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DOI: 10.1542/peds.2010-2211
; originally published online January 9, 2012;Pediatrics
Meghna Nayak, Susan Chinitz and Andrew D. Racine
Rahil D. Briggs, Erin M. Stettler, Ellen Johnson Silver, Rebecca D. A. Schrag,
Social-Emotional Screening for Infants and Toddlers in Primary Care
http://pediatrics.aappublications.org/content/early/2012/01/04/peds.2010-2211
located on the World Wide Web at:
The online version of this article, along with updated information and services, is
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
publication, it has been published continuously since 1948. PEDIATRICS is owned,
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Social-Emotional Screening for Infants and Toddlers
in Primary Care
WHAT’S KNOWN ON THIS SUBJECT: Recommendations in
pediatrics call for general developmental screening of young
children; however, research suggests social-emotional
development, in particular, is important as an initial indicator of
general well-being versus risk, and may warrant inclusion in
screening protocols.
WHAT THIS STUDY ADDS: Via a social-emotional screening
program, significant percentages of children can be identified as
being at risk for social-emotional problems, and colocation of an
early childhood psychologist promotes the ability to effectively
address young children’s social-emotional development within
their medical home.
abstract
BACKGROUND AND OBJECTIVES: Recommendations in pediatrics call
for general developmental screening of young children; however, research
suggests social-emotional development, in particular, is important as an
initial indicator of general well-being versus risk. We aim to describe a
program designed to identify the social-emotional status of young children
in the pediatric setting by using the Ages and Stages Questionnaires:
Social-Emotional (ASQ:SE) as a universal screening tool, and to assess
the effect of interventions by a colocated psychologist on changes in
ASQ:SE scores over time.
METHODS: In a prospective cohort design we analyzed scores on ASQ:
SE surveys completed on children 6 to 36 months of age, to determine if
children were at risk for problems in social-emotional development.
The probability of remaining at risk over time was then compared
between subjects receiving intervention by the psychologist, and
those who declined intervention. Logit specifications were used in
multivariate comparisons to control for a set of covariates.
RESULTS: Three thousand one hundred and sixty-nine children were
screened; 711 (22.4%) scored at or above the risk cutoff. Among the
711 at-risk children, 170 were rescreened. At the time of rescreening,
those children who received intervention from the psychologist
showed significant improvement on ASQ:SE scores compared with
those who declined intervention (P= .01).
CONCLUSIONS: Universal social-emotional screening in a busy pediatric
practice is challenging. Significant percentages of children can be
identified as being at risk for social-emotional problems, and colocation
of a psychologist promotes the ability to effectively address young
children’s social-emotional development within their medical home.
Pediatrics 2012;129:1–8
AUTHORS: Rahil D. Briggs, PsyD,
a
,
b
Erin M. Stettler, MPH,
a
Ellen Johnson Silver, PhD,
a
,
b
Rebecca D. A. Schrag, PhD,
a
,
b
Meghna Nayak, MD,
b
Susan Chinitz, PsyD,
a
and Andrew D.
Racine, MD, PhD
a
,
b
a
Department of Pediatrics, Albert Einstein College of Medicine,
Bronx, New York; and
b
Department of Pediatrics, Children’s
Hospital at Montefiore, Bronx, New York
KEY WORDS
preventive mental health services, colocation, infant mental
health, social-emotional screening
ABBREVIATIONS
ASQ:SE, Ages and Stages Questionnaires—Social-Emotional
ITS—infant toddler specialist
www.pediatrics.org/cgi/doi/10.1542/peds.2010-2211
doi:10.1542/peds.2010-2211
Accepted for publication Oct 4, 2011
Address correspondence to Rahil D. Briggs, PsyD, Albert Einstein
College of Medicine, 1621 Eastchester Road, Bronx, NY 10461.
E-mail: rabriggs@montefiore.org
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2012 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
PEDIATRICS Volume 129, Number 2, February 2012 1
ARTICLE
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In recognition of the importance of early
identification and referral of develop-
mental concerns in pediatrics,
1,2
the
American Academy of Pediatrics rec-
ommends an algorithm that calls for
universal developmental surveillance
and screening of infants and young
children within the medical home.
3
Although there is sufficient evidence
related to the feasibility and effec-
tiveness of developmental surveillance
and screening within pediatrics, there
is relatively scant literature regarding
social-emotional screening of young
children in the pediatric setting, despite
compelling research on the importance
of this particular developmental do-
main. Even as research findingson early
childhood brain development under-
score the importance of the child’sre-
lational and environmental experiences
during these earliest years,
4
formal
assessment of this area within primary
pediatrics is infrequent.
Despite reports of universal social-
emotional screening within clinical
treatment programs,
5
foster care pop-
ulations,
6
or early intervention sites,
7
published experience in the general
pediatric literature is scant. Barriers
that impede pediatricians from perform-
ing routine social-emotional screening
include time limitations and lack of
confidence/training to address con-
cerns of pediatric mental health.
8,9
The
prevalence of social-emotional prob-
lems within the pediatric primary care
population, however, and their impor-
tance in terms of later outcomes for
children, suggest the need for enhanced
models of care within pediatrics.
One such model involves colocating
early childhood mental health pro-
fessionals directly in the pediatric pri-
mary care medical home. Operating
within this venue, such professionals
can coordinate high-quality social-
emotional screening programs, com-
plete with follow-up assessment and
intervention. Although the distinct
challenges to successfully colocating
mental health professionals within the
health care system are well docu-
mented,
10–12
the objective of this re-
port is as follows:
1. To document the feasibility of using
such a model with a colocated psy-
chologist (referred to as an infant
toddler specialist [ITS]) to screen,
identify, treat, and refer a high vol-
ume of young patients at a federally
qualified health center in an urban
community with an elevated preva-
lence of risk factors; and
2. To conduct a preliminary test of the
effectiveness of the model by com-
paring the outcomes for children
whose families accepted interven-
tion by the ITS with outcomes for
children whose families declined.
METHODS
Study Design
Our primary objective was to evaluate,
by using a prospective cohort design,
a universal social-emotional screen-
ing program. We attempted sequen-
tial (every 6 months) social-emotional
screenings of all children 6 months to
3 years of age presenting to a primary
care pediatric practice from March
2005 to March 2010. We used a parent-
completed validated screening tool: the
Ages and Stages Questionnaires: Social-
Emotional (ASQ:SE).
13
During the 5 years
of program implementation, children
who screened above the ASQ:SE risk
cutoff thresholds were referred for
assessment/intervention to the ITS,
which enabled us to compare follow-
up ASQ:SE scores for those who ac-
cepted ITS intervention with those
who declined. This study was approved
by the institutional review board at
Montefiore Medical Center.
Setting
The study was conducted at a federally
qualified health center affiliated with
a major academic medical center. A li-
censed bilingual early childhood psy-
chologist with training in infant mental
health was colocated within the health
center, and was referred to as an ITS, in
part to explain the specific age focus
(children ages 3 and younger), and to
reduce the stigma attached to a men-
tal health title. The pediatric practice,
staffed by 12 pediatric attending phy-
sicians, 1 pediatric nurse practitioner,
licensed practical nurses, registered
nurses, patient care technicians, 30
pediatric residents, a social worker, a
nutritionist, and a developmental and
behavioral pediatrician, serves as the
continuity clinic for a large urban child-
ren’s hospital, and annually provides
more than 23 000 pediatric visits to
more than 11 000 distinct patients, ages
0 to 21 years. The patient population of
this practice reflects the urban nature
of its setting, as more than 80% of pa-
tients are either Hispanic or African
American, and more than two-thirds of
patients are served by Medicaid or other
state-sponsored insurance programs.
Program Description
The intent of the program was to screen
all patients 6 to 36 months of age pre-
senting for health care maintenance
visits to identify those at risk for social-
emotional difficulties; to offer moni-
toring, on-site intervention, or referral
depending on clinical evaluation by the
ITS; and to perform follow-up screening
at regular intervals (see Fig 1). Screen-
ing was performed at 6 well-child visits
(6, 12, 18, 24, 30, and 36 months) by
using the ASQ:SE. The ASQ:SE is a parent-
completed questionnaire, available in
English and Spanish at a fifth-grade
reading level, with questions specificto
age intervals that correspond to well-
child visits. The number of questions
varies per form depending on the age of
child being screened (19–33 items).
Questionnaires take ∼10 minutes to
complete and 1 to 3 minutes to score.
The questions assess 7 characteristics
2BRIGGS et al at Montefiore Hosp & Med Ctr on January 10, 2012pediatrics.aappublications.orgDownloaded from
of development and behavior: self-
regulation, compliance, communica-
tion, adaptive functioning, autonomy,
affect, and interaction with others. Each
questionnaire has an empirically de-
rived cutoff score, at or above which
children should be assessed further.
The questionnaires are distinct from the
“regular”Ages and Stages question-
naires, more commonly used, which
assess motor, cognitive, language,
and social-emotional characteris-
tics. Psychometrics of the ASQ:SE are
consistently high to strong; internal
consistency ranges from 67% to 91%,
test-retest reliability is 94%, con-
current validity ranges from 81% to
95%, sensitivity ranges from 71% to
85%, and specificity ranges from 90%
to 98%.
14
Nursing staff distributed the ASQ:SE
while the family was waiting in the
private examination room for the pro-
vider. The ASQ:SE was accompanied by
a letter of explanation (in English or
Spanish), reviewing the purpose of the
screening. Families could decline to
complete the ASQ:SE, or ask for help
with completion. Completed question-
naires were returned to the ITS either
during the child’s visit or after the
visit in a mailbox. The ITS reviewed and
scored all questionnaires, and a scoring
sheet for each ASQ:SE was placed in the
child’s chart. The ITS also collected de-
mographic variables, including insur-
ance type, race, and gender.
When children were identified via an
elevated score (above the empirically
validated risk cutoff, considered at risk
for social-emotional development) on
the ASQ:SE, the ITS offered to complete
a more comprehensive assessment.
This assessment could occur as 1 as-
pect of the well-child visit, or at a sep-
arate appointment within the pediatric
practice. The assessment addressed
the concerns of the parent, provider
(if applicable), and the ITS. Domains
assessed included development, sleep,
behavior, psychosocial concerns (such
as domestic violence and homeless-
ness), and mental health (of the child
and the caregivers). From this assess-
ment, the ITS made treatment and re-
ferral decisions, and, in consultation
with the pediatric provider, either de-
livered the treatment (when short-
term) or closely followed all referrals
made (if long-term care, caregiver-
focused care, or exclusively develop-
mental therapies were indicated).
Treatment by the ITS included office-
and home-based appointments (as
needed), and was dyadic (caregiver-
child) in nature. Treatment ranged
from 1-time consultations to more on-
going (yet short-term) arrangements,
focusing on parenting education re-
garding discipline, sleep, feeding,
toileting, and so forth, clarifying de-
velopmental goals and abilities of
children, play therapy, and parent-child
interaction therapy.
15
A telephone in-
formation line was also available to all
parents of identified children. Most
commonly used outside referral op-
tions included early intervention, Early
Head Start, preschool special educa-
tion, and maternal and/or infant men-
tal health services.
Subjects
Eligible subjects included all toddlers
ages 6 months to 36 months presen-
ting to the pediatric practice over the
studyinterval for well-child care atthe 6-,
12-, 18-, 24-, 30-, and 36-month visits. The
focus of the preliminary effectiveness
analysis we report here includes 170
FIGURE 1
Program overview.
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infants and toddlers who had elevated
ASQ:SEscores on an initial screening and
who returned for subsequent screening
after evaluation/intervention by the ITS.
Outcome Measures
Screening results on the ASQ:SE were
dichotomized as the percentage of
children screened who received a score
above therisk cutoff at the 6-, 12-, 18-, 24-,
30-, and 36-month assessments, sep-
arately and combined at any screening
occasion.
Data and Statistical Analysis
Demographic information and ASQ:SE
scores were collected on all 6- to 36-
month-olds screened at the pediatric
practice between March 2005 and March
2010. To address the study’sfirst ob-
jective (feasibility), we calculated the
percentage of children screened who
received a score above the risk cutoff,
both overall and at the 6-, 12-, 18-, 24-,
30-, and 36-month assessments sepa-
rately. We also compared these per-
centages across demographic groups
by using x
2
analyses. Finally, we de-
termined the proportions originally
screened who had at least 1 follow-up
screening and reasons for lack of follow-
up in those with only a single screening.
We compared all children whose clinical
screening scores were above the at-risk
threshold with a random sample of chil-
drenwhoscoredbelowtheriskcutoff
to determine if there were differences
between at-risk and not-at-risk children
in reasons for lack of follow-up screen-
ing. We also calculated total percentage
of children screened at least once, from
the entire practice population, and de-
termined the type of follow-up care
these children received, if any.
To address the second objective (effec-
tiveness), we conducted analyses of
data from the subset of children who
scored above the risk cutoff and were
subsequently rescreened. By using x
2
analyses, we compared the proportions
continuing to score above the risk cutoff
on subsequent screening among those
who did and those who did not receive
intervention from the ITS in the interim.
Logistic regression analysis was con-
ducted to assess whether differences
in improvement (moving from a score
above the risk cutoff to a score below
the risk cutoff at rescreening) on the
ASQ:SE was associated with receiving
intervention from the ITS while control-
ling for a series of covariates: gender,
age, insurance type, and presenting
problem (development, sleep, behavior,
psychosocial, mental health).
RESULTS
Universal Screening
A total of 3169 infants and toddlers from
6 to 36 months of age were screened
either once or repeatedly at regular
intervals. A total of 4954 infants and
toddlers presented to the pediatric
practice for well-child care visits at the
indicated screening intervals (6-, 12-,
18-, 24-, 30-, and 36-month health care
maintenance visits), which results in
a screening rate of 64% (3169/4954).
Descriptive statistics of the screened
cohort are presented in Table 1. Those
children eligible for screening yet
never screened did not differ from the
screened cohort by gender, race, or in-
surance status (data not shown but
availableonrequest).
The percentage of children who received
ASQ:SE scores above the risk cutoff
ranged from a low of 8% at 6 months to
a high of 29% at 36 months. Figure 2
displays scores above the risk cutoff by
age. Age at screening was significantly
associated with scoring above the risk
cutoff (P,.001).
In Table 2 we display bivariate associ-
ations between demographic variables
and the percentage of children scoring
above the risk cutoff on at least 1 ASQ:
SE screen. We documented a significant
relationship between insurance status
(used as a proxy for poverty status
16
)
and scores above the risk cutoff. Chil-
dren with Medicaid, State Children’s
Health Insurance Program, or no insur-
ance were significantly more likely to
score above the risk cutoff than were
children with private insurance (P=
.001). In addition, we found a higher
rate of scores above the risk cutoff
for male children (P,.001), but no
significant difference with respect to
race (P= .056).
Rescreening Rate
Although program design called for
screening all age-eligible children
who presented for well-child checkups,
only 34% of children were screened
more than once. Reasons for lack of
rescreening of the remaining children
were multiple. To test whether the rea-
sons for lack of rescreening differed
between children who scored at-risk
on their initial ASQ:SE screen with those
who did not score at-risk , we catego-
rized all 541 at-risk children and a
random sample of 394 not-at-risk chil-
dren according to the reasons for lack
of rescreening.
TABLE 1 Descriptive Statistics for Screened
Children at Time of Initial
Screening: Total Population
Characteristic Frequency No. Percentage
Total 3169 100
Gender
Male 1647 52.0
Female 1522 48.0
Age, mo
6 798 25.2
12 704 22.2
18 494 15.6
24 431 13.6
30 308 9.7
36 434 13.7
Ethnicity
Hispanic 1618 51.1
African American 982 31.0
White 235 7.5
Asian 104 3.3
Other/Unknown 230 7.3
Insurance Status
Medicaid or SCHIP 2183 68.9
Private insurance 780 24.6
Uninsured 206 6.5
SCHIP, State Children’s Health Insurance Program.
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Within the group of children not-at-risk
according to their initial ASQ:SE, 31%
were older than 36 months (our last
screening interval), and thus were de-
termined ineligible for further screen-
ing. We thenexamineda random sample
(n= 394) of the not-at-risk children still
age eligible for rescreening. We found
that 79 children (14%) were too young
for the next screening at the time of
this study, 114 children (20%) never
returned to the clinic, and 201 (35%)
were eligible for follow-up screen-
ing yet never rescreened for unknown
reasons. In the at-risk children, 30%
were older than 36 months and thus
determined ineligible for further screen-
ing, 81 children (15%) were too young for
the next screening, 121 children (22%)
never returned to the clinic, and 176
(33%) were eligible for follow-up screen-
ing yet never rescreened. Differences in
the rescreening rates and reasons for
lack of rescreening between the at-risk
and not-at-risk groups did not reach sta-
tistical significance (P= .71). These find-
ings suggest that neither elevated initial
screening scores nor the probability of
being rescreened were associated with
thereasonsforlackoffollow-up.In
addition, children with scores above
the risk cutoff who were rescreened,
and children with scores above the
risk cutoff who were eligible for re-
screening yet missed, did not differ
according to bivariate comparisons
on gender, race, insurance type, or mean
age (P..05).
Impact of Intervention From ITS on
Screening Scores
To determine the impact of intervention
from the ITS on screening scores, we
examined the 170 children who scored
above the risk cutoff and received a
subsequent rescreening. Of these, 41
(24%) received intervention by the
ITS during the time period between
screenings, 38 (22%) were monitored
(ie, the ITS conducted an assessment
and determined that behaviors were
within normal limits and continued
monitoring would occur via screening),
24 (14%) were referred for outside ser-
vices owing to a presenting problem too
severe for sufficient intervention from
the ITS (eg, early intervention for de-
velopmental delay), and 67 (40%) de-
clined services (either did not return
phone calls or reported that they had no
significant concerns or need for inter-
vention).Forchildrenwithaninitial
screening score above the risk cutoff,
receipt of intervention from the ITS
predicted improvement on subsequent
screening, as more thanhalf (56%) of the
children who received intervention by
the ITS improved (had scoresthat moved
below the risk cutoff on subsequent
assessment). In contrast, only 25% of
those who were referred to other ser-
vices, 43% of those whose parent/
guardian declined follow-up inter-
vention, and 45% of those who were
monitored showed improvement on
a subsequent screening.
Table 3 shows the adjusted odds ratio
of the ASQ:SE score declining below the
risk threshold on follow-up screen-
ings, subsequent to intervention from
the ITS in the interim. Controlling for
the child’s presenting problem, gender,
FIGURE 2
Percentage of screening tests above risk cutoff score by age of child: total population. Figure represents
multiple screenings for each child; number of screeners at each age varies: 6 months = 65/807; 12
month s = 82/8 89; 18 months = 107/773; 24 months = 197/847; 30 months = 158/574; 36 months = 220/768.
x
2
(5, n= 4658) = 221.48, P= .000.
TABLE 2 Bivariate Associations Among Participants Above and Below Risk Cutoff Scores on
ASQ:SE Screener
Characteristic
a
Total
No.
Below Risk Cutoff,
n(%)
Above Risk Cutoff,
n(%)
x
2
P
Total 3169 2458 711 (22.4)
Gender
Male 1647 1236 (75.0) 411 (25.0) 12.50 ,.001
Female 1522 1222 (80.3) 300 (19.7)
Ethnicity
Hispanic 1618 1243 (76.8) 375 (23.2) 9.21 .056
African-American 982 777 (79.1) 205 (20.9)
White 235 193 (82.1) 42 (17.9)
Asian 104 80 (76.9) 24 (23.1)
Other/Unknown 230 165 (71.7) 65 (28.3)
Insurance Status
Medicaid or SCHIP 2183 1669 (76.5) 514 (23.5) 13.81 .001
Private Insurance 780 640 (82.1) 140 (17.9)
Uninsured 206 149 (72.3) 57 (27.7)
SCHIP, State Children’s Health Insurance Program.
a
Table represents subjects who scored above risk cutoff on at least 1 screener at any point in screening program;
demographic characteristic taken at time of initial screening.
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insurance type, and age, children
whose parents declined services were
only one-fourth as likely as those who
received intervention from the ITS to
demonstrate an improved screening
score (odds ratio = 0.25, P=.01).By
contrast, the odds of ASQ:SE scores
declining below the risk cutoff among
children who were referred elsewhere
or only required simple monitoring
were also lower, but not significantly
different from those of children who
received ITS intervention (the omitted
category).
Having a developmental problem as the
reason for an elevated ASQ:SE score
was a significant predictor of the like-
lihood of improving on subsequent
evaluation, as these children were less
than one-third as likely to improve
(odds ratio = 0.29, P= .01) compared
with children without developmental
problems. Developmental problems in-
cluded diagnoses such as language,
motor, or cognitive delay, and autism.
Other types of presenting problems
(sleep, behavior, psychosocial, and mental
health), gender, age, and insurance
type were not associated with whether
a child continued to score above the
risk threshold at follow-up.
DISCUSSION
Our experience confirms the feasibility
and effectiveness of a colocation model
of an early childhood psychologist in
a pediatric practice, the role of whom
was to facilitate screening all young
children for social-emotional concerns,
and to treat and refer those children
appropriately. Results from this pro-
gram suggest the need for social-
emotional screening in pediatric prac-
tices, the utility of the ASQ:SE as a valid
and useful screening tool, and the pos-
itive impact of intervention from the ITS.
The program uncovered a high preva-
lence of social-emotional and develop-
mental concerns in this population,
many of which appear to be responsive
to short-term intervention. Our study
population showed an increase in the
proportion of children with ASQ:SE
scores above the risk cutoff as children
aged, which may provide further evi-
dence for the cumulative effects of risk,
and the need for early identification and
intervention. Modelshave demonstrated
that at-risk children are subjected to
more risks/negative health impacts,
and this prevalence exerts a negative
long-term effect on their health and
well-being outcomes.
17
Male children,
andchildrenwithaformoffederally
or state-sponsored insurance or with-
out health insurance, were more likely
than any other group to receive an ASQ:
SE score above the risk cutoff. These
findings are congruent with the original
ASQ:SE sample,
18
which showed a sig-
nificant difference in scores based on
risk status. The original sample also
found a gender difference, but only
among older children, at 30, 36, 48,
and 60 months.
Intervention from the ITS was a signifi-
cant predictor of future reduction in
scores, and, thus, reduction in risk for
problematic social-emotional develop-
ment. An exception was the group of
children with developmental delay, who
were less likely to show improvement at
rescreening. These children were re-
ferred to external treatment programs
to address these problems, as they
were beyond the scope of the current
program, which was geared toward
short-term assessmentand intervention
related to social-emotional problems.
We also gain some insight regarding the
effectiveness of the program by com-
paring the unadjusted and adjusted
associations of improved ASQ:SE scores
and intervention status in our sample.
The unadjusted associations indicate
that the probability of scoring below
the risk cutoff among children who ini-
tially screened at risk on their first
screen was 43% among children whose
parents declined ITS intervention and
56% among families who accepted this
service. Once we controlled for demo-
graphic factors and the presenting
problem, the odds of having an improved
score among children who declined ser-
vicesrelativetothosewhoaccepted
ITS intervention was 0.25. This change in
TABLE 3 Multivariate Association of Improvement in ASQ:SE Score at Rescreening for Children
Initially Above Risk Cutoff, by Intervention Status
Adjusted Odds Ratio of Improved ASQ:SE Score 95% CI P
Gender
Female 0.80 0.39–1.64 NS
Male 1.0 ——
Age
Younger than 2 y 1.89 0.65–5.52 NS
Older than 2 y 1.0 ——
Insurance
Medicaid 1.16 0.50–2.66 NS
Other 1.0 ——
Presenting problem
Developmental 0.29 0.12–0.70 = .01
Sleep 0.65 0.24–1.77 NS
Behavior 0.65 0.31–1.40 NS
Parental concern 0.29 0.11–0.77 = .01
Psychosocial 0.61 0.17–2.23 NS
Mental health 0.24 0.02–3.40 NS
Disposition
Declined 0.25 0.09–0.71 = .01
Referred 0.48 0.14–1.72 NS
Monitored 0.73 0.26–2.04 NS
Intervention 1.0 ——
All Pvalues reflect comparison with residual category; N= 170. CI, confidence interval; NS, not significant; –, not applic able.
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effectiveness can be attributed to the
inclusion of the presenting problem in
the logistic specification (data available
on request). This suggests 2 possible
interpretations. It is possible that fami-
lies with children who accepted in-
tervention selected to do so because of
an underlying sense on their part that
their children would benefitfromthis
service and this decision proved correct
on subsequent testing. An additional
explanation might be that the triage
decisions made by the ITS were partic-
ularly astute and the ITS was uniquely
successful in convincing families of
children who would be likely to benefit
from the intervention to accept this
service. Our data do not permit us to
distinguish between these explanations.
To our knowledge, this is the first report
of the effectiveness of using the ASQ:SE
to identify children at risk within a
general pediatric sample, treat those
children, and chart their improvement
via ASQ:SE scores. The results reported
here, however, must be interpreted
cautiously. Limitations of the current
study include the fact that it was con-
ducted at a single site so that the gen-
eralizability of these findings remains to
be demonstrated. In addition, because
the study was not constructed with a
randomized control design, the possi-
bility of selection bias among those par-
ents who declined services cannot be
discounted. Despite intensive efforts,
there remains a portion of those eligible
for repeat screening who did not re-
ceive it, and although we have no rea-
son to believe that those children differ
systematically from those who were
successfully rescreened, we cannot dis-
count the possibility of some attrition bias
in our findings. True “universal”screen-
ing remains a formidable goal. Since this
study, we have taken significant steps
to increase our universal screening rate.
In addition, the model proposed by this
study raises questions of feasibility,
namely the financial cost to provide
office space and personnel to achieve
the program goals. The concern of
space is likely a significant one for
smaller practices, where devoting an
exam room or other office to this type of
program may prove problematic. For
such practices, a reduced presence of
the ITS (1 or 2 sessions per week) may
lessen the space burden.
Personnel costs represent the most
significant implementation hurdle to be
addressed. These costs can be offset to
some extent by the coding of screening,
formal evaluations and treatment, when
appropriate. The American Academy of
Pediatrics has supplied information on
coding for developmental screening
through its Practice Management Online
service.
19
The 2010 Medicare fee sche-
dule (Resource-Based Relative Value
Scale) assigns a total relative value unit
of 0.2 for the Current Procedural Ter-
minology code 96110 (Developmental
testing; limited), which is the appropri-
ate code for initial developmental
screening with a validated instrument.
This translates into a payment of $7.21
by using the Medicare 2010 conversion
factor. For children who need more ex-
tensive testing, the Current Procedural
Terminology code of 96111 is associated
with a relative value unit value of 3.61,
translating into a Medicare payment of
$130.20. Although such reimbursement
may not cover all personnel costs for a
program of the kind described here, it
must be recognized that, because ongoing
developmental screening and manage-
ment of screening results is the current
standard of care within pediatrics, the
relevant question is whether it is more
costly to devote scarce physician time to
this enterprise when a less costly al-
ternative would provide this service at
lower cost. Practices can either institute
a program such as this one, which may
not completely pay for itself, or they
must use current personnel to achieve
a comprehensive screening program.
Inevitably, this will take pediatricians
away from seeing additional patients to
conduct the assessment or referrals.
CONCLUSIONS
The findings of the current study suggest
that social-emotional development be
considered an important area for fea-
sible andeffective universal screeningof
infantsand toddlers. A recent proposal
20
suggests that screening for social-
emotional problems should occur, but
only after an abnormal developmental
or autism screening test or as a result
of clinical observation and concerns. As
the field increasingly understands the
primacy of social-emotional develop-
ment, however, it may be warranted to
include such screening measures as
a universal standard of pediatric care.
As we seek to prevent developmental
and social-emotional difficulties for
future generations, successful coloca-
tion, screening, treatment, and referral
regimens located in primary care set-
tings represent a critical foundation
for any comprehensive approach to
these endeavors.
ACKNOWLEDGMENT
This research was supported by grants
from the Altman Foundation, the Price
Family Foundation, and the New York
City Council Children Under 5 Mental
Health Initiative.
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; originally published online January 9, 2012;Pediatrics
Meghna Nayak, Susan Chinitz and Andrew D. Racine
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Social-Emotional Screening for Infants and Toddlers in Primary Care
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/peds.2010-2211
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