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Developmental Screening in the DC Primary Care Setting [Name of Presenter] Title of Presenter A A P H e a l t h y P e o p l e 2 0 2 0 Why This Matters Taking action to support a childs development from birth to 5 alters the trajectory

  1. Developmental Screening in the DC Primary Care Setting [Name of Presenter] Title of Presenter

  2. A A P – H e a l t h y P e o p l e 2 0 2 0 Why This Matters Taking action to support a child’s development from birth to 5 alters the trajectory of a child’s academic career and life path. Children who receive needed services before age 5: • See their conditions fully treated or substantially mitigated • Are better prepared for Kindergarten Achieve higher rates of educational attainment • • Live in families that have greater support and reduced stress Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  3. A A P – H e a l t h y P e o p l e 2 0 2 0 A A P - H E A L T H Objectives of this Presentation 1. Describe DC’s early intervention services and process. 2. Summarize evidence regarding effectiveness of developmental screenings by primary care providers. 3. Discuss implementation of the American Academy of Pediatrics (AAP) recommendations. Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  4. A A P – H e a l t h y P e o p l e 2 0 2 0 AAP – Healthy P eople 2020 DC’s Early Intervention Services and Process Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  5. A A P – H e a l t h y P e o p l e 2 0 2 0 IDEA in Washington, DC • The Individuals with Disabilities Education Act (IDEA) is the federal law that outlines the rights of children with special needs from birth through age 21. • In DC, two programs serve children under age 5:  Strong Start (0 to 3) run by Office of the State Superintendent  Early Stages (3 through 5) run by DC Public Schools Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  6. AAP – Healthy People 2020 Making Referrals Strong Start Early Stages Age Range: Birth to 2 years 8 months 2 years 8 months to 5 years 10 months Reason: • Developmental delay • Same as Strong Start • Diagnosed condition or risk • Concerns over school factor associated with readiness and social- developmental delay emotional issues • Parental concern Examples: Very low birth weight, genetic Most common: speech delay, condition, prematurity, hearing developmental delay, and or vision impairments, birth behavioral concerns, as well defects, delayed speech as physical and fine motor concerns. >> See handouts for information on how to refer << Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  7. AAP – Healthy People 2020 Early Intervention in DC: How are we doing? Percentage of children found eligible for services. 12.00% 10.00% 8.00% DC 6.00% National 4.00% 2.00% 0.00% 0-3 Eligibility 3-5 Eligibility We need to find more children and find them earlier. Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  8. AAP – Healthy People 2020 Evidence regarding developmental surveillance and screening in primary care settings Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  9. How Pediatricians Currently Assess Child Standardized 6% Development Screening Tool 23% Developmental Surveillance 71% Other/No Assessment Sand, 2005 Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  10. How Effective is Developmental Surveillance? A LOOK AT TWO STUDIES: Hollie Hix-Small, et.al. 2007 R. Christopher Sheldrick, et.al. 2011 Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  11. AAP – Healthy People 2020 DC Early Intervention Program and Early Stages Identification of Developmental-Behavioral Problems in Primary Care: A Systematic Review R. Christopher Sheldrick, et.al. 2011 Context: a systematic review of 11 studies on the effectiveness of surveillance Developmental surveillance has low rates of sensitivity  Sensitivity: 14% to 54%  Specificity: 69% to 100% Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  12. AAP – Healthy People 2020 DC Early Intervention Program and Early Stages Impact of Implementing Developmental Screening at 12 and 24 Months in a Pediatric Practice Hollie Hix-Small, et.al. 2007 Context: a study of 1428 children in private practices Developmental surveillance missed 67.5% of children later identified by ASQ as needing referral Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  13. A A P – H e a l t h y P e o p l e 2 0 2 0 Why does developmental surveillance miss children? • Inaccuracy of clinical judgment • Tends to identify most severe delays • Non-standardized administration • Partial vs. complete administration • Targeted vs. universal screening • Parental report when direct observation was intended Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  14. How Effective is Standardized Developmental Screening? A LOOK AT TWO STUDIES: North Carolina ABCD Project 2004 Hollie Hix-Small, et.al. 2007 Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  15. A A P – H e a l t h y P e o p l e 2 0 2 0 North Carolina ABCD Project, 2004 Context: Broad implementation of developmental screening (ASQ) during Medicaid well child visits Result: • Increase in referrals to early intervention from 3.9% to 7% of all children <36 months • 70% of these children were found eligible for services Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  16. A A P – H e a l t h y P e o p l e 2 0 2 0 Hollie Hix-Small, et.al. 2007 Context: a study of 1428 children in private practices were screened at 12- and 24-month well-child visits. Result: • Referral rate increased 224% once developmental screening process was implemented. • 94% of referred children were found eligible for services. Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  17. AAP – Healthy People 2020 Implementation of the AAP Recommendations for Screening Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  18. A A P – H e a l t h y P e o p l e 2 0 2 0 AAP Recommendations Key Points The Screening Tool is Standardized Screening is Universal • All children screened, regardless of risk Screening is Periodic • Completed at 9, 18 and 30* months *If 30-month visit is not routine, 3 rd screening at 24 months Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  19. A A P – H e a l t h y P e o p l e 2 0 2 0 AAP Recommendations Why? The Screening Tool is Standardized • Eliminates inconsistent surveillance techniques Screening is Universal Eliminates problem of low sensitivity of surveillance • Screening is Periodic • Ensures children are not missed • Tracks developmental changes over time Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  20. A A P – H e a l t h y P e o p l e 2 0 2 0 AAP Recommendations: Response to Failed Screening If a screening reveals a concern, providers should • Refer to early intervention programs ( Strong Start/Early Stages: see Special Ed Cheat Sheet handout for details ) • Refer to medical subspecialists Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  21. A A P – H e a l t h y P e o p l e 2 0 2 0 Ages & Stages Questionnaire • Well-validated • One-time cost – Unlimited duplication • Milestone/skill-based – Facilitates parent education • Options: parent administration or parent self-report – Waiting room/exam room Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  22. A A P – H e a l t h y P e o p l e 2 0 2 0 Use of ASQ-3 in DC (FY 2011) • Widespread use: – Used as intake tool by both Strong Start and Early Stages – DCPS screens all Head Start children (4,500) with ASQ-3 • Strong correlation to eligibility in DC: – Strong Start: 57% of ASQ-referred children were eligible. – Early Stages: 65% of ASQ-referred children were eligible. Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  23. A A P – H e a l t h y P e o p l e 2 0 2 0 Developmental Surveillance and Screening Policy Implementation Pilot Established by the AAP to test the feasibility of implementing the 2006 AAP screening guidelines. A 9-month project involving 17 practices using ASQ 3 Results: 85% of presenting patients were screened. Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

  24. A A P – H e a l t h y P e o p l e 2 0 2 0 Lessons from the AAP Pilot Practices struggled most in three areas: 1. Conducting screening at 30-month visit. 1. Administering a screening after surveillance suggested a concern. 1. Referring children to both medical subspecialists and local early intervention programs. (Only 61% of children with failed screenings were referred.) King, Tandon et al. 2010 Strong Start I T: 202.727.3665 Early Stages I T: 202.698.8037 I www.earlystagesdc.org

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