I. The problem of underdetection. Most children with developmental and behavioral problems have subtle symptoms that are not readily apparent in the absence of measurement. Because few medical professionals use standardized screening tests routinely, 70%-80% of children with disabilities are not detected prior to school entrance and vital opportunities for early intervention are missed. As few as 2 years of early intervention prior to school entrance increases the likelihood of high school graduation, employment, and independent living and reduces the rates of teen pregnancy, criminal activity, and violent crime.
II. Pearls. Timely early detection relies upon frequent, periodic screening where measures are promptly scored and interpreted, ideally before the visit begins. Frequent, periodic screening is important because developmental-behavioral problems tend to worsen over time, especially when a history exists of adverse psychosocial risk factors such as poverty, exposure to domestic violence, parental mood disorders, parental substance abuse, negative approaches to parenting, child abuse/ neglect, etc. When an efficient clinic system is in place, developmental-behavioral screening does not necessarily lengthen the well-child visit and yet it simultaneously raises the quality of care with a parent-centered approach.
The optimal tools for identifying developmental and behavioral problems in primary care are those that
Have proven levels of accuracy (at least 70%-80% of children with and without problems should be detected correctly) and have been properly standardized and validated on a large, national, general (not referred) sample of children.
Are feasible in a primary care setting and rely on information from parents. Parent-report screens take little time to administer (because parents can complete them in waiting or examination rooms). Parents, regardless of their level of education or parenting experience, are equally able to provide predictive information about their children. For non-Englishspeaking parents, many screens are published in multiple languages.
Offer both evidence-based surveillance as well as screening, and they are easy to use because pediatric clinician need not elicit skills directly from children who may be fearful, uncooperative, sick, or asleep.
III. Pitfalls. While surveillance (meaning clinical observation and judgment) is important, the informal methods typically deployed are associated with limited identification rates. Nonstandardized, non-validated checklists lack definable scoring/referral criteria and many include items that are far too easy for the age levels given. Checklists lack any proof of accuracy.
IV. Tools. Several good quality measures relying on information from parents are presented in Table 12-1. Several of these can be administered directly to children by clinicians who prefer this approach. Other alternatives to direct measurement are to (a) send such parents home with a copy of parent-report screen and ask that he or she complete it with other caregivers or (b) refer for screening through the public schools or through child find services through the Individuals with Disabilities Education Act (see list of referral resources below to locate them for every state and region).
V. Making it work in primary care. There are many approaches to organizing pediatric settings so that developmental and behavioral problems can be easily detected and addressed while also maintaining patient flow and office efficiency. Table 12-1 is a list of such methods and Web sites for specific tools often have useful information on how to apply them in busy practices. In settings where there are healthcare providers, such professionals can and should document carefully both medical history and physical examination findings to determine whether organic conditions are contributory. The physical examination should include attention to growth parameters, head shape and circumference, facial and other body dysmorphology, eye findings (e.g., cataracts in various inborn errors of metabolism), vascular markings, and signs of neurocutaneous disorders (e.g., café-au-lait spots in neurofibromatosis, hypopigmented macules in tuberous sclerosis), muscle strength, tone, presence of abnormal reflexes, and disturbance of movement.
Table 12-1. Parent-report, standardized, validated, and accurate developmental-behavioral screens
Screens for primary care—general screens
Parent-report developmental and/or behavioral screens
Age range
Description
Scoring
Accuracy
Administration time and cost
Parents’ Evaluations of Developmental Status (PEDS). (2006) Ellsworth & Vandermeer Press, Ltd. 1013 Austin Court, Nolensville, TN 37135
Phone: 615-776-4121; fax: 615-776-4119
http://www.pedstest.com ($30.00)
See electronic options below.
Training options: downloadable slide shows with notes, case examples, and handouts, Web site discussion list (covering all screens), short videos coming soon) some live training.
Birth to 8 years
10 questions eliciting parents’ concerns in English, Spanish, Vietnamese, and many other languages. Written at the 4th-5th grade level. Determines when to refer, provide a second screen, provide patient education, or monitor development, behavior/emotional, and academic progress. Provides longitudinal surveillance and triage.
Identifies children as low, moderate, or high risk for various kinds of disabilities and delays
Sensitivity 74%-79%;
Specificity 70%-80% across age levels.
About 2 min (if interview needed)
Print materials ∽$.31
Admin. ∽$.88 Total = ∽$1.19
Ages and Stages Questionnaire-3 (3rd ed., 2009). Paul H. Brookes Publishing, Inc., P.O. Box 10624, Baltimore, MD 21285
Phone: 1-800-638-3775). ($249)
http://www.pbrookes.com/
See electronic options below.
Training options: purchasable videos, case examples, and live training.
1-66 months
Parents-report, elicits children’s developmental skills in 5 domains with 30 items and 6-7 overall questions using an age-appropriate form for each well visit. Reading level varies across items from 4th to 5th grade. Proven feasible for office use with an option to complete at home (ideally before the visit). Online and mail-out approaches are used for child find programs. In English, Spanish, French, Korean, and others.
Straightforward (refer/no-refer) cutoff scores, along with a near cutoff monitoring zone per age interval.
Sensitivity (overall 86%), 82.5%-89.2% across all age intervals;
Specificity (overall 85%), 77.9%-92.1% across all age intervals.
10-20 min (dependent upon whether the ASQ-3 is completed in a clinic, at home, or by direct interview)
Materials ∽$.40
Admin. ∽$4.20
Total = ∽$4.60
PEDS: Developmental Milestones (Screening Version) Ellsworth & Vandermeer Press, Ltd. 1013 Austin Court, Nolensville, TN 37135
Phone: 615-776-4121; fax: 615-776-4119 http://www.pedstest.com ($275.00). Electronic options coming soon.
Training Options: 2-min movie on Web site, plus slide shows with notes, case examples, handouts, some live training, and a discussion list.
0-8 years
PEDS-DM consists of 6-8 items at each age level (spanning the well visit schedule). Each item taps a different domain (fine/gross motor, self-help, academics, expressive/receptive language, social-emotional). Items are administered by parents or professionals. Forms are laminated and marked with a grease pencil. It can be used to complement PEDS or stand alone. Written at the 2nd grade level. A longitudinal score form tracks performance. Supplemental measures are included (see descriptions below): the M-CHAT, Family Psychosocial Screen, Pictorial PSC-17, the SWILS, the Vanderbilt ADHD scale, and the Brigance Parent-Child Interactions Scale. In English and Spanish.
Cutoffs tied to performance above and below the 16th percentile for each item and its domain.
On the assessment level, age equivalent scores are produced and enable users to compute percentage of delays.
Sensitivity 75%-87%;
Specificity 71%-88% to performance in each domain.
Sensitivity 70%-94%;
Specificity 77%-93% across age intervals
About 3-5 min
Materials ∽$.02
Admin. ∽$1.00
Total ∽$1.02
Narrow-band screens for primary care (for psychosocial risk, mental health, and autism spectrum disorder. These are valuable adjuncts in primary care and elsewhere but should not be used as the sole measure of developmental-behavioral status)
Ages & Stages Questionnaires: Social-Emotional (ASQ:SE)
Paul H. Brookes, Publishers, P.O. Box 10624, Baltimore, MD 21285
Phone: 1-800-638-3775). ($149)
http://www.pbrookes.com/
Training options: live training, training video
3-65 months
Parent-report tool designed to complement the ASQ, the ASQ:SE consists of 8 intervals with 22-36 items per age interval (4-5 page questionnaire). Items focus on self-regulation, compliance, communication, adaptive functioning, autonomy, affect, and interaction with people. Items are based on parental recall and do not ask parents to elicit developmental skills so quicker to complete than the ASQ.
Single (above or below) cutoff score indicating when a referral is needed
Sensitivity 71%-85%;
Specificity 90%-98% in detecting children with social-emotional delays/a need for an early intervention and/or mental health referral
10-15 min
Materials ∽$.40
Admin. ∽$4.20
Total = ∽ $4.40
Brief-Infant-Toddler Social-Emotional Assessment (BITSEA);
Harcourt Assessment, Inc, 19500 Bulverde Road, San Antonio, TX 78259
Phone: 1-800-211-8378 ($105.00)
http://pearsonassess.com/
Training options: none
12-36 months
42-item parent-report measure for identifying social-emotional/behavioral. Problems and delays in competence. Items were drawn from the assessment level measure, the ITSEA. Written at the 4th-6th grade level. Available in Spanish, French, Dutch, and Hebrew. Has a CD-ROM for ease of scoring.
Cut-points based on child age and sex show presence or absence of problems and competence.
Sensitivity 80%-85%; specificity 75%-80% in detecting children with social-emotional problems and in need of an early intervention and/or mental health referral.
5-7 min
Materials ∽$1.15
Admin. ∽$.88
Total ∽$2.03
Modified Checklist for Autism in Toddlers (M-CHAT) (1999). Free download including follow-up interview at http://www.mchatscreen.com
Included in the PEDS:DM. See electronic records options below.
Training options: none
16-30 months
Parent report of 23 questions modified for American usage at 4th-6th grade reading level. Available in multiple languages. Screens for Autism Spectrum Disorder (ASD). Downloadable scoring template and .xls file for automated scoring. Requires a follow-up interview (also downloadable in English and Spanish, in response to problematic performance).
Cutoff based on 2 of 3 critical items or any 3 from the 23-item “yes or no” checklist.
Initial study demonstrated sensitivity at 90%; specificity at 99%.
Note: a revised 7-item M-CHAT is under development.
Subsequent studies recommended that a failed M-CHAT (6%-10% of children at 18 and 24 months) should lead to an in-office, standardized
“M-CHAT Follow-up Interview.”
About 5 min (excluding the M-CHAT Follow-up Interview)
Print Materials ∽$.10
Admin. ∽$.88
Total = ∽$.98
M-CHAT Follow-up Interview is designed to reduce false positive M-CHAT results and reduce the number of expensive comprehensive ASD diagnostic evaluations
Clarifies ASD concerns with failed M-CHAT items
SCREENS FOR OLDER CHILDREN (these screens focus on academic skills and mental health, including ADHD screening and are brief enough for primary care).
Safety Word Inventory and Literacy Screener (SWILS). Glascoe FP, Clinical Pediatrics, 2002. Items courtesy of Curriculum Associates, Inc. The SWILS can be freely downloaded at: http://www.pedstest.com/ and is included in the PEDS:DM.
Training Options: none
6-14 years
Children are asked to read 29 common safety words (e.g., High Voltage, Wait, Poison) aloud. The number of correctly read words is compared to a cutoff score. Results predict performance in math, written language, and a range of reading skills. Test content may serve as a springboard to injury prevention counseling.
Single cutoff (refer/no-refer) score indicating the need for a referral
78%-84% sensitivity and specificity across all ages
About 7 min (if interview needed)
Materials ∽$.30
Admin. ∽$2.38
Total = ∽$2.68
Pediatric Symptom Checklist (PSC): Jellinek MS, Murphy JM, Robinson J, et al. Screens school age children for academic and psychosocial dysfunction. Research studies and downloads at: http://www2.massgeneral.org/allpsych/psc/psc home.htm or http://www.brightfutures.org/mentalhealth/pdf/professionals/ped sympton chklst.pdf
Pictorial PSC (PPSC, is more effective with Spanish-speaking and low-SES families) can be downloaded at www.dbpeds.org and is also included in the PEDS:DM.
Training Options: none
PSC age range is 4-16 years
PPSC age range is 4-16 years.
Parent-report, 35 short statements of problem behaviors including both externalizing (conduct) and internalizing (depression, anxiety, adjustment, etc.). Ratings of never, sometimes or often are assigned a value of 0, 1, or 2. For children 4-5 years old, referral cutoff score is 24 or higher; 6-10 years old, 28 or higher; 11-16 years old, the (Youth Report) Y-PSC referral cutoff score is 30 or higher. Factor scores identify attentional, internalizing, and externalizing problems. Factor scoring is freely downloadable at: http://www.pedstest.com/links/resources.html
Single cutoff (refer/no-refer) score
All but one study showed high sensitivity (80%-95%) but somewhat scattered specificity (68%-100%).
About 7 min (if interview needed)
Materials ∽$.10
Admin. ∽$2.38
Total = ∽$2.48
Electronic Records Options for Screening with Quality tools
Company
Training/Support options
Description and Pricing
CHADIS (http://www.chadis.com/)
PEDS, ASQ, M-CHAT, and other measures online for touch screen, tablet PCs, keyboards, telephony, and parent portal methods. Spanish language version coming soon.
Downloadable guides, live training at exhibits, and other training services on request.
CHADIS also includes decision support for a large range of other measures, both diagnostic and parent/family focused, such as the Vanderbilt ADHD Diagnostic Rating Scale, and various parental depression inventories. CHADIS offers integration with existing EHRs. works with a range of equipment/applications, and automatically generates reports. Pricing is ∽$2.00 per use.
Press/Forepath.org (www.pedstest.com)
PEDS, M-CHAT online for keyboard and tablet PCs. (PEDS:DM, Spanish language and other translations coming—June, 2009)
Slide shows, Web site FAQs, e-mail support, online videos, discussion list
This site offers PEDS and the Modified Checklist in Toddlers for applications including tablet PCs, keyboards (allowing for actual comments from parents). Offers a parent portal (wherein families do not see the results), etc. Scoring is automated as are summary reports for parents, referral letters when needed, and ICD-9/procedure codes. In English and Spanish (with other languages coming soon along with the PEDS:DM). Integration with electronic records is available as is data export and aggregate views of records. $1.00-$2.00 per use (depending on volume).
Patient Tools
(www.patienttools.com or http://pediatrics.patienttools.com/why pediatrics.asp)
(PEDS, M-CHAT, ASQ, ASQ:SE, PSC and others measures online for tablet PCs)
Webcasts/webinars, live support by phone, e-mail
Patient tools offers the ASQ, ASQ:SE, M-CHAT, PEDS, PSC, the Vanderbilt ADHD Scales, and a wide range of behavioral/mental health measures for adolescents and adults. A parent portal approach is available via Survey Tablets. Equipment including docking stations is rented, lease-purchased, or purchased ($74.00-$1320) after which $58.00 per month is the ongoing cost of hosting, data storage, telephone technical, installation support. Copyrighted measures are licensed from their publishers and incur per use fees. From www.pedstest.com (above) at $1.00-$2.00 per use depending on volume.
Brookes Publishing
(www.agesandstages.com/)
(ASQ via CD-ROM installed on keyboard computers, web-based scoring service coming in June 2008)
Live training, online training, purchasable training videos, e-mail LISTSERV
ASQ on a CD-ROM enables users to click answers and receive an automated score. The software offers aggregation of results, report writing templates, and progress tracking.
Curriculum Associates
(www.cainc.com)
(Brigance Screens-II online for keyboards. English only but with Spanish-language score/administration forms)
Live training, online training, e-mail, and phone support, customer suggestion box
This service, web-based or via CD-ROM, provides clickable datasheets, which automatically calculate scores including age equivalents, quotients, progress indicators, at-risk cutoff scores quotients, etc. Aggregated reports are available through the online service. $3.00-$5.00 per use, depending on volume.
Riverside Publishing
(http://www.riverpub.com) for Battelle Developmental Inventory along with the screening version (BDIST-II) online via keyboards, and/or CD-ROM
Web site FAQs, e-mail support, live workshops, webcasts/webinars
Scoring services include report writing, all via web-based services. The Web site indicates a version for Personal Digital Assistants (PDAs), but this will be phased out shortly. In English and Spanish. Pricing, ∽$765 per year
© 2009, updated from Glascoe FP. Collaborating with Parents and Glascoe FP, Robertshaw NS, PEDS: Developmental Milestones, Professionals’ Manual. Nashville, Tennessee: Ellsworth & Vandermeer Press, Ltd. Permission is given to reproduce this document.
Disclosure: This table was compiled and vetted in collaboration with many researchers, clinicians, and test authors, without regard to the latter’s potential financial interests in products mentioned.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
Developmental and Academic Surveillance and Screening
Developmental and Academic Surveillance and Screening
Kevin P. Marks
Frances Page Glascoe
