Setting the stage for success: implementation of developmental and behavioral screening and surveillance in primary care practice--the North Carolina Assuring Better Child Health and Development (ABCD) Project

The association between learning disorders, motor function, and primitive reflexes in pre-school children: A systematic review

This study aimed to systematically review evidence of the association between learning disorders, motor function, and primitive reflexes in preschool children. Seven databases were systematically searched (EMBASE, CINAHL, Academic Search Complete, Medline, PsycINFO, ScienceDirect, and Cochrane) with no restrictions. Inclusion criteria were full text peer-reviewed articles reporting new empirical data, assessing any two of three phenomena in preschool children: learning disorders, motor function, or primitive reflexes. Intervention studies or studies examining congenital, chromosomal or acquired neurological, or pathological conditions and prematurity were excluded. Included papers (n = 27) were assessed for methodological quality by the Hoy et al. Risk of bias tool. Learning and motor function were assessed in all except two articles and motor deficits found to be associated with speech/language and executive function as well as several areas of academic performance. Three studies included primitive reflexes, with high levels of the asymmetrical tonic neck reflex positively correlated with fine motor skills, "school readiness" and "impulsivity, hyperactivity and inattention." Caution must be used when interpreting the review results due to significant study heterogeneity. Further research is needed to further understand common underlying mechanisms that may inform earlier diagnostic methods for these three phenomena. PROSPERO: CRD42021265793.

Routine developmental screening in Australian general practice: a pilot study

BACKGROUND

Parents' Evaluation of Developmental Status, (PEDS), is a validated screening tool designed for primary health care clinicians to assess child development. Despite widespread use by local government child-nurse services, PEDS has not been tested in Australian general practice. We examined the effect of an intervention that aimed to use PEDS to improve documented assessment of child developmental status during routine general practice consultations.

METHODS

The study took place in a single general practice in Melbourne, Australia. The intervention included training of all general practice staff regarding PEDS processes and provision of PEDS questionnaires, scoring and interpretation forms. Mixed methods incorporated audits of clinical records of young children (1 to ≤ 5 years) before and after the intervention, and written questionnaires and a focus group (informed by the Theoretical Domains Framework and COM-B model) with receptionists, practice nurses and general practitioners.

RESULTS

Documented developmental status more than doubled after the intervention with almost one in three (30.4%) records documenting the PEDS tool. Overall, staff responses to questionnaires indicated that PEDS processes had been successfully implemented, half of the staff felt PEDS had developed their professional skills and clinicians expressed confidence using the tool (71%). Thematic analysis of the focus group transcript revealed divided reactions to PEDS screening with most barriers arising from general practitioners' motivation to use PEDS tools and perceptions of environmental constraints.

CONCLUSIONS

A team-practice intervention that applied PEDS training and implementation, more than doubled documented rates of child developmental status during routine visits. Solutions to underlying barriers could be incorporated into a revised training module. Future studies need to test the tool in more methodologically robust studies that include analysis of the outcomes of developmental surveillance and long-term sustainability of PEDS use in practices.

Barriers and facilitators to implementation of developmental screening and early intervention in Canadian organizations following completion of a training and coaching model: a thematic analysis

Introduction

Developmental delay affects approximately 1 in 4 children under 6 years old. Developmental delay can be detected using validated developmental screening tools, such as the Ages and Stages Questionnaires. Following developmental screening, early intervention can occur to address and support any developmental areas of concern. Frontline practitioners and supervisors must be trained and coached to organizationally implement developmental screening tools and early intervention practice. No prior work has qualitatively investigated the barriers and facilitators to implementing developmental screening and early intervention in Canadian organizations from the perspectives of practitioners and supervisors who have completed a specialized training and coaching model.

Methods and Results

Following semi-structured interviews with frontline practitioners and supervisors, thematic analysis identified four themes: cohesive networks support implementation efforts, implementation success is dependent on shared perspectives, established organizational policies increase implementation opportunities, and COVID-19 guidelines create organizational challenges. Each theme encompasses sub-themes that describe implementation facilitators: strong implementation context, multi-level multi-sectoral collaborative partnerships, adequate and collective awareness, knowledge, and confidence, consistent and critical conversations, clear protocols and procedures, and accessibility to information, tools, and best practice guidelines.

Discussion

The outlined barriers and facilitators fill a gap in implementation literature by informing a framework for organization-level implementation of developmental screening and early intervention following training and coaching.

Exploring parent-engaged developmental monitoring of young children before and during the COVID-19 pandemic, Porter Novelli Styles 2019 and 2021

Background

Early identification of developmental delays may have been negatively impacted by the COVID-19 pandemic. Parental engagement in developmental monitoring is a key component to successfully identifying developmental concerns.

Objective

/Hypothesis.The purpose of this project was to understand whether parental engagement in developmental monitoring changed over the course of the COVID-19 pandemic, from Spring 2019 to Fall 2021.

Methods

Survey data was obtained from 2019 SpringStyles and 2021 FallStyles Porter Novelli Public Services ConsumerStyles cross-sectional surveys. Only respondents with at least one child under the age of 8 at the time of the survey were included in the analytic sample (2019 N = 403; 2021 N = 344). Participants were asked several questions about how they monitor their children’s development. Changes in frequency of developmental monitoring from 2019 to 2021 were estimated using chi-squared tests.

Results

In both 2019 and 2021, 89% of parents reported engaging in any type of developmental monitoring. Within the group of parents who engaged in any monitoring, there were no differences across years in the percentage of parents reporting using the methods surveyed, except that a smaller percentage reported comparing their children to others in 2021 (25%) compared to 2019 (36%, p <.002).

Conclusions

Despite major disruptions to families’ lives, there were no significant changes to parents’ overall engagement in developmental monitoring prior to and during the COVID-19 pandemic.

The Ages and Stages Questionnaire: Social-Emotional-What Is the Optimal Cut-Off for 3-Year-Olds in the Swedish Setting?

OBJECTIVE

Expressions of emotional and behavioral symptoms in preschool age can predict mental health problems in adolescence and adulthood. The Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) has been successful in detecting social and emotional problems in young children in some countries but had not been tested in Sweden. The objective of this study was to determine the optimal cut-off for the ASQ:SE instrument when administered to 3-year-old children in a northern Swedish setting, using the Strengths and Difficulties Questionnaire (SDQ) as the reference.

METHODS

The ASQ:SE (36-month interval, first edition) was administered at routine 3-year-olds' visits to Child Health Care centers in Region Västerbotten, Sweden. During the study period (September 2017 to March 2018) parents were invited to also fill out the SDQ (2-4 year version). In the final analyses 191 children fulfilled the criteria for inclusion in the study sample. Non-parametric Receiver Operating Characteristic analysis was performed to quantify the discriminatory accuracy of ASQ:SE based on SDQ.

RESULTS

The Pearson correlation between ASQ:SE and SDQ indicated strong correlation between the two instruments. The Receiver Operating Characteristic curve showed good accuracy of ASQ:SE in relation to SDQ. However, our results suggest that the existing ASQ:SE cut-off score of 59 was not optimal in the Swedish context. Changing the cut-off from 59 to 50 would allow us to detect 100% (n = 14) of children with problems according to SDQ, compared to 64% (n = 9) when the cut-off was 59. However, the proportion of false positives would be higher (9% compared to 3%).

CONCLUSION

The main finding was that for 3-year-olds in Sweden a decreased ASQ:SE cut-off score of 50 would be optimal. This would increase the detection rate of at-risk children according to SDQ (true positive), thus prioritizing sensitivity. Our conclusion is that, although this change would result in more false positives, this would be justifiable.

Improving Child Development Screening: Implications for Professional Practice and Patient Equity

INTRODUCTION AND OBJECTIVES

A pediatric group with 25 clinics and 150 providers used multifaceted approaches to implement workflow processes and an electronic health record (EHR) flowsheet to improve child developmental screening. The key outcome was developmental screening done for every patient during 3 periods between ages 8 and 36 months. Identification of developmental concerns was the secondary study outcome. Screening rates and referrals were hypothesized to be optimized for children regardless of demographic backgrounds.

METHODS

During preventive visits, developmental screens targeted patients in age groups 8 to 12, 13 to 24, and 25 to 36 months. EHRs were analyzed for screening documentation, results, and referrals by patient demographics. Fifteen pediatric professionals were interviewed about their qualitative experiences. Quality improvement interventions included appointing clinic champions, training staff about the screening process and responsibilities, using a standardized tool, employing plan-do-study-act cycles, posting EHR prompts, providing financial incentives, and monitoring screening rates using control charts.

RESULTS

Within 25 months, screening rates improved from 60% to >95% within the 3 preventive visit age groups for a total of more than 30 000 children. Professionals valued the team process improvements. Children enrolled in Medicaid, black children, and those living in lower income zip codes had lower screening rates than privately insured, white children, and those living in higher income areas. Ages and Stages Questionnaire 3rd edition results were significantly different by gender, race/ethnicity, insurance, and income categories across all groups. Referral rates varied by race/ethnicity and zip code of residence.

CONCLUSIONS

This project resulted in an effective and efficient process to improve child developmental screening that was valued by pediatric professionals. Analyses of patient demographics revealed disparities in services for the most vulnerable families. Ongoing quality improvement, health services research, and advocacy offer hope to improve health equity.

Early developmental outcome in children born to mothers with obstructive sleep apnea

Obstructive sleep apnea (OSA) during pregnancy leads to adverse maternal and perinatal outcomes. There have been limited studies evaluated the effect of intrauterine exposure to maternal OSA on childhood developmental outcomes. This study was aimed to evaluate the early development of children born to mothers with gestational OSA and the impact of continuous positive airway pressure (CPAP) treatment. METHODS: Children aged 6-36 months, born to high risk pregnant mothers who had overnight polysomnography performed, were invited to participate. The Ages and Stages Questionnaires, third edition (ASQ-3), age-specific parent-completed questionnaires determining five developmental domains (communication, gross motor, fine motor, problem-solving, and personal-social) were used for developmental screening. Children who had a score of at least one domain less than -1 SD of age cut-off were determined as having a risk of developmental delay (RDD). RESULTS: There were 159 children (47% male, mean age 18 months) enrolled. The maternal PSG showed non-OSA, mild OSA, and moderate OSA in 14%, 46%, and 40%, respectively. Forty-two children (26%) had RDD, and the most affected domains were fine motor and problem-solving. Maternal moderate OSA was significantly associated with RDD (adjusted OR 5.39, 95%CI 1.11-26.12, P 0.037). Subgroup analysis showed that maternal moderate OSA with no CPAP treatment was significantly associated with RDD (OR 6.43, 95%CI 1.34-30.89, P = 0.020) CONCLUSION: Gestational moderate OSA in high-risk pregnancy mothers likely had a negative effect on early childhood developmental outcomes, particularly the mothers who did not have appropriate CPAP treatment.

Race/ethnic inequities in conjoint monitoring and screening for U.S. children 3 and under: Disparities in Monitoring and Screening

BACKGROUND

Non-White children with developmental disabilities are frequently identified later than White children and therefore miss out on opportunities for early intervention (EI). Recent research indicates that conjoint monitoring and screening is more strongly associated with EI receipt than monitoring or screening alone.

OBJECTIVE

To determine if there are racial/ethnic inequities in the conjoint receipt of monitoring and screening.

METHOD

A series of survey weighted and stratified logistic regression analyses were conducted on National Surveys of Children's Health (2016-2018) data with conjoint monitoring and screening, screening alone, monitoring alone, and non-receipt as outcomes for children aged 9-23 months of age. The primary predictor was child race/ethnicity (Black, Hispanic, Other, and White). Additional co-variates included child (e.g., Age), caretaker/family (e.g., poverty level), healthcare (e.g., usual source of healthcare), state EI policies, and city metropolitan status.

RESULTS

Bivariate analyses indicated significant variation in conjoint monitoring and screening across racial/ethnic groups and covariates. Bivariate analyses showed that Black and Hispanic children had significantly lower odds of conjoint monitoring and screening receipt than White children. Multivariate analyses showed that this relationship was better accounted by co-variates. The health service variable, usual source of healthcare, had the strongest relationship with receipt of conjoint monitoring and screening.

CONCLUSIONS

Black and Hispanic children are less likely to receive conjoint monitoring and screening than White children. Analyses investigating the role of usual source of healthcare seem particularly promising for understanding the sources of inequities in monitoring and screening receipt.

Trauma in Schools: An Examination of Trauma Screening and Linkage to Behavioral Health Care in School-Based Health Centers

BACKGROUND

This study examined trauma screening and behavioral health linkage rates in school-based health centers (SBHCs).

METHODS

Participants included 4161 English- and Spanish-speaking patients between the ages of 12 and 22 across 8 urban SBHCs 2 years. Screening rates at medical visits and linkage to additional behavioral health screening and services were assessed via electronic medical records and a chart audit.

RESULTS

Medical providers administered the Primary Care-PTSD screen to 66.3% of patients in year 1 and 46.7% of patients in year 2. Rates of positive trauma screens were 27.5% and 32.1%, respectively, with more girls screening positive than boys. Few (year 1; 8.1%; year 2: 9.6%) adolescents received additional trauma screening by a behavioral health clinician. However, the majority were linked to services (year 1: 66%; year 2: 74%). Lack of documentation (year 1: 24%; year 2: 33%) was a common gap in the charts of patients who did not receive a second stage trauma screening. Demographic differences in screening rates were minimal.

CONCLUSION

The current study supports the feasibility of traumatic stress screening and linkage within an integrated care setting. Process improvement efforts should, however, address communication gaps around trauma assessment and its integration into ongoing care.

Improving autism and developmental screening and referral in US primary care practices serving Latinos

LAY ABSTRACT

Latino children experience delays in access to diagnosis and treatment of autism spectrum disorder. Primary care-based screening of all children for autism spectrum disorder and referring them for services may reduce racial/ethnic differences and improve care. REAL-START, a yearlong screening intervention, was effective in increasing screening for autism spectrum disorder and general developmental delays, increasing therapy referrals, and shortening time for developmental assessment in primary care clinics with Latino patients.

Increasing Early Childhood Screening in Primary Care Through a Quality Improvement Collaborative

OBJECTIVES

Multiple early childhood screenings are recommended, but gaps persist in implementation. Our aim for this project was to improve screening, discussion, referral, and follow-up of development, autism spectrum disorder (ASD), maternal depression, and social determinants of health (SDoH) to 90% by July 2018.

METHODS

This 1-year national quality improvement collaborative involved 19 pediatric primary care practices. Supported by virtual and in-person learning opportunities, practice teams implemented changes to early childhood screening. Monthly chart reviews were used to assess screening, discussion, referral, and follow-up for development, ASD, maternal depression, and SDoH. Parent surveys were used to assess parent-reported screening and referral and/or resource provision. Practice self-ratings and team surveys were used to assess practice-level changes.

RESULTS

Participating practices included independent, academic, hospital-affiliated, and multispecialty group practices and community health centers in 12 states. The collaborative met development and ASD screening goals of >90%. Largest increases in screening occurred for maternal depression (27% to 87%; +222%; P < .001) and SDoH (26% to 76%; +231%; P < .001). Statistically significant increases in discussion of results occurred for all screening areas. For referral, significant increases were seen for development (53% to 86%; P < .001) and maternal depression (23% to 100%; P = .008). Parents also reported increased screening and referral and/or resource provision. Practice-level changes included improved systems to support screening.

CONCLUSIONS

Practices successfully implemented multiple screenings and demonstrated improvement in subsequent discussion, referral, and follow-up steps. Continued advocacy for adequate resources to support referral and follow-up is needed to translate increased screening into improved health outcomes.

ESSENCE-Q obtained in routine Japanese public child health check-ups may be a valuable tool in neurodevelopmental screening

AIM

Our aim was to extend the validity of a questionnaire developed for screening and identifying early symptomatic syndromes eliciting neurodevelopmental clinical examinations-questionnaire (ESSENCE-Q) in young children.

METHODS

Early symptomatic syndromes eliciting neurodevelopmental clinical examinations-questionnaire data for 207 children, living in Aki City, Japan, in 2014-2015, were obtained from mothers, public health nurses and psychologists at 20- and 40-month routine check-ups at child healthcare centres. These were checked against subsequent ESSENCE diagnoses made by physicians. Receiver operating characteristic curves were constructed, and the area under the curves was compared. Sensitivity, specificity, positive predictive values (PPVs) and negative predictive values were calculated at optimal cut-off values. The clinical utility index was also calculated.

RESULTS

When the ESSENCE-Q was used by public health nurses, it demonstrated good validity, in terms of high sensitivity and high NPVs, at the 20-month check-up, but not at 40 months. Psychologists demonstrated good validity at both ages, but mothers did not. Good negative utility indexes, indicating screening accuracy, were obtained from the psychologists at both check-ups and from nurses at 20 months.

CONCLUSION

The ESSENCE-Q results used by nurses and psychologists showed good validity. Future studies should confirm the effectiveness of this tool to identify children in need of clinical detailed neurodevelopmental assessment.

Physician leadership and health information exchange: literature review

Background

Notwithstanding two decades of health information exchange (HIE) failures across the country, the US government has incorporated HIE into Meaningful Use Stage 2, which, in turn, has sparked renewed physicians’ interest in HIE.

Objective

The purpose of this paper was to conduct a literature review to understand how physician leadership might have assisted in supporting organisations in achieving HIE collaboration.

Method

The authors conducted a review of the literature about HIE and physician challenges from 2009 to present to identify peer-reviewed publications which might apply. Reviewers abstracted each publication for predetermined issues related to physician leadership. Themes were identified based on the literature findings.

Results

The literature review demonstrated four important themes (physician leader characteristics) that can assist in bridging the gap and creating collaboration in an HIE. The themes found in this study were: trust among physicians, promote involvement and buy-in, infuse value proposition and competition.

Conclusion

This paper contributes to the healthcare literature by conducting a literature review of the existing literature of surrounding HIE implementation and physician leaders. Specifically, we sought to gain insight into the change process and how physician leaders have demonstrated an impact on the process. This research is the first of its kind to synthesise leadership issues related to HIE and specifically explore the role of physician leader impact on HIE.

A Framework to Measure and Improve Well-Being in Primary Care

Pediatricians aspire to optimize overall health and development, but there are no comprehensive measures of well-being to guide pediatric primary care redesign. The objective of this article is to describe the Cincinnati Kids Thrive at 5 outcome measure, along with a set of more proximal outcome and process measures, designed to drive system improvement over several years. In this article, we describe a composite measure of "thriving" at age 66 months, using primary care data from the electronic health record. Thriving is defined as immunizations up-to-date, healthy BMI, free of dental pain, normal or corrected vision, normal or corrected hearing, and on track for communication, literacy, and social-emotional milestones. We discuss key considerations and tradeoffs in developing the measure. We then summarize insights from applying this measure to 9544 patients over 3 years. Baseline rates of thriving were 13% when including all patients and 31% when including only patients with complete data available. Interpretation of results was complicated by missing data in 50% of patients and nonindependent success rates among bundle components. There was considerable enthusiasm among other practices and sectors to learn with us and to measure system performance using time-linked trajectories. We learned to present our data in ways that balanced aspirational long-term or multidisciplinary goal-setting with more easily attainable short-term aims. On the basis of our experience with the Thrive at 5 measure, we discuss future directions and place a broader call to action for pediatricians, researchers, policy makers, and communities.

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.

Improving Developmental Screening, Discussion, and Referral in Pediatric Practice

Objective. Although pediatricians' use of standardized screening tools for identifying developmental delays has increased, only 63% of pediatricians report performing standardized screening as recommended. The purpose of the current quality improvement project was to improve developmental monitoring, screening, and referral for developmental concerns by pediatricians. Method. Twenty-eight pediatricians completed an in-person meeting, monthly webinars, and individualized feedback from an Expert Work Group on progress across a 3-month action period. Results. Statistically significant increases were observed in rates of autism screening, discussions of screening results with families, and referral following abnormal results. There was no statistically significant change in rates of general developmental screening. Comparing self-report with record review, pediatricians overestimated the extent to which they conducted discussion and referral. Conclusions. Universal screening for all children has yet to be achieved. The current project supports that practice-based improvements can be made and delineates some of the routes to success.

School Readiness

School readiness includes the readiness of the individual child, the school's readiness for children, and the ability of the family and community to support optimal early child development. It is the responsibility of schools to meet the needs of all children at all levels of readiness. Children's readiness for kindergarten should become an outcome measure for a coordinated system of community-based programs and supports for the healthy development of young children. Our rapidly expanding insights into early brain and child development have revealed that modifiable factors in a child's early experience can greatly affect that child's health and learning trajectories. Many children in the United States enter kindergarten with limitations in their social, emotional, cognitive, and physical development that might have been significantly diminished or eliminated through early identification and attention to child and family needs. A strong correlation between social-emotional development and school and life success, combined with alarming rates of preschool expulsion, point toward the urgency of leveraging opportunities to support social-emotional development and address behavioral concerns early. Pediatric primary care providers have access to the youngest children and their families. Pediatricians can promote and use community supports, such as home visiting programs, quality early care and education programs, family support programs and resources, early intervention services, children's museums, and libraries, which are important for addressing school readiness and are too often underused by populations who can benefit most from them. When these are not available, pediatricians can support the development of such resources. The American Academy of Pediatrics affords pediatricians many opportunities to improve the physical, social-emotional, and educational health of young children, in conjunction with other advocacy groups. This technical report provides an updated version of the previous iteration from the American Academy of Pediatrics published in 2008.

Implementation of M-CHAT Screening for Autism in Primary Care in Saudi Arabia

Background. Integration of autism screening into primary care practice in Saudi Arabia is not well established. Objectives. To evaluate the feasibility and effectiveness of implementing the Arabic Modified Checklist for Autism in Toddlers (M-CHAT) in a primary care practice at John Hopkins Aramco Healthcare Center in Saudi Arabia. Method. The Arabic version of M-CHAT was distributed to caregivers of 1207 toddlers (16-32 months) from January to December 2014. Feasibility was assessed by measuring the proportion of visits with M-CHAT completed, and reports of workflow challenges and provider satisfaction. The effectiveness of screening was evaluated based on the number of referrals for autism evaluation and autism identification rates. Results. Total M-CHAT completion rate was 89% (1078 out of 1207 child-specific visits). Those identified as low risk (n = 951; 88%) were reassured and followed routinely. Those screening positive (n = 127; 12%) were referred for diagnostic assessment. Twelve (1% of toddlers screened) were diagnosed with autism at a mean age of 24 months. In addition, positive M-CHAT detected speech delay and social anxiety. Providers acknowledged their satisfaction with the M-CHAT implementation process; the main challenge was communicating to families the importance of screening. Referrals for diagnostic evaluations increased from 23 to 43 cases in the first year, and 35 in the second year. Conclusion. Implementation of the autism screening using the Arabic M-CHAT is feasible and effective in a primary care setting in Saudi Arabia. Sustaining the implementation of developmental screening in practice requires staff engagement and systematic monitoring of the impact of change.

Development of the Dimensional Inventory of Child Development Assessment (IDADI)

Abstract Child development is complex and includes multiple domains, such as cognition, communication and language, motor skills, socialization, and emotional development. The objective of this paper was to present the development process of the Dimensional Inventory of Child Development Assessment (IDADI) and evidence of its content validity. IDADI was conceived to assess child development of children from zero to 72 months of age through parental reports covering Cognitive, Motor (Gross and Fine), Communication and Language (Receptive and Expressive), Socioemotional and Adaptive Behavior domains. The development process involved: description of the theoretical foundation; development of the preliminary version of the instrument; expert item analysis; semantic analysis of the items by the target population; and a pilot study. The initial item pool had 2,365 items and the final version consisted of 524, after exclusions, modifications and additions. The stages of development led to changes in most of the items. This process is considered to have ensured IDADI’s content validity. Thus, it is believed that IDADI will contribute to child development assessment in Brazil in clinical and research contexts.

Accuracy of Reported Community Diagnosis of Autism Spectrum Disorder

To compare community diagnoses of Autism Spectrum Disorder (ASD) reported by parents to consensus diagnoses made using standardized tools plus clinical observation. 87 participants (85% male, average age 7.4 years), with reported community diagnosis of ASD were evaluated using the Autism Diagnostic Observation Schedule) (ADOS-2), Differential Ability Scale (DAS-II), and Vineland Adaptive Behavior Scales (VABS-II). Detailed developmental and medical history was obtained from all participants. Diagnosis was based on clinical consensus of at least two expert clinicians, using test results, clinical observations, and parent report. 23% of participants with a reported community diagnosis of ASD were classified as non-spectrum based on our consensus diagnosis. ASD and non-spectrum participants did not differ on age at evaluation and age of first community diagnosis. Non-verbal IQ scores and Adaptive Behavior Composite scores were significantly higher in the non-spectrum group compared to the ASD group (104.5 ± 21.7 vs. 80.1 ± 21.6, p < .01; 71.1 ± 15 versus 79.5 ± 17.6, p < .05, respectively). Participants enrolled with community diagnosis of PDD-NOS were significantly more likely to be classified as non-spectrum on the study consensus diagnosis than Participants with Autism or Asperger (36% versus 9.5%, Odds Ratio = 5.4, p < .05). This study shows suboptimal agreement between community diagnoses of ASD and consensus diagnosis using standardized instruments. These findings are based on limited data, and should be further studied, taking into consideration the influence of DSM 5 diagnostic criteria on ASD prevalence.

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.

Acceptability of Psychosis Screening and Factors Affecting Its Implementation: Interviews With Community Health Care Providers

OBJECTIVE

Although screening for psychosis may reduce the duration of untreated psychosis, the barriers and facilitators associated with implementing such a procedure in various care settings have not been explored.

METHODS

Investigators conducted in-depth, semistructured interviews with 17 members of school counseling services or community mental health staff at sites that administer a psychosis screening tool. Using an inductive approach to thematic analysis, they evaluated the acceptability of psychosis screening and barriers to and facilitators of implementation.

RESULTS

Participants reported few barriers to implementation. However, several service-, client-, and program-level factors were considered to significantly affect the implementation of screening. Most participants found that using the screening tool did not significantly affect their overall workload. Facilitators included leadership support, the novelty of using a technology-based screener, regular staff training, and the importance of establishing an effective link between community services and specialty care, with these factors important at different stages of the process. Screening for psychosis was associated with significant advantages over referrals based on clinical judgment alone, including increased speed and accuracy of identification, increased confidence in diagnosis, and the provision of a clear pathway to specialty treatment.

CONCLUSIONS

The experiences of school counseling and community mental health teams suggest that incorporating a technology-based screening procedure for early psychosis is feasible. Identifying barriers and facilitators at various stages of the screening procedure may reduce the dropout of clients potentially eligible for early psychosis care.

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.

Influence of mental health and alcohol or other drug use risk on adolescent reported care received in primary care settings

Background

To describe patterns of alcohol and other drug (AOD) use risk and adolescent reported primary care (PC) screening and intervention, and examine associations of AOD risk and mental health with reported care received.

Methods

We analyzed data from cross-sectional surveys collected from April 3, 2013 to November 24, 2015 from 1279 diverse adolescents ages 12–18 who reported visiting a doctor at least once in the past year. Key measures were AOD risk using the Personal Experience Screening Questionnaire; mental health using the 5-item Mental Health Inventory; binary measures of adolescent-reported screening and intervention.

Results

Half (49.2%) of the adolescents reported past year AOD use. Of the 769 (60.1%) of adolescents that reported being asked by a medical provider in PC about AOD use, only 37.2% reported receiving screening/intervention. The odds of reported screening/intervention were significantly higher for adolescents with higher AOD risk and lower mental health scores.

Conclusions

Adolescents at risk for AOD use and poor mental health are most likely to benefit from brief intervention. These findings suggest that strategies are needed to facilitate medical providers identification of need for counseling of both AOD and mental health care for at risk youth.

Trials registration

clinicaltrials.gov, Identifier: NCT01797835, March 2013.

Designing and Validation of a Hindi-language Parent Self-report Developmental Screening Tool

AIM

To design and validate Hindi-language parent self-report developmental screening questionnaires for 9-month and 18-month-old Indian children.

DESIGN

Cross-sectional study.

SETTING

Tertiary-care pediatric hospital from April 2014 to March 2016.

PARTICIPANTS

In each age group (9-month and 18-month), 45 children were enrolled for designing of questionnaires (30 for obtaining parental observations of current development and 15 for pre-testing). For validation of tool, 100 children (60 low risk and 40 high risk) were enrolled in each age group.

METHODS

For designing, observations regarding current developmental milestones were obtained from parents and a list of all enumerated milestones was prepared. After detailed discussion by a team of developmental pediatricians, pediatric resident, clinical psychologist and language specialist, milestones were chosen for drafting of questionnaires. In each age group, drafts were pre-tested and required modifications were done. The final questionnaires contained 20 items each to be scored on a Likert scale (total score ranging from 20 to 60, a lower score indicating a higher risk of developmental delay). These questionnaires were validated against Developmental Assessment Scale for Indian Infants (DASII), a gold standard instrument.

RESULTS

On ROC analysis, the 9-month and 18-month screening tool had area under curve of 0.988 and 0.953, respectively, for detecting developmental delay. Score ≤50 on the 9-months questionnaire had sensitivity of 100% and specificity of 87.2%. Score ≤49 on the 18-months questionnaire had sensitivity of 91.4% and specificity of 88.7%.

CONCLUSION

The new questionnaires have a promising role in developmental screening of children at the time of routine immunizations in our country.

Beliefs Regarding Development and Early Intervention Among Low-Income African American and Hispanic Mothers

OBJECTIVES

Understand the role of health beliefs in shaping maternal decisions regarding help-seeking for children with developmental delay (DD) and explore differences between African American and Hispanic mothers.

METHODS

Open-ended, semistructured interviews were conducted with African American and Hispanic mothers of children aged 0 to 36 months with DD. Interviews were recorded, transcribed, and analyzed by using inductive content analysis.

RESULTS

Mothers (n = 22) were African American (36%) or Hispanic (64%), 25 to 34 years old (64%), had less than a high school education (59%), and had children receiving public insurance (95%). Five major themes emerged describing the role of maternal health beliefs in shaping key stages of the help-seeking pathway for children with DD: (1) "I can see" (observing other children and making comparisons); (2) "Children are different and develop in their own time" (perceiving that their child might be different, but not necessarily delayed); (3) "It's not that I don't trust the doctor" (relying on social networks rather than pediatricians to inform the help-seeking pathway); (4) "I got so much going on" (difficulty prioritizing early intervention [EI] because of competing stressors); and (5) limited and conflicting information (delaying or forgoing EI because of limited or conflicting information). Differences between African American and Hispanic mothers are also described.

CONCLUSIONS

Understanding maternal health beliefs and expectations regarding DD and EI, acknowledging the influence of social networks on help-seeking, and addressing social and financial stressors are critical to ensuring that children with DD are identified and supported at an early age.

IMPLEMENTATION ON STIMULATION, DETECTION, AND EARLY INTERVENTION OF CHILD GROWTH AND DEVELOPMENT (SDIDTK) PROGRAM IN PUSKESMAS MOJO, SURABAYA STILL EMPHASIZE ON GROWTH SCREENING

It’s Important to conduct child development screening regularly in primary health services, so child developmental delay cases can be detected and treated as early as possible. Child development screening program in Puskesmas should been carried out integrated with growth screening in Stimulation, Detection, and Early Intervention of Child Growth and Development (SDIDTK) Program. Aims of this study was to gathering informations about the implementation of child development screening activity conducted by Puskesmas Mojo. This was a cross sectional study with kualitatif method. Primary data taken from under 5 years old child’s mothers, kindergarten teachers, cadres, and health staff of Puskesmas Mojo. Secondary data gotten from PWS KIA report of Puskesmas Mojo.Results of SDIDTK activities in Puskesmas Mojo according to PWS KIA report, achieve 88.1% in 2013 and 95.2% in 2014. Child development screening activities done infrequenly in Posyandu. Routine activities of Posyandu was growth/nutrition screening. Child development screening activities done by visiting kindergarten school every 6 month but not every child getting development screen, only those who suspicious have developmental delay because of minimum number of staff and aids. Results of SDIDTK activities in Puskesmas Mojo only represents child growth screening activities.

Preventive healthcare for young children: A systematic review of interventions in primary care

High rates of preventable health problems amongst children in economically developed countries have prompted governments to seek pathways for early intervention. We systematically reviewed the literature to discover what primary care-targeted interventions increased preventive healthcare (e.g. review child development, growth, vision screening, social-emotional health) for preschool children, excluding vaccinations. MEDLINE, EMBASE, CINAHL, and Cochrane databases were searched for published intervention studies, between years 2000 and 2014, which reflected preventive health activities for preschool children, delivered by health practitioners. Analysis included an assessment of study quality and the primary outcome measures employed. Of the 743 titles retrieved, 29 individual studies were selected, all originating from the United States. Twenty-four studies employed complex, multifaceted interventions and only two were rated high quality. Twelve studies addressed childhood overweight and 11 targeted general health and development. Most interventions reported outcomes that increased rates of screening, recording and recognition of health risks. Only six studies followed up children post-intervention, noting low referral rates by health practitioners and poor follow-through by parents and no study demonstrated clear health benefits for children. Preliminary evidence suggests that multi-component interventions, that combine training of health practitioners and office staff with modification of the physical environment and/or practice support, may be more effective than single component interventions. Quality Improvement interventions have been extensively replicated but their success may have relied on factors beyond the confines of individual or practice-led behaviour. This research reinforces the need for high quality studies of pediatric health assessments with the inclusion of clinical end-points.

Examining Profiles of Family Functioning in Pediatric Asthma: Longitudinal Associations With Child Adjustment and Asthma Severity

Objective

Identify profiles of functioning in families of children with asthma and examine whether profile membership predicts subsequent child mental and physical well-being.

Methods

Primary caregivers and children ( N  = 1,030) from the Childhood Asthma Management Program completed questionnaires assessing family functioning and child adaptation at five time points. Asthma severity was also assessed via spirometry.

Results

Latent profile analyses identified a four-profile solution as best fitting the data: cohesive, permissive, controlling/disengaged, and controlling/enmeshed families. Distal outcome analyses using Bolck-Croon-Hagenaars techniques suggested that children from families that were more cohesive had fewer internalizing and externalizing symptoms. These associations remained stable across time. Family profiles did not differ with regards to child asthma severity.

Conclusion

Results highlight the importance of looking beyond the effects of distinct components of family functioning and instead using pattern-based approaches. Recommendations for incorporating screenings and services for families in pediatric care settings are provided.

Screening for Developmental Disorders in 3- and 4-Year-Old Italian Children: A Preliminary Study

BACKGROUND

The "Osserviamo" project, coordinated by the Municipality of Rome and the Department of Pediatrics and Child Neuropsychiatry of Sapienza University, aimed to validate an Italian version of the Ages and Stages Questionnaire-3 and to collect, for the first time in Italy, data on developmental disorders in a sample of 4,000 children aged 3 and 4 years. The present paper presents the preliminary results of the "Osserviamo" project.

METHODS

600 parents of children between 39 and 50 months of age (divided in two age stages: 42 and 48 months) were contacted from 15 kindergarden schools.

RESULTS

23.35% of the whole sample scored in the risk range of at least one developmental area of the Ages and Stages Questionnaire-3rd Edition (ASQ-3) and 7.78% scored in the clinical range. Specifically, 23.97% of the children in the 42-month age stage scored in the risk range and 5.79% scored in the clinical range. Males scored lower than females in the fine motor skills and personal-social development domains. Moreover, 22.79% of the children in the 48-month age stage scored in the risk range, while 9.55% scored in the clinical range. Males scored lower than females in fine motor skills.

CONCLUSION

Italian validation of the ASQ-3 and recruitment of all 4,000 participants will allow these data on the distribution of developmental disorders to be extended to the general Italian pediatric population. One main limitation of the study is the lack of clinical confirmation of the data yielded by the screening programme, which the authors aim to obtain in later stages of the study.

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.

Primary Health Care: Potential Home for Family-Focused Preventive Interventions

Family-focused prevention programs have been shown to effectively reduce a range of negative behavioral health outcomes but have had limited reach. Three key barriers must be overcome to expand the reach of family-focused prevention programs and thereby achieve a significant public health impact. These barriers are (1) current social norms and perceptions of parenting programs; (2) concerns about the expertise and legitimacy of sponsoring organizations to offer parenting advice; and (3) a paucity of stable, sustainable funding mechanisms. Primary healthcare settings are well positioned to overcome these barriers. Recent changes within health care make primary care settings an increasingly favorable home for family-focused prevention and suggest possibilities for sustainable funding of family-focused prevention programs. This paper discusses the existing advantages of primary care settings and lays out a plan to move toward realizing the potential public health impact of family-focused prevention through widespread implementation in primary healthcare settings.

Topical Review: Building Competency: Professional Skills for Pediatric Psychologists in Integrated Primary Care Settings

OBJECTIVES : In the midst of large-scale changes across our nation's health care system, including the Affordable Care Act and Patient-Centered Medical Home initiatives, integrated primary care models afford important opportunities for those in the field of pediatric psychology. Despite the extensive and growing attention, this subspecialty has received in recent years, a comprehensive set of core professional competencies has not been established. METHODS : A subset of an Integrated Primary Care Special Interest Group used two well-established sets of core competencies in integrated primary care and pediatric psychology as a basis to develop a set of integrated pediatric primary care-specific behavioral anchors. CONCLUSIONS : The current manuscript describes these behavioral anchors and their development in the context of professional training as well as with regard to Triple Aim goals and securing psychology's role in integrated pediatric primary care settings.

Mitigating the Effects of Family Poverty on Early Child Development through Parenting Interventions in Primary Care

Poverty related disparities in early child development and school readiness are a major public health crisis, the prevention of which has emerged in recent years as a national priority. Interventions targeting parenting and the quality of the early home language environment are at the forefront of efforts to address these disparities. In this article we discuss the innovative use of the pediatric primary care platform as part of a comprehensive public health strategy to prevent adverse child development outcomes through the promotion of parenting. Models of interventions in the pediatric primary care setting are discussed with evidence of effectiveness reviewed. Taken together, a review of this significant body of work shows the tremendous potential to deliver evidence-based preventive interventions to families at risk for poverty related disparities in child development and school readiness at the time of pediatric primary care visits. We also addresss considerations related to scaling and maximizing the effect of pediatric primary care parenting interventions and provide key policy recommendations.

Narrowing Care Gaps for Early Language Delay: A Quality Improvement Study

BACKGROUND AND OBJECTIVE

Poverty is a risk factor for both language delay and failure to access appropriate therapies. The objective of this study was to increase the percentage of children 0 to 3 years old referred from an urban primary care center who attended an initial appointment with speech pathology or audiology within 60 days from 40% to 60%.

METHODS

The Model for Improvement was used to develop and test the intervention, which addressed potential logistical barriers faced by low-income families. Adherence was plotted on run charts in time series to assess overall improvement, and subgroups were analyzed to identify reduction in disparities.

RESULTS

Median referral adherence improved from 40% to 60%. Families from lower income neighborhoods had lower preintervention adherence; these differences were eliminated postintervention.

CONCLUSIONS

System-level changes improved access to evaluation and treatment for low-income children with language delay and narrowed the gap in access between families in lower versus higher income neighborhoods.

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.

Examining Parents' Experiences and Information Needs Regarding Early Identification of Developmental Delays: Qualitative Research to Inform a Public Health Campaign

OBJECTIVE

The purpose of this study was to assess the approach and materials of Centers for Disease Control and Prevention's "Learn the Signs. Act Early." (LTSAE) health education campaign, which aims to improve awareness of developmental milestones and early warning signs of developmental delay among parents of young children.

METHODS

We conducted 2 phases of qualitative research. Focus groups assessed the campaign's objectives by exploring the experiences of parents with children who have developmental delays or disabilities to determine facilitators of and barriers to identification. In-depth interviews were conducted with parents of typically developing children, who reviewed campaign materials and provided feedback on appropriateness, appeal, and clarity with regard to the campaign's objectives.

RESULTS

Phase 1: Parents were typically the first to express concern about their child's development, and most talked with their child's health care provider. Two categories of health care providers emerged: those who proactively asked about a child's development, used tools to facilitate conversations, and made referrals, and those who did not ask about development, told parents to "wait and see," and did not provide information about services and supports. Few parents knew about special education services before identification. Phase 2: Participants found the campaign materials appealing, but were unclear about how to act early and why acting early was important.

CONCLUSIONS

Results affirmed LTSAE's evidence-based approach to educating parents about child development. Additional campaign considerations include providing more information about how to act early and why acting early is important and enhancing outreach to providers to help them communicate with concerned parents.

Psychometric properties and validation of Portuguese version of Ages & Stages Questionnaires (3rd edition): 9, 18 and 30 Questionnaires

BACKGROUND

The essential underlying foundations of Early Intervention (EI), in which parents/family play a critical role in their child's development, leads us to conclude that their contribution assessing early detection of problems is fundamental. The Ages & Stages Questionnaires (ASQ) is a standardized screening instrument that has been successfully studied in different countries and cultures.

AIMS

Translate and study the psychometrics proprieties of the Portuguese version of the 9, 18 and 30month questionnaires of the Ages and Stages Questionnaires, 3rd edition (ASQ-3).

STUDY DESIGN

Cross-sectional study.

SUBJECTS

Validity and reliability were studied in a sample of 234 parents of children within 9, 18 and 30months.

RESULTS

The results indicated that the questionnaires had good internal consistency, strong agreement between observers and between observations with two weeks interval, and strong Pearson product-moment correlation coefficients between the overall and the total for each domain. The cutoff points (i.e. 2 standard deviations below the mean domain score), that identifies children who should receive further referral for more comprehensive assessment, were close to those determined in the original ASQ-3 psychometric studies. Cronbach's alpha ranging from .42 to .70 and Pearson's r values varies from .22 to .60.

CONCLUSIONS

Although some weaknesses were noted in psychometric qualities analysis, it can be concluded that the ASQ-PT of 9, 18 and 30months of age fulfills the requirements of a screening tool validated for the Portuguese population.

PRACTICE IMPLICATIONS

To allow the early identification of children with developmental problems.

Can Screening with the Ages and Stages Questionnaire Detect Autism?

OBJECTIVE

Parents rely on pediatricians to monitor their child's development. The American Academy of Pediatrics recommends routine developmental screening with both broadband and autism-specific instruments at specified ages. If broadband screeners can detect autism risk, this might minimize the burden of administering autism-specific screens to all children. The current study examines the ability of the Ages and Stages Questionnaire-Third Edition (ASQ-3) to identify children at risk for autism. We looked at ASQ-3 scores of children who screen positive on the Modified Checklist for Autism in Toddlers-Revised (M-CHAT-R), children who continue to screen positive on the M-CHAT-R Follow-up Interview, and children diagnosed with autism spectrum disorder (ASD).

METHODS

A total of 2848 toddlers, aged 16 to 30 months, were screened with the ASQ-3 and M-CHAT-R across 20 pediatric sites. Children who screened positive on the M-CHAT-R and its follow-up interview were offered a diagnostic evaluation.

RESULTS

Using the "monitor and/or fail" cutoff on any domain, the ASQ-3 identified 87% of the children who screened positive on the M-CHAT-R with follow-up and 95% (20/21) of those diagnosed with an ASD. Monitor and/or fail on the Communication domain alone also identified 95% of the diagnosed children.

CONCLUSIONS

Scores below the "monitor" cutoff on the Communication domain of the ASQ-3 can indicate initial concern requiring autism-specific follow-up. If these results are confirmed with a sample large enough to separately examine toddlers of different ages and different cultural backgrounds, it may be feasible to implement a 2-stage screening strategy, with autism-specific screening reserved for those who are positive on a broadband screen.

Evaluation of the psychometric properties of the Spanish version of the Denver Developmental Screening Test II

The objective of this study was to examine the psychometric properties of the Spanish version of the Denver Developmental Screening Test II in a population of Spanish children. Two hundred children ranging from 9 month to 6 years were grouped into two samples (healthy/with psychomotor delay) and screened in order to check whether they suffered from psychomotor delay. Children from three Early Intervention Centres and three schools participated in this study. Criterion validity was calculated by the method of extreme groups, comparing healthy children to those with development delay. Interobserver and intraobserver reliability were calculated using Cohen Kappa coefficient, and internal consistency was calculated via the Kuder-Richardson coefficient. The scale demonstrated 89% sensitivity, 92% specificity, a positive predicted value of 91% and a negative predicted value of 89%, whereas the positive and negative likelihood ratio was 11.12 and 0.12, respectively. Intraobserver reliability ranged from 0.662 to 1, and interobserver reliability ranged from 0.886 to 1. The Kuder-Richardson coefficient values ranged from 87.5 to 97.6%.

CONCLUSION

The Spanish version of the Denver Developmental Screening Test II was found to have a good criterion validity, reliability and internal consistency and is a suitable screening test for use in a population of Spanish children.

Training pediatric residents to provide parent education: a randomized controlled trial

OBJECTIVE

We evaluated the effect of Primary Care Positive Parenting Program (Triple P) training on pediatric residents and the families they serve to test 2 hypotheses: first, training would significantly improve resident skill in identifying and addressing discrete parenting and child behavior problems; and second, parents would report an improvement in their sense of self-efficacy, use of positive discipline strategies, and their child's behavior.

METHODS

Study participants included pediatric residents from 3 community clinics of a pediatric residency program, as well as English-speaking parents of children aged 18 months to 12 years without a diagnosed behavior disorder cared for by study residents. Residents were randomized to receive Primary Care Triple P training either at the beginning or end of the study period. The measured resident outcomes were self-assessed confidence and skills in giving parenting advice. The measured family outcomes were parent sense of self-efficacy, child externalizing behavior, and discipline strategies.

RESULTS

Primary Care Triple P training had a positive, significant, and persistent impact on residents' parenting consultation skills (mean increase on Parent Consultation Skills Checklist 48.11, 95% confidence interval [CI] 40.07, 57.36). Parents visiting intervention-trained residents demonstrated improved disciplinary practices compared to parents visiting control residents (mean change in Child Discipline Survey 0.322, 95% CI 0.02, 0.71), with stronger differential effects for parents with lower baseline skills (mean Child Discipline Survey change 0.822, 95% CI 0.48, 1.83). No differences were found for child behavior or parenting sense of confidence.

CONCLUSIONS

Training residents in Primary Care Triple P can have a positive impact on consultation skills and parent disciplinary practices. This finding adds strength to the call for increased residency training in behavioral pediatrics.

Improving developmental screening among pediatricians in New Mexico: findings from the developmental screening initiative

BACKGROUND

Seven pediatric primary care practices participated in New Mexico's Developmental Screening Initiative in a year-long quality improvement project with the goal of implementing standardized developmental screening tools.

METHODS

The initiative utilized a learning collaborative approach and the Model for Improvement to promote best practice about developmental screening outlined by the American Academy of Pediatrics. Also, the project emphasized interagency collaboration to improve communication between medical providers and state and community agencies that provide services to children with developmental delays.

RESULTS

A total of 1139 medical records were reviewed by the 7 practices, at 5 intervals during the intervention. At baseline, there were dramatic differences among the practices, with some not engaged in screening at all. Overall, the use of standardized developmental screening increased from 27% at baseline to 92% at the end of the project.

Pediatricians' and health visitors' views towards detection and management of maternal depression in the context of a weak primary health care system: a qualitative study

BACKGROUND

The present study's aim has been to investigate, identify and interpret the views of pediatric primary healthcare providers on the recognition and management of maternal depression in the context of a weak primary healthcare system.

METHODS

Twenty six pediatricians and health visitors were selected by using purposive sampling. Face to face in-depth interviews of approximately 45 minutes duration were conducted. The data were analyzed by using the framework analysis approach which includes five main steps: familiarization, identifying a thematic framework, indexing, charting, mapping and interpretation.

RESULTS

Fear of stigmatization came across as a key barrier for detection and management of maternal depression. Pediatric primary health care providers linked their hesitation to start a conversation about depression with stigma. They highlighted that mothers were not receptive to discussing depression and accepting a referral. It was also revealed that the fragmented primary health care system and the lack of collaboration between health and mental health services have resulted in an unfavorable situation towards maternal mental health.

CONCLUSIONS

Even though pediatricians and health visitors are aware about maternal depression and the importance of maternal mental health, however they fail to implement detection and management practices successfully. The inefficiently decentralized psychiatric services but also stigmatization and misconceptions about maternal depression have impeded the integration of maternal mental health into primary care and prevent pediatric primary health care providers from implementing detection and management practices.

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.

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.

Continuing education on child development for primary healthcare professionals: a prospective before-and-after study

CONTEXT AND OBJECTIVE

Children's developmental disorders are often identified late by healthcare professionals working in primary care. The aim of this study was to assess the impact of a continuing education program on child development, on the knowledge and practices of these professionals.

DESIGN AND SETTING

Prospective single-cohort study (before-and-after study), conducted in the city of Belém, Pará , Brazil.

METHODS

Two hundred and twenty-one professionals working in primary healthcare (82.2%) participated in a continuing education program on child development and were assessed before and after implementation of the program through tests on their knowledge of child development, consisting of 19 questions for physicians and 14 for nurses, and questionnaires on their professional practices.

RESULTS

One to three years after the program, the mean number of correct answers in the tests had increased from 11.5 to 14.3 among physicians in the Healthy Family Program (Programa Família Saudável, PFS); 13.0 to 14.3 among physicians in Municipal Health Units (Unidades Municipais de Saúde, UMS); 8.3 to 10.0 among PFS nurses; and 7.8 to 9.4 among UMS nurses. In interviews with mothers attended by these professionals before the program, only 21.7% reported that they were asked about their children's development, 24.7% reported that the professional asked about or observed their children's development and 11.1% received advice on how to stimulate them. After the program, these percentages increased to 34.5%, 54.2% and 30.3%, respectively.

CONCLUSIONS

Professionals who participated in the program showed improved performance regarding child development knowledge and practices.