helps clinicians decide whether, for those children who land on Path B (moderate risk) or who land on Path C after 4 1/2 years of age (mental health risk), a referral is needed or whether advising parents is the best course (with vigilant monitoring,of course). Use of the PEDS:DM is a brief and helpful adjunct. Providers should also take opportunities at all well-visits to promote development, share information about typical development, etc.

Parents’ concerns about their children’s development or behaviour predicted clinically significant levels of parenting stress on the PSI (Parenting Stress Index) even though parents who requested medical evaluations for their children didn’t have PSI or PEDS scores that were associated with the requests. Primary Care providers need to consider this relationship when they’re interpreting screening results and to provide support and referrals to families.

Objectives: This study investigated the sensitivity and specificity of two brief, parent-completed developmental screening measures—the Ages and Stages Questionnaire (ASQ) and the Parents’ Evaluation of Developmental Status (PEDS)—in children presenting to their primary care providers.

Method: A sample of 334 children aged 12 to 60 months was recruited. Parents completed the PEDS and the ASQ in their home or the primary care clinic of one of the investigators. The presence of >1 predictive concerns or abnormal domains was considered a positive screen. All children underwent evaluation (administered by a psychologist) with the following criterion measures: the Bayley Scales of Infant Development—Third Edition or the Wechsler Pre- school and Primary Scale of Intelligence—Third Edition, the Preschool Language Scale—Fourth Edition, and the Vineland Adaptive Behavior Scales—Second Edition.

Results: The mean age of children was 32.3 months. Developmental delay was identified in 34 children (10%). The PEDS had moderate sensitivity (74%) but low specificity (64%); comparatively, the ASQ had significantly higher sensitivity (82%) and specificity (78%). The ASQ had moderate sensitivity and specificity across age subgroups, whereas the PEDS had either low sensi- tivity or specificity in each of the age subgroups, except for the <30 month group, where there was moderate sensitivity (78%) and specificity (75%). Using >2 predictive concerns on the PEDS or >2 abnormal domains on the ASQ significantly improved specificity of both tests (89% and 94%, respectively) but resulted in very low sensitivity (41% and 47%, respectively).

Conclusions: These findings support the guidelines of the American Academy of Pediatrics, demonstrating that both the ASQ and, to a lesser extent, the PEDS have reasonable test characteristics for developmental screening in primary care settings. Although the ASQ seems to have higher sensitivity and specificity across a variety of age groups, the choice of which measure to use should be determined by the practice setting, population served, and preference of the physician.

Comment from Dr. Glascoe: In response to the above paper, several researchers including the author of PEDS and the ASQ, raised concerns about the overly strict definition of developmental delay. PEDS is designed to identify children with milder delays, i.e., not just high risk but also at risk and this explains its lower specificity in comparison with the ASQ. In addition, it is not clear that the researchers dealt appropriately with PEDS Response Forms on which nothing was written–these should either be met with a readministration by interview or discarded from studies. The in-press letter to the editor is below.

Glascoe FP, Marks KP, Squires J. Improving the Definition of Developmental Delay. JDBP. 2011, in press

To the Editor:

We compliment Drs. Limbos and Joyce on their careful and well-written study (Comparison of the ASQ and PEDS in Screening for Developmental Delay in Children Presenting for Primary Care. The authors’ research was exemplary in viewing how well the ASQ and PEDS performed in the identification of children with probable disabilities, i.e., those scoring below the 10th percentile and ostensibly eligible for early intervention/special education.

But the term ‘developmental delay’ also embraces those likely to fail in school—those performing above the 9thth percentile and below the 25th percentile. Such at-risk children rarely qualify for Early Intervention or special education but that does not mean they don’t need to be identified by screens as in need of other kinds of intervention (e.g., Head Start, Reach Out and Read, parent training, etc.).

Screens should identify not only disabled but also at-risk children and provide clinicians appropriate guidance for selecting diverse resources needed to help both groups. We encourage the authors to review their findings in order to speak to the complete meaning of developmental delay. Such an analysis seems likely to render different levels of sensitivity and specificity for both PEDS and the ASQ.

Frances Page Glascoe, Ph.D.

Professor of Pediatrics
Vanderbilt University
Nashville, Tennessee

Kevin P. Marks, M.D., FAAP
PeaceHealth Medical Group
1162 Willamette
Eugene, Oregon 97401

Jane Squires, Ph.D.
Professor, College of Education
Director, Center on Human Development
Director, Early Intervention Program
University of Oregon
Eugene, Oregon

Objectives: This study investigated the sensitivity and specificity of two brief, parent-completed developmental screening measures—the Ages and Stages Questionnaire (ASQ) and the Parents’ Evaluation of Developmental Status (PEDS)—in children presenting to their primary care providers. Method: A sample of 334 children aged 12 to 60 months was recruited. Parents completed the PEDS and the ASQ in their home or the primary care clinic of one of the investigators. The presence of >1 predictive concerns or abnormal domains was considered a positive screen. All children underwent evaluation (administered by a psychologist) with the following criterion measures: the Bayley Scales of Infant Development—Third Edition or the Wechsler Pre- school and Primary Scale of Intelligence—Third Edition, the Preschool Language Scale—Fourth Edition, and the Vineland Adaptive Behavior Scales—Second Edition. Results: The mean age of children was 32.3 months. Developmental delay was identified in 34 children (10%). The PEDS had moderate sensitivity (74%) but low specificity (64%); comparatively, the ASQ had significantly higher sensitivity (82%) and specificity (78%). The ASQ had moderate sensitivity and specificity across age subgroups, whereas the PEDS had either low sensi- tivity or specificity in each of the age subgroups, except for the <30 month group, where there was moderate sensitivity (78%) and specificity (75%). Using >2 predictive concerns on the PEDS or >2 abnormal domains on the ASQ significantly improved specificity of both tests (89% and 94%, respectively) but resulted in very low sensitivity (41% and 47%, respectively). Conclusions: These findings support the guidelines of the American Academy of Pediatrics, demonstrating that both the ASQ and, to a lesser extent, the PEDS have reasonable test characteristics for developmental screening in primary care settings. Although the ASQ seems to have higher sensitivity and specificity across a variety of age groups, the choice of which measure to use should be determined by the practice setting, population served, and preference of the physician.

Comment from Dr. Glascoe: In response to the above paper, several researchers including the author of PEDS and the ASQ, raised concerns about the overly strict definition of developmental delay. PEDS is designed to identify children with milder delays, i.e., not just high risk but also at risk and this explains its lower specificity in comparison with the ASQ. In addition, it is not clear that the researchers dealt appropriately with PEDS Response Forms on which nothing was written–these should either be met with a readministration by interview or discarded from studies. The in-press letter to the editor is below.

Glascoe FP, Marks KP, Squires J. Improving the Definition of Developmental Delay. JDBP. 2011, in press

To the Editor:

We compliment Drs. Limbos and Joyce on their careful and well-written study (Comparison of the ASQ and PEDS in Screening for Developmental Delay in Children Presenting for Primary Care. The authors’ research was exemplary in viewing how well the ASQ and PEDS performed in the identification of children with probable disabilities, i.e., those scoring below the 10th percentile and ostensibly eligible for early intervention/special education.

But the term ‘developmental delay’ also embraces those likely to fail in school—those performing above the 9thth percentile and below the 25th percentile. Such at-risk children rarely qualify for Early Intervention or special education but that does not mean they don’t need to be identified by screens as in need of other kinds of intervention (e.g., Head Start, Reach Out and Read, parent training, etc.).

Screens should identify not only disabled but also at-risk children and provide clinicians appropriate guidance for selecting diverse resources needed to help both groups. We encourage the authors to review their findings in order to speak to the complete meaning of developmental delay. Such an analysis seems likely to render different levels of sensitivity and specificity for both PEDS and the ASQ.

Frances Page Glascoe, Ph.D.
Professor of Pediatrics
Vanderbilt University
Nashville, Tennessee

Kevin P. Marks, M.D., FAAP
PeaceHealth Medical Group
1162 Willamette
Eugene, Oregon 97401.

Jane Squires, Ph.D.
Professor, College of Education
Director, Center on Human Development
Director, Early Intervention Program
University of Oregon
Eugene, Oregon

Purpose: Quality screens are standardized on a sample of children and families whose socio-economic and demographic characteristics represent those of an entire nation (e.g., in the US by creating a normative group that reflects Census Bureau population parameters). Standardization of tests on such a sample defines what is typical performance and, in the case of screening tests, predicted frequencies of referral rates. Should researchers and clinicians working with Medicaid, NICU follow-up, or other at-risk groups expect their referral rates to differ from national norms?

Methods: Referral rates based on national norms for Parents Evaluation of Developmental Status (PEDS) (N = 771) were compared to those from a pediatric clinic serving mostly Medicaid patients in Milwaukee, Wisconsin (N = 744), and to 211LA, a warm line serving mostly ethnic minority families (47% Latino and 30% Arican-American) in non-medical crisis (e.g., housing or food instability)(N = 257).

Results: Chi-square comparisons among the three groups revealed that clinics serving families with elevated rates of psychosocial risk (e.g., poverty, less than a high school education, limited English proficiency, etc.) had significantly higher rates of children with problematic performance on PEDS (p < .0001). These results are corroborated by other studies of at-risk children administered different screening tests.

Conclusions: The impact of psychosocial risk on development is well known to developmental-behavioral specialists. Helping trainees and generalist pediatricians anticipate increased referral rates when working with at-risk populations is needed. Screening test authors should help by reporting, not only the frequency of problematic performance on nationally representative samples, but also frequencies for various at-risk populations (e.g., children in foster-care, NICU follow-up, etc.).

Purpose: Quality screens are standardized on a sample of children and families whose socio-economic and demographic characteristics represent those of an entire nation (e.g., in the US by creating a normative group that reflects Census Bureau population parameters). Standardization of tests on such a sample defines what is typical performance and, in the case of screening tests, predicted frequencies of referral rates. Should researchers and clinicians working with Medicaid, NICU follow-up, or other at-risk groups expect their referral rates to differ from national norms?

Methods: Referral rates based on national norms for Parents Evaluation of Developmental Status (PEDS) (N = 771) were compared to those from a pediatric clinic serving mostly Medicaid patients in Milwaukee, Wisconsin (N = 744), and to 211LA, a warm line serving mostly ethnic minority families (47% Latino and 30% Arican-American) in non-medical crisis (e.g., housing or food instability)(N = 257).

Results: Chi-square comparisons among the three groups revealed that clinics serving families with elevated rates of psychosocial risk (e.g., poverty, less than a high school education, limited English proficiency, etc.) had significantly higher rates of children with problematic performance on PEDS (p < .0001). These results are corroborated by other studies of at-risk children administered different screening tests.

Conclusions: The impact of psychosocial risk on development is well known to developmental-behavioral specialists. Helping trainees and generalist pediatricians anticipate increased referral rates when working with at-risk populations is needed. Screening test authors should help by reporting, not only the frequency of problematic performance on nationally representative samples, but also frequencies for various at-risk populations (e.g., children in foster-care, NICU follow-up, etc.).

The number of foster children and their psychological and medical morbidity are growing. To gain insight into how to recruit and retain foster homes, characteristics of 64 foster families were determined by interview. Foster parents had low-to-moderate incomes, were approaching middle age, had underutilized home space, and wanted more children. Most enjoyed foster care and planned to continue. Twenty-three percent of the 64 had half of all foster children in the study in their homes at interview and had cared for seven times as many children in the past, including 66% of all the teens and 83% of all the handicapped children who had been in the 64 homes. These “high providers” functioned like group homes for mentally handicapped individuals. Adapting the group-home concept to foster homes could improve care, especially for children with special needs.

One of the oldest and best known developmental screening tests was recently restandardized and revised as the Denver-II. Because it was published without evidence of its accuracy, the present study was undertaken with 104 children between 3 and 72 months of age attending one of five day-care centers. To determine the presence of developmental problems, children were administered individual measures of intelligence, speech-language, achievement, and adaptive behavior. A second psychological examiner, blind to the outcome of the diagnostic battery, administered the Denver-II. Developmental problems including language impairments, learning disabilities, mild mental retardation, and/or functional developmental delay were found in 17% of the children. The Denver-II identified correctly 83% and thus had high rates of sensitivity. However, more than half the children with normal development also received abnormal, questionable, or untestable Denver-II scores. Thus the test had limited specificity (43%) and a high overreferral rate. The alternative scoring method, categorizing questionable/untestable scores as normal, caused sensitivity to drop to 56% although specificity rose to 80%. Since neither scoring method produced acceptable levels of accuracy, an effort was made to locate the sources of accuracy and inaccuracy within the test. Only items in the language domain were modestly helpful in discriminating children with and without difficulties. The findings suggest that the authors of the Denver-II need to engage in further development of the instrument including revising scoring criteria and item placement in relation to children’s ages. In the interim, test users should employ screening tests which are more accurate such as the Minnesota Inventories or the Battelle Developmental Inventory Screening Test.

Recent research and legislation support the importance of early identification and intervention for children with developmental and behavioral or emotional problems. Detecting these children often depends on medical professionals, especially pediatricians. However, few pediatricians use developmental screening tests to help them identify children. Rather, physicians usually rely on their clinical impressions to discriminate children with and without difficulties. Research on the accuracy of clinical impressions, although sparse, suggests that only half the children in need are identified. The most obvious reasons, such as severity of the problem or the type of clinical information physicians select (e.g., parents’ concerns, observations of the child, history, etc.), do not fully explain why some children are identified and others are not. More complete explanations are found in research on clinical impression formation that suggests physician’s selection from the array of clinical data is mediated by their unique experiences, beliefs, and attitudes. These qualities provide a set of judgment heuristics for sorting seemingly relevant from irrelevant information. Judgment heuristics, depending on their content, may lead to accurate or inaccurate impressions. This article suggests a model of ideal impression formation that may help physicians learn to more accurately identify children with developmental and behavioral or emotional problems.

Comment: Almost 20 years later, we are still not finding a way for clinical judgment to detect young children with delays and disabilities without the support of accurate screening tools. This isn’t a slight on clinical acumen but rather that professional judgment is enhanced by and needs to depend on evidence. Problems are often subtle and quality measurement is critical (and informal milestones checklists, even if drawn from standardized measures, fail to provide a sufficient threshold of suspicion).

Developmental screening tests are widely used for early identification but few are studied for their accuracy—the percentage of children with and without problems correctly detected. The absence of such data makes it difficult for professionals to choose measures wisely and to avoid those that under-detect or over-refer. In this article, the accuracy of three developmental screening tests was assessed. Measures included the Academic Scale of the Developmental Profile-II (DP-II), the Denver II, and the Battelle Developmental Inventory Screening Test (BDIST). Each was administered, along with a criterion battery of intelligence, adaptive, language, and achievement measures, to 89, 7- to 70-month-old children, enrolled in one of five day care centers. Twenty percent of the children tested were found to have developmental disabilities, including language delays, mental retardation, developmental delay, and autism. The Academic Scale identified fewer than one in four of the children with diagnoses, although under-referrals were minimal. The Denver-II detected the majority of children (if questionable/untestable scores were grouped with abnormal) with difficulties, but most children without problems also failed the measure. The BDIST, using the 1.5 cut-offs, was more accurate than the other screening tests and identified correctly 72% of the children with difficulties, and 76% of the children without diagnoses.

Comment: The BDIST has been revised since this article was written. The Developmental Profile is now out in its 3rd edition (but without evidence that it works as a screening measure, i.e., no cutoff scores but is helpful for NICU follow-up and EI intake as is the more recently published PEDS: Developmental Milestones. The Denver-II remains as it was in 1992 and continues to under-detect if questionables/untestables are not referred and over-detected if they are referred. Work on this tool is needed!

To determine whether parents’ estimates of children’s developmental ages can function as a prescreening technique.

OBJECTIVE: To examine parent concerns about development, learning, and behavior for young children of Mexican origin, and to identify whether these reports differ by families’ citizenship/documentation status.

METHODS: Data come from the 2005 California Health Interview Survey, a population-based random-digit dial telephone survey of California’s noninstitutionalized population. California Health Inerview Survey (CHIS) investigators completed interviews of 43 020 households with a total of 5856 children under age 6 years, of whom 1786 were reported being of Mexican origin. Developmental risk was measured by parent concerns elicited by the Parents’ Evaluation of Developmental Status. We used bivariate and multivariate analyses to examine associations between developmental risk and family citizenship/documentation status (parents are undocumented, at least one documented noncitizen parent, or both parents are US citizens) among children of Mexican origin and US-born non-Latino white children, after adjusting for age, income, parental education, and predominant household language.

RESULTS: In multivariate analyses, children of Mexican origin did not differ significantly from US-born white children in developmental risk (odds ratio 1.12, 95% confidence interval 0.88-1.42). In subgroup analyses, children of Mexican origin with undocumented parents had higher odds of developmental risk (odds ratio 1.53, 95% confidence interval 1.00-2.33) than non-Latino white children whose parents were citizens, after adjusting for confounders.

CONCLUSIONS: Mexican children with undocumented parents have greater parent-reported developmental risk than Mexican and white children whose parents are US citizens or otherwise legally documented. More research is needed to understand the roles of immigration stress and home environments on the developmental risks of children in households with undocumented parents.

This is the third in a series of articles in Contemporary Pediatrics devoted to early detection of children with developmental-behavioral problems, the most common of all childhood conditions and one we can often treat, with good outcomes. This article covers how to help parents participate in the process of early detection and addresses these topics:

• Early intervention assessment is often critical to diagnosing a potentially treatable or preventable condition.
• Early intervention and early childhood special education services depend on early detection.
• Early intervention is associated with long-term improvements in math and language scores.
• Clinicians are responsible for discussing screening test results with parents.
• Before explaining a screen’s results, how to ask parents to discuss concerns they have about their child.
• How to tell parents that many developmental-behavioral disorders or disabilities have evidence-based treatment plans and positive outcomes

OBJECTIVE The goal of this study was to assess which parenting behaviors, perceptions, and risk factors were associated with optimal versus delayed development.

METHODS A total of 382 families from the national Brigance Infant and Toddler Screens standardization and validation study participated. Data sources included parent questionnaires, child testing, and examiner observations of parent-child interactions. Parenting styles research was operationalized with the Brigance Parent-Child Interactions Scale, a brief measure of parenting behaviors and perceptions.

RESULTS Six positive parenting behaviors and perceptions predicted average to above-average development on the Brigance screens. Conversely, <2 positive parenting behaviors and negative perceptions of children indicated child performance nearly 2 SDs below the mean on Brigance screens. Psychosocial risk factors associated with fewer positive parenting behaviors and with negative perceptions included >3 children in the home, multiple moves, limited English, and parental depression.

CONCLUSIONS A dearth of positive parenting behaviors plus negative perceptions of children, with or without psychosocial risk factors, negatively affect child development, which is apparent as early as 6 months of age. The older the child is, the greater the performance gaps are. Language development is particularly at risk when parenting is problematic. Findings underscore the importance of early development promotion with parents, focusing on their talking, playing, and reading with children, and the need for interventions regarding psychosocial risk factors.

Background: Because PEDS’ is quite brief and enjoys abundant supporting research, it has been included in the National Survey of Children’s Health, National Survey on Early Childhood Health (NSECH), Promoting Healthy Developmental Survey (PHDS), California Health Interview Survey (CHIS), California First Five Survey, Calgary and Toronto’s Public Health Departments. (Abstracts and commentary from a range of studies, appear at the bottom of this document). When used in surveys, PEDS has traditionally differed from (clinical) PEDS in that it eliminates all open-ended questions and includes several others items that encourage parents to indicate concerns about their child’s vision, hearing, health, and global developmental status.

Challenges: While helpful in population-focused needs assessment and public health mapping studies, PEDS in a survey format cannot be used to clinical care because it does not elicit parents’ actual concerns. Verbatim comments are essential for focusing an encounter, i.e., choosing parent education materials, creating a follow-up plan and a problem checklist, identifying the types of referrals needed, and managing visit length by reducing the ever problematic, “oh by the way” concerns. Parents who have been encouraged to give voice to their concerns are far more likely to follow through with recommendations.

An additional challenge when using PEDS as a closed-ended survey is that Spanish speakers seem to have difficulty with the questions and thus have suspiciously low rates of risk. Translation problems seem explanatory (since translation problems have dogged other measures such as the Pediatric Symptom Checklist). Further, some questions, even in English, have varied across studies, making it hard for researchers to compare findings across studies. Scoring for PEDS within surveys, even though established within the PHDS survey, seems to be a continuing mystery to many researchers, requiring hours of uncompensated input from PEDS’ staff.

Solutions: As a consequence, we have created an electronic, official version of Survey PEDS. This features the 12 questions with CATI (computer-assisted telephone interview) style prompts for the closed-ended responses; all much improved over that used in earlier surveys, and all questions and responses have been the focus of very careful translation into Spanish, i.e., vetted by more than 20 Spanish-English speaking health care providers, and then trialled against clinical PEDS and shown to have a high level of agreement (98%).

Scoring is automated and thus both error free and a substantial time-saver over hand-scoring. The scoring service also automatically computes the child’s exact chronological age with corrections for prematurity up to 24 months of age. The results parallel clinical PEDS: high risk, moderate risk, low risk but concerned, or low risk/not concerned.

Other features of the online scoring service are brief recommendations about the apparent needs of each child and family (e.g., for speech-language evaluation, information on child-rearing, more vigilant monitoring of developmental-behavioral status, mental health services, etc.). The service also offers the (optional) Modified Checklist of Autism in Toddlers, and will soon have the 6 – 8 skill focused questions at each age from PEDS: Developmental Milestones, along with translations into languages other than English and Spanish.

The Survey PEDS online scoring service also provides, optionally, space to type in parents’ exact comments. This enables interviewers to capture the specific types of concerns parents have, and thus use Survey PEDS in both population research and clinical care. Additional information, mostly clinical in nature, returned from our site include summary reports for parents, referral letters if needed, and ICD-9 and procedure codes. The service also houses an administrative panel so that licensed users can review records of all screens administered and view of summary of overall results.

Although the Survey PEDS service costs, research discounts apply and per use fees range from $1.03 to $1.37, depending on volume. The site can be used in various ways as follows:

The Survey PEDS scoring service can be used in various ways:

1. Accessing the site when administering PEDS. Results are returned in real time;
2. Collecting PEDS answers within your own software/database and sending, usually at the end of your study, a batch submission that we score and return for you (and for which we will send formatting specifications, and the Survey PEDS questions to include in your software). You would then concatenate the Excel type database we return into your own; and/or
3. a truly integrated approach where parents’ comments are sent to our server, scored, and returned into your software/database (we can send the details on how to create and program the 25 or so fields needed in your software, but some IT support will be needed on your end as well).

We are happy to discuss the pros and cons of each approach according to how your project is structured, the skill levels of interviewers, their needs for real-time results, etc. Please contact us through our website (electronic inquiries).

Abstracts on PEDS as used in population research studies

Several studies fromToronto Public Health and Calgary Public Health (abstracted near the bottom of this document) used clinical PEDS in a CATI and capitalized on our scoring service.

It is the recommendation of the American Academy of Pediatrics Committee on the Psychosocial Aspects of Child and Family Health1 and the authors of Bright Futures2 that at each health supervision visit, pediatricians discuss parents’ psychosocial concerns. The value of this recommendation is supported, in part, by research showing that in response to a standardized protocol for eliciting and interpreting parents’ concerns, parents can provide highly accurate indicators of childhood disabilities.

Nevertheless, little is known about how parents express concerns outside of research settings. Pediatricians may use varying methods for eliciting concerns or they may depend on parents to raise concerns spontaneously. These approaches may alter the content of discussions or affect referral decisions. For example, Sharp et al. showed that despite readily engaging parents in discussions of psychosocial issues, pediatric residents had difficulty responding appropriately to parents’ concerns – often ignoring concerns or failing to explore them further.8 Another study showed that fewer than 50% of patients with psychiatric disturbance were referred even when parents raised concerns.

Thus there are a number of research questions to be answered about the actual use and impact of parents’ concerns about children’s development on provider referrals. These include:

• Are parents more likely to seek health care when they have concerns about their children?
• How likely are parents to discuss concerns about development with health care providers?
• What kinds of concerns are discussed?
• Do parental socioeconomic status and other family characteristics affect the likelihood of raising concerns?
• What happens after concerns are discussed?

The goal of this study is to provide preliminary answers to these questions. The results should have implications for the use of parents’ concerns in developmental surveillance and promotion as well as for future research.

Background: Developmental screening tests, even those meeting standards for screening test accuracy, produce numerous false-positive results for 15% to 30% of children. This is thought to produce unnecessary referrals for diagnostic testing or special services and increase the cost of screening programs.

Objectives: To explore whether children who pass screening tests differ in important ways from those who do not and to determine whether children over-referred for testing benefit from the scrutiny of diagnostic testing and treatment planning.

Methods: Subjects were a national sample of 512 parents and their children (age range of the children, 7 months to 8 years) who participated in validation studies of various screening tests. Psychological examiners adhering to standardized directions obtained informed consent and administered at least 2 developmental screening measures (the Brigance Screens, the Battelle Developmental Inventory Screening Test, the Denver-II, and the Parents’ Evaluations of Developmental Status) and a concurrent battery of diagnostic measures, including tests of intelligence, language, and academic achievement (for children aged 21⁄2 years and older). The performance on diagnostic measures of children who failed screening but were not found to have a disability (false positives) was compared with that of children who passed screening and did not have a disability on diagnostic testing (true negatives).

Results: Children with false-positive scores performed significantly (p< .001) lower on diagnostic measures than did children with true – negative scores . The false-positive group had scores in adaptive behavior, language, intelligence, and academic achievement that were 9 to 14 points lower than the scores of those in the true-negative group. When viewing the likelihood of scoring below the 25th percentile on diagnostic measures, children with false-positive scores had a relative risk of 2.6 in adaptive behavior (95% confidence interval [CI], 1.67- 4.21), 3.1 in language skills (95% CI, 1.90-5.20), 6.7 on intelligence tests (95% CI, 3.28-13.50), and 4.9 on academic measures (95% CI, 2.61-9.28). Overall, 151 (70%) of children with false-positive results scored below the 25th percentile on 1 or more diagnostic measures (the point at which most children have difficulty benefiting from typical classroom instruction) in contrast with 64 (29%) of the children with true-negative scores (odds ratio, 5. 6; 95% CI , 3. 73- 8. 49) . Children with false-positive scores were also more likely to be nonwhite and to have parents who had not graduated from high school. Performance differences between children with true-negative scores and children with false-positive scores continued to be significant (p < .001) even after adjusting for sociodemographic differences between groups.

Conclusions: Children overreferred for diagnostic testing by developmental screens perform substantially lower than children with true-negative scores on measures of intelligence, language, and academic achievement—the 3 best predictors of school success. These children also carry more psychosocial risk factors, such as limited parental education and minority status. Thus, children with false-positive screening results are an at-risk group for whom diagnostic testing may not be an unnecessary expense but rather a beneficial and needed service that can help focus intervention efforts. Although such testing will not indicate a need for special education placement, it can be useful in identifying children’s needs for other programs known to improve language, cognitive, and academic skills, such as Head Start, Title I services, tutoring, private speech-language therapy, and quality day care.

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 ≥70%. For each domain/age level (birth to 8 years of age), ensitivity 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; κ, .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.

Objective: To propose and preliminarily assess a model for helping providers select, based on empirical evidence, the optimal in-office developmental/behavioral service to offer families: (1) when to refer patients for diagnostic evaluations; (2) use screening measures to assist with referral decisions; (3) offer patient education; (4) watch vigilantly over time; and (5) when to offer reassurance and routine monitoring. The rationale is that if providers can respond optimally to children’s developmental and behavioral needs, children may be more likely to receive early intervention that can ameliorate or eliminate disabilities. This Is known to reduce the risk of school failure, drop out, criminality, teen child-bearing, and unemployment.

Subjects and Sites: Data from four previously published studies on the relationship between parents’ concerns and children’s developmental/behavioral status was grouped and reanalyzed in order to test optimal decision-making regarding parents’ concerns. Subjects were 771 children between 0 – 8 year of age and their parents who approximated demographic characteristics of the US. Settings included teaching hospitals, private pediatric practices, day care centers and public schools.

Measurement and Procedures: In all four studies, parents’ concerns were elicited by Parents’ Evaluation of Developmental Status (PEDS) and children were administered a battery of developmental and behavioral tests.

Results: The relationship between PEDS and concurrent measures revealed five distinct groups of families who either had different types of concerns or children with differing levels of risk. Children at highest risk were those whose parents had multiple of the concerns predictive of disabilities (OR = 20.1, CI = 10.5 – 36.3). Responding with screening tests reduced sensitivity below acceptable levels suggesting that referrals for diagnostic evaluations are the best response. Parents whose children had moderate levels of risk for disabilities were those with either single of the predictive concerns or with communication barriers, defined as incomplete, inconsistent or nonsensical responses on PEDS (OR ranges 4.4 to 7.6). These groups benefited from screening first to reduce false positives. Nevertheless, children in these groups who passed screening were likely to perform below average in areas critical to school success. This suggests the need for patient education and watchful waiting. Parents whose children had low levels of risk were those with no concerns or concerns nonpredictive of disabilities (OR ranges 1.0 -= 1.3). Screening these groups resulted in an unacceptable loss of specificity which suggests that patient education should be offered to those with nonpredictive concerns and routine monitoring for those with no concerns at all.

Conclusions: – The results suggest that clinicians can make reasonably accurate decisions about which psychosocial services to provide families if these decisions are based on the empirically derived relationship between parents’ concerns and children’s developmental status. Such an approach is not only brief but also offers a three fold improvement over the usual rates of disability detection in pediatric offices.

BACKGROUND: Early detection of autism spectrum disorders (ASD) is crucial for best outcomes; therefore it is essential to identify the specific characteristics on developmental-behavioral (DB) screening that call for further ASD screening.

OBJECTIVE: This study determines what DB concerns on the Parents’ Evaluation of Developmental Status (PEDS), a parent competed DB screening tool, were associated with critical (2/6 items most sensitive to ASD diagnosis) failures on an ASD specific screening tool, the Modified Checklist for Autism in Toddlers (M-CHAT), and if specific concerns are predictive for certain failed M-CHAT critical items.

DESIGN/METHODS: By retrospective chart review, demographic data and scores for M-CHAT and PEDS were abstracted from the website www.forepath.org. Subjects who failed the M-CHAT were divided into two groups: Critical vs. Non-Critical Failure. One or more predictive concerns on PEDS constituted a failed screen. Concerns in each PEDS developmental domain were analyzed for prediction of critical M-CHAT failures, and if particular concerns were associated with certain failed items.

RESULTS: Of the 361 subjects, 59% failed on the basis of critical items. With respect to demographic factors, the 2 groups differed only on residential location. The Critical Fail group was more likely to have a PEDS score that would lead to referral for further testing (OR 4.3 CI 1.34-13.77). The predictive items on PEDS for M-CHAT critical failure included expressive language (OR 2.1 CI 1.01-4.55), receptive language (OR 2.3 CI 1.33-3.91), and self-help (OR 2.2 CI 1.30-3.69), while behavior concerns were less predictive (OR .46 CI .21-.99). Each of these domains was associated with failed responses for 3 M-CHAT items-imitation, sharing, and joint attention; receptive language was also associated with response to name (p<0.05).

CONCLUSIONS: Concerns within language domains are expected, as these are prominent ASD features. The association between the self-help domain and M-CHAT critical items reinforces the importance of joint attention in detecting a possible ASD. Particular attention to the language and self-help domains in DB screening tools such as PEDS may elicit concerns for behaviors most sensitive to ASD which require further screening.

OBJECTIVE: The objective of this study was to estimate the prevalence of developmental and behavioral disorders in a convenience sample of children in an acute care pediatric hospital setting. We hypothesized that hospitalized children would have a higher prevalence of developmental and behavioral disorders than the general population.

METHODS: Data for this cross-sectional study were collected during interviews with primary caregivers of 325 children from infancy throughout childhood who were admitted to a general pediatric service. Screening tests included the Child Development Inventory (3 months to 6 years), Parents’ Evaluation of Developmental Status (0–8 years), Pediatric Symptom Checklist (4–18 years), and Vanderbilt Attention-Deficit/Hyperactivity Disorder Parent Rating Scale (6–18 years). Children were classified as having a known developmental and behavioral disorder, a suspected developmental and behavioral disorder, or no developmental and behavioral disorder.

RESULTS: The prevalence of developmental and behavioral disorders among the hospitalized children 6 months to 17 years of age was 33.5%. A total of 72 children (22.1%) had known developmental and behavioral disorders and 37 (11.4%) had suspected developmental and behavioral disorders. This high prevalence of developmental and behavioral disorders included high rates of cerebral palsy (6.1%) and mental retardation or developmental delay (8.6%).

CONCLUSION: Hospitalization for treatment of acute conditions provides another opportunity for developmental surveillance. This higher prevalence of developmental and behavioral disorders in hospitalized children emphasizes the need to screen for developmental disabilities at every opportunity. Strategies to implement systematic screening of hospitalized children should be examined.

Comment: One out of three hospitalized children perform poorly on a screening test, suggesting that routine developmental-behavioral screening is essential. Nevertheless, parents of children already enrolled in special services do not need screening, and will under-report developmental delays given likely satisfaction with services. Asking parents about which services they already receive is wise.

Pinto-Martin et al’s study of whether a broad-band developmental screen, i.e., “Parents’ Evaluation of Developmental Status” (PEDS), detects children with probable autism spectrum disorder (ASD) is fraught with problems in methodology and analysis. Although the authors report administering PEDS by interview in 7% of cases, it is not evident that interviews were also provided if parents failed to answer any PEDS questions in writing. The very low reported rates of parents with non-predictive concerns (13% in the study in question, versus 20% to 28% across various PEDS’ standardization studies) suggests PEDS was not administered correctly. The apparent lack of adherence to standardized directions raises concerns about whether reported frequencies on other PEDS paths and on the M-CHAT itself reflect legitimate results. That PEDS has established sensitivity and specificity to social-emotional problems, language impairments, learning and intellectual disabilities, also casts doubt on the study’s methods, results, and interpretation.

In addition, the authors used an outdated scoring protocol for viewing the relationship between PEDS performance and possible ASD. In a much larger discriminant validity study on 427 children administered both PEDS and the M-CHAT,4 three or more parental concerns among social-emotional, behavioral, fine motor, gross motor, or receptive language development was 78% sensitive to problematic M-CHAT scores, while fewer than three such concerns was 75% specific. That the researchers excluded most of the above concerns from their analysis only to conclude that PEDS does not capture such issues as social interactions and play behaviors, obfuscates the thoroughly established value of listening to parents. The authors were personally informed of scoring changes for PEDS more than two years ago when they presented findings on 66 children presumably included in the current study.5 At the time, their results were markedly different: PEDS was found to have 78% sensitivity to M-CHAT failures and 26% specificity, confirming, as is consistent with other research,3-4 that PEDS identifies children at risk for other types of disabilities and that a different scoring paradigm is needed to refine referrals for ASD evaluations. That Pinto-Martin et al have continued in their refusal to re-evaluate their data, is completely bewildering.

The value of viewing unique performance patterns for children with ASD has also been found on the Ages and Stages Questionnaire.6 In a presentation at the October 2008 Annual Meeting of the Society for Developmental-Behavioral Pediatrics, children with ASD had high rates of deficits in the personal-social, problem-solving, communication, and in the motor domain to a lesser extent. This illustrates the importance of viewing more than just pass/fail results when attempting to discern ASD from other developmental disorders, and is a recommendation that makes sense given the complex characteristics of children on the spectrum.

Although we agree with Pinto-Martin et al in their recommendation that an ASD specific screen should be deployed periodically alongside broad-band screens, many providers do not find time to use measures such as the M-CHAT. Pinto-Martin et al’s study could have contributed much to early detection of ASD in primary care settings if they had administered and correctly scored the broad-band screen they researched and cross-validated prior research by viewing performance patterns. Instead, the researchers proffer only the erroneous conclusion that broad-band screens “will miss a substantial proportion” of those at risk for ASD. This conclusion is not supported by their study. We urge the authors to review their data, deal with the probability that some test administrations were confounded by literacy and/or language barriers, apply current scoring paradigms, reanalyze their results and conclusions, and/or retract their manuscript.

References

• Pinto-Martin JA, Young LM, Mandell DS, Poghosyan L, Giarelli E, Levy SE. Screening Strategies for Autism Spectrum Disorder in Pediatric Primary Care. Journal of Developmental and Behavioral Pediatrics. 2008; 29(5): 345 – 350.
• Glascoe FP. Parents’ Evaluation of Developmental Status (PEDS). Nashville, Tennessee: Ellsworth & Vandermeer Press, LLC, 2006 (www.pedstest.com).
• Glascoe FP. Collaborating with Parents: Using Parents’ Evaluations of Developmental Status to Detect and Address Developmental and Behavioral Problems. Nashville, Tennessee: Ellsworth & Vandermeer Press, Ltd. ,2002. (with subsequent research updates on www.pedstest.com)
• Glascoe FP, Macias M., Wegner L. Robertshaw N. Can Parents’ Concerns Detect Children with Probable Autism Spectrum Disorder. Clinical Pediatrics. 2007; 46: 801 – 805.
• Young L, Pinto-Martin J, Warszawa A, Giarelli E, Levy S. Comparison of a General Developmental Screening Tool and an Autism Specific Screening Tool in Autistic Spectrum Disorder (ASD) Assessment. Presentation at the Annual Meeting of the Society for Developmental & Behavioral Pediatrics. Journal of Developmental & Behavioral Pediatrics. 2006;27(5):431
• Nickel RE, Murphy K, Grant K, Squires JK. Identification of Children with Autism Spectrum Disorders (ASDs) by the Ages and Stages Questionnaires (ASQ). Presentation at the Annual Meeting of the Society for Developmental & Behavioral Pediatrics. October, 2008. Journal of Developmental & Behavioral Pediatrics, in press.</li

This article covers the many issues that need to be addressed before deploying quality screening tools in primary care, including why clinicians should screen for developmental-behavioral problems, why informal measures including selected items from the Denver-II don’t work, how to chose an accurate screen and what tools are available, how to get staff enthused about screening, implementation planning, and billing/coding for optimal reimbursement

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OBJECTIVE: In analyzing data from a larger study, we noticed significant disagreement between results of 2 commonly used developmental screening tools (Parents’ Evaluation of Developmental Status [PEDS; parent concern questionnaire] and Ages & Stages Questionnaires [ASQ; parent report of developmental skills]) delivered to children at the same visit in primary care. The screens have favorable reported psychometric properties and can be efficient to use in practice; how- ever, there is little comparative information about the relative performance of these tools in primary care. We sought to describe the agreement between the 2 screens in this setting.

METHODS: Parents of 60 children aged 9 to 31 months completed PEDS and ASQ screens at the same visit. Concordance (PEDS and ASQ results agree) and discordance (results differ) for the 2 screens were determined.

RESULTS: The mean age of children was 17.6 months, 77% received Medicaid, and 50% of parents had a high school education or less. Overall, 37% failed the PEDS and 27% failed the ASQ. Thirty-one children passed (52%) both screens; 9 (15%) failed both; and 20 (33%) failed 1 but not the other (13 PEDS and 7 ASQ). Agreement between the 2 screening tests was only fair, statistically no different from agreement by chance.

CONCLUSIONS: There was substantial discordance between PEDS and ASQ developmental screens. Although these are preliminary data, clinicians need to be aware that in implementing revised American Academy of Pediatrics screening guidelines, the choice of screening instrument may affect which children are likely to be identified for additional evaluation.

Comment from Dr. Glascoe: PEDS and the ASQ have very different measurement methods. PEDS identifies, in addition to developmental delays, developmental disorders (meaning children who accomplish milestones on time but…’ something is still clearly wrong’, such as mangled syntax, restricted social interests, etc.). PEDS also identifies mental health and physical health issues, as well as parents’ needs for information and training (e.g., some parental concerns about expressive language are statements such as “I don’t know what a 6 month old should be able to do”. While this automatically places children on a moderate risk path, it also serves as an important alert to clinicians to monitor development carefully and also provide parents critically needed advice on how to promote development).

The ASQ, in contrast, is designed to identify developmental delays. In its 3rd edition, the ASQ also includes prompts encouraging parents to express their perceptions about child-rearing and other issues.

We should not expect the results of each measure to overlap completely. Indeed PEDS calls for use of a measure like the ASQ or PEDS: Developmental Milestones in some 20% of cases– in order to verify children’s and families needs for developmental and other interventions. The ASQ, in turn, calls for completion of the ASQ: Social-Emotional when children have difficulty on the ASQ.

In any case, both measures pick up nearly 80% of children with various difficulties.

Settings: More Evidence of Feasibility and Effectiveness a Divisions of Developmental Medicine b General Pediatrics, Children’s Hospital Boston, Boston, Massachusetts c Department of Pediatrics, Harvard Medical School, Boston, Massachusetts

OBJECTIVES:The purpose of this study was to examine the feasibility and effectiveness of implementation of validated developmental screening by using the Parents’ Evaluation of Developmental Status in 2 urban pediatric practices.

DESIGN AND METHODS: We implemented the Parents’ Evaluation of Developmental Status at Boston Children’s Hospital Primary Care Center and at Joseph Smith Community Health Center as quality improvement initiatives. Each practice offered screening to all of the patients attending well-child care visits between 6 months and 8 years of age. The implementation process was investigated by using preimplementation and postimplementation surveys and a focus group of pediatric primary care providers. To assess outcomes, such as changes in identification rates and referrals for developmental and behavioral concerns, we reviewed medical charts of all of the 2- and 3-year-olds present at Children’s Hospital Primary Care Center well-child care visits in the periods before and after screening implementation.

RESULTS: Providers found routine screening easier than expected and feasible to conduct in a busy primary care setting. The practice change resulted in screening of 61.6% of eligible children. Compared with same-aged children before screening, after screening was implemented more behavioral concerns were detected in the 2-year-old group, and more children with developmental concerns were identified in the 3-year-old group. Referral rates for additional evaluation increased only for 3-year-olds, although the types of referrals (ie, audiology and early intervention) were consistent as those found before screening started.

CONCLUSIONS: Implementation of validated screening by using the Parents’ Evaluation of Developmental Status was feasible in large, urban settings. Effectiveness was demonstrated via chart review documenting an increased rate of identification of developmental and behavioral concerns. Perceived obstacles, such as the time requirement, should not prevent widespread adoption of screening.

BACKGROUND: The AAP recommends periodic administration of standardized developmental screens during well child visits to facilitate identification of developmental delays. However, little is known about how parents and physicians communicate about development, or how screening impacts communication.

OBJECTIVE:

1. To describe communication about development between parents and pediatricians.
2. To determine effect on communication of PEDS parent concern screener, with or without video presentation on developmental skills.

DESIGN/METHODS: 6 primary care pediatricians in Ohio participated. 15 parents of children 9-31 mos of age per pediatrician were assigned to 1 of 3 groups:

1. usual care;
2. parent completed PEDS screener; or
3. parent completed PEDS after viewing 5-minute video on development, importance of parent input, and Early Intervention (EI). 89 visits were audiotaped and coded by blinded raters using a classification system of communication content. Inter-rater reliability was established by comparing 2 raters’ coding of 19 tapes. Outcomes:
   1. visit length;
   2. physicians: # of open-ended questions about development or health; and close-ended questions, information giving, reassurance or counseling about development;
   3. parents: # of developmental or health questions or concerns; and
   4. requests for developmental services. Group means were adjusted for clustering by physician using mixed model methods.

RESULTS: Mean child age 17.1 mos; 77% Medicaid insured. Mean visit duration was similar for the 3 groups. Physicians: no difference in use of open or close-ended questions or statements of reassurance; but more information-giving and counseling statements about development, and more developmental concerns raised in group 3 (PEDS plus video) than 1 (usual care) (p<0.05). Parents: no difference in developmental or health-related questions, but more likely to raise a developmental concern in group 3 than 1 (p<0.05), but not group 2 (PEDS only). No parent requested EI. Overall, 4 children were referred to EI, 3 from group 3.

CONCLUSIONS: Use of the PEDS did not increase mean visit duration. Although the PEDS alone did not change parent-physician communication in this inner-city sample, addition of a brief parent activation video was associated with an increase in physician and parent communication about developmental concerns. Most children referred to EI were in the PEDS plus video group, suggesting an effect from this intervention.

Comments from Frances Glascoe: I’m a bit confused by this one as to whether Dr. Sices counted the concerns raised on PEDS or just any new concerns raised AFTER the administration PEDS. And…whether these were first time administrations of PEDS (in which parents are a bit more quiet than they are the second time through). I’ll update this as the more information comes my way. Anyway, the visit length issue is interesting–as is the fact that we really need to encourage parents to talk with providers.

BACKGROUND: The AAP recommends routine primary care screening to identify children at risk for developmental concerns. However, there is no published data with rates of successful evaluation of children with positive screening results.

OBJECTIVE: To determine if use of a validated developmental screener led to needed evaluations for at-risk children, and the factors associated with completed follow-up.

DESIGN/METHODS: Setting: The PEDS was implemented at a large, urban clinic.

Subjects: In the first 9 mos of screening children under 9 yrs, 1861 were screened and 224 (12%) referred for evaluation of a new developmental concern.

Methods: Follow-up data on 171 of the 224 children referred for further evaluation were collected by parent interview (46) and/or chart review (125). Parents were asked if the evaluation recommended was completed; probes clarified reasons for failure to follow up. A structured abstraction form was used to extract chart data comparable to that elicited from direct interview. As 71% of referrals were to in-hospital services, chart review data was accurate for tracking completed referrals; determining why those patients failed to follow up was more difficult. Bivariate analyses were performed.

RESULTS: New referrals were evenly distributed across ages. Of newly referred children, 59% were male, 86% had public insurance. The most common parent concerns were expressive language (63%) and behavior (40%). Most children (59%) received more than 1 referral, usually audiology and developmental testing. Only 71 (42%) of those referred were subsequently evaluated. Boys were twice as likely as girls to complete evaluations (χ2,1=12.19;p<0.001). Children whose parent had more than 1 concern were more likely to be evaluated than those whose parent had 1 concern (χ2,1=4.61;p=0.03). There was no difference in ages of children who were or were not evaluated. We collected data on reasons for non-evaluation of 66 of the 100 children not evaluated. 28 of those 66 (42%) missed or cancelled an evaluation appointment. Parents of another 11 children (17%) reported believing the referral was unnecessary.

CONCLUSIONS: Fewer than 1/2 of children identified with risk via a validated developmental screener completed the evaluation recommended. For routine screening to succeed in its mission, pediatric practices should take an active role to ensure that referral appointments are made and kept, and to educate parents on the importance of further evaluation.

Comment from Frances Glascoe: Dr.Schonwald and colleagues showed that if appointments were made for parents rather than by parents, they were more likely to keep them. That boys were more likely to be referred was a surprise to all of us who heard her presentation. She pointed out that boys are more likely to have behavioral problems and that this might goad parents into making/keeping appointments but speculation that families have a greater achievement orientation for boys than was also entertained understandably and sadly. An additional point of discussion was that service-seeking by parents is a process. Some need time to adjust, while some feel they should try to intervene on their own and need time to observe when progress is less than ideal. Only then do some decide that help is needed. Surely tolerance among professionals for variations in alacrity in getitng to early intervention is worthwhile, but assisting families in making appointments, and checking on their progress toward early intervention services is clearly beneficial.

The Community Perinatal Care (CPC) Study was initiated by the Conception to Age Five Working Group of The Calgary Children’s Initiative. The working group consisted of representatives from the Calgary Health Region, City of Calgary, child and youth serving community agencies, Calgary Board of Education, Alberta Health and Wellness, University of Calgary, Mount Royal College, and immigrant serving agencies. The Working Group developed the study to address the goal of The Calgary Children’s Initiative that “All babies are born healthy” and to address the recommendations from a Calgary Health Region report which suggested that redesign of prenatal care may lead to improved access to resources.

The CPC study was a prospective randomized controlled trial of pregnant women attending one of three family physician low risk maternity practices within the Calgary Health Region. 2,015 women were randomly assigned to receive one of the following: 1) standard of care at the prenatal clinics (control); 2) standard of care plus consultation with a registered Nurse: or 3) standard of care plus consultation with a Nurse and a Home Visitor. Participants completed a baseline interview, as well as interviews at mid-pregnancy and eight weeks post-partum. The primary results showed that, compared to women in the control group, women who had Nurse or Nurse plus Home Visitor supports were more likely to:

1. Use community-based resources (such as prenatal classes, parenting classes, breastfeeding supports, nutritional counseling).
2. Report having a health care worker provide information on pregnancy-related topics.

The full results of the CPC study can be found in an earlier report.

Approximately three years post partum, a follow-up telephone questionnaire was conducted with the original CPC cohort. The questionnaire was designed to learn about parenting, child health, development, health care utilization, and well-being. Data from the CPC follow up questionnaire are the subject of this report.

This study was undertaken to determine which parental concerns are most associated with significant behavioral/emotional problems and the extent to which parents’ concerns can be depended on in the detection of mental health problems. An additional goal is to view how well a recently published screening test relying on parents’ concerns, Parents’ Evaluation of Developmental Status (PEDS), detects behavioral and emotional problems.

Subjects were a national sample of 472 parents and their children (21 months to 8 years old) who were participants in 1 of 2 test standardization and validation studies. Sites included various pediatric settings, public schools, and Head Start programs in 5 diverse geographic locations. Subjects were representative of U.S. demographics in terms of ethnicity, parental level of education, gender, and socioeconomic status. At each site, psychological examiners, educational diagnosticians, or school psychologists recruited families, and obtained informed consent. Examiners disseminated a demographics questionnaire (in English or Spanish) and a developmental screening test that relies on parents’ concerns (PEDS).

Examiners were blinded to PEDS’ scoring and interpretation administered either by interview or in writing, the Eyberg Child Behavior Inventory (ECBI) or the Possible Problems Checklist (PPC), a subtest of the Child Development Inventory that includes items measuring emotional well-being and behavioral selfcontrol. PEDS was used to sort children into risk for developmental disabilities according to various types of parental concern. Those identified as having high or moderate risk were nominated for diagnostic testing or screening followed by developmental and mental health services when indicated. Because their emotional and behavioral needs would have been identified and addressed, these groups were removed from the analysis (N = 177). Of the 295 children who would not have been nominated for further scrutiny on PEDS due to their low risk of developmental problems, 102 had parents with concerns not predictive of developmental disabilities (e.g., behavior, social skills, self-help skills) and 193 had no concerns at all. Of the 295 children, 12% had scores on either the ECBI or the PPC indicative of mental health problems.

Two parental concerns were identified through logistic regression as predictive of mental health status: behavior (OR = 4.74, CI = 1.69-13.30); and social skills (OR = 5.76, CI = 2.46-13.50). If one or more of these concerns was present, children had 8.5 times the risk of mental health problems (CI = 3.69-19.71) In children 434 years of age and older, one or both concerns was 87% sensitive and 79% specific to mental health status, figures keeping with standards for screening test accuracy. In young children, the presence of one or both concerns was 68% sensitive and 66% specific to mental health status. The findings suggest that certain parental concerns, if carefully elicited, can be depended on to detect mental health problems when children are 41 years and older and at low risk of developmental problems. For younger children, clinicians should counsel parents in disciplinary techniques, follow up, and if suggestions were not effective, administer a behavioral-emotional screening test such as the Pediatric Symptoms Checklist or the ECBI before making a referral decision.

Glascoe FP.
Vanderbilt University, USA.

Related Links:
Parents’ evaluation of developmental status: how well do parents’ concerns identify children with behavioral and emotional problems?

OBJECTIVE: We studied the accuracy of the Parents’ Evaluation of Developmental Status (PEDS) at school entry in predicting academic, language, and health-related quality of life (HRQoL) outcomes 2 years later.

DESIGN/METHOD: Prospective population study in elementary schools in Melbourne, Australia. Base Population. A total of 1591 school entry children who participated in a separate cross-sectional study. Cases. One hundred seventy-three children randomly selected from those with significant parental developmental concerns. Controls. One hundred twenty-nine children without significant parental development concerns.

Predictors (1997). Parents completed all 10 PEDS items; teachers completed 5 PEDS items. Outcomes (1999). The PEDS and the Child Health Questionnaire (parents) and the Comprehensive Inventory of Basic Skills-Revised and the Renfrew Action Picture Test of language (children). Odds ratios (ORs) were calculated for low outcome scores, defined as >1.0 standard deviation below the mean or <16th centile.

RESULTS: At outcome, case parents reported more “significant” concerns on the PEDS than did control parents (65% vs 26%, OR 5.3), but mean language and academic scores were only slightly lower for case children. Parent-reported self-help and school skills concerns predicted low language (ORs 2.1-2.8) and academic (ORs 1.3-6.6) scores. Teacher concerns about early school skills predicted low academic scores (ORs 3.7-4.7). However, sensitivity and specificity values were modest. Baseline developmental concerns predicted poor scores on a number of domains of HRQoL 2 years later.

CONCLUSIONS: Although individual developmental concerns at school entry variably predict later academic and language scores, sensitivity and specificity values would not support use of the PEDS as a stand-alone screen to detect later problems.

Comments: In the study, parents of five-year-olds were administered PEDS1 and their children’s academic and language outcomes viewed two years later. Fifty-four percent of the sample consisted of children whose parents held concerns associated with high rates of developmental disabilities.2 Why did the authors not track what happened in the time elapsed? Other than in-grade retention, the study does not account for such interventions as homework assistance, tutoring, remedial programs, summer school, or even special education placement. Given the strong association between parents’ discussion of concerns and children’s receipt of interventions, it seems likely that many parents would have taken actions leading to improvements in their children’s outcomes.3 If so, the long-term predictive power of PEDS would have been masked. It would have been particularly helpful had the authors had assessed performance on concurrent measures at age 5 and compared this to performance at age 7 in order to account for positive trajectories. In any case, failure to account for interventions during the two-year interval, is a serious limitation in the study and should be carefully addressed.

For a more detailed discussion of issues to consider in predictive validity studies, please see this article written by several screening test authors and research:

The Thorny Nature of Predictive Validity Studies on Screening Tests for Developmental-Behavioral Problems PEDIATRICS Vol. 122 No. 4 October 2008, pp. 866-868 (doi:10.1542/peds.2007-3142)

Kevin Marks, MDa, Frances Page Glascoe, PhDb, Glen P. Aylward, PhDc, Michael I. Shevell, MDd, Paul H. Lipkin, MDe,f, Jane K. Squires, PhD

The Thorny Nature of Predictive Validity Studies on Screening Tests for Developmental-Behavioral Problems

Related Files:
Predictive Validity

Half of all children with disabilities are not identified before school entrance, which precludes their participation in early intervention programs. Such programs have known value in reducing high school drop-out rates, increasing employment, delaying child-bearing and reducing criminal behaviour. Although there are many screening tests that can greatly improve detection rates, these have not been popular in primary care due to test length, difficulty managing children’s behaviour, etc. An alternative is to carefully elicit and interpret parents’ concerns. Research shows that parents’ concerns are as accurate as quality screening tests and that parents are equally able to raise important concerns regardless of differences in education and child-rearing experience. Parents’ concerns can be elicited quickly and 92% of parents can answer questions in writing while in exam or waiting rooms. Unlike screening tests, use of parents’ concerns facilitates an evidenced-based approach to comprehensive surveillance and aids in making a range of other important decisions about children’s developmental and behavioural needs. These include when to: offer suggestions on developmental promotion; watch children more vigilantly; screen for emotional and behavioural problems; advise families about behaviour management; offer reassurance and routine monitoring of development that is likely normal; administer a second screening test; or refer for additional testing and the kinds of testing needed.