Effectiveness of developmental screening in an urban setting

Analysing four Norweigian population-based samples using the six-month version of the Ages and Stages Questionnaire showed few relevant clinical differences

AIM

We investigated whether there were clinically relevant differences in the area mean scores of the six-month Ages and Stages Questionnaire (ASQ) between four Norwegian population-based samples.

METHODS

Area mean scores and standard deviations (SDs) were investigated for the five developmental areas of the ASQ: communication, gross motor, fine motor, problem solving and personal-social. Sample sizes varied from 166 to 1192 and the ASQ was completed on paper or by computer. ASQ scores in the four samples were compared using ANOVA and Tukey's procedure was used to adjust for multiple comparisons.

RESULTS

The ASQ mean area scores were generally similar in the four data sets, with few clinically relevant differences, defined as a mean difference of greater than five points, which is the smallest increment in area score, or an effect size of >0.5 in absolute value. All the clinically relevant differences occurred when samples used a modified ASQ administration format. Several additional minor differences were statistically significant, which was expected due to the large samples.

CONCLUSION

These results support the original Norwegian normative findings for the ASQ six-month form and the ASQ's use as a low-cost developmental screening tool in Norway, at least when the original format is administered.

Pre-school screening for developmental and emotional health: Comparison with neurodevelopmental assessment

AIM

The study aim was to compare detection of and referral for developmental and emotional problems in a school readiness screening programme (New Zealand Before School Check, B4SC) with that of a comprehensive neurodevelopmental assessment.

METHODS

This is a prospective cohort study of children (n = 274) born at risk of neonatal hypoglycaemia and recruited to a follow-up study of neurodevelopmental outcomes at 4.5 years (Children with Hypoglycaemia and their Later Development (CHYLD) Study). Children identified as of significant concern for developmental and emotional problems, and referrals made, were compared in the B4SC and CHYLD Study. Scores of the parent-completed Strengths and Difficulties Questionnaire used in both assessments were compared.

RESULTS

Of the 274 children who underwent clinical neurodevelopmental assessment at a mean (standard deviation) age of 53.3 (1.8) months, 237 had the B4SC developmental and emotional health screening. Of these, 44 (19%) children met B4SC referral criteria, and 15 (6%) were referred, but only 21 (9%) children met CHYLD referral criteria, and 10 (4%) were referred. Twelve children (5%) met both the B4SC and CHYLD referral criteria, and two were referred by both. When assessed twice, 39 (17%) children changed parent-completed Strengths and Difficulties Questionnaire category. Children who did not have B4SC screening had higher mean total difficulties score (10.5 vs. 8.2, P = 0.009) and were more likely to have cognitive delay than those who were screened (19% vs. 8%, P = 0.04).

CONCLUSION

More children met referral criteria for the B4SC screening programme than for a more comprehensive neurodevelopmental assessment. Children who did not have screening had a higher incidence of cognitive and behaviour problems than those who did.

Rates of detection of developmental problems at the 18-month well-baby visit by family physicians' using four evidence-based screening tools compared to usual care: a randomized controlled trial

BACKGROUND

Early and regular developmental screening can improve children's development through early intervention but is insufficiently used. Most developmental problems are readily evident at the 18-month well-baby visit. This trial's purpose is to: (1) compare identification rates of developmental problems by GPs/family physicians using four evidence-based tools with non-evidence based screening, and (2) ascertain whether the four tools can be completed in 10-min pre-visit on a computer.

METHODS

We compared two approaches to early identification via random assignment of 54 families to either: 'usual care' (informal judgment including ad-hoc milestones, n = 25); or (2) 'Evidence-based' care (use of four validated, accurate screening tools, n = 29), including: the Parents' Evaluation of Developmental Status (PEDS), the PEDS-Developmental Milestones (PEDS-DM), the Modified Checklist for Autism in Toddlers (M-CHAT) and PHQ9 (maternal depression).

RESULTS

In the 'usual care' group four (16%) and in the evidence-based tools group 18 (62%) were identified as having a possible developmental problem. In the evidence-based tools group three infants were to be recalled at 24 months for language checks (no specialist referrals made). In the 'usual care' group four problems were identified: one child was referred for speech therapy, two to return to check language at 24 months and a mother to discuss depression. All forms were completed on-line within 10 min.

CONCLUSIONS

Despite higher early detection rates in the evidence-based care group, there were no differences in referral rates between evidence-based and usual-care groups. This suggests that clinicians: (1) override evidence-based screening results with informal judgment; and/or (2) need assistance understanding test results and making referrals. Possible solutions are improve the quality of information obtained from the screening process, improved training of physicians, improved support for individual practices and acceptance by the regional health authority for overall responsibility for screening and creation of a comprehensive network.

'Now I use words like asymmetry and unstable': nurses' experiences in using a standardized assessment for motor performance within routine child health care

RATIONALE, AIMS AND OBJECTIVES

There is an increasing recognition that early intervention is important for children with motor disorders. The use of standardized assessment methods within the Swedish Child Health Services (CHS) may improve early identification of these children and thereby their development and quality of care. Given the key role of nurses within the CHS, we explored their experiences of using a structured assessment of motor performance (SOMP-I) in a clinical setting, and investigated possible barriers and facilitators for implementation of the method within the CHS.

METHODS

The study was conducted in 2013 in Uppsala County, Sweden. Ten child health nurses participated in two focus group interviews, which were analysed using systematic text condensation.

RESULTS

The analysis yielded three themes: (1) increased knowledge and professional pride - nurses described their desire to provide high-quality care for which SOMP-I was a useful tool; (2) improved parent-provider relationship - nurses felt that using SOMP-I involved both the parents and their infant to a greater extent than routine care; and (3) conditions for further implementation - nurses described that the time and effort needed to master new skills must be considered and practical barriers, such as lack of examination space, resource constraints and difficulties in documenting the assessment must be addressed before implementing the SOMP-I method in routine care.

CONCLUSION

Child health nurses felt that the SOMP-I method fitted well with their professional role and increased the quality of care provided. However, significant barriers to implementing SOMP-I into routine child health care were described.

Adaptation of the Ages and Stages Questionnaire for Remote Aboriginal Australia

A key challenge to providing quality developmental care in remote Aboriginal primary health care (PHC) centers has been the absence of culturally appropriate developmental screening instruments. This study focused on the cross-cultural adaptation of the Ages and Stages Questionnaires, 3rd edition (ASQ-3), with careful attention to language and culture. We aimed to adapt the ASQ-3 for use with remote dwelling Australian Aboriginal children, and to investigate the cultural appropriateness and feasibility of the adapted ASQ-3 for use in this context. We undertook a qualitative study in two remote Australian Aboriginal communities, using a six-step collaborative adaptation process. Aboriginal Health Workers (AHWs) were trained to use the adapted ASQ-3, and follow-up interviews examined participants' views of the cultural acceptability and usefulness of the adapted instrument. The adapted ASQ-3 was found to have high face validity and to be culturally acceptable and relevant to parents, AHWs, and early childhood development experts.

Examining Infertility Treatment and Early Childhood Development in the Upstate KIDS Study

IMPORTANCE

An increasing percentage of births are conceived with assisted reproductive technology (ART) and other infertility treatment. Despite findings that such treatments may be associated with diminished gestation and birth size, scarce data exist regarding infertility treatments and children's development in the United States.

OBJECTIVE

To assess the use and type of infertility treatment in relation to children's development through age 36 months.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study (conducted 2008-2014) that sampled based on infertility treatment and plurality. Included in the study were infants born between 2008 and 2010 in New York state (excluding New York City) whose parents completed developmental screening instruments through 36 months of age. A total of 4824 mothers (97% of 4989) completed 1 or more developmental screening instruments for 5841 children, including 1830 conceived with infertility treatment and 2074 twins.

EXPOSURES

Maternal self-report of any infertility treatment was further categorized into ART and ovulation induction/intrauterine insemination. Assisted reproductive technology use was previously validated by linkage with the Society for Assisted Reproductive Technology-Clinical Outcome Reporting System.

MAIN OUTCOMES AND MEASURES

Five developmental domains (fine motor, gross motor, communication, personal-social functioning, and problem-solving ability), as measured by the parental completion of the Ages and Stages Questionnaires at 4, 8, 12, 18, 24, 30, and 36 months of age. Generalized linear mixed modeling techniques estimated adjusted odds ratios (aORs) and 95% CIs for use and type of infertility treatment in relation to failing a developmental domain. Data were stratified by plurality and weighted for the sampling scheme.

RESULTS

There were 1422 mothers (29.5%; mean [SD], age, 34.1 [5.2] years) who underwent infertility treatment. Infertility treatment was not associated with risk of their children failing any developmental domain (aOR, 1.33; 95% CI, 0.94-1.89). Assisted reproductive technology was associated with increased risk for failing any developmental domain but only when singletons and twins were evaluated together (aOR, 1.81; 95% CI, 1.21-2.72). Adjustment for birth weight further attenuated this estimate (aOR, 1.26; 95% CI, 0.82-1.93). After stratifying by plurality, type of treatment also was not significantly associated with failing any developmental domain for ovulation induction/intrauterine insemination (aOR, 1.00; 95% CI, 0.57-1.77 for singletons and aOR, 1.30; 95% CI, 0.76-2.21 for twins) or ART (aOR, 1.38; 95% CI, 0.78-2.43 for singletons and aOR, 1.58; 95% CI, 0.94-2.65 for twins).

CONCLUSIONS AND RELEVANCE

After considering plurality, children's development through age 3 years was similar irrespective of infertility treatment or specific type. To our knowledge, these findings are among the first to focus on non-ART treatments in the United States.

Correcting for prematurity affects developmental test scores in infants born late and moderately preterm

BACKGROUND

Corrected age is typically applied when assessing the development of children born <32 weeks of gestation. There is no consensus as to whether corrected age should be applied when assessing children born late/moderately preterm (LMPT; 32-36 weeks of gestation).

AIMS

This study explored the impact of corrected age on developmental test scores in infants born LMPT.

STUDY DESIGN

221 LMPT infants were assessed at two years corrected age using the Bayley-III cognitive and language scales, from which cognitive and language composite scores were derived (Normative Mean 100; SD 15). Assessments were then re-scored using chronological age. Bayley-III composite scores <80 were used to define developmental delay. Paired sample t-tests were used to assess the difference in mean test scores derived using corrected versus chronological age, and McNemar's tests to assess the difference in the proportion of infants with developmental delay using corrected versus chronological age.

RESULTS

Mean corrected age scores were significantly higher than chronological age scores (cognitive: 2.1 points; 95% CI 1.6, 2.5; language 2.5; 95% CI 2.1, 2.8). Overall, significantly more LMPT infants were classified with developmental delay when chronological (18.3%) versus corrected (15.0%) age was used (p=0.016).

CONCLUSIONS

Correcting for prematurity results in significantly higher developmental test scores and a significantly lower prevalence of developmental delay in LMPT infants and may affect eligibility for intervention services. Researchers and clinicians should be aware that the use of corrected age may impact on developmental test scores at both an individual and population level among infants born LMPT.

Translating Research to Practice for Children With Autism Spectrum Disorder: Part I: Definition, Associated Behaviors, Prevalence, Diagnostic Process, and Interventions

INTRODUCTION

The number of children with autism spectrum disorder (ASD) is rising, along with the potential for challenging behaviors during health care encounters.

METHOD

We present an overview of the emerging science related to ASD diagnosis and interventions for children with ASD.

RESULTS

Emerging science on ASD reveals common associated challenging behaviors, increasing prevalence, emphasis on early diagnosis at 18 to 24 months of age, changes in the diagnostic process with criteria from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, and interventions with medication, education, and behavior management.

DISCUSSION

Family and health care provider preparation strategies facilitate care of children with ASD and their families. Early diagnosis at 18 to 24 months of age and evidence-based interventions contribute to best outcomes for children and families. Health care providers must be aware of the state of the science for diagnosis and best practices to provide family-centered care for this growing population.

Screening for developmental delay among children aged 1-4 years: a systematic review

BACKGROUND

Existing guidelines on screening children less than 5 years of age for developmental delay vary. In this systematic review, we synthesized the literature on the effectiveness and harms of screening for developmental delay in asymptomatic children aged 1-4 years.

METHODS

We searched MEDLINE, Embase and PsychINFO for relevant articles published to June 16, 2015. We identified studies that included children aged 1-4 years who were not at high risk of developmental delay, screened in a primary care setting. Randomized trials and controlled cohort studies were considered for benefits (cognitive, academic and functional outcomes); no restrictions on study design were imposed for the review of harms.

RESULTS

Two studies were included. One used the Ages and Stages Questionnaire II for screening and reported significantly more referrals to early intervention in the intervention groups than in the control group (relative risk [RR] 1.95, 95% confidence interval [CI] 1.49-2.54, in the intervention group with office support and RR 1.71, 95% CI 1.30-2.25, in the intervention group without office support). The time to referral was 70% shorter in the intervention group with office support (rate ratio 0.30, 95% CI 0.19-0.48) and 64% shorter in the intervention group without office support (rate ratio 0.36, 95% CI 0.23-0.59), compared with the control group. The other study used the VroegTijdige Onderkenning Ontwikkelingsstoornissen Language Screening instrument to screen children aged 15 months at enrolment for language delay. It reported no differences between groups in academic performance outcomes at age 8 years.

INTERPRETATION

The evidence on screening for developmental delay in asymptomatic children aged 1-4 years is inconclusive. Further research with longer-term outcomes is needed to inform decisions about screening and screening intervals.

Prevalence of suspected developmental delays in early infancy: results from a regional population-based longitudinal study

Background

Prevalence estimates on suspected developmental delays (SDD) in young infants are scarce and a necessary first step for planning an early intervention. We investigated the prevalence of SDD at 4, 6 and 12 months, in addition to associations of SDD with gender, prematurity and maternal education.

Methods

This study is based on a Norwegian longitudinal sample of 1555 infants and their parents attending well-baby clinics for regular health check-ups. Moreover, parents completed the Norwegian translation of the Ages and Stages Questionnaires (ASQ) prior to the check-up, with a corrected gestational age being used to determine the time of administration for preterm infants. Scores ≤ the established cut-offs in one or more of the five development areas: communication, gross motor, fine motor, problem solving and personal-social, which defined SDD for an infant were reported. Chi-square tests were performed for associations between the selected factors and SDD.

Results

According to established Norwegian cut-off points, the overall prevalence of SDD in one or more areas was 7.0 % (10.3 % US cut-off) at 4 months, 5.7 % (12.3 % US cut-off) at 6 months and 6.1 % (10.3 % US cut-off) at 12 months. The highest prevalence of SDD was in the gross motor area at all three time points. A gestational age of < 37 weeks revealed a significant association with the communication SDD at 4 months, and with the fine motor and personal social SDD at 6 months. Gender was significantly associated with the fine motor and problem solving SDD at 4 months and personal- social SDD at 6 months: as more boys than girls were delayed. No significant associations were found between maternal education and the five developmental areas of the ASQ.

Conclusion

Our findings indicate prevalence rates of SDD between 5.7 and 7.0 % in Norwegian infants between 4 and 12 months of age based on the Norwegian ASQ cut-off points (10.3–12.3 %, US cut-off points). During the first year of life, delay is most frequent within the gross motor area. Special attention should be paid to infants born prematurely, as well as to boys. Separate norms for boys and girls should be considered for the ASQ.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0528-z) contains supplementary material, which is available to authorized users.

Validation of the Chilean version of the Ages and Stages Questionnaire (ASQ-CL) in Community Health Settings

OBJECTIVE

To validate the translated and cross culturally adapted Chilean version of the 8 and 18month Ages and Stages Questionnaire (ASQ-CL) in a community sample.

PARTICIPANTS

Parents of 1572 term children (82.9%) and 324 children at risk for developmental delay (17.1%) were included.

INSTRUMENT

ASQ-3rd edition translated and culturally adapted for Chilean urban population.

MAIN MEASURES

8 and 18months ASQ-CL reliability, validity and mean scores. Feasibility was assessed using qualitative methods in healthcare professionals and mothers.

RESULTS

ASQ-CL mean scores were comparable to U.S. normative data. The overall total score and all domains were reliable (Cronbach alpha 0.66-0.85). Test-retest and inter-rater reliability were high (Pearson's r range 0.73-0.94; intraclass correlation r range 0.68-0.93). Early preterm infants were more likely to fail on several criteria. Qualitative methods confirmed ASQ-CL as a feasible tool in this Chilean urban community.

CONCLUSIONS

ASQ-CL is a valid, reliable and feasible tool for assessing development in children at 8 and 18months in Chilean urban population.

Thresholds and accuracy in screening tools for early detection of psychopathology

BACKGROUND

The accuracy of any screening instrument designed to detect psychopathology among children is ideally assessed through rigorous comparison to 'gold standard' tests and interviews. Such comparisons typically yield estimates of what we refer to as 'standard indices of diagnostic accuracy', including sensitivity, specificity, positive predictive value (PPV), and negative predictive value. However, whereas these statistics were originally designed to detect binary signals (e.g., diagnosis present or absent), screening questionnaires commonly used in psychology, psychiatry, and pediatrics typically result in ordinal scores. Thus, a threshold or 'cut score' must be applied to these ordinal scores before accuracy can be evaluated using such standard indices. To better understand the tradeoffs inherent in choosing a particular threshold, we discuss the concept of 'threshold probability'. In contrast to PPV, which reflects the probability that a child whose score falls at or above the screening threshold has the condition of interest, threshold probability refers specifically to the likelihood that a child whose score is equal to a particular screening threshold has the condition of interest.

METHOD

The diagnostic accuracy and threshold probability of two well-validated behavioral assessment instruments, the Child Behavior Checklist Total Problem Scale and the Strengths and Difficulties Questionnaire total scale were examined in relation to a structured psychiatric interview in three de-identified datasets.

RESULTS

Although both screening measures were effective in identifying groups of children at elevated risk for psychopathology in all samples (odds ratios ranged from 5.2 to 9.7), children who scored at or near the clinical thresholds that optimized sensitivity and specificity were unlikely to meet criteria for psychopathology on gold standard interviews.

CONCLUSIONS

Our results are consistent with the view that screening instruments should be interpreted probabilistically, with attention to where along the continuum of positive scores an individual falls.

Can nurses be key players in assessing early motor development using a structured method in the child health setting?

RATIONAL, AIMS AND OBJECTIVES

Increasing evidence highlights the importance of early interventions for motor disorders in children. Given the key medical role of the nurse within the Swedish Child Health Service (CHS), we aimed to examine if nurses could apply a structured assessment of early motor development at the child health centre to enable early identification of children at risk.

METHODS

Structured Observation of Motor Performance in Infants (SOMP-I) assesses infant's level of motor development and quality of motor performance using subscales converted to total scores. The total score for both level and quality can then be plotted within the SOMP-I percentile distribution at the child's age for comparison with a reference population. Fifty-five infants (girls: 30) were assessed according to SOMP-I at three child health centres. Assessments were performed by nurses (n = 10) in a clinical setting; one nurse performed the assessment while another nurse and a physiotherapist observed.

RESULTS

Agreement for the assessment of level as a continuous variable was excellent [intraclass correlation coefficient (ICC) 0.97-0.98], but was lower for quality (ICC 0.02-0.46). When the children were categorized according to the percentile range categories, the assessors were in agreement for the majority of the children, with respect to both level (78-82%) and quality (78-87%).

CONCLUSION

Despite brief experience with SOMP-I, the agreement was excellent when assessing the level of motor development, but was less satisfactory for the assessment of quality of motor performance. More extensive education and training may be necessary to improve the nurses' ability to assess quality, as this domain was an entirely new concept to the nurses. Further research is warranted to determine the applicability of SOMP-I as a standardized method for nurses to assess motor development within the CHS.

Gestational age and developmental risk in moderately and late preterm and early term infants

OBJECTIVES

The objective of this study was to evaluate the association between gestational age (GA) at birth and risk of developmental delay at 8 and 18 months of corrected postnatal age.

METHODS

During 2008 to 2011, infants at a corrected postnatal age of 8 or 18 months attending health centers in Santiago, Chile, were recruited. Participants completed a form on biographical and demographic characteristics and the Chilean validated version of the Ages and Stages Questionnaires, Third Edition (ASQ). Logistic regression was used to detect the capacity of GA to predict scores < -2 SDs on the basis of the Chilean ASQ reference group, in at least 1 ASQ domain, adjusted by different control variables.

RESULTS

A total of 1667 infants were included in the analysis. An inverse "dose response" relationship between developmental delay risk and GA at birth was found, both in the crude and adjusted models. Compared with those born full term, the odds ratio for developmental delay risk was 1.56 for those born early term (95% confidence interval [CI]: 1.19-2.06), 2.58 for infants born late preterm (95%CI: 1.66-4.01), and 3.01 for those born moderately preterm (95%CI: 1.59-5.71).

CONCLUSIONS

An inverse dose-response relationship between GA and risk of developmental delay was found in the tested population. Future prospective studies and predictive models are needed to understand whether this higher developmental risk in moderately and late preterm infants is transient and modifiable or persists throughout life, allowing for better targeting of early-intervention strategies.

Evidence-based early detection of developmental-behavioral problems in primary care: what to expect and how to do it

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

Children's compliance with American Academy of Pediatrics' well-child care visit guidelines and the early detection of autism

This study estimated compliance with American Academy of Pediatrics (AAP) guidelines for well-child care and the association between compliance and age at diagnosis in a national sample of Medicaid-enrolled children with autism (N = 1,475). Mixed effects linear regression was used to assess the relationship between compliance and age at diagnosis. Mean age at diagnosis was 37.4 (SD 8.4) months, and mean compliance was 55 % (SD 33 %). Children whose care was compliant with AAP guidelines were diagnosed 1.6 months earlier than children who received no well-child care. Findings support that the timely receipt of well-child care may contribute to earlier detection. Additional research on the contribution of compliance, well-child visit components and provider characteristics on the timely diagnosis of autism is needed.

Improving developmental screening documentation and referral completion

BACKGROUND AND OBJECTIVES

Screening, early identification, and referral improves outcomes for young children at risk for developmental delays. Effective developmental screening processes should include efforts to ensure referral completion and documentation of evaluation results and service eligibility in the child's medical record. Our objectives were to improve provider documentation of actions taken after an abnormal developmental screening result and increase Early Intervention (State Part C) referrals.

METHODS

Various strategies including an electronic medical record template, monthly clinical informatics reporting, and a phone follow-up after an abnormal screening result were implemented to enhance provider documentation of screening results and improve referral actions and outcomes.

RESULTS

Of the children eligible for screening (n = 3023), 2610 (86%) were screened, with 382 (15%) scoring in the abnormal range. With phone follow-up, 50% of the abnormal screenings were referred to community resources, including 43% to Early Intervention (EI), in contrast to 20% community referrals and 13% EI referrals with the screening template only (P < .0001). Provider documentation of EI outcomes increased when screening templates and follow-up calls were implemented together (31%) as compared with using the screening template alone (15%).

CONCLUSIONS

Enhanced documentation of developmental screening efforts using screening templates and clinical informatics reporting in combination with phone follow-up after an abnormal screening result improved developmental screening outcomes, including referral rates, completed evaluations, and provider documentation of EI services. Such strategies can be effectively used in pediatric primary care settings to improve screening processes and ensure that young children access appropriate services.

A comparison of Child Health Programmes recommended for preschool children in selected high-income countries

BACKGROUND

The UK Child Health Programme (CHP) aims to ensure that children attain their development and health potential. It comprises a series of proactive child health reviews incorporating growth and development surveillance and health promotion; routine immunizations; and certain screening tests, and is offered to all children. The evidence underpinning different elements of the CHP varies from robust to sparse, and consequently there is uncertainty about optimal programme design. This study aimed to compare the CHP currently recommended in the UK with that recommended in selected other high-income countries in order to inform ongoing CHP policy development.

METHODS

The CHP recommended for preschool children in the UK was compared with that in Australia; Canada; the USA; and Sweden using a combination of literature review, focused website searches, and consultation with experts in the countries studied. Delivery, content, and uptake of child health reviews, immunizations, and screening were considered.

RESULTS

All the countries studied recommend CHP services including child health reviews, immunizations, and screening to their preschool populations. Despite this superficial uniformity, considerable variation exists between countries in the detail of CHP delivery and content. The UK programme is relatively narrow in scope, offering the fewest child health reviews, a relatively restricted immunization programme (although some expansion is planned), and limited newborn bloodspot screening. Internationally comparable data on the uptake/coverage of CHP services are patchy: the available information suggests substantial variation between and within countries in the uptake of child health reviews.

CONCLUSIONS

In the absence of uncontested evidence on the 'ideal' CHP for preschool children, demonstrating variation between countries in recommended programmes provides valuable contextual information for policy makers. Further work looking at relationships between CHP services and children's outcomes would add further value.

A parent questionnaire for developmental screening in infants born late and moderately preterm

BACKGROUND

The Parent Report of Children's Abilities-Revised (PARCA-R) is a questionnaire for assessing cognitive and language development in very preterm infants. Given the increased risk of developmental delay in infants born late and moderately preterm (LMPT; 32-36 weeks), this study aimed to validate this questionnaire as a screening tool in this population.

METHODS

Parents of 219 children born LMPT completed the PARCA-R questionnaire and the Brief Infant Toddler Social and Emotional Assessment when children were 24 months corrected age (range, 24 months-27 months). The children were subsequently assessed by using the cognitive and language scales of the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III).

RESULTS

An average Bayley-III, cognitive and language (CB-III) score and a total PARCA-R Parent Report Composite (PRC) score were computed. There was a large association between PRC and CB-III scores (r = 0.66, P < .001) indicating good concurrent validity. Using Youden index, the optimum PARCA-R cutoff for identifying children with moderate/severe developmental delay (CB-III scores < 80) was PRC scores < 73. This gave sensitivity 0.90 (95% confidence interval: 0.75-1.00) and specificity 0.76 (95% confidence interval: 0.70-0.82), indicating good diagnostic utility. Approximately two-thirds of the children who had a PRC score < 73 had false-positive screens. However, these children had significantly poorer cognitive and behavioral outcomes than children with true negative screens.

CONCLUSIONS

The PARCA-R has good concurrent validity with a gold standard developmental test and can be used to identify LMPT infants who may benefit from a clinical assessment. The PARCA-R has potential for clinical use as a first-line cognitive screening tool for this sizeable population of infants in whom follow-up may be beneficial.

Barriers and enablers to delivery of the Healthy Kids Check: an analysis informed by the Theoretical Domains Framework and COM-B model

BACKGROUND

More than a fifth of Australian children arrive at school developmentally vulnerable. To counteract this, the Healthy Kids Check (HKC), a one-off health assessment aimed at preschool children, was introduced in 2008 into Australian general practice. Delivery of services has, however, remained low. The Theoretical Domains Framework, which provides a method to understand behaviours theoretically, can be condensed into three core components: capability, opportunity and motivation, and the COM-B model. Utilising this system, this study aimed to determine the barriers and enablers to delivery of the HKC, to inform the design of an intervention to promote provision of HKC services in Australian general practice.

METHODS

Data from 6 focus group discussions with 40 practitioners from general practices in socio-culturally diverse areas of Melbourne, Victoria, were analysed using thematic analysis.

RESULTS

Many practitioners expressed uncertainty regarding their capabilities and the practicalities of delivering HKCs, but in some cases HKCs had acted as a catalyst for professional development. Key connections between immunisation services and delivery of HKCs prompted practices to have systems of recall and reminder in place. Standardisation of methods for developmental assessment and streamlined referral pathways affected practitioners' confidence and motivation to perform HKCs.

CONCLUSION

Application of a systematic framework effectively demonstrated how a number of behaviours could be targeted to increase delivery of HKCs. Interventions need to target practice systems, the support of office staff and referral options, as well as practitioners' training. Many behavioural changes could be applied through a single intervention programme delivered by the primary healthcare organisations charged with local healthcare needs (Medicare Locals) providing vital links between general practice, community and the health of young children.

Brief approaches to developmental-behavioral promotion in primary care: updates on methods and technology

Well-child visits are a critical opportunity to promote learning and development, encourage positive parenting practices, help children acquire behavioral self-control, enhance the development and well-being of children and their families, identify problems not amenable to brief in-office counseling, and refer for services when needed. This article outlines the communication skills, instructional methods, and resource options that enable clinicians to best assist families. Also covered is how to monitor progress and outcomes. A total of 239 articles and 52 Web sites on parent/patient education were reviewed for this study. Providers require a veritable armamentarium of instructional methods. Skills in nonverbal and verbal communication are needed to elicit the parent/patient agenda, winnow topics to a manageable subset, and create the "teachable moment." Verbal suggestions, with or without standardized spoken instructions, are useful for conveying simple messages. However, for complex issues, such as discipline, it is necessary to use a combination of verbal advice, written information, and "teach-back," aided by role-playing/modeling or multimedia approaches. Selecting the approaches most likely to be effective depends on the topic and family characteristics (eg, parental literacy and language skills, family psychosocial risk and resilience factors, children's developmental-behavioral status). When providers collaborate well (with parents, patients, and other service providers) and select appropriate educational methods, families are better able to act on advice, leading to improvements in children's well-being, health, and developmental-behavioral outcomes. Provided are descriptions of methods, links to parenting resources such as cell phone applications, Web sites (in multiple languages), interactive technology, and parent training courses.

Factors associated with early intervention referral and evaluation: a mixed methods analysis

OBJECTIVE

To identify parent, child, community, and health care provider characteristics associated with early intervention (EI) referral and multidisciplinary evaluation (MDE) by EI.

METHODS

We conducted a mixed methods secondary analysis of data from a randomized controlled trial of a developmental screening program in 4 urban primary care practices. Children <30 months of age not currently enrolled in EI and their parents were included. Using logistic regression, we tested whether parent, child, community, and health care provider characteristics were associated with EI referral and MDE completion. We also conducted qualitative interviews with 9 pediatricians. Interviews were recorded, transcribed, and coded. We identified themes using modified grounded theory.

RESULTS

Of 2083 participating children, 434 (21%) were identified with a developmental concern. A total of 253 children (58%) with a developmental concern were referred to EI. A total of 129 children (30%) received an MDE. Failure in 2 or more domains on developmental assessments was associated with EI referral (adjusted odds ratio [AOR] 3.15, 95% confidence interval [CI] 1.89-5.24) and completed MDE (AOR 2.16, 95% CI 1.19-3.93). Faxed referral to EI, as opposed to just giving families a phone number to call was associated with MDE completion (AOR 2.94, 95% CI 1.48-5.84). Pediatricians reported that office processes, family preference, and whether they thought parents understood the developmental screening tool influenced the EI referral process.

CONCLUSIONS

In an urban setting, one third of children with a developmental concern were not referred to EI, and two thirds of children with a developmental concern were not evaluated by EI. Our results suggest that practice-based strategies that more closely connect the medical home with EI such as electronic transmission of referrals (e.g., faxing referrals) may improve completion rates of EI evaluation.

Primary care physicians' knowledge of and confidence in their referrals for special education services in 3- to 5-year-old children

BACKGROUND

Children 3 to 5 years old with developmental delays are eligible for special education services.

OBJECTIVE

To assess primary care physicians' (PCPs) knowledge, attitudes, and practices regarding their referrals to the special education system on behalf of children 3 to 5 years old.

DESIGN/METHODS

Mail survey of 400 office-based general pediatricians and 414 family physicians in Michigan, fielded in fall 2012 and winter 2013, with a response rate of 44%. The 4-page survey included knowledge questions about special education eligibility, PCPs' role in accessing school-based services, and self-confidence in ability to help patients access these services.

RESULTS

PCPs neither fully understood requirements for special education services nor were they very confident in identifying 3- to 5-year-old children eligible for special education services.

CONCLUSIONS

PCPs recognize interacting with special education as a relative weakness, and they may be accepting of interventions to improve their knowledge and skills.

Approaches to enhancing the early detection of autism spectrum disorders: a systematic review of the literature

BACKGROUND

A reliable diagnosis of autism can be made as early as 24 months, yet in many children diagnoses are made much later. A delay in diagnosis translates into a missed opportunity to provide early intervention services and to improve outcomes. The aim of the current study was to review the literature on early detection approaches in primary care and other community settings in the United States.

METHODS

A search was conducted of the peer-reviewed and gray literature to identify studies published from January 1990 through January 2013 testing approaches to enhance the early detection of autism in community settings in the United States.

RESULTS

The search identified 40 studies describing 35 approaches, which were grouped into the following categories: awareness (n = 4), routine screening (n = 21), and practice improvement to enhance screening (n = 10). Awareness approaches were associated with positive changes in knowledge of autism-related topics. Routine screening yielded high or increased rates of screening and referrals; however, few studies assessed the effect of screening on age at diagnosis or services enrollment. Practice improvement approaches resulted in increased screening and referral rates and highlighted the importance of adopting a multipronged approach to enhance early detection.

CONCLUSIONS

Although studies that tested screening approaches in community settings found positive results, the effectiveness of such efforts on reducing time to diagnosis and services enrollment remains largely untested. The fact that few studies reported outcomes beyond rates of referral indicates the need for enhanced methodological rigor, particularly with respect to length of follow-up and quality of measures used.

Developmental screening in a Canadian First Nation (Mohawk): psychometric properties and adaptations of ages & stages questionnaires (2nd edition)

Background

The need for early intervention tools adapted to the First Nation culture is well documented. However, standards derived from First Nation communities are absent from the literature. This study examines the psychometric properties of an adaptation of a caregiver-completed screening tool, the Ages & Stages Questionnaires (ASQ), for the Mohawk population.

Methods

Participants who completed the questionnaires include 17 teachers, along with the parents of 282 children (130 girls and 152 boys) between the ages of 9 and 66 months who attend the Child and Family Center Mohawk Territory, Quebec.

Results

For the internal consistency of the four questionnaires (36-, 42-, 48- and 54-month intervals), Cronbach’s alphas varied between .61 and .84. Five results were below 0.60: “gross motor” (Q36 and Q42), “problem solving” (Q36) and “personal-social” (Q36 and Q42). A comparison of the results shows that parents and teachers agreed in 85% of the cases concerning the referral of the child for further evaluation. Moreover, the group discussion with the parents revealed that the use of the questionnaire was appreciated and was deemed appropriate for use within the community.

Conclusion

The results show that the ASQ is a screening test that may be appropriate for use with children from communities that are seemingly very different in terms of geographic, climatic and cultural backgrounds. This preliminary study with the Child and Family Center appears to support further study and the use of the ASQ with the Mohawk population.

Challenges to implementation of developmental screening in urban primary care: a mixed methods study

Background

Research is needed to identify challenges to developmental screening and strategies for screening in an urban pediatric setting.

Methods

Parents of young children and clinicians at four urban pediatric practices participated in focus groups prior to implementation of screening. Participants were queried regarding attitudes, social norms, and barriers to developmental screening. Using information from the focus groups, workflow strategies were developed for implementing screening. Referral rates and satisfaction with screening were gathered at the conclusion.

Results

Six focus groups of parents and clinicians were conducted. Major themes identified included 1) parents desired greater input on child development and increased time with physicians, 2) physicians did not fully trust parental input, 3) physicians preferred clinical acumen over screening tools, and 4) physicians lacked time and training to conduct screening. For the intervention, developmental screening was implemented at the 9-, 18-, 24-, and 30-month well visits using the Ages & Stages Questionnaire-II and the Modified Checklist for Toddlers. 1397 (98% of eligible) children under 36 months old were enrolled, and 1184 (84%) were screened at least once. 1002 parents (85%) completed a survey at the conclusion of the screening trial. Most parents reported no difficulty completing the screens (99%), felt the screens covered important areas of child development (98%), and felt they learned about their child’s strengths and limitations (88%).

Conclusions

Developmental screening in urban low-income practices is feasible and acceptable, but requires strategies to capture parental input, provide training, facilitate referrals, and develop workflow procedures and electronic decision support.

Evaluating developmental screening in clinical practice

Objective:

To demonstrate a method of evaluating accuracy of developmental screening modeled on the evidence-based medical literature.

Method:

A retrospective review was performed on 418 children screened with the Denver II by a trained technician. Two models for analyzing screening data were examined, using predictive values and likelihood ratios (LR+ and LR−).

Results:

The technician, working at 20% time, screened 44% of eligible children. There were 129/418 (31%) children with Suspect Denver II results, 115/418 who were referred, 81/115 (70%) who were evaluated by Early Intervention, and 64/81 (79%) who qualified for services. The uncorrected positive predictive value for the Denver II alone (44%) was insufficient to meet the preset standard of 60%, but the LR+ of 4.16 indicated a significant contribution of test information to improving predictive value. Combining test results with information from the parent–technician conference to achieve a referral decision resulted in an uncorrected predictive value of 56%, which rose with correction for children referred but not evaluated to 72% (LR+ 10.33). Negative predictive values and likelihood ratios of a negative test and a non-referral decision achieved recommended levels. Parents who expressed concern were significantly more likely to complete recommended evaluation than those who did not (82% vs 58%, p < .01). Results were in the same range as in published studies with other screening tests but showed three areas for improvement: screening more children, more carefully supervising some referral decisions, and getting more children to evaluation.

Conclusion:

Levels of predictive accuracy above 60% can be obtained by combining different types of information about development to make decisions about referral for more complete evaluation. Systematic study of such combinations could lead to improved predictive accuracy of screening programs and support attempts to close the gap between referral and evaluation.