Effectiveness of developmental screening in an urban setting

Multi-stage Screening in Early Intervention: A Critical Strategy for Improving ASD Identification and Addressing Disparities

Health disparities in ASD detection affect children's access to subsequent interventions. We examined potential disparities in implementation of a multi-stage ASD screening and diagnostic evaluation protocol in Part C Early Intervention with 4943 children ages 14-36 months (mean 22.0 months; 62.9% boys, 73.3% children of color, 34.9% non-English-primary language, 64.5% publicly-insured). Participation and follow-through were high (64.9% and 65.3% at first- and second-stage screening, respectively, 84.6% at diagnostic evaluation). Logistic regressions identified predictors of screening participation and outcomes at each stage; demographic differences (race, language, public insurance) were observed only at first-stage screening and reflected higher participation for children of color and higher positive screens for publicly-insured children. Results suggest the multi-stage screening protocol shows promise in addressing disparities in early diagnosis.

Initial psychometric properties of the Denver II in a sample from Northeast Brazil

This paper assesses the initial psychometric properties of the Denver Developmental Screening Test (Denver II), a widely used child development measure in its first population-level administration in Brazil. The Portuguese version was administered to 2755 children under three years of age who were eligible for a home visiting program in Fortaleza, Northeast Brazil. We examine the measure's internal consistency and verify construct validity by testing the dimensionality through confirmatory factor analysis (CFA) and estimating associations with household socioeconomic variables (e.g., poverty, maternal education, stunting, and parenting practices). The test was found to be psychometrically robust and culturally relevant. Although we found a good fit with the structure proposed by the instrument's author, a structure of two latent variables (motor and cognitive) provided a better fit. This validity exercise provides useful information for policymakers and researchers interested in using this instrument in the Brazilian context or a similar one in the region.

Child characteristics and early intervention referral and receipt of services: a retrospective cohort study

BACKGROUND

Early Intervention (EI) is a federally mandated, state-administered system of care for children with developmental delays and disabilities under the age of three. Gaps exist in the process of accessing EI through pediatric primary care, and low rates of EI access are well documented and disproportionately affect poor and minority children. The aims of this paper are to examine child characteristics associated with gaps in EI (1) referral, (2) access and (3) service use. To our knowledge, this is the first study to leverage linked safety net health system pediatric primary care and EI records data to follow EI-referred children longitudinally to understand EI service use gaps from EI referral to EI service utilization.

METHODS

In a retrospective cohort design (14,710 children with developmental disability or delay), we linked pediatric primary care records between a large, integrated safety net health system in metro Denver and its corresponding EI program (2014-2016). Using adjusted marginal effects [ME, (95% CI)], we estimated gaps in EI referral, access, and service type (i.e., physical [PT], occupational [OT], speech therapy [ST] and developmental intervention [DI]). Analyses accounted for child characteristics including socio-demographics, diagnosis, condition severity, and baseline function.

RESULTS

Only 18.7% of EI-eligible children (N = 2726) received a referral; 26% of those (N = 722) received services for a net enrollment rate of 5% among EI-eligible children. Having the most severe developmental condition was positively associated with EI referral [ME = 0.334 [0.249, 0.420]) and Individualized Family Services Plan (IFSP) receipt [ME = 0.156 [0.088, 0.223]). Children less likely to be EI-referred were Black, non-Hispanic (BNH) [ME = -0.029 (- 0.054, - 0.004)] and had a diagnosed condition ([ME = - 0.046 (- 0.087, - 0.005)]. Children with a diagnosis and those with higher income were more likely to receive PT or OT. Higher baseline cognitive and adaptive skills were associated with lower likelihood of PT [ME = -0.029 (- 0.054, - 0.004)], OT [ME = -0.029 (- 0.054, - 0.004)], and ST [ME = -0.029 (- 0.054, - 0.004)].

CONCLUSIONS

We identified and characterized gaps in EI referral, access, and service use in an urban safety-net population of children with high rates of developmental delay. Interventions are needed to improve integrated systems of care affecting primary care and EI processes and coordination.

Well-Child Care Adherence After Intrauterine Opioid Exposure

BACKGROUND AND OBJECTIVES

For children with intrauterine opioid exposure (IOE), well-child care (WCC) provides an important opportunity to address medical, developmental, and psychosocial needs. We evaluated WCC adherence for this population.

METHODS

In this retrospective cohort study, we used PEDSnet data from a pediatric primary care network spanning 3 states from 2011 to 2016. IOE was ascertained by using physician diagnosis codes. WCC adherence in the first year was defined as a postnatal or 1-month visit and completed 2-, 4-, 6-, 9-, and 12-month visits. WCC adherence in the second year was defined as completed 15- and 18-month visits. Gaps in WCC, defined as ≥2 missed consecutive WCC visits, were also evaluated. We used multivariable regression to test the independent effect of IOE status.

RESULTS

Among 11 334 children, 236 (2.1%) had a diagnosis of IOE. Children with IOE had a median of 6 WCC visits (interquartile range 5-7), vs 8 (interquartile range 6-8) among children who were not exposed (P < .001). IOE was associated with decreased WCC adherence over the first and second years of life (adjusted relative risk 0.54 [P < .001] and 0.74 [P < .001]). WCC gaps were more likely in this population (adjusted relative risk 1.43; P < .001). There were no significant adjusted differences in nonroutine primary care visits, immunizations by age 2, or lead screening.

CONCLUSIONS

Children <2 years of age with IOE are less likely to adhere to recommended WCC, despite receiving on-time immunizations and lead screening. Further research should be focused on the role of WCC visits to support the complex needs of this population.

Promoting Optimal Development: Identifying Infants and Young Children With Developmental Disorders Through Developmental Surveillance and Screening

Early identification and intervention for developmental disorders are critical to the well-being of children and are the responsibility of pediatric professionals as an integral function of the medical home. This report models a universal system of developmental surveillance and screening for the early identification of conditions that affect children's early and long-term development and achievement, followed by ongoing care. These conditions include autism, deafness/hard-of-hearing, intellectual and motor disabilities, behavioral conditions, and those seen in other medical conditions. Developmental surveillance is supported at every health supervision visit, as is as the administration of standardized screening tests at the 9-, 18-, and 30-month visits. Developmental concerns elicited on surveillance at any visit should be followed by standardized developmental screening testing or direct referral to intervention and specialty medical care. Special attention to surveillance is recommended at the 4- to 5-year well-child visit, prior to entry into elementary education, with screening completed if there are any concerns. Developmental surveillance includes bidirectional communication with early childhood professionals in child care, preschools, Head Start, and other programs, including home visitation and parenting, particularly around developmental screening. The identification of problems should lead to developmental and medical evaluations, diagnosis, counseling, and treatment, in addition to early developmental intervention. Children with diagnosed developmental disorders are identified as having special health care needs, with initiation of chronic condition management in the pediatric medical home.

Evolving Roles for Health Care in Supporting Healthy Child Development

Health care reaches more children under age three in the United States than any other family-facing system and represents the most common entry point for developmental assessment of and services for children. In this article, Adam Schickedanz and Neal Halfon examine how well the child health care system promotes healthy child development early in life. They also review children's access to health care through insurance coverage, the health care system's evolution in response to scientific and technical advances, and the shifting epidemiology of health and developmental risk. The authors find that the health care system is significantly underperforming because it is constrained by antiquated conventions, insufficient resources, and outmoded incentive structures inherent in the traditional medical model that still dominates pediatric care. These structural barriers, organization challenges, and financial constraints limit the system's ability to adequately recognize, respond to, and, most importantly, prevent adverse developmental outcomes at the population level. To achieve population-level progress in healthy child development, Schickedanz and Halfon argue that pediatric care will need to transform itself and go beyond simply instituting incremental clinical process improvement. This will require taking advantage of opportunities to deliver coordinated services that bridge sectors and focusing not only on reducing developmental risk and responding to established developmental disability but also on optimizing healthy child development before developmental vulnerabilities arise. New imperatives for improved population health, along with the growing recognition among policy makers and practitioners of the social and developmental determinants of health, have driven recent innovations in care models, service coordination, and coverage designs. Yet the available resources and infrastructure are static or shrinking, crowded out by rising overall health care costs and other policy priorities. The authors conclude that child health systems are at a crossroads of conflicting priorities and incentives, and they explore how the health system might successfully respond to this impasse.

Parent satisfaction before and after implementing of a developmental screening tool in nine well-baby clinics in Norway

AIM

The aim of the study was to compare parental satisfaction items before and after the implementation of The Ages & Stages Questionnaires (ASQ) as part of the health check-up.

METHODS

ASQ was implemented in regular health check-ups of infants up to two years of age in 9 Norwegian well-baby clinics. After the infant's two years' health check-ups, a questionnaire-based survey among 652 families before and 562 families after intervention was conducted. Descriptive analyses and ordinal logistic regression were used to report and compare parental satisfaction items before and after the project.

RESULTS

Parents reported high satisfaction with well-baby services both before and after the implementation of ASQ, and ninety-six per cent recommended other well-baby clinics to use ASQ. Some significant differences appeared, before the implementation of ASQ, parents were more satisfied with the support they received regarding parenting and child development in general and information about the child's physical health. After ASQ was implemented, parents were significantly more satisfied with the information they received about 'the child's mental health'.

CONCLUSION

Developmental screening in well-baby clinics in Norway is acceptable among parents with young children. The use of standardised instruments must not come at the expense of listening to parents' concerns.

Quantitative Evaluation of Content and Age Concordance Across Developmental Milestone Checklists

OBJECTIVE

Clinicians and caregivers rely on milestone checklists as tools for tracking a child's development. In addition, medical students and residents use milestone checklists to learn about normal child development. However, there are multiple published milestone checklists that vary qualitatively in structure and content, hindering their effective use in developmental surveillance and medical education. This project systematically evaluated the consistency and variability between commonly used milestone checklists.

METHODS

A team of child psychologists and developmental pediatricians reviewed a total of 1094 milestones derived from 4 published checklists (2 developed for providers, 2 developed for caregivers) to create a comprehensive set of 728 discrete developmental observations, with each observation mapped to corresponding milestones. This observation-milestone relational database was then used to determine the degree of content overlap and milestone age range concordance across milestone checklists.

RESULTS

Of the 728 discrete developmental observations, 40 (5.5%) were mapped to milestones in all 4 milestone checklists, and an additional 90 (12.4%) were mapped to 3 checklists. Among these 40 "universal" observations, most (42.5%) were in the motor domain. Of those 130 observations mapped to milestones in at least 3 of the 4 checklists, 26.9% (35/130) were mapped to milestones that were discordant in their associated age range.

CONCLUSION

Four commonly used developmental milestone checklists were found to have limited overlap in content, and those that overlapped were inconsistent in their associated age ranges. The resulting observation-milestone relational database could be used to further validate age estimates of milestones and facilitate milestone surveillance through the electronic health record.

Ethnic Disparities in Autism Spectrum Disorder Screening and Referral: Implications for Pediatric Practice

OBJECTIVE

Autism spectrum disorder (ASD) screening completion rates are often low despite their validity and influence on earlier intervention and positive treatment outcomes. This study sought to examine the use of one ASD screening tool, the Modified Checklist for Autism in Toddlers-Revised (MCHAT-R), in a racially and ethnically diverse urban pediatric clinic to review potential disparities within screening rates and referral practices.

METHODS

A retrospective chart review was conducted for children (N = 999) within the ages of 17 to 34 months seen for a well-child appointment at one of 3 pediatric clinics: a general pediatric clinic, resident pediatric clinic, and Hispanic pediatric clinic.

RESULTS

MCHAT-R screening completion rates were low for all clinics. There were no significant differences in MCHAT-R screening completion based on ethnicity; however, the percentage of children screening positive on the MCHAT-R was significantly higher for Hispanic versus non-Hispanic children. Referral practices were highly variable across positive screenings, and few children received the appropriate combination of referrals.

CONCLUSION

Ethnic disparities in ASD positive screening rates and inconsistent referrals represent a critical issue in current pediatric practice. There is a great need for the development of more culturally sensitive ASD screening instruments. Additionally, to help increase ASD screening rate and accuracy, as well as consistency in referrals, greater emphasis is needed on professional training, parental education, and technology use within pediatric clinics.

Cost-Effectiveness of Universal or High-Risk Screening Compared to Surveillance Monitoring in Autism Spectrum Disorder

The American Academy of Pediatrics recommends universal screening for autism spectrum disorder at 18 and 24 months. This study compared the cost-effectiveness of universal or high-risk screening to surveillance monitoring. Simulation models estimated the costs and outcomes from birth to age 6 years. The incremental cost per child diagnosed by 36 months was $41,651.6 for high-risk screening and $757,116.9 for universal screening from the societal perspective. Universal screening may not be a cost-effective approach to increase earlier treatment initiation, as most children initiated treatment after age 60 months. Eliminating wait times resulted in more children initiated treatment by 48 months, but at a high initial cost that may be offset by future cost-savings related to better outcomes.

Factors Influencing Low Prevalence of Neurodevelopmental Disabilities Among US Hispanic/Latino Children

OBJECTIVES

Hispanic/Latino (H/L) children have lower prevalence of neurodevelopmental disabilities (NDD) than other groups. The explanations for this are complex, but may be related to nativity, language barriers, and lack of access to and utilization of healthcare. Previous research focused on how these factors affect children with NDD, but little research has jointly examined whether these factors predict NDD. This study examines whether social and environmental factors explain low prevalence of NDD in this population.

METHODS

This study uses nationally representative Integrated Public Use Microdata Series National Health Interview Survey data (N = 200,622) and multivariate logistic regression analysis to compare NDD prevalence in white and H/L children (average age of 10.2), and examines whether nativity, healthcare access, healthcare utilization, and language barriers explain this disability disparity.

RESULTS

Findings reveal that the H/L NDD disparity is not explained by differences in access to or utilization of healthcare, or as a result of language differences that may create barriers to NDD diagnosis. While H/L children whose sampled adult was born in the USA have lower rates of NDD than whites, H/Ls whose sampled adult were not born in the USA have even lower probability of NDD than H/Ls who were born in the USA.

CONCLUSIONS

These findings may be a result of cultural differences in knowledge or understanding of what constitutes a disability or the result of differential treatment within the healthcare system among H/Ls. The findings underscore the importance of accessible and culturally appropriate health and clinical care interventions among H/L communities.

Prenatal and early life exposures to ambient air pollution and development

BACKGROUND

Residential proximity to major roadways, and prenatal exposures to particulate matter <2.5 μm (PM_2.5) and ozone (O₃) are linked to poor fetal outcomes but their relationship with childhood development is unclear.

OBJECTIVES

We investigated whether proximity to major roadways, or prenatal and early-life exposures to PM_2.5 and O₃ increase the risk of early developmental delays.

STUDY DESIGN

Prospective cohort.

SETTINGS

New York State excluding New York City.

PARTICIPANTS

4089 singletons and 1016 twins born between 2008 and 2010.

EXPOSURES

Proximity to major roadway was calculated using road network data from the NY Department of Transportation. Concentrations of PM_2.5 and O₃ estimated by the Environmental Protection Agency Downscaler models were spatiotemporally linked to each child's prenatal and early-life addresses incorporating residential history, and locations of maternal work and day-care.

OUTCOMES

Parents reported their children's development at ages 8, 12, 18, 24, 30 and 36 months in five domains using the Ages and Stages Questionnaire. Generalized mixed models estimated the relative risk (RR) and 95% CI for failing any developmental domain per 10 units increase in PM_2.5 and O₃, and for those living <1000 m away from a major roadway compared to those living further. Models adjusted for potential confounders.

RESULTS

Compared to those >1000 m away from a major roadway, those resided 50-100 m [RR: 2.12 (1.00-4.52)] and 100-500 m [RR: 2.07 (1.02-4.22)] away had twice the risk of failing the communication domain. Prenatal exposures to both PM_2.5 and ozone during various pregnancy windows had weak but significant associations with failing any developmental domain with effects ranging from 1.6% to 2.7% for a 10 μg/m³ increase in PM_2.5 and 0.7%-1.7% for a 10 ppb increase in ozone. Average daily postnatal ozone exposure was positively associated with failing the overall screening by 8 months [3.3% (1.1%-5.5%)], 12 months [17.7% (10.4%-25.5%)], and 30 months [7.6%, (1.3%-14.3%)]. Findings were mixed for postnatal PM_2.5 exposures.

CONCLUSIONS

In this prospective cohort study, proximity to major roadway and prenatal/early-life exposures to PM_2.5 and O₃ were associated with developmental delays. While awaiting larger studies with personal air pollution assessment, efforts to minimize air pollution exposures during critical developmental windows may be warranted.

How universal are universal preschool health checks? An observational study using routine data from New Zealand's B4 School Check

OBJECTIVES

We aimed to estimate how many children were attending a universal preschool health screen and to identify characteristics associated with non-participation.

DESIGN

Analysis of population-level linked administrative data.

PARTICIPANTS

Children were considered eligible for a B4 School Check for a given year if:(1) they were ever resident in New Zealand (NZ),(2) lived in NZ for at least 6 months during the reference year, (3) were alive at the end of the reference year, (4) either appeared in any hospital (including emergency) admissions, community pharmaceutical dispensing or general practitioner enrolment datasets during the reference year or (5) had a registered birth in NZ. We analysed 252 273 records over 4 years, from 1 July 2011 to 30 June 2015.

RESULTS

We found that participation rates varied for each component of the B4 School Check (in 2014/2015 91.8% for vision and hearing tests (VHTs), 87.2% for nurse checks (including height, weight, oral health, Strengths and Difficulties Questionnaire [SDQ] and parental evaluation of development status) and 62.1% for SDQ - Teacher [SDQ-T]), but participation rates for all components increased over time. Māori and Pacific children were less likely to complete the checks than non-Māori and non-Pacific children (for VHTs: Māori: OR=0.60[95% CI 0.61 to 0.58], Pacific: OR=0.58[95% CI 0.60 to 0.56], for nurse checks: Māori: OR=0.63[95% CI 0.64 to 0.61], Pacific: OR=0.67[95% CI 0.69 to0.65] and for SDQ-T: Māori: OR=0.76[95% CI 0.78 to 0.75], Pacific: OR=0.37[95% CI 0.38 to 0.36]). Children from socioeconomically deprived areas, with younger mothers, from rented homes, residing in larger households, with worse health status and with higher rates of residential mobility were less likely to participate in the B4 School Check than other children.

CONCLUSION

The patterns of non-participation suggest a reinforcing of existing disparities, whereby the children most in need are not getting the services they potentially require. There needs to be an increased effort by public health organisations, community and whānau/family to ensure that all children are tested and screened.

Rating early child development outcome measurement tools for routine health programme use

BACKGROUND

Identification of children at risk of developmental delay and/or impairment requires valid measurement of early child development (ECD). We systematically assess ECD measurement tools for accuracy and feasibility for use in routine services in low-income and middle-income countries (LMIC).

METHODS

Building on World Bank and peer-reviewed literature reviews, we identified available ECD measurement tools for children aged 0-3 years used in ≥1 LMIC and matrixed these according to when (child age) and what (ECD domains) they measure at population or individual level. Tools measuring <2 years and covering ≥3 developmental domains, including cognition, were rated for accuracy and feasibility criteria using a rating approach derived from Grading of Recommendations, Assessment, Development and Evaluations.

RESULTS

61 tools were initially identified, 8% (n=5) population-level and 92% (n=56) individual-level screening or ability tests. Of these, 27 tools covering ≥3 domains beginning <2 years of age were selected for rating accuracy and feasibility. Recently developed population-level tools (n=2) rated highly overall, particularly in reliability, cultural adaptability, administration time and geographical uptake. Individual-level tool (n=25) ratings were variable, generally highest for reliability and lowest for accessibility, training, clinical relevance and geographical uptake.

CONCLUSIONS AND IMPLICATIONS

Although multiple measurement tools exist, few are designed for multidomain ECD measurement in young children, especially in LMIC. No available tools rated strongly across all accuracy and feasibility criteria with accessibility, training requirements, clinical relevance and geographical uptake being poor for most tools. Further research is recommended to explore this gap in fit-for-purpose tools to monitor ECD in routine LMIC health services.

Nurses' experiences of screening for communication difficulties at 18 months of age

AIM

Early identification of communication disorders is important and may be possible through screening in the child health services. The aim of the study was to investigate nurses' experiences and sense of competence when using the Infant-Toddler Checklist (ITC) communication screening at the 18-month health visit.

METHODS

A mixed-methods design including three focus group interviews (n = 14) and a web-based survey (n = 22) among nurses using the ITC or the standard method. Interview data were analysed through systematic text condensation and a deductive analysis based on implementation theory. Groups were compared using Mann-Whitney tests.

RESULT

Three themes emerged: Using a structured evaluation of communication changes, the dynamic, ITC is a beneficial tool and Implementation of the ITC faces a few challenges. Nurses who used the ITC perceived to a greater extent that they used a structured method (p = 0.003, r = 0.9) and felt more secure in describing the child's communication and language development to parents (p = 0.006, r = 0.83) compared to the standard method group.

CONCLUSION

Using the ITC supported the nurses in their assessment of communication at 18 months. Nurses' sense of competence was higher when using the ITC, both in their assessment and in communicating with parents.

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

AIM

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

METHOD

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

RESULTS

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

INTERPRETATION

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

WHAT THIS PAPER ADDS

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

When Do Clinicians Decide to Screen Children for Mental Health-Behavioral-Developmental Delays/Disorders: Is it Time to Reconsider Policy Recommendations?

OBJECTIVES

To determine at which ages providers choose to screen for mental, behavioral, and developmental disorder/delay (MBDD), and what they find; and which, if any, public and professional guidelines are most effective at identification.

STUDY DESIGN

Naturalistic retrospective cohort study of 215 general pediatric and family practice clinics within 24 US states involving 160 634 encounters during which MBDD screening tests were administered.

RESULTS

Almost all clinicians (96%) administered screens at ages targeted by the American Academy of Pediatrics (AAP), that is, 9, 18, 24, and/or 30 months of age, but also at younger and older ages: 57% opted to screen at ≥5 years of age. Of the 8% of children at risk for probable MBDD, 27% were detected at American Academy of Pediatrics-targeted ages-71% across the birth to 5-year age range and an additional 29% at ≥5 years of age. Children >30 months of age were 3 times more likely to have probable MBDD than were younger children, and those >5 years of age were almost 4 times more likely to have probable MBDD. Older children were more likely to have psychosocial risk factors, but age itself was the most powerful predictor.

CONCLUSIONS

Most clinicians preferred to screen across the birth to 8-year age range and their findings revealed that most MBDDs cannot be detected in the earliest years of life. Policies regarding the timing of screening should be expanded to include all well visits and between visits if needed.

Maternal intelligence quotient and motor development in early childhood: The mediating role of mother's education

AIM

To examine the association between maternal intelligence quotient (IQ) and early childhood motor development and whether maternal education mediates this relationship.

METHODS

Data were collected prospectively in the Ma'anshan Birth Cohort study. Maternal IQ was assessed using the Wechsler Adult Intelligence Scale-Revised by China (WAIS-RC). Information on baseline characteristics and maternal education was obtained from questionnaires and medical records. The study outcome was motor development evaluated at 18 months by the Third Edition of Ages and Stages Questionnaire. Logistic regression analyses and mediation analyses were used.

RESULTS

Of 2739 valid subjects (84% follow-up), the rate of developmental delay was 3.1% in the gross motor domain and 6.2% in the fine motor domain. The mean value for maternal IQ was 96.2 (standard deviation 10.6). About 40.3% of the mothers had secondary education or less, while 59.7% had a college education. Mothers with higher IQ had a significantly higher educational level and had children with better motor development. Maternal education significantly mediated the association between maternal IQ and fine motor development. There was a direct effect of maternal IQ on gross motor development, but the mediation effect of maternal education was not found.

CONCLUSIONS

Maternal IQ was associated with motor development. Maternal education played an important role in reducing the disparities in fine motor development among children of different maternal IQs.

Prevalence and Variation of Developmental Screening and Surveillance in Early Childhood

IMPORTANCE

Since 2001, the American Academy of Pediatrics has recommended universal developmental screening and surveillance to promote early diagnosis and intervention and to improve the outcomes of children with developmental delays and disabilities.

OBJECTIVE

To examine the current prevalence and variation of developmental screening and surveillance of children by various sociodemographic, enabling, and health characteristics.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional analysis of the Health Resources and Services Administration's 2016 National Survey of Children's Health-a nationally representative survey of US children completed between June 2016 and February 2017-examined 5668 randomly selected children 9 through 35 months of age whose parent or caregiver responded to the address-based survey by mail or via a website. All analyses were weighted to account for the probability of selection and nonresponse and to reflect population counts of all noninstitutionalized US children residing in housing units.

MAIN OUTCOMES AND MEASURES

Developmental screening was measured through a validated set of 3 items indicating receipt in the past year of parent-completed screening from a health care professional with age-appropriate content regarding language development and social behavior. Surveillance was determined by an item capturing verbal elicitation of developmental concerns by a health care professional.

RESULTS

Of the estimated 9.0 million children aged 9 through 35 months, an estimated 30.4% (95% CI, 28.0%-33.0%) were reported by their parent or guardian to have received a parent-completed developmental screening and 37.1% (95% CI, 34.4%-39.8%) were reported to have received developmental surveillance from a health care professional in the past year. Characteristics associated with screening and/or surveillance that remained significant after adjustment included primary household language, family structure, household education, income, medical home, past-year preventive visit, child health status, and special health care needs. Having health care that meets medical home criteria was significantly associated with both developmental screening (adjusted rate ratio, 1.34; 95% CI, 1.13-1.57) and surveillance (adjusted rate ratio, 1.24; 95% CI, 1.08-1.42), representing an 8 to 9 absolute percentage point increase. State-level differences spanned 40 percentage points for screening (17.2% in Mississippi and 58.8% in Oregon) and surveillance (19.1% in Mississippi and 60.8% in Oregon), with approximately 90% of variation not explained by child and family characteristics.

CONCLUSIONS AND RELEVANCE

Despite more than a decade of initiatives, rates of developmental screening and surveillance remain low. However, state-level variation indicates continued potential for improvement. Systems-level quality improvement efforts, building on the medical home, will be necessary to achieve recommended screening and surveillance goals.

Socioemotional developmental surveillance in young children: monitoring and screening best identify young children that require mental health treatment

BACKGROUND

Widely recommended socioemotional developmental surveillance methods include monitoring and development screening techniques. Currently, very little research has compared the effectiveness of monitoring and screening together, and existing research primarily focuses on the relationship between surveillance techniques and referrals or receipt of early intervention (EI). This study investigates the relationship between monitoring and screening and mental health treatment receipt in 3-5 year olds.

METHODS

The authors conducted logistic regression analyses on data from the National Surveys of Children's Health (NSCH; 2007) and NSCH (2011/2012) on the odds of mental health treatment receipt in children aged 3-5 years of age who either received (a) screening only, (b) monitoring only, (c) both monitoring and screening, or (d) no monitoring or screening. Sociodemographic control variables were also considered.

RESULTS

In both 2007 and 2011/2012 datasets, monitoring and screening together was the best predictor of mental health treatment receipt. Neither screening alone nor monitoring alone was associated with mental health treatment receipt.

CONCLUSIONS

Children who received monitoring and screening together had the greatest odds of treatment receipt compared with children receiving screening only, monitoring only, or no monitoring or screening.

Maternal polycystic ovarian syndrome and early offspring development

STUDY QUESTION

Is maternal polycystic ovarian syndrome (PCOS) associated with developmental delays in offspring?

SUMMARY ANSWER

Offspring of mothers with PCOS were at higher risk of failure on the Ages and Stages Questionnaire (ASQ).

WHAT IS KNOWN ALREADY

There is growing evidence that offspring of mothers with PCOS may be at higher risk for developmental disorders due to potential exposure to hyperandrogenism and insulin resistance. Few studies exist regarding maternal PCOS and early childhood development in the USA.

STUDY DESIGN, SIZE, DURATION

The Upstate KIDS Study is a population-based prospective cohort study of infants born between 2008 and 2010 in New York State (excluding New York City), originally designed to study-and finding no impact of-infertility treatment exposure on child development. Children were followed up to 36 months of age. In all, 4453 mothers completed one or more developmental screening instruments for 5388 children (35.5% twins) up to 36 months of age.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In our study, 458 mothers (10.3%) reported a healthcare provider's diagnosis of PCOS, as well as the related treatment received, on the baseline study questionnaire. Parents completed the ASQ on their child's development at 4, 8, 12, 18, 24, 30 and 36 months of age to assess fine motor, gross motor, communication, personal-social functioning and problem-solving cognitive domains. We used generalized linear mixed models to estimate odds ratios (OR) between PCOS diagnosis and failures in the ASQ adjusted for maternal age, race, BMI, education, marital status, smoking, alcohol consumption, diabetes, insurance and plurality.

MAIN RESULTS AND THE ROLE OF CHANCE

Diagnosis of PCOS was associated with increased risk of the offspring failing the fine motor domain (adjusted odds ratio (aOR) = 1.77; 95% CI: 1.09, 2.89), largely driven by higher risk in female singletons (aOR = 2.23; 1.16, 4.29). Twins of mothers with PCOS had higher risk of failing the communication (aOR = 1.94; 1.19, 3.18) and personal-social functioning (aOR = 1.76; 1.12, 2.77) domains compared to twins born to mothers without PCOS. Compared to offspring of women without PCOS, offspring of women who reported receiving no treatment for their PCOS had a stronger association with failing the ASQ (aOR = 1.68; 0.95, 2.75) than the association among offspring of women who reported PCOS treatment (aOR = 1.16; 0.79, 1.73).

LIMITATIONS, REASONS FOR CAUTION

Further study is needed to confirm the role of maternal PCOS in early offspring development with provider-validated diagnosis of PCOS.

WIDER IMPLICATIONS OF THE FINDINGS

If confirmed, these findings suggest that offspring of women with PCOS may be at increased risk for developmental delay.

STUDY FUNDING/COMPETING INTEREST(S)

Supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD; contracts HHSN275201200005C, #HHSN267200700019C). Authors have no competing interests to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Ensuring Timely Connection to Early Intervention for Young Children With Developmental Delays

BACKGROUND AND OBJECTIVES

Timely provision of developmental services can improve outcomes for children 0 to 3 years old with developmental delays. Early Intervention (EI) provides free developmental services to children under age 3 years; however, data suggests that many children referred to EI never connect to the program. We sought to ensure that 70% of patients referred to EI from an academic primary care clinic serving a low-income population were evaluated within 120 days of referral.

METHODS

Recognizing that our baseline system of EI referrals had multiple routes to referral without an ability to track referral outcome, we implemented a multifaceted referral process with (1) a centralized electronic referral system used by providers, (2) patient navigators responsible for processing all EI referrals submitted by providers, and (3) a tracking system postreferral to facilitate identification of patients failing to connect with EI.

RESULTS

The percentage of patients evaluated by EI within 120 days increased from a baseline median of 50% to a median of 72% after implementation of the systems (N = 309). After implementation, the centralized referral system was used a median of 90% of the time. Tracking of referral outcomes revealed decreases in families refusing evaluations and improvements in exchange of information with EI.

CONCLUSIONS

Rates of connection to EI improved substantially when referrals were centralized in the clinic and patient navigators were responsible for tracking referral outcomes. Knowledge of EI intake processes and relationships between the practice and the EI site are essential to ensure successful connections.

Caretaker Awareness of Health Care Provided Developmental Screening: Increases from 2007 to 2012

Objectives Developmental screening is considered critical to identifying children with developmental delays and disabilities so that they may receive early intervention. To date, only a handful of studies report data on the percentage of health care professionals (HCP) who provide developmental screening. These reports are limited by low participation rates and reporters being pediatricians who may be biased towards reporting higher rates of developmental screening. The purpose of this study is to verify reported increases by reporting on changes in caretakers' awareness of HCP provided developmental screening from 2007/2008 to 2011/2012. Methods Authors report data on caretaker reported receipt of HCP provided developmental screening from the National Survey of Children's Health (NSCH, 2007/2008) and NSCH (2011/2012), as well as changes from the 2007/2008 to 2011/2012. Changes for the 50 states plus Washington D.C. are visualized using 'micromapST' and states are organized in ascending order according to changes in caretaker awareness of developmental screening. Results Nationally, the proportion of caretakers aware that their HCP provided developmental screening increased from 23.0% in 2007/2008 (range 12.6-46%) to 33.3% in 2011/2012 (range 19.4-61.6%) and states level changes ranged from -2 to +35%, with a median change of +10%. Conclusions for Practice Data reported here indicate that a greater number of caretakers are aware that their HCP is providing developmental screening. This reinforces the existing reports indicating increases in HCP reported developmental screening. Despite growth, there is still a need to increase developmental screening efforts in many states.

Using the ages and stages questionnaire in the general population as a measure for identifying children not at risk of a neurodevelopmental disorder

Background

Early detection of neurodevelopmental disorders (NDDs) enables access to early interventions for children. We assess the Ages and Stages Questionnaire (ASQ)’s ability to identify children with a NDD in population data.

Method

Children 4 to 5 years old in the National Longitudinal Survey of Children and Youth (NLSCY) from cycles 5 to 8 were included. The sensitivity, specificity, positive and negative predictive values were calculated for the ASQ at 24, 27, 30, 33, 36 and 42 months. Fixed effects regression analyses assessed longitudinal associations between domain scores and child age.

Results

Specificity for the ASQ was high with 1SD or 2SD cutoffs, indicating good accuracy in detecting children who will not develop a NDD, however the sensitivity varied over time points and cut-offs. Sensitivity for the 1 SD cutoff at 24 months was above the recommended value of 70% for screening. Differences in ASQ domains scores between children with and without NDD increases with age.

Conclusions

The high specificity and negative predictive values of the ASQ support its use in identifying children who are not at the risk of developing a NDD. The capacity of the ASQ to identify children with a NDD in the general population is limited except for the ASQ-24 months with 1SD and can be used to identify children at risk of NDD.

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1105-z) contains supplementary material, which is available to authorized users.

Better together: Developmental screening and monitoring best identify children who need early intervention

BACKGROUND

Widely recommended developmental surveillance methods include developmental monitoring (DM) and development screening (DS). Much research has been done on DS, but very little research has compared the effectiveness of DM and DS together.

OBJECTIVES

To investigate the relationship between DM and DS in Part C early intervention (EI) service receipt.

METHODS

Authors used data from the 2007/2008 and 2011/2012 National Survey of Children's Health (NSCH). Authors report the prevalence of children aged 10 months to 3 years who received (a) DM only, (b) DS only, (c) both DM and DS, and (c) no DM or DS across survey years. Authors compare the odds of EI receipt across these groups.

RESULTS

During both periods, estimated EI receipt prevalence was higher for children receiving both DM and DS (8.38% in 2007/2008; 6.47% in 2011/2012) compared to children receiving no DM or DS (1.31% in 2007/2008; 1.92% in 2011/2012), DM alone (2.74% in 2007/2008; 2.70% in 2011/2012), or DS alone (3.59% in 2007/2008; 3.09% in 2011/2012) (for both time frames, p < .05). From 2007/2008 to 2011/2012, the proportion of children receiving DS only and both DM and DS increased, while children receiving DM only and no DM or DS decreased.

CONCLUSIONS

Children receiving DM and DS together were more likely to receive EI compared to children receiving DM alone, DS alone, or neither DM nor DS. These findings support the AAP recommendations indicating that DM and DS are complementary strategies for improving early identification and linkage to EI for young children.

Thailand's national universal developmental screening programme for young children: action research for improved follow-up

Introduction

In low-income and middle-income countries, it is estimated that one in every three preschool-age children are failing to meet cognitive or socioemotional developmental milestones. Thailand has implemented a universal national developmental screening programme (DSPM) for young children to enable detection of developmental disorders and early intervention that can improve child health outcomes. DSPM implementation is being hampered by low attendance at follow-up appointments when children fail the initial screening.

Methods

Action research, using qualitative methods was conducted with 19 caregivers, 5 health workers and 1 chief at two Health Promotion Hospitals to explore the factors affecting attendance at follow-up appointments. Transcripts and notes were analysed using descriptive content analysis. Findings were then discussed with 48 health workers, managers, researchers and policymakers.

Results

The high workload of health workers during busy vaccination clinics, and inadequate materials prevented clear communication with caregivers about the screening, how to stimulate child development and the screening result. Caregivers, particularly grandparents, had a lack of understanding about how to stimulate child development, and did not fully understand failed screening results. Caregivers felt blamed for not stimulating their child’s development, and were either worried that their child was severely disabled, or they did not believe the screening result and therefore questioned its usefulness. This led to a lack of attendance at follow-up appointments.

Conclusion

Task-sharing, mobile health (mhealth), community outreach and targeted interventions for grandparent caregivers might increase awareness about child development and screening, and allow health workers more time to communicate effectively. Sharing best practices, communication training and mentoring of DSPM workers coupled with mhealth job aids could also improve caregiver attendance at follow-up. Engagement of caregivers in understanding the barriers to attendance at follow-up and engagement of stakeholders in the design and implementation of interventions is important to ensure their effectiveness.

Avaliação do crescimento e desenvolvimento infantil na consulta de enfermagem

Objetivo: Analizar la evaluación del crecimiento y desarrollo infantil en la consulta de enfermería.Metodología: Estudio descriptivo con enfoque cualitativo. Los participantes del estudio fueron cuatro enfermeros que realizaban la consulta de enfermería a los niños de manera programática en unidades de salud de familia en Cuiabá, Mato Grosso, Brasil. La recolección de los datos se llevó a cabo mediante la observación participante de 21 consultas de enfermería entre enero y febrero de 2012. Los datos se analizaron con la técnica de análisis de contenido.Resultados: A partir del análisis de los datos, surgieron las siguientes dos categorías: Evaluación del crecimiento infantil en la consulta de enfermería y Evaluación del desarrollo infantil en la consulta de enfermería. Los enfermeros evaluaron el crecimiento infantil en todas las consultas, utilizando las curvas contenidas en la libreta personal de registro médico del niño. Sin embargo, el desarrollo infantil sólo fue evaluado parcialmente en la mayoría de las consultas observadas.Conclusión: Entre los aspectos más significativos de las consultas de enfermería se destacan la evaluación del crecimiento y desarrollo en todas ellas; y el uso de la libreta personal de registro médico del niño como instrumento de orientación para las madres y como estrategia de seguimiento del crecimiento y desarrollo infantil.

Association of teen mothers' and grandmothers' parenting capacities with child development: A study protocol

Children born to teen mothers may experience less responsive and supportive parenting and are at heightened risk for a range of social, developmental, and health issues. There is literature to support the positive impact of grandmothers on teen parents and their children. However, what if the teen's mother is also limited in her parenting capacities? How do parenting capacities across these two generations of mothers affect the developing child? In this ongoing study we are examining two important aspects of parenting capacities, attachment quality and executive functioning, in teen mothers (TM) and their biological, co- residing mothers or grandmothers (GM or GGM). Both are essential components of effective parenting, but little is known about their impact on young children's development when raised by two generations of parents. In a cross- sectional, descriptive design, a convenience sample of 50 TM/GM dyads with children 1 to 3 years old is being recruited from two urban teen-tot clinics. Participants complete a paper-and-pencil measure of attachment quality and a computerized measure of multiple aspects of executive function (working memory, inhibitory control, cognitive flexibility). A standardized maternal report measure is used to assess child developmental status. The biggest challenges of the study thus far include recruitment and transience of the study population. Progress to date and experiences from recruitment and data collection are discussed, as well as successful strategies to address challenges.

Determinants of neonatal brain-derived neurotrophic factor and association with child development

Using a population-based birth cohort in upstate New York (2008-2010), we examined the determinants of brain-derived neurotrophic factor (BDNF) measured in newborn dried blood spots (n = 2,637). We also examined the association between neonatal BDNF and children's development. The cohort was initially designed to examine the influence of infertility treatment on child development but found no impact. Mothers rated children's development in five domains repeatedly through age 3 years. Socioeconomic and maternal lifestyle determinants of BDNF were examined using multivariable linear regression models. Generalized linear mixed models estimated odds ratios for neonatal BDNF in relation to failing a developmental domain. Smoking and drinking in pregnancy, nulliparity, non-White ethnicity/race, and prepregnancy obesity were associated with lower neonatal BDNF. Neonatal BDNF was not associated with failure for developmental domains; however, there was an interaction between BDNF and preterm birth. In preterm infants, a higher BDNF was associated with lower odds of failing any developmental domains, after adjusting for confounders and infertility treatment. This result was particularly significant for failure in communication. Our findings suggest that BDNF levels in neonates may be impacted by maternal lifestyle characteristics. More specifically, lower neonatal BDNF might be an early marker of aberrant neurodevelopment in preterm infants.

Utilizing two-tiered screening for early detection of autism spectrum disorder

Despite advances in autism screening practices, challenges persist, including barriers to implementing universal screening in primary care and difficulty accessing services. The high false positive rate of Level 1 screening methods presents especially daunting difficulties because it increases the need for comprehensive autism evaluations. This study explored whether two-tiered screening-combining Level 1 (Modified Checklist for Autism in Toddlers, Revised with Follow-Up) and Level 2 (Screening Tool for Autism in Toddlers and Young Children) measures-improves the early detection of autism. This study examined a sample of 109 toddlers who screened positive on Level 1 screening and completed a Level 2 screening measure prior to a diagnostic evaluation. Results indicated that two-tiered screening reduced the false positive rate using published Screening Tool for Autism in Toddlers and Young Children cutoffs compared to Level 1 screening alone, although at a cost to sensitivity. However, alternative Screening Tool for Autism in Toddlers and Young Children scoring in the two-tiered screening improved both positive predictive value and sensitivity. Exploratory analyses were conducted, including comparison of autism symptoms and clinical profiles across screening subsamples. Recommendations regarding clinical implications of two-tiered screening and future areas of research are presented.

Consistency and sources of divergence in recommendations on screening with questionnaires for presently experienced health problems or symptoms: a comparison of recommendations from the Canadian Task Force on Preventive Health Care, UK National Screening Committee, and US Preventive Services Task Force

BACKGROUND

Recently, health screening recommendations have gone beyond screening for early-stage, asymptomatic disease to include "screening" for presently experienced health problems and symptoms using self-report questionnaires. We examined recommendations from three major national guideline organizations to determine the consistency of recommendations, identify sources of divergent recommendations, and determine if guideline organizations have identified any direct randomized controlled trial (RCT) evidence for the effectiveness of questionnaire-based screening.

METHODS

We reviewed recommendation statements listed by the Canadian Task Force on Preventive Health Care (CTFPHC), the United Kingdom National Screening Committee (UKNSC), and the United States Preventive Services Task Force (USPSTF) as of 5 September 2016. Eligible recommendations focused on using self-report questionnaires to identify patients with presently experienced health problems or symptoms. Within each recommendation and accompanying evidence review we identified screening RCTs.

RESULTS

We identified 22 separate recommendations on questionnaire-based screening, including three CTFPHC recommendations against screening, eight UKNSC recommendations against screening, four USPSTF recommendations in favor of screening (alcohol misuse, adolescent depression, adult depression, intimate partner violence), and seven USPSTF recommendations that did not recommend for or against screening. In the four cases where the USPSTF recommended screening, either the CTFPHC, the UKNSC, or both recommended against. When recommendations diverged, the USPSTF expressed confidence in benefits based on indirect evidence, evaluated potential harms as minimal, and did not consider cost or resource use. CTFPHC and UKNSC recommendations against screening, on the other hand, focused on the lack of direct evidence of benefit and raised concerns about harms to patients and resource use. Of six RCTs that directly evaluated screening interventions, five did not report any statistically significant primary or secondary health outcomes in favor of screening, and one trial reported equivocal results.

CONCLUSIONS

Only the USPSTF has made any recommendations for screening with questionnaires for presently experienced problems or symptoms. The CTFPHC and UKNSC recommended against screening in all of their recommendations. Differences in recommendations appear to reflect differences in willingness to assume benefit from indirect evidence and different approaches to assessing possible harms and resource consumption. There were no examples in any recommendations of RCTs with direct evidence of improved health outcomes.

Clinical utility of the Structured Observation of Motor Performance in Infants within the child health services

AIM

This study aimed to evaluate the clinical utility of the Structured Observation of Motor Performance in Infants (SOMP-I) when used by nurses in routine child healthcare by analyzing the nurses' SOMP-I assessments and the actions taken when motor problems were suspected.

METHOD

Infants from three child health centers in Uppsala County, Sweden, were consecutively enrolled in a longitudinal study. The 242 infants were assessed using SOMP-I by the nurse responsible for the infant as part of the regular well-child visits at as close to 2, 4, 6 and 10 months of age as possible. The nurses noted actions taken such as giving advice, scheduling an extra follow-up or referring the infant to specialized care. The infants' motor development was reassessed at 18 months of age through review of medical records or parental report.

RESULTS

The assessments of level of motor development at 2 and 10 months showed a distribution corresponding to the percentile distribution of the SOMP-I method. Fewer infants than expected were assessed as delayed at 4 and 6 months or deficient in quality at all assessment ages. When an infant was assessed as delayed in level or deficient in quality, the likelihood of the nurse taking actions increased. This increased further if both delay and quality deficit were found at the same assessment or if one or both were found at repeated assessments. The reassessment of the motor development at 18 months did not reveal any missed infants with major motor impairments.

INTERPRETATION

The use of SOMP-I appears to demonstrate favorable clinical utility in routine child healthcare as tested here. Child health nurses can assess early motor performance using this standardized assessment method, and using the method appears to support them the clinical decision-making.

Is a Positive Developmental-Behavioral Screening Score Sufficient to Justify Referral? A Review of Evidence and Theory

In their recommendations on screening for autism and developmental disabilities, the American Academy of Pediatrics recommends referral subsequent to a positive screening result. In this article, we argue that positive screening results are not always sufficient to justify a referral. We show that although positive predictive values are often low, they actually overstate the probability of having a disorder for many children who screen positive. Moreover, recommended screening thresholds are seldom set to ensure that the benefits of referral will equal or exceed the costs and risk of harm, which is a necessary condition for an optimal threshold in decision analysis. Drawing on recent recommendations for the Institute of Medicine/National Academy of Medicine, we discuss the implications of this argument for pediatric policy, education, and practice. In particular, we recommend that screening policies be revised to ensure that the costs and benefits of actions recommended in the event of a positive screen are appropriate to the screening threshold. We recommend greater focus on clinical decision-making in the education of physicians, including shared decision-making with patients and their families. Finally, we recommend broadening the scope of screening research to encompass not only the accuracy of specific screening instruments, but also their ability to improve decision-making in the context of systems of care.

Use of a Digital Modified Checklist for Autism in Toddlers - Revised with Follow-up to Improve Quality of Screening for Autism

OBJECTIVES

To assess changes in quality of care for children at risk for autism spectrum disorders (ASD) due to process improvement and implementation of a digital screening form.

STUDY DESIGN

The process of screening for ASD was studied in an academic primary care pediatrics clinic before and after implementation of a digital version of the Modified Checklist for Autism in Toddlers - Revised with Follow-up with automated risk assessment. Quality metrics included accuracy of documentation of screening results and appropriate action for positive screens (secondary screening or referral). Participating physicians completed pre- and postintervention surveys to measure changes in attitudes toward feasibility and value of screening for ASD. Evidence of change was evaluated with statistical process control charts and χ² tests.

RESULTS

Accurate documentation in the electronic health record of screening results increased from 54% to 92% (38% increase, 95% CI 14%-64%) and appropriate action for children screening positive increased from 25% to 85% (60% increase, 95% CI 35%-85%). A total of 90% of participating physicians agreed that the transition to a digital screening form improved their clinical assessment of autism risk.

CONCLUSIONS

Implementation of a tablet-based digital version of the Modified Checklist for Autism in Toddlers - Revised with Follow-up led to improved quality of care for children at risk for ASD and increased acceptability of screening for ASD. Continued efforts towards improving the process of screening for ASD could facilitate rapid, early diagnosis of ASD and advance the accuracy of studies of the impact of screening.

A Pilot Randomized Trial of a Video Patient Decision Aid to Facilitate Early Intervention Referrals From Primary Care

Many young children identified with developmental concerns in pediatric settings do not receive early intervention (EI). We assessed the impact of a video decision aid and text message reminder on knowledge and attitudes regarding developmental delay and EI as well as referral completion. We conducted a pilot randomized controlled trial in an urban setting and enrolled 64 parent-child dyads referred to EI. Compared with controls, participants who received the intervention demonstrated increased knowledge regarding developmental delay and EI as well as more favorable attitudes in certain topics. Although we did not find a significant difference between arms in EI intake and evaluation, we found a pattern suggestive of increased intake and evaluation among participants with low health literacy in the intervention arm. Additional study is needed to identify strategies that improve the EI referral process for families and to understand the potential targeted role for decision aids and text messages.

[Predictive value of Ages & Stages Questionnaires for cognitive performance at early years of schooling]

The Ages and Stages questionnaires (ASQ) has been recently validated in our country for developmental screening. The objective of this study is evaluate the validity of ASQ to predict low cognitive performance in the early years of schooling.

PATIENTS AND METHOD

Diagnostic test studies conducted on a sample of children of medium-high socioeconomic level were evaluated using ASQ at least once at 8, 18 and/or 30 months old, and later, between 6 and 9 years old, reevaluated using the Wechsler Intelligence Scale for Children-third edition (WISC-III). Each ASQ evaluation was recorded independently. WISC-III was standardized, considering underperformance when the total score were under -1 standard deviation.

RESULTS

123 children, corresponding to 174 ASQ assessments (42 of them were 8 months old, 55 were 18 months and 77 were 30 months of age) were included. An area under the ROC curve of 80.7% was obtained, showing higher values at 8 months (98.0%) compared to 18 and 30 months old (78.1 and 79.3%, respectively). Considering different ASQ scoring criteria, a low sensitivity (27.8 to 50.0%), but a high specificity (78.8 to 96.2%) were obtained; the positive predictive value ranged between 21 and 46%, while the negative value was 92.0-93.2%. Conclusion ASQ has low sensitivity but excellent specificity to predict a low cognitive performance during the first years of schooling, being a good alternative to monitor psychomotor development in children who attend the private sector healthcare in our country.

Parental Obesity and Early Childhood Development

BACKGROUND

Previous studies identified associations between maternal obesity and childhood neurodevelopment, but few examined paternal obesity despite potentially distinct genetic/epigenetic effects related to developmental programming.

METHODS

Upstate KIDS (2008-2010) recruited mothers from New York State (excluding New York City) at ∼4 months postpartum. Parents completed the Ages and Stages Questionnaire (ASQ) when their children were 4, 8, 12, 18, 24, 30, and 36 months of age corrected for gestation. The ASQ is validated to screen for delays in 5 developmental domains (ie, fine motor, gross motor, communication, personal-social functioning, and problem-solving ability). Analyses included 3759 singletons and 1062 nonrelated twins with ≥1 ASQs returned. Adjusted odds ratios (aORs) and 95% confidence intervals were estimated by using generalized linear mixed models accounting for maternal covariates (ie, age, race, education, insurance, marital status, parity, and pregnancy smoking).

RESULTS

Compared with normal/underweight mothers (BMI <25), children of obese mothers (26% with BMI ≥30) had increased odds of failing the fine motor domain (aOR 1.67; confidence interval 1.12-2.47). The association remained after additional adjustment for paternal BMI (1.67; 1.11-2.52). Paternal obesity (29%) was associated with increased risk of failing the personal-social domain (1.75; 1.13-2.71), albeit attenuated after adjustment for maternal obesity (aOR 1.71; 1.08-2.70). Children whose parents both had BMI ≥35 were likely to additionally fail the problem-solving domain (2.93; 1.09-7.85).

CONCLUSIONS

Findings suggest that maternal and paternal obesity are each associated with specific delays in early childhood development, emphasizing the importance of family information when screening child development.

Ages and Stages Questionnaire: a global screening scale

With standardized screening tools, research studies have shown that developmental disabilities can be detected reliably and with validity in children as young as 4 months of age by using the instruments such as the Ages and Stages Questionnaire. In this review, we will focus on one tool, the Ages and Stages Questionnaire, to illustrate the usefulness of developmental screening across the globe.

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

BACKGROUND

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

AIMS

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

SUBJECTS

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

RESULTS

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

CONCLUSIONS

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

A system dynamics model of clinical decision thresholds for the detection of developmental-behavioral disorders

Background

Clinical decision-making has been conceptualized as a sequence of two separate processes: assessment of patients’ functioning and application of a decision threshold to determine whether the evidence is sufficient to justify a given decision. A range of factors, including use of evidence-based screening instruments, has the potential to influence either or both processes. However, implementation studies seldom specify or assess the mechanism by which screening is hypothesized to influence clinical decision-making, thus limiting their ability to address unexpected findings regarding clinicians’ behavior. Building on prior theory and empirical evidence, we created a system dynamics (SD) model of how physicians’ clinical decisions are influenced by their assessments of patients and by factors that may influence decision thresholds, such as knowledge of past patient outcomes. Using developmental-behavioral disorders as a case example, we then explore how referral decisions may be influenced by changes in context. Specifically, we compare predictions from the SD model to published implementation trials of evidence-based screening to understand physicians’ management of positive screening results and changes in referral rates. We also conduct virtual experiments regarding the influence of a variety of interventions that may influence physicians’ thresholds, including improved access to co-located mental health care and improved feedback systems regarding patient outcomes.

Results

Results of the SD model were consistent with recent implementation trials. For example, the SD model suggests that if screening improves physicians’ accuracy of assessment without also influencing decision thresholds, then a significant proportion of children with positive screens will not be referred and the effect of screening implementation on referral rates will be modest—results that are consistent with a large proportion of published screening trials. Consistent with prior theory, virtual experiments suggest that physicians’ decision thresholds can be influenced and detection of disabilities improved by increasing access to referral sources and enhancing feedback regarding false negative cases.

Conclusions

The SD model of clinical decision-making offers a theoretically based framework to improve understanding of physicians’ behavior and the results of screening implementation trials. The SD model is also useful for initial testing of hypothesized strategies to increase detection of under-identified medical conditions.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0517-0) contains supplementary material, which is available to authorized users.

Protective factors for child development at age 2 in the presence of poor maternal mental health: results from the All Our Babies (AOB) pregnancy cohort

OBJECTIVE

To identify the combination of factors most protective of developmental delay at age 2 among children exposed to poor maternal mental health.

DESIGN

Observational cohort study.

SETTING

Pregnant women were recruited from primary healthcare offices, the public health laboratory service and community posters in Calgary, Alberta, Canada.

PARTICIPANTS

1596 mother-child dyads who participated in the All Our Babies study and who completed a follow-up questionnaire when their child was 2 years old. Among participants who completed the 2-year questionnaire and had complete mental health data (n=1146), 305 women (27%) were classified as high maternal mental health risk.

PRIMARY MEASURES

Child development at age 2 was described and a resilience analysis was performed among a subgroup of families at maternal mental health risk. The primary outcome was child development problems. Protective factors were identified among families at risk, defined as maternal mental health risk, a composite measure created from participants' responses to mental health life course questions and standardised mental health measures.

RESULTS

At age 2, 18% of children were classified as having development problems, 15% with behavioural problems and 13% with delayed social-emotional competencies. Among children living in a family with maternal mental health risk, protective factors against development problems included higher social support, higher optimism, more relationship happiness, less difficulty balancing work and family responsibilities, limiting the child's screen time to <1 hour per day and the child being able to fall asleep in <30 min and sleeping through the night by age 2.

CONCLUSIONS

Among families where the mother has poor mental health, public health and early intervention strategies that support interpersonal relationships, social support, optimism, work-life balance, limiting children's screen time and establishing good sleep habits in the child's first 2 years show promise to positively influence early child development.

Behavioral Health Screening among Massachusetts Children Receiving Medicaid

OBJECTIVE

To assess the impact of a Massachusetts Medicaid policy change (the Children's Behavioral Health Initiative; CBHI, which required and reimbursed behavioral health [BH] screening with standardized tools at well child visits and developed intensive home- and community-based BH services) on primary care practice examining the relationship of BH screening to subsequent BH service utilization.

STUDY DESIGN

Using a repeated cross-sectional design, our 2010 and 2012 Medicaid study populations each included 2000 children/adolescents under the age of 21 years. For each year, the population was randomly selected and stratified into 4 age groups, with 500 members selected per group. Two data sources were used: medical records and Medicaid claims.

RESULTS

The CBHI had a large impact on formal BH screening and treatment utilization among children/adolescents enrolled in Medicaid. Screening increased substantially (73%: 2010; 74%: 2012) since the baseline/premandate period (2007) when only 4% of well child visits included a formal screen. BH utilization increased among those formally screened but decreased among those with informal assessments.

CONCLUSIONS

CBHI implementation transformed the relationship between primary care and BH services. Changes in regulation and payment resulted in widespread BH screening in Massachusetts primary care practices caring for children/adolescents on Medicaid.