General Developmental Screening Research Articles

Accuracy of Three Screening Instruments in Identifying Preschool Children at Risk for Autism Spectrum Disorder

An efficient approach for screening and identifying children at risk for autism spectrum disorder (ASD) remains a pressing need. The aim of this exploratory study was to examine the ability of two general developmental screening tests to identify children at risk for ASD. We compared the accuracy of one general developmental screening instrument, Ages and Stages Questionnaires (ASQ), and one general social emotional screening instrument, the Ages and Stages Questionnaire: Social Emotional (ASQ:SE), with the Social Communication Questionnaire (SCQ), an ASD-specific screening instrument. Two hundred eight children between 36 and 66 months were recruited through 19 community ASD programs, websites, and magazines. The three screening instruments were given to 285 parent/child dyads with and without a diagnosis of ASD, online via a screening website linked to a university. Sixty-four children had been diagnosed with ASD and were receiving special education services (e.g., behavioral interventions) prior to their participation. The classification agreement of the ASQ (i.e., sensitivity = 84.38%, specificity = 81.45%) outperformed the other two screening instruments; classification agreement of the SCQ was sensitivity = 70.31% and specificity = 87.33%; and of the ASQ: SE, sensitivity = 82.81% and specificity = 72.40%. Agreement among the questionnaires ranged from moderate to strong as measured by Pearson Product Moment Correlation Coefficients. Children diagnosed with ASD had scores below the screening cutoff points, indicating risk, most often on three ASQ domains: (a) communication, (b) gross motor, and (c) personal social. This exploratory study indicated the feasibility of using the ASQ in screening clinics for finding children at risk for ASD, if the ASQ is followed by specific ASD assessments. Design limitations, including a sample of children with ASD already receiving intervention services may explain the somewhat lower sensitivity of the SCQ.

A proposed service model for early identification of autism spectrum disorder in ethnic communities in Southern Israel.

Early autism spectrum disorder (ASD) detection is a precondition for effective intervention and facilitates significant improvements in functioning. In Israel, toddlers undergo general developmental screening by public health nurses (PHNs) at maternal and child health centres (MCHCs). Nevertheless, there are disparities among ethnic groups in the reported incidence of ASD. By means of an ecological model (EM), we identified strategies that improve ASD detection in the Bedouin community by investigating the social and policy factors that affect diagnosis. We conducted in-depth interviews with 18 policy makers and service providers and three focus groups of PHNs and paediatricians. We mapped the strategies for identifying toddlers with ASD based on the three EM levels. Correlations were established by comparing the codes within and between the EM levels. At the macro-level, the policy makers' strategy for improving ASD detection in the Bedouin community reflected the ideology, values and goals of the PHNs and included the MCHCs as the sole institution involved in detecting ASD. At the meso-level of the service providers, the key elements of the strategy consisted of actualising the professional potential of PHNs and patients' case management. At the micro-level was the population that utilises the services and complies with recommendations. A correlation was established between the PHNs' values and goals and patients' case management. Actualising their professional potential influenced the population's compliance. To reduce gaps in ASD diagnosis between Bedouin communities and the general population, it is necessary to identify and change the policy factors that influence access to services for children with ASD at every EM level while incorporating PHNs from the Bedouin community in future services. Culturally appropriate policies, screening policies and interventions must be developed to serve the needs of Bedouin children.

Autism and General Developmental Screening Practices Among Primary Care Providers.

Using standardized screening tools increases accuracy in early identification of autism. The American Academy of Pediatrics recommends systematic developmental screening at all 9-, 18-, and 24- or 30-month well-child visits (WCVs) and autism-specific screening at all 18- and 24-month WCVs. The study objectives were to examine the extent to which these guidelines have been adopted in practice among primary care providers (PCPs) and to identify potential provider-level factors associated with screening practices. Participants included 94 PCPs (79% pediatricians) from 13 states enrolled in a study of an autism training program. Self-report and chart-review data collected before training were examined. Screening practices were assessed through chart review of all 9-, 18-, and 24-month WCVs within a 30-day window. Sixty-four percent of PCPs administered developmental screening tools at all 9-month WCVs, and 62% at all 18-month WCVs. Fifty-one percent administered autism screening tools at all 18-month WCVs, and 41% at all 24-month WCVs. Screening practices varied by provider type (pediatrician vs other PCP), self-efficacy in screening and identification, and previous autism training (autism screening only), but not by years of experience. Overall, general developmental and autism-specific screenings are not being consistently administered across recommended WCVs in primary care practices. Provider self-efficacy in autism identification and screening and previous autism training were associated with increased autism screening. As such, these results suggest a need for increased training and dissemination of information on screening implementation for practicing PCPs.

Strategy for a Service Model for Early Identification of Autistic Spectrum Disorders in Ethnic Communities in Southern Israel

Abstract: The occurrence of autistic spectrum disorder (ASD) is increasing worldwide. Early detection is a precondition for effective intervention, enabling significant improvements in functioning. However, in Israel and in other countries, ASD is underreported in ethnic minorities. In Israel, toddlers undergo general developmental screening by public health nurses (PHNs) at maternal and child health centers (MCHCs). Nevertheless, there are disparities among ethnic groups in the reported incidence of ASD. Objective: Using an ecological model, we identify strategies that improve the screening for ASD in minorities by investigating the social factors influencing diagnosis. Methodology: We conducted in-depth interviews with 18 policymakers and service providers and 3 FGs of PHNs and pediatricians. Results we used to construct a service model for identifying toddlers with ASD. Results: Each of the three ecological levels contains factors that affect screening. On the macro level, of policymakers, factors include clear official policy, ideology, values, and goals and professional identification of the PHNs, and the MCHCs as the exclusive institution involved in assessing ASD. On the meso level, of service providers, the key factors are actualizing the professional potential of the PHNs and case management. On the micro level, the main factor is that the population utilizes the services and complies with its recommendations. We established a correlation between the nurses’ values and objectives, and their case management. Actualizing their professional potential influenced the population’s compliance. Discussion: On the macro level, there is a need to determine a clear policy supported by the requisite budget and professional staff, while maintaining and developing the strengths of the MCHCs. On the meso level, there is a need to use specific tools for ASD screening, along with professional training. Funding Statement: None to declare Declaration of Interests: None to declare Ethics Approval Statement: I received the approval of the Ben Gurion University Ethics Committee and the Israeli Ministry of Health to conduct the research.

ECHO Autism: Integrating Maintenance of Certification with Extension for Community Healthcare Outcomes Improves Developmental Screening.

Recent estimates indicate that most pediatricians do not consistently meet the American Academy of Pediatrics developmental screening guidelines, contributing to the delay of vital evaluations and interventions for autism spectrum disorder (ASD). Our objective was to evaluate the utility of Maintenance of Certification (MOC) Quality Improvement (QI) training designed to improve developmental screening rates in underserved, rural primary care practices. Trainings on best screening practices were disseminated to primary care providers (PCPs) through Extension for Community Healthcare Outcomes (ECHO) Autism, a virtual learning network. Across 2 cohorts, 24 PCPs were enrolled in MOC Part 4 training modules delivered through the ECHO Autism QI Learning Network. Throughout the 12 months of enrollment, PCPs reported information on general and ASD-specific developmental screenings conducted at 18- and 24-month well-child visits. A 1-year follow-up was conducted to assess the maintenance of screening rates. Baseline rates for general and ASD-specific developmental screenings were 53.3% and 68.3%, respectively. By the end of the 12-month learning module, screening rates increased significantly for general development (88.6%) and ASD-specific screenings (99.0%). At the 1-year follow-up, the rate for general developmental screening was 96.7% and for ASD-specific screening was 97.1%. Maintenance of Certification Part 4 training delivered through the ECHO Autism QI Learning Network was found to be incentivizing and highly effective in shaping and maintaining PCP developmental screening practices. Improved screening rates show promise in decreasing time to critical developmental evaluations, interventions, and resources. Our methodology is likely transferable to other ECHO communities and may facilitate expedient implementation of best practice standards in primary care.

General paediatric practice in autism spectrum disorder screening in Ontario, Canada: Opportunities for improvement.

Screening is important for early identification of children with autism spectrum disorder (ASD), potentially leading to earlier intervention. Research has identified some barriers to early identification of ASD, however, information about ASD screening in Canadian general paediatric practice is lacking. The aim of the study is to better understand ASD screening practice patterns by examining the use of ASD and general developmental screening tools by general paediatricians. The research team conducted a cross-sectional survey of general paediatricians. Two-hundred and sixty-seven paediatricians responded and 132 were eligible for the study. Ninety-three per cent of the responders used a developmental screening tool. Eighty-five per cent of the responders used an ASD screening tool when there were concerns for ASD, and 15% never used one. The most commonly used ASD screening tool was the M-CHAT. Children suspected of having ASD were referred to specialists not only to confirm the diagnosis but also to facilitate access to resources. General paediatricians were keen to incorporate formal ASD screening tools in their practice but identified the need for clearer guidelines. Previous studies have shown that children at risk of ASD continue to be missed through developmental surveillance and targeted screening. Paediatricians are interested in implementing an ASD screening tool and cite brevity and forms that can be completed by parents as factors that would support the use of a screening tool. Clearer guidelines and tools to support ASD screening and access to resources are needed.

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.

168: Screening Practices and Factors Influencing Autism Spectrum Disorder (ASD) Screening by Community Paediatricians

The prevalence of ASD is estimated at 1 per 68 based on US surveillance data. In many cases, ASD can be accurately diagnosed at two to three years old and high risk children can be identified earlier than 24 months, but Canadian data shows a median age at diagnosis of 39 to 55 months. Despite advances in diagnosis of ASD, there is little data on ASD screening among Canadian general paediatricians. The objectives of this study were to examine community paediatricians' ASD screening practices, obtain quantitative date on the use of ASD and general developmental screening tools, and identify factors influencing paediatricians' use of ASD screening tools. A questionnaire was designed base on a survey by dosReis et al to assess developmental and ASD screening among general paediatricians (dosReis 2006) with questions added based on themes drawn from the investigator's qualitative data from focus groups with community paediatricians on ASD screening. Main focus areas were quantitative data on developmental and ASD screening tools use, facilitators and barriers of ASD screening, tool characteristics that encourage their use, and collection of demographic data. After revision by community (n=5) and developmental (n=5) paediatricians, the questionnaire was piloted to n=30 general paediatricians, further refined, and distributed to all general paediatricians in a large multicultural urban centre. Descriptive statistics was used. Results from ongoing data collection showed that most respondents routinely used a developmental screening tool (95%) with the majority using the Nipissing Developmental Screen (95%) and the Rourke Baby Record (42%). 15% routinely using an ASD screening tool while most used an ASD specific screening tool (most commonly the M-CHAT) when they suspected ASD on exam, history, or if there was parental concern. Respondents were divided 50–50 in making the diagnosis of ASD in their practice while 90% agreed or strongly agreed to feeling confident in their ability to identify children with signs and symptoms of ASD. 70% of respondents felt there should be clearer guidelines on how and when to screen for ASD. As for specific ASD screening tool characteristics, the most valued were brevity, ability to be completed by a parent, and availability in multiple languages. This study provides critical data on developmental and ASD screening practices and identifies factors influencing physician decision making and clinical practice. Assessing factors affecting screening in primary care is vital to the future design and implementation of sustainable programs for early detection of ASD.

Comparison of a broad-based screen versus disorder-specific screen in detecting young children with an autism spectrum disorder

The goals of our study were to (a) compare agreement between autism spectrum disorder diagnosis and outcome of the Modified Checklist for Autism in Toddlers and Parents Evaluation of Developmental Status in a sample of toddlers and (b) examine specific concerns noted for toddlers who screened negative on the Modified Checklist for Autism in Toddlers or Parents Evaluation of Developmental Status but were later diagnosed with autism spectrum disorder. Participants were administered the Modified Checklist for Autism in Toddlers and Parents Evaluation of Developmental Status during well-child visits. Families were invited for a clinical evaluation if autism spectrum disorder symptoms were noted on the Modified Checklist for Autism in Toddlers and Modified Checklist for Autism in Toddlers Follow-Up Interview or if autism spectrum disorder concerns were noted by the pediatrician. Fifty-two children completed the Modified Checklist for Autism in Toddlers, Parents Evaluation of Developmental Status, and a clinical evaluation, and 30 of these children were diagnosed with an autism spectrum disorder. Modified Checklist for Autism in Toddlers results showed higher agreement with autism spectrum disorder diagnosis than any individual Parents Evaluation of Developmental Status screen result, although the latter detected many children with other developmental concerns. Children who screened negative on the Modified Checklist for Autism in Toddlers or Parents Evaluation of Developmental Status but were diagnosed with autism spectrum disorder had concerns noted in sensory response and proto-declarative pointing that can be considered in the context of screen results. In sum, our findings support universal autism spectrum disorder-specific screening in addition to general developmental screening and offer considerations to encourage early identification of toddlers with autism spectrum disorder.

Social-Emotional Screening for Infants and Toddlers in Primary Care

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. 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. 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). 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.

Cultural Transformation Needed to Solve Public Health Problem of Chronic Pain

the more the better and the earlier the better.” Volkmar, who also was not involved in Gorter’s study, said general developmental screening at ages 12, 18, and 24 months can be the foundation for detecting several symptoms that distinguish autism from developmental delays. A correct diagnosis and appropriate care for autism, he said, can be “the difference between somebody being 24/7 in institutional care as an adult and being independent and self-sufficient.” Several recent reviews indicate that existing studies of interventions for autism and autism spectrum disorders are not particularly rigorous, and so current evidence is not sufficient to show wide-ranging treatment benefits. One review showed that improvements may be linked with children’s baseline IQ levels, but it concluded that early interventions are effective only for some preschool children with autism (Howlin P et al. Am J Intellect Dev Disabil. 2009;114[1]:23-41). Another review suggested that Lovaas treatment, which is based on applied behavioral analysis and tailored to individual needs, may produce better outcomes than special education but that any treatment should be guided by children’s unique needs (Ospina MB, et al. PLoS One. 2008; 3[11]:e3755). But Lord and Volkmar said Gorter and his colleagues are correct to note that access to specialized care is poor. Lord said the major difficulty for pediatricians is time. “Appointments are so short, and they have to see so many kids,” she said. Volkmar noted that well-trained specialists are scarce, and that pediatriciansneed more education about autism. “One of the things worth thinking about is taking a big step back and saying, ‘What can we do to enhance pediatricians’ awareness of this?’” he said.

Speech and Language Development: Monitoring Process and Problems

1. Susan McQuiston, PhD* 2. Nancy Kloczko, MD† 1. *Pediatric Psychologist. 2. †Developmental-Behavioral Pediatrician, Baystate Children's Hospital, Springfield, MA. After completing this article, readers should be able to: 1. Describe the progression of normal speech-language development. 2. Recognize delayed and disordered speech-language development and indications for referral. 3. Understand possible biologic and environmental contributions to delayed language. 4. Implement appropriate management strategies. You are seeing a 2½-year-old boy for a routine health supervision visit. On a general developmental screening questionnaire, his mother reports that he is not yet talking. She has not been too concerned because the child's father was a late talker and they live in a bilingual household. Although the boy has had several episodes of otitis media, she feels strongly that there is no question of hearing loss because he seems to understand what is said to him. Other domains of development are reported as age-appropriate. His physical examination results are normal, and he appears to be a socially engaging toddler. However, you have concerns about his apparent low frustration tolerance and tendency to throw tantrums. It has been said that all typically developing children in all cultures master the basics of their language by 4 years of age. (1) However, 5% to 8% of children experience speech-language delays or disorders by the preschool years, which may be associated with later learning, socioemotional, or behavioral problems. The primary clinician often is the first professional to whom parents turn when a developmental problem is suspected, and in the course of routine health supervision visits, the clinician may encounter any of the following language-related questions or concerns:

Parental Concerns Based General Developmental Screening Tool and Autism Risk: The Taiwan National Birth Cohort Study

Early detection of developmental delay and childhood disorders are important for early intervention. This study aimed to describe the distribution of responses in a large population-based survey, identify cutoff points for the parent concern checklist (PCC) suitable for the Chinese language and culture, and explore how many children were identified as having evidence of problems at age 18 mo different from those at age 6 mo. Using a national randomly selected sample, the overall development of 21,248 children was investigated using the Taiwan Birth Cohort study instrument, and the PCC, a problem-oriented screening instrument. The Newton-Raphson iteration showed that the PCC should be separated into three groups, those scoring 1-2 in the first group, 3- 6 in the second group, and 7- 8 in the third group.Structural equation models showed that 6-mo development was predictive of 18-mo development; additionally, 18-mo development and the PCC showed good concurrent validity. This study identified three groups with distinct developmental trajectories and two cutoff points of 2/3 and 6/7. Thus, the PCC can be used as a first-stage screening instrument in a two-stage window screening procedure. Further studies are needed to investigate the factors, which contribute to the differences among these groups;follow-up on the typical and atypical development of these children is necessary.

Screening Strategies for Autism Spectrum Disorders in Pediatric Primary Care

Two strategies have been proposed for early identification of children with autism spectrum disorders (ASD): (1) using a general screening tool followed by an ASD-specific screening tool for those who screen positive on the former or (2) using an ASD-specific tool for all children. The relative yield of these two strategies has not been examined. This study compared the number of children identified at risk for ASD at their well child visits between the ages of 18 and 30 months using a general developmental screening tool and an autism-specific screening tool. The Parents' Evaluation of Developmental Status (PEDS) was used as the general developmental screening tool and the Modified Checklist for Autism in Toddlers (M-CHAT) was used as the autism-specific tool. These tools were administered concurrently to 152 children. Cross tabulations and chi tests were used to determine the utility of the PEDS as the first step of a two-part screen for ASD. Of those who screened positive for developmental concerns on the PEDS (n = 38), 16% screened positive for ASD on the M-CHAT; of those who did not screen positive for developmental concerns on the PEDS (n = 114), 14% screened positive for ASD on the M-CHAT (p = .79). The PEDS missed the majority of children who screened positive for ASD on the M-CHAT, suggesting that these two tools tap into very different domains of developmental concerns. The findings support the use of an ASD-specific tool for all children in conjunction with regular standardized developmental screening.

Comparison of a General Developmental Screening Tool and an Autism Specific Screening Tool in Autistic Spectrum Disorder (Asd) Assessment

Comparison of a General Developmental Screening Tool and an Autism Specific Screening Tool in Autistic Spectrum Disorder (Asd) Assessment

Early Diagnosis of Autism Spectrum Disorders.

Autistic spectrum disorders (ASD) are an often-disabling continuum of disorders affecting two to four in 1000 children. These disorders have a core set of defining features including impaired verbal and nonverbal communication, impaired social interaction, and restricted or repetitive patterns of behavior. The cause of autism is unclear. The disorder can be defined only by related behaviors. Although there has been considerable improvement in standardized screening techniques for ASD in the past 10 years, screening and diagnostic practices in medicine and education lag far behind clinical research. Various studies have found the average age of diagnosis to be between 3 and 6 years, with significant differences as a function of ethnicity and socio-economic status. Preliminary research suggests that in some populations, missed diagnosis and misdiagnosis of ASD are common. This may be caused partly by inadequate screening practices. It also may reflect that presentation of symptoms varies from patient to patient. Lack of resources for appropriate referral, diagnosis, and treatment may play an important role. This article discusses recent progress in ASD screening, what is known of current screening and diagnostic practices, and future directions for research and practice improvement. The best practice model for the screening and early diagnosis of autism spectrum disorders and other developmental disabilities should include routine developmental surveillance as part of well-child pediatric care. General developmental screening should be followed by autism-specific screening for those children who fail the initial developmental screen, or whose parents report suspect behaviors.

Hearing thresholds in four-year-old children with weak or no transient-evoked otoacoustic emissions.

Play audiometry is part of the general developmental screening covering 4-year-old children in the city of Malmö (Sweden). In an open study, 10% of the cohort was tested with transient-evoked otoacoustic emissions (TEOAEs), using the ILO88 system. The aim was to reveal a hearing loss exceeding 25 dB HL in 4-year-old children. As the first step in determining whether emissions can be used as an efficient method of screening for hearing loss, 295 children were tested with TEOAEs. Audiometry was performed in 160 children. Audiometry was not performed if the TEOAEs were strong (> or = 10 dB SPL) in both ears. In the group with TEOAEs of 8.8dB SPL or greater, all ears tested with audiometry had a pure-tone average (PTA) of 25 dB HL or better. Twenty-one percent of the ears had TEOAEs < or = 0 dB SPL. Only 9% of the ears had a hearing threshold exceeding 25 dB HL (PTA). In conclusions, the number of pathological TEOAE results was much larger than the number of pathological audiograms, making TEOAEs too sensitive to use as a single screening test, but the method may be used as first-line screening.

Balance and Motor Skills in Young Children With Sensorineural Hearing Impairment

The purpose of this study was to compare the static and dynamic balance, motor abilities, and postrotatory nystagmus (PRNT) test results of four- to five-year-old children with sensorineural hearing impairment (SNHI) to those of typically developing peers. Seven children with SNHI and six typically developing peers comprised the experimental and control groups, respectively. Static balance was measured as duration of single-leg stance with eyes open and eyes closed. Kinematic analysis of responses during tilt board perturbation with eyes open and eyes closed comprised testing of dynamic balance. Motor abilities were defined by performance on the Learning Accomplishment Profile Gross Motor Subscale. The data indicate that a majority of children with SNHI present with aberrant PRNT results, delayed maturation of equilibrium reactions, and age-appropriate performance in a general developmental screening test. Implications for clinicians working with preschool-aged children with SNHI are discussed, as are directions for future research.