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Talking Points on Developmental-Behavioral Screening

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Talking Points on Developmental-Behavioral Screening

    Talking Points on Developmental-Behavioral Screening

    Current Detection Rates

    ; Early intervention is effective and saves society $17 for each $1 spent

    ; 70% - 80% of children with disabilities are not detected in primary care

    ; Only 2% - 4% of children between 0 5 are served in early intervention. The Center for Disease Control

    holds the prevalence to be 8%: twice that for school age children.

    ; Providers should be referring 1 out of 6 patients!

    ; Informal detection methods are the cause of under-detection (e.g., checklists, informal questions to parents,

    key items on the Denver, observation, etc.)

    ; The American Academy of Pediatrics and Medicaid EPSDT recommend validated screening at each well

    visit

    Time and Expense

    ; Informal detection methods take time

    ; The Denver-II, a measure which over-detects and under-refers, takes 20 25 minutes and costs $40 or

    more in professional time

    ; Quality screens using information from parents take less time, cost between $1.50 and $19 in professional

    time. Office organization, commitment, and patient education materials are essential when using these tools.

    Reimbursement

    ; The Center for Medicaid and Medicare guaranteed reimbursement for the 96110 (broad-band screens) and

    96111 procedure code (narrow-band screens and assessments) unbundled from the well visit via 25

    modifer on the preventative services code

    ; Only standardized and validated screens qualify for reimbursement

    ; The Denver-II is not a validated screen

    ; Many private payors are also reimbursing for 96110

    ; Denied claims should be appealed

    ; The AAP has an office on billing and coding (www.aap.org) and encourages providers to alert them if

    appeals are denied

    Better Alternatives

    ; There are validated and standardized parent report screens that parents can generally complete on their own

    thus saving substantial professional time

    ; Measures include the Ages and Stages Questionnaire and Parents’ Evaluation of Developmental Status, the

    Pediatric Symptoms Checklist, etc.

    ; Information on both can be found at the AAP’s website on screening: www.dbpeds.org

    ; A second-stage screen, the Modified Checklist of Autism in Toddlers is recommended by the American

    Academy of Neurology and can be downloaded at www.firstsigns.org or completed online at

    www.forepath.org

    ; Several screens for older children can also be downloaded at www.pedstest.com

    Services

    ; There are numerous free but high quality services for helping children and families:

; To find services for children 3 and older, see www.nectac.org or call the public schools department of

    special education

    ; For more information on autism and other disabilities, wall charts on critical milestones, information

    handouts for families, implementation assistance, etc. See www.firstsigns.org and www.dbpeds.org

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    Developmental, Mental Health/Behavioral and Academic Screens

    Compiled by Frances Page Glascoe, Ph.D. Adjunct Professor of Pediatrics

    Frances.P.Glascoe@Vanderbilt.edu

    The following chart is a list of measures that meet standards for screening test accuracy, meaning that they correctly identify, at all ages, at least 70% of children with disabilities while also correctly identifying at least 70% children without disabilities. All included measures were standardized on national samples, proven to be reliable, and validated against a range of measures.

    The first column provides publication information and the cost of purchasing a specimen set. The ―Description‖ column provides information on alternative ways, if available, to administer measures (e.g., waiting rooms). The ―Accuracy‖ column shows the percentage of patients with

    and without problems identified correctly. The ―Time Frame/Costs‖ column shows the costs of materials per visit along with the costs of professional time (using the an average salary of $50 per hour) needed to administer and interpret each measure. Time/cost estimates do not include expenses associated with referring. For parent report tools, administration time reflects not only scoring of test results, but also the relationship between each test’s reading level and the percentage of parents with less than a high school education (who may or may not be able to complete measures in waiting rooms due to literacy problems and thus will need interview administrations).

    Please note: not included are measures such as the Denver-II that fail to meet standards (limited standardization, absent validation, and no proof of accuracy) or measures of single developmental domains (e.g., just language or motor).

    DEVELOPMENTAL SCREENS Age Description Scoring Accuracy Time Frame/Costs RELYING ON INFORMATION range

    FROM PARENTS

    Birth to 8 10 questions eliciting parents’ concerns in Identifies Sensitivity ranging from About 2 minutes Parents’ Evaluations of Developmental

    Status (PEDS). (1997) Ellsworth & years English, Spanish and Vietnamese. children as 74% to 79% and specificity (if interview Vandermeer Press, Ltd. P.O. Box 68164 Written at the 5th grade level. Determines low, moderate ranging from 70% to 80% needed)

    Nashville, Tennessee 37206 Phone: 615-when to refer, provide a second screen, or high risk for across age levels. Print Materials 226-4460; fax: 615-227-0411 provide patient education, or monitor various kinds ~$.31

    http://www.pedstest.com ($30.00) development, behavior/emotional, and of disabilities Admin. ~$.88 PEDS is also available online together academic progress. Provides longitudinal and delays Total = ~$1.19 with the Modified Checklist of Autism in surveillance and triage.

    Toddlers for electronic records: contact .

    support@forepath.org

    4 to 60 Parents indicate children’s developmental Single Sensitivity ranged 70% to about 15 minutes Ages and Stages Questionnaire

    (formerly Infant Monitoring System) months skills on 25 35 items (4 5 pages) using pass/fail score 90% at all ages except the 4 (if interview (2004). Paul H. Brookes Publishing, Inc., a different form for each well visit. for month level. Specificity needed) rdPO Box 10624, Baltimore, MD 21285 Reading level varies across items from 3 developmental ranged from 76% to 91% Materials ~$.40 th(1-800-638-3775). ($190) to 12 grade. Can be used in mass mail-status Admin. ~$4.20 http://www.pbrookes.com/ outs for child-find programs. In English, Total = ~$4.60

    Spanish, French

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    DEVELOPMENTAL SCREENS Age Description Scoring Accuracy Time Frame/Costs RELYING ON INFORMATION range

    FROM PARENTS (continued)

    6-24 Parents complete the Checklist's 24 Manual table Sensitivity is 78%; About 5 to 10 Infant-Toddler Checklist for Language

    and Communication (1998). Paul H. months multiple-choice questions in English. of cut-off Specificity is 84%. minutes thBrookes Publishing, Inc., P.O. Box Reading level is 6 grade. Based on scores at 1.25 Materials ~.$.20 10624, Baltimore, MD, 21285 screening for delays in language standard Admin. ~$3.40 (1-800-638-3775). (Part of CSBS-DP, $ development as the first evident symptom deviations Total ~$3.60 http://www.pbrookes.com/ ($99.95 w/ that a child is not developing typically. below the

    CD-ROM) Does not screen for motor milestones. mean OR an

    The Checklist is copyrighted but remains optional

    free for use at the Brookes Web site scoring CD-

    although the factor scoring system is ROM s

    complicated and requires purchase of the

    CD-ROM.

    0 8 PEDS-DM consists of 6 8 items at each Cutoffs tied to Sensitivity (.75 - .87); About 3 - 5 PEDS- Developmental Milestones

    (PEDS-DM (2007) Ellsworth & years age level (spanning the well visit performance specificity (.71 - .88 to minutes Vandermeer Press, Ltd. P.O. Box 68164 schedule). Each item taps a different above and performance in each Materials ~.$.20 thNashville, Tennessee 37206 Phone: 615-domain (fine/gross motor, self-help, domain. Sensitivity (.70 -Admin. ~$1.00 below the 16

    226-4460; fax: 615-227-0411 academics, expressive/receptive percentile for .94); specificity (.77 - .93) Total ~$1.20 http://www.pedstest.com, to be online at language, social-emotional). Items are each item and across age

    www.forepath.org administered by parents or professionals. its domain.

    Forms are laminated and marked with a On the

    Assessment grease pencil. It can be used to

    complement PEDS or stand alone. Level, age

    Administered by parent report or directly. equivalent ndWritten at the 2 grade level. A scores are

    longitudinal score form tracks produced and

    performance. Supplemental measures also enable users to

    included include the M-CHAT, Family compute

    Psychosocial Screen, PSC-17, the percentage of

    SWILS, the VAnderbilt, and a measure of delays.

    parent-child interactions. An Assessment

    Level version is available for NICU

    follow-up and early intervention

    programs.

    BEHAVIORAL/EMOTIONAL SCREENS RELYING ON INFORMATION FROM PARENTS

    2 to 16 The ECBI/SESBI consists of 36 38 short Single Sensitivity 80%, specificity About 7 minutes Eyberg Child Behavior

    Inventory/Sutter-Eyberg Student years of statements of common behavior refer/nonrefer 86% to disruptive behavior (if interview Behavior Inventory. Psychological age problems. More than 16 suggests the score for problems needed) Assessment Resources, P.O. Box 998 referrals for behavioral interventions. externalizing Materials ~$.30 Odessa Florida: 33556 (1-800-331-8378) Fewer than 16 enables the measure to problems, --Admin. ~$2.38

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    ($120.00) http://www.parinc.com/ function as a problems list for planning conduct, Total = ~$2.68

     in-office counseling, selecting handouts, aggression,

     and monitoring progress. etc.

    Pediatric Symptom Checklist. Jellinek 4 - 16 35 short statements of problem behaviors Single All but one study showed About 7 minutes MS, Murphy JM, Robinson J, et al. years. including both externalizing (conduct) refer/nonrefer high sensitivity (80% to (if interview Pediatric Symptom Checklist: Screening and internalizing (depression, anxiety, score 95%) but somewhat needed) school age children for academic and adjustment, etc.) Ratings of never, scattered specificity (68% - Materials ~$.10 psychosocial dysfunction. Journal of sometimes or often are assigned a value 100%). Admin. ~$2.38 Pediatrics, 1988;112:201-209 (the test is of 0,1,or 2. Scores totaling 28 or more Total = ~$2.48 included in the article). Also can be freely suggest referrals. Factor scores identify downloaded at http://psc.partners.org/ or attentional, internalizing and

    with factor scores at www.pedstest.com externalizing problems. Factor scoring is The Pictorial PSC, useful with low-available for download at: http://www.

    income Spanish speaking families can be pedstest.com/links/resources.html

    downloaded freely at www.dbpeds.org

    (included in the PEDS:DM)

    Birth to 9 10 questions eliciting parents’ concerns in Identifies Sensitivity ranging from About 2 minutes Parents’ Evaluations of Developmental

    Status (PEDS). (1997) Ellsworth & years English, Spanish and Vietnamese, Arabic, children as 74% to 79% and specificity (if interview Vandermeer Press, Ltd. P.O. Box 68164 Somali, etc. Written at the 4th grade low, moderate ranging from 70% to 80% needed) Nashville, Tennessee 37206 Phone: 615-level. Determines when to refer, provide a or high risk for across age levels. Print Materials 226-4460; fax: 615-227-0411 second screen, provide patient education, various kinds ~$.31 http://www.pedstest.com ($30.00) or monitor development, of disabilities Admin. ~$.88 PEDS is also available online and for behavior/emotional, and academic and delays Total = ~$1.19 electronic medical records. Contact progress. Provides longitudinal support@forepath.org surveillance and triage

    6 60 Designed to supplement the ASQ, the Single cutoff Sensitivity ranged from 10 15 minutes Ages & Stages Questionnaires: Social-

    months ASQ SE consists of 30 item forms (4 5 score 71% - 85%. Specificity if interview Emotional (ASQ:SE)

    Paul H. Brookes, Publishers, PO Box pages long) for each of 8 visits between 6 indicating from 90% to 98% needed. 10624, Baltimore, Maryland 21285 (1-and 60 months. Items focus on self-when a referral Materials ~ $.40 800-638-3775). ($125) regulation, compliance, communication, is needed Admin. ~$4.20 http://www.pbrookes.com/ adaptive functioning, autonomy, affect, Total = ~ $4.40

    and interaction with people

    Brief-Infant-Toddler Social-Emotional 12 36 42 item parent-report measure for Cut-points Sensitivity (8085%) in 57 minutes Assessment (BITSEA); months identifying social-emotional/behavioral. based on child detecting children with Materials ~$1.15 Harcourt Assessment, Inc, 19500 Bulverde problems and delays in competence. age and sex socialemotional/ Admin. ~$.88 Road | San Antonio, Texas 78259 |(1-Items were drawn from the assessment show present/ behavioral problems and Total ~$2.03 800-211-8378) ($99.00) level measure, the ITSEA. Written at the absence of specificity 75% to 80%. ththharcourtassessment.com 4 6 grade level. Available in Spanish, problems and

    French,Dutch, Hebrew competence.

     4

    0 8 PEDS-DM consists of 6 8 items at each Cutoffs tied to Sensitivity (.75 - .87); About 3 - 5 PEDS- Developmental Milestones

    (PEDS-DM (2007) Ellsworth & years age level (spanning the well visit performance specificity (.71 - .88 to minutes Vandermeer Press, Ltd. P.O. Box 68164 schedule). Each item taps a different above and performance in each Materials ~.$.20 thNashville, Tennessee 37206 Phone: 615-domain (fine/gross motor, self-help, domain. Sensitivity (.70 -Admin. ~$1.00 below the 16

    226-4460; fax: 615-227-0411 academics, expressive/receptive percentile for .94); specificity (.77 - .93) Total ~$1.20 http://www.pedstest.com, to be online at language, social-emotional). Items are each item and across age

    www.forepath.org administered by parents or professionals. its domain.

    Forms are laminated and marked with a On the

    grease pencil. It can be used to Assessment

    complement PEDS or stand alone. Level, age

    Administered by parent report or directly. equivalent ndWritten at the 2 grade level. A scores are

    longitudinal score form tracks produced and

    performance. Supplemental measures also enable users to

    included include the M-CHAT, Family compute

    Psychosocial Screen, PSC-17, the percentage of

    SWILS, the VAnderbilt, and a measure of delays.

    parent-child interactions. An Assessment

    Level version is available for NICU

    follow-up and early intervention

    programs.

     FAMILY SCREENS

    screens A two-page clinic intake form that Refer/nonrefer All studies showed about 15 minutes Family Psychosocial Screening.

    Kemper, KJ & Kelleher KJ. Family parents identifies psychosocial risk factors scores for each sensitivity and specificity to (if interview psychosocial screening: instruments and and best associated with developmental problems risk factor. larger inventories greater needed) techniques. Ambulatory Child Health. used including: a four item measure of parental Also has than 90% Materials ~$.20 1996;4:325-339. (the measures are along history of physical abuse as a child; (2) a guides to Admin. ~$4.20 included in the article) and downloadable with the six item measure of parental substance referring and Total = ~$4.40 at http://www.pedstest.com (included in above abuse;and (3) a three item measure of resource lists.

    the PEDS:DM) screens maternal depression.

    DEVELOPMENTAL SCREENS RELYING ON ELICITING SKILLS DIRECTLY FROM CHILDREN

    Brigance Screens-II.. Curriculum 0 - 90 nine separate forms, one for each 12 Cutoff, sensitivity and specificity to 10 15 minutes Associates, Inc. (2005) 153 Rangeway months month age range. Taps speech-language, quotients, giftedness and to Road, N. Billerica, MA, 01862 (1-800-motor, readiness and general knowledge percentiles, developmental and Materials ~$1.53 225-0248 ($501.00). at younger ages and also reading and age equivalent academic problems are 70% Admin.~$10.15 http://www.curriculumassociates.com/ math at older ages. Uses direct elicitation scores in to 82% across ages Total = ~$11.68

     and observation. In the 0 2 year age various

    range, can be administered by parent domains and

    report overall.

     5

    3 - 24 uses 10 - 13 directly elicited items per 3 - categorizes specificity and sensitivity 10 - 15 minutes Bayley Infant Neurodevelomental

    Screen (BINS). San Antonio, Texas: The months 6 month age range assess neurological performance are 75% to 86% across ages Psychological Corporation, 1995. 555 processes (reflexes, and tone); into low, Materials ~$.30 Academic Court, San Antonio, TX 78204 neurodevelopmental skills (movement, moderate or Admin.~$10.15 (1-800-228-0752) ( $265) and symmetry) and developmental high risk via Total = ~$10.45 http://www.psychcorp.com accomplishments (object permanence, cut scores.

    imitation, and language).. Provides

    subtest cut

    scores for each

    domain

    0 - 95 Items (20 per domain) use a combination Age Sensitivity (72% to 93%) to 10 30 minutes Battelle Developmental Inventory

    Screening Test II (BDIST) 2 (2006). months of direct assessment, observation, and equivalents various disabilities; Riverside Publishing Company, 8420 parental interview. A high level of and cutoffs at Specificity (79% to 88%). Materials ~$1.65 Bryn Mawr Avenue, Chicago, Illinois examiner skill is required. Well 1.0, 1.5, and Accuracy information Admin.~$20.15 60631 (1-800-323-9540) ($239 standardized and validated. Scoring 2.0 SDs below across age ranges is not Total = ~$21.80 www.riversidepublishing.com software including a PDA application is the mean in available.

     available. English and Spanish each of 5

     domains

    ACADEMIC SCREENS th1 6 Administration involves one or more of Computerized 70% to 80% accuracy across Takes 10 15 Comprehensive Inventory of Basic

    grade three subtests (reading comprehension, or hand- all grades minutes Skills-Revised Screener (CIBS-R

    Screener) Curriculum Associates, Inc. math computation, and sentence writing). scoring Materials ~$.53

    Timing performance also enables an produces Admin.~$10.15 (1985) 153 Rangeway Road, N. Billerica,

    MA, 01862 (1-800-225-0248 ($224.00). assessment of information processing percentiles, Total = ~$10.68 http://www.curriculumassociates.com/ skills, especially rate. quotients,

    cutoffs

    6 - 14 Children are asked to read 29 common single cutoff 78% to 84% sensitivity and about 7 minutes Safety Word Inventory and Literacy

    Screener (SWILS). Glascoe FP, Clinical safety words (e.g., High Voltage, Wait, score specificity across all ages (if interview Pediatrics, 2002. Items courtesy of Poison) aloud. The number of correctly indicating the needed) Curriculum Associates, Inc. The SWILS read words is compared to a cutoff score. need for a Materials ~$.30 can be freely downloaded at: Results predict performance in math, referral Admin. ~$2.38 http://www.pedstest.com/ written language and a range of reading Total = ~$2.68

    skills. Test content may serve as a

    springboard to injury prevention

    counseling.

     6

Narrow-Band Screens for AUTISM and ADHD

    18 60 Parent report of 23 questions modified for Cutoff based Initial study shows About 5 minutes Modified Checklist for Autism in thToddlers (M-CHAT) (1997). Free months American usage at 4-6 grade reading on 2 of 3 sensitivity at 90%; Print Materials download at the First Signs Web site: level. Available in English and Spanish. critical items specificity at 99%. Future ~$.10 http://www.firstsigns.org/downloads/m-Uses telephone follow-up for concerns. or any 3 from studies are needed for a full Admin. ~$.88 chat.PDF ($0.00) The M-CHAT is copyrighted but remains checklist. picture. Promising tool. Total = ~$.98 Online for parents and EMRS at free for use on the First Signs Web site. www.forepath.org ($1.00) The full text article appeared in the April (also included in the PEDS:DM) 2001 issue of the Journal of Autism and

     Developmental Disorders.

    3 to 17 Although the CRSR can screen for a Cutoff tied to Sensitivity 78% to 92% About 20 minutes Connors Rating Scale-Revised (CRS-R) rdMulti-Health Systems, Inc. years range of problems, Several subscales Specificity: 84% to 94% Materials ~$.2.25 the 93

    P.O. Box 950, North Tonawanda, NY specific to ADHD are included: DSM-IV percentile for Admin. ~$20.15 14120-0950 Call 1.800.456.3003 or symptom subscales (Inattentive, each factor Total = ~$22.40 +1.416.492.2627 Fax 1.888.540.4484 or Hyperactive/Impulsive, and Total); 1.416.492.3343 Global Indices (Restless-Impulsive,

    http://www.mhs.com/ Emotional Lability, and Total), and an ($193.00) ADHD Index. The GI is useful for

    treatment monitoring. Also available in

    French

    ? 2006, Glascoe FP. Collaborating with Parents. Nashville, Tennessee: Ellsworth & Vandermeer Press, Ltd. Permission is given to reproduce

    this table.

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    Screening Implementation Worksheet

Action Item Time Frame Person(s) Responsible Date Completed

    1. Who will ensure that copies of screens are available each day for parents to complete?

    2. Who will ask whether parents can complete the

    forms on their own or need

    assistance?

    3. Who will help parents who need assistance?

    4. Who will collect screens from families?

    5. Who will score screens? 6. Who will attach screens to the chart or otherwise make

    sure they are available to

    clinicians?

    7. Who will locate patient education materials and

    referral resources? Who will

    follow up if needed? How will this person know when to

    follow up?

    8. Who will explain results to families?

    9. Who will contact referral resources when a referral is

    needed? Who will locate

    referral resources when

    needed?

    10. What will you do with the screening materials once

    they’ve been discussed with

    families?

    11. If using electronic records or age-specific encounter

    forms, who will indicate and

    where, the fact that screening has been completed?

    12. Who will bill/code for completion of screens and for positive/negative results?

    13. What procedure and diagnosis codes will you use?

    14. Who will explain to utilization review personnel

    your decision about CPT and

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DX codes?

    15. Where will you keep supplies of screens and patient education materials?

    16. Who will make sure enough screens on on-hand at all

    times?

    17. Who will lead staff through your rationale for deploying

    validated screening in your

    practice and otherwise inspire them about the value of

    screening?

    18. How will you handle things if staff is unwilling?

    19. Who will spearhead efforts to include your screen of

    choice into your electronic

    record (note: this usually requires

    the effort of your software consultant and test publishers-- all

    developmental measures are

    copyright because they are so

    expensive to develop and cannot be

    included without appropriate

    licensing into ERs).

?from ABCD project of the Commonwealth Fund. Permission to reproduce is granted.

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     - Primary Care Practice - Screening & Referral Practice Flow

    PEDS sent home with appointment reminder

    Med Tech pullsParent checks in/Registers-chart,presents PEDSencounter

    Med Tech takesform,

    anticipatory vitals, places

    developmentfamily in examguideline sheet,roomReceptionist. scores PEDSattaches to chartattaches to chartfor nurse to scoreMD examines child

    Discusses PEDS

    Med Tech administers shots, contacts referral results, seeks consent

    sources if needed to refer if needed,

    Retrieves/discusses

    patient ed materials,

    Parent checks out- Staff toetc.

    assist with check-out

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