Windows to Success: Developmental Screening In the

Early Years

Jane Squires, Ph.D.Chile Grows With You

November, 2008Santiago, ChileJsquires@uoregon.edu

Objectives

What is risk in early development?

What is the importance of early identification?

Why screen young children?

Risk factorsFactors that hamper typical development in

young children Environmental

• Poverty• Teen parents• Abuse/neglect

Biological• Low birth weight

Identified/established delays• Down syndrome

Cumulative Effects of RiskSameroff et al, 1987

PovertyHow does poverty affect developmental

outcomes? Is not a direct cause of poor outcomes Parents in poverty are not “poor parents” Produces a constellation of stresses and risks

PovertyLack of food

Iron deficiency• Anemia• Problems with problem-solving, concentration, lower

IQHousing Problems

Homelessness• Infant mortality, asthma, delayed immunizations• Frequent moving

• Not completing high school

Poverty

Family stress• Perceived financial

hardship• Parent stress and

depression• Family conflict, less

effective parenting behavior• Child behavior problems,

aggressiveness, learning problems

Poverty

Fewer resources for learning Inferior child care

• Less exposure to print, learning materials• More child stress--anxious, aggressive, less active

Financial barriers for school, college• Less educational attainment

Meaningful Differencesin the Everyday Experiences of

Young American ChildrenHart & Risley, 1995, Brookes Publishing

Meaningful Differencesin the Everyday Experiences of

Young American ChildrenHart & Risley, 1995, Brookes Publishing

How can we improve child outcomes?

Early Child DevelopmentSeries of interactions

between child and environment

Series of qualitative reorganizations among and within biological systems stimulated by environmental interactions

Transactional Model of Development

Reciprocal, ongoing exchanges between the child and environment serve as the foundation of development.

Child is active participant in development.

Outcomes depend upon quality of caregiving environment as well as the child’s characteristics.

Plasticity of Young Brain

Brain imaging research shows affects of stimulating environment on young children

Children of depressed mothers show 40% less brain activity (Shore, 1997)

With rich interactions from the environment, brain develops in optimal way

Differential genetic susceptibility to effects of caregiving environment

Genes + caregiving environment = adult outcomes

Early Identification

On going monitoring of young children’s development

Identifying children with delays in development

Providing enrichment activities and/or special education

Early Intervention

Early intervention provides continuum of supports to children and families

Intervening early is necessary to compensate

Continued intervention and support are often necessary to sustain gains

Early intervention makes a substantial difference in the lives of young children and families

Evidence for Early Intervention

Intelligence is enhanced in some children.

Substantial gains are made in all developmental areas

Secondary handicapping conditions are inhibited or prevented.

Family support is provided.

Evidence for Early Intervention

Dependency is reduced

Need for special education services at school age is reduced.

Substantial cost savings in health care and education costs.

2.3% 11.6 %5.9%

Incidence of children identified as having a disability by age

Primary PreventionBuilding Positive Relationships for Families

Prevention Triangle

Tertiary Level

Special education, OT/PT

Secondary Prevention

Targeted interventions with risk population

Screening, education, health

Early childhood programs save money

3 to 1 benefit-cost ratio

Better health and academic outcomes

$3-9 for every dollar invested

16% annual return• http://epinet.org• http://brookings.edu• http://minneapolisfed.org/

Heckman, J. (2006). Skill formation and the economics of investing in disadvantaged children.Science 312(5782), pp. 1900-1902.

Risk Factors and Development:Review

• Environmental, medical, and combination risk factors affect development

• Quality of caregiving environment can mitigate effects of risk

• Poverty presents most devastating risk factors for young children

• Prevention is cost-efficient and effective

WHAT IS SCREENING?

ScreeningA brief assessment procedure designed to

identify children who should receive more intensive diagnosis or evaluation from local education, health, mental health agencies

Screening

Not near cutoffBeyond Cutoff

Eligible

Near Cutoff

Professional

Assessment

Not Eligible

Continue to monitor (re-screen) & use curriculum-based

assessment to develop learning

plans

WHY SCREEN YOUNG CHILDREN?

Clinical judgment is not accurate

Increases identification rates of children with delays

If used system-wide, increase communication, collaboration among agencies

Why use screening tests?

Increased rates of poverty for families with young children Poverty associated with increased medical,

developmental, and social-emotional problems

Medical interventions increasing numbers of children with delays Children born below 1500 grams have greatly

increased chance for developmental delays

Increased use of illegal substances by stressed families

Why screen?

Early childhood time for brain plasticity and growth

Neurons to Neighborhoods, http://www4.nationalacademies.org/

Early intervention is effective For low-birth weight children

McCormick et al. 2006 Ecological focus on family and child

Bronfenbrenner, 1977; Sameroff & Fiese, 2000 Home and center based programs effective

Olds, 1997; Ramey & Ramey, 2000

Why screen?

Identification by pediatricians

In U.S. 60-80% with delays not identified early

American Academy of Pediatrics 2006: Pediatricians recommended screening at

9, 18-24, 30 months

Referral rates in 1 practice increased 224% in one year with formal screening test (Hix-Small, Marks, Squires & Nickel, 2007)

What are effective screening measures?

Qualities of assessment tools to considerValidity

Reliability

Adequate normative

population

Cultural sensitivity

Comprehensiveness

Attractiveness to children

Types of screening instruments

Professionally-administered

Parent-completed

Information on screening tools http://www.dbpeds.org/ http://www.fpnotebook.com http://www.cimh.org Individual publishers

Professionally-administeredBattelle Developmental Inventory Screen, 2nd (http://www.assess.nelson.com)

Bayley Scales of Infant Development Screen, 3rd (http://harcourtassessment.com)

Brigance Screens (http://www.curriculumassociates.com)

Denver II (http://www.denverii.com/DenverII.html)

Early Screening Inventory (www.pearsonearlylearning.com)

Parent-Completed Pediatric Evaluation of Developmental

Status PEDS--Glascoe• www.pedstest.com

MacArthur Communicative Development Inventory--Fenson et al.

Minnesota Child Development Inventories• http://www.childdevrev.com/cdi.html

Ages & Stages Questionnaires• http://www.brookespublishing.com• http://agesandstages.com

Assessment

“the science of examining the strange behaviors of children in a strange situation with strange adults for the briefest possible periods of time”

(Bronfenbrenner, 1979)

Advantages of Parent-Completed Screening Measures

Engaging families in the assessment of their child

Parents are reservoirs of rich information about their children

Parental involvement reduces cost

Screening structures observations, reports and communications about child development

Screening may become a teaching tool for parents and teaching staff

Information/communication can be useful for primary health care providers and communication based rehabilitation center

Effective and efficient method of early identification

Engaging families in the assessment of their child

Research on parent report of child developmental level

As accurate as formal measures for identifying cognitive delay (Glascoe, 1989, 1990; Pulsifer, 1994)

As accurate as formal measures for identifying language delay (Tomblin, 1987)

As accurate as formal measures for identifying symptoms of ADHD and school related problems (Mulhern, 1994)

More accurate than Denver for predicting school-age learning problems (Diamond, 1987)

Accuracy of low and middle income parents

Agreement between parent-completed ASQ and

professionally administered standardized assessment:

Low income parents .85

(below federal poverty level)

Middle income parents .89

No statistical significance between groups

(Squires, Potter, & Bricker, (1998) Early Childhood Research Quarterly,13, 2, 345-354.)

Advantages of parent-completed screening tests

Parents/caregivers can provide rich information about child across settings

Parent involvement reduces cost• 3-5 times less

Screening structures observations, reports, communications about child development

Parent-completed assessments range between $3-10 per assessment (U.S. interview/mail models)

Professionally-administered cost 3-5 times more(Chan & Taylor, 1998; Dobrez Lo Sasso, Holl et

al., 2001; Glascoe, Foster, & Wolraich, 1997)

Cost Effective

Characteristics of parentsImpaired mental functioning

Mental health issues

Cultural and language differences

Involvement with child protective agencies

Low literacy

Factors that may affect the accuracy of parental report

PARENTS’ EVALUATION OF DEVELOPMENTAL STATUS

A Method for Detecting and Addressing Developmental and Behavioral Problems

• For children 0 through 8 years• In English, Spanish and Vietnamese• Takes 2 minutes to score• Elicits parents’ concerns/family-focused/culturally

competent• Sorts children into high, moderate or low risk • 4th – 5th grade reading level • Score/Interpretation form printed front and back• and used longitudinally• Screens for developmental and behavioral/mental health problems

7. Do you have any concerns about how your child gets along with others?

PEDS Response Form 1. Please list any concerns about your child’s

learning, development, and behavior.

2. Do you have any concerns about how your child talks and makes speech sounds?Circle: Yes No A little Comment:

Circle: Yes No A little Comment:

What are the ASQ and ASQ:SE?

Series of parent- completed developmental questionnaires

Screen children for possible developmental delays, difficulties

Monitor the development of young children from 1 month to 5 years

Enlist parents and caregivers in assessment process

ASQ Communication

12 month ASQ• Does your baby follow one simple command, such as

Come here, Give it to me, Put it back, without your using gestures? Yes Sometimes Not Yet

• Does your baby say one word in addition to Mama and Dada?

Yes Sometimes Not Yet

ASQ Fine motor 24-month ASQ

• Does your child turn the pages of a book by himself? (He may turn more than one page at a time.)

Yes Sometimes Not Yet

• Does your child flip switches off and one?

Yes Sometimes Not Yet

12 month ASQ:Social Emotional

• Does your baby laugh or smile at you and other family members?(z)Most of the time (v) Sometimes (x) Rarely or never

• Does your baby like to be picked up and held?(z)Most of the time (v) Sometimes (x) Rarely or never

24 month ASQ:Social Emotional

•Does your child seem too friendly with strangers?(x)Most of the time (v) Sometimes (z) Rarely or never

•Do you and your child enjoy mealtimes together?(z)Most of the time (v) Sometimes (x) Rarely or never

ASQ & ASQ:SE for autism

ASQ identified 76/76 children in retrospective study (Nickel, 2006)

70/76 parents made comments in overall section

ASQ:SE in clinical settings is identifying children with autism

Two studies just beginning using ASQ and ASQ:SE

ASQ Office Study

12 and 24 months 20 pediatric practitioners 76% agreement between ASQ and pediatrician

estimate of development (OK, at risk) Pediatricians referred mostly for communication,

gross motor delays Referrals for further assessment increased 224%

in one year

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12-months 24-months

control year

screening year

Control and screening year referrals

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12-months 24-months

doc controlyear

doc screeningyear

asq screening

Control and screening year referrals

Recommendations for a screening system

Best practices in screening

Use formal, validated screening measuresInclude parents in decision makingConsider cultural adaptationsDevelop systematic screening and referral

proceduresInclude personnel and agency trainingEvaluate screening system

Cost Efficacy Utility

Include social-emotional areasLinks between earliest emotional development

and later social behavior. (Cicchetti & Cohen 1995; Reynolds et al., 2001)

Behaviors, even in infancy, signal the need for intervention (Shonkoff & Phillips, 2000)

Links between early risk factors, poor outcomes & violence (Conroy & Brown, 2004)

By third grade, programs for children with anti-social behavior are mostly ineffective (Walker, 2004; Greenberg et al., 2003)

21st Century Screening Programs

Short, effective screening tests Increased use of parent report Internet-based Touch screens at health and educational

centers Follow-up through health and educational

outreach staff

In Summary Early identification is critical for improving

developmental outcomes

Valid and reliable screening tests are central to early identification efforts

Several parent-completed screening tests assist in early identification efforts

Early identification and intervention have extensive cost savings as well as improving child and family outcomes

To make change, we must have unwarranted optimism about our children and our future

• “All this will not be finished in the first 100 days.. Nor will it be finished in the life of this Administration, nor even perhaps in our lifetime on this planet. But let us begin.”

John F. Kennedy, 1961

• “We must become the change we seek to create.” Gandhi

Thank you