Lowering Developmental Screening Thresholds and Raising Quality Improvement for Preterm Children

Department of Pediatrics, PeaceHealth Medical Group, 1162 Willamette, Eugene, OR 97401, USA.
PEDIATRICS (Impact Factor: 5.47). 06/2009; 123(6):1516-23. DOI: 10.1542/peds.2008-2051
Source: PubMed

ABSTRACT To determine: 1) if preterm children were referred, identified and received early intervention (EI)/ early childhood special education (ECSE) services at rates equivalent to term children after implementation of a universal, periodic Ages and Stages Questionnaire (ASQ) surveillance and screening system; 2) if pediatricians sufficiently lowered their screening thresholds with preterm children;and 3) if quality improvement opportunities exist.
Secondary analysis was performed on 64 lower-risk, mostly late-preterm and 1363 term children who originally presented to their 12- or 24-month well- visits. Higher-risk preemies already involved with an EI agency/ identified with a delay were excluded. Board-certified pediatricians (N=18), and nurse practitioners (N = 2), blind to the ASQ results, were secondary participants. Differences between preterm and term developmental agency referrals were examined comparing Pediatric Developmental Impression to the ASQ under natural clinic conditions using a combined in-office or mail-back data collection protocol. Medical record and county EI/ECSE follow-up outcomes were conducted at 36 to 60 months.
At 12 and 24 months, preterm (versus term) referral rates were 9.5%(versus 5.6%) with Pediatric Developmental Impression and 26.2% (versus 8.1%) with the ASQ. By 36 to 60 months, 37.5% of preterm (20.8% term) children were referred to EI/ECSE; of which, 50.0% of preterm (42.4% term) children were eligible for services, 54.2%of preterm children were identified with a developmental-behavioral disorder and 29.2% of preterm (20.8% term) children did not follow-up. For ASQ-only preterm referrals,55.6% were subsequently diagnosed with a developmental delay and/or disorder.Preterm children were 2 times more likely to be eligible than term children [corrected].
Combined referral, quality improvement and outcome data suggests that clinicians should lower their threshold for administering a psychometrically sound developmental screen when providing surveillance for ex-preemies. Quality improvement opportunities exist with diligent developmental surveillance and a more collaborative, standardized, reliable and interpersonal referral process.

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Available from: Kevin Marks, Sep 26, 2015
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    • "Other studies, however, have demonstrated that the referral rate of infants should be rather liberal. In one study, following 1363 term children not referred for or identified with delay, the referral rates were 5.6% or 8.1% according to pediatric or ASQ assessment respectively, at 12- or 24-month well-child visits [17]. In the 36-60 months follow-up, 20.8% received referrals of which 42.4% were eligible for services. "
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    ABSTRACT: Few population-based samples have previously published performance on the Ages and Stages Questionnaire (ASQ), a recommended screening tool to detect infant developmental delay. The aim of the study was to investigate performance on the ASQ in a population-based sample of 6-month-old infants. In this population-based questionnaire study from Oslo, Norway, the 30 item ASQ 6 month Questionnaire (N = 1053) were included, however without the pictograms, and compared to the Norwegian reference sample (N.ref) (N = 169) and to US cut-off values. Exclusion criteria were maternal non-Scandinavian ethnicity, infant age < 5.0 or > 7.0 months (corrected age), twins, and birth weight < 2.5 kg. Cut-off = 2.5 percentile (equivalent to mean minus 2 standard deviations). Pearson's Chi square and Mann-Whitney U were used to compare items and areas, respectively, with N.ref. The reported ASQ scores were lower on all but one of the 10 significantly different items, and in all areas except Personal social, compared to the N.ref sample. The estimated cut-off values for suspected developmental delay (Communication 25, Gross motor 15, Fine motor 18, Problem solving 25 and Personal social 20) were lower than the recommended American (US) values in all areas, and lower than the Norwegian values in two areas. Scores indicating need for further assessment were reached by 13.8% or 20.5% of the infants (missing items scored according to the US or the Norwegian manual), and by 33.8% or 30.3% of the infants using the recommended US or the Norwegian cut-off values, in this population-based sample. The Fine motor area demonstrated a large variability depending on the different cut-off and scoring possibilities. Both among the items excluding pictograms and the items that do not have pictograms, approximately every third item differed significantly compared to the N.ref sample. The psychomotor developmental scores were lower than in the reference samples in this study of ASQ 6 month Questionnaire; to our knowledge the first study to be both representative and comparatively large. Approximately every third child with birth weight above 2.5 kg, received scores suggesting further assessment using recommended ASQ cut-off scores.
    BMC Pediatrics 12/2011; 11:117. DOI:10.1186/1471-2431-11-117 · 1.93 Impact Factor
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    • "These and other studies provided support for the approach that sees ADHD as an early developmental disorder . It supports that the need of pediatricians to provide more diligent surveillance and actively lower their thresholds for administering a quality screening of preterm children in order to identify children in need of early intervention [Marks et al., 2009]. "
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    ABSTRACT: Attention deficit hyperactivity disorder (ADHD) is a childhood-onset disorder that is considered one of the most common neurobehavioral disorders. The symptoms of ADHD should be cast, not as static or fixed neurobehavioral deficits, but rather in terms of underlying developmental processes. Targeting attentional disorders early in life can bring about fundamental alterations in the pathogenesis of ADHD, and thus prevent or moderate the course of the disorder. The developmental approach can enable predictions concerning characteristics of ADHD that develop over time and inform us about multiple risk and protective factors that transact to impact its development, as well as the development of a broad range of associated co-morbid features. In this review, we describe the complex factors that predict and mediate the developmental course of ADHD, providing early cues for ADHD diagnosis and intervention in young children that will optimize outcome. © 2013 Wiley Periodicals, Inc. Dev Disabil Res Rev 2011;17:170-179.
    Developmental Disabilities Research Reviews 11/2011; 17(2):170-9. DOI:10.1002/ddrr.1111 · 2.75 Impact Factor
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    • "K-ASQ is advantageous in that it is cost-effective, can be filled out reliably without special training and it is simple in scoring, eliminating the need for an expert in its interpretation. Previous reports showing that parents of the children could successfully assess the development of growing children further supported the findings of this study.27 "
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    ABSTRACT: To evaluate concurrent validity between the Korean-Ages and Stages Questionnaires (K-ASQ) and the Denver Developmental Screening Test II (DDST II), and to evaluate the validity of the K-ASQ as a screening tool for detecting developmental delay of Korean children. A retrospective chart review was done to examine concurrent validity of the screening potentials for developmental delay between the K-ASQ and the DDST II (n=226). We examined validity of the K-ASQ compared with Capute scale (n=141) and Alberta Infant Motor Scale (AIMS) (n=69) as a gold standard of developmental delay. Correlation analysis was used to determine the strength of the associations between tests. A fair to good strength relationship (k=0.442, p<0.05) was found between the K-ASQ and the DDST II. The test characteristics of the K-ASQ were sensitivity 76.3-90.2%, specificity 62.5-76.5%, positive likelihood ratio (PLR) 2.41-3.40, and negative likelihood ratio (NLR) 0.16-0.32. Evidence of concurrent validity of the K-ASQ with DDST II was found. K-ASQ can be used for screening of developmental delay.
    Annals of Rehabilitation Medicine 06/2011; 35(3):369-74. DOI:10.5535/arm.2011.35.3.369
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