Supporting & Related Research

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.

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.

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.

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.

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.

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.

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

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.