Developmental Screening in the Primary Care Setting Dr Kang Ying Qi - PowerPoint PPT Presentation

Developmental Screening in the Primary Care Setting Dr Kang Ying Qi Associate Consultant Child Development Unit National University Hospital 28 May 2016

Content 1. Overview of terminology and concepts 2. Importance of Primary Care setting 3. Importance of developmental screening 4. Singapore Health Booklet 5. MCHAT 6. Vanderbilt assessment scale 7. Pediatric Symptom Checklist

Ov Overvie iew of of Con oncepts s an and Te Terminology

Factors influencing a child’s development Culture Community Children’s services Support for parenting Family Housing Family relationships Parenting styles and values Financial situation Parent’s level of education / occupation Parent’s physical and mental health Child Siblings Genetic inheritance Temperament Gender Physical Health

Developmental Domains

Developmental Quotient (DQ) = Developmental Age x 100 Chronological Age DQ = 100 → average • DQ < 70 → significant delay • > 2 domain Tervo R. Red Flags and Rules of Thumb: Sorting Out Developmental Delay. Gillette Children’s Specialty Healthcare: A Pediatric Perspective 2009; 18: 1.

WH WHY Pr Primary Care Setting ? ?

Ongoing relationship

Age related developmental manifestation 8 % 1 – 2 %

Family factors and trust

1 in 6 children with developmental delay or disorder Lian WB, Ho SKY, Yeo CL et al. General Practitioners’ Knowledge on Childhood Developmental and Behavioural Disorders. Singapore Med J 2003; 44: 397.

WH WHY De velopmental screening ? ? Deve

Detection Methods Developmental Developmental Surveillance Evaluation http://www.medmerits.com/index.php/article/developmental_delay_in_children_evaluation_and_management/P2

Half detected before 5 years old Hamilton S. Screening for developmental delay: Reliable, easy-to-use tools. J Fam Pract 2006; 55: 415.

Developmental disorders exist as a spectrum Language

Developmental Screening Developmental Developmental Surveillance Evaluation http://www.medmerits.com/index.php/article/developmental_delay_in_children_evaluation_and_management/P2

Early Intervention Matters.

Developmental Surveillance Developmental Screening Glascoe FP . Screening for Developmental and Behavioral Problems. Ment Retard Dev Disabil Res Rev 2005; 11: 173. Hamilton S. Screening for developmental delay: Reliable, easy-to-use tools. J Fam Pract 2006; 55: 415.

Tools for screening for developmental delays

Denver Developmental Screening Test (DDST) developed in 1989 Lim HC, Chan T, Yoong T. Standardisationand Adaptation of the Denver Developmental Screening Test (DDST) and Denver II for Use in Singapore Children. Singapore Med J 1994; 35: 156. Lim HC, Ho LY, Goh LY et al. The Field Testing of Denver Developmental Screening Test, Singapore: A Singapore Version of the Denver II Developmental Screening Test. Ann Acad Med

• Objective: The aim of this study was to investigate parents' perceptions of developmental checklists and the child development monitoring schedule in the Singapore health booklet. • Method: Parents of children aged 2 years 6 months to 3 years 11 months with or without developmental concerns (n = 450) completed a structured interview, and their child's health booklets were reviewed. • Results: Most parents reported reading and using the developmental checklists. However, only about half of them attempted the checklists with minimal help from professionals. Approximately 7 in 10 parents of children with developmental concerns found the checklists useful for identifying concerns about their child. Despite positive feedback from parents about the checklists, only about 1 in 4 parents brought their child for a 2 to 3 years developmental monitoring visit at the time of the survey, and the completion rates of the checklists were less than desirable. • Conclusions: Further revisions to the checklists can include simplifying the words and sentences and providing relevant pictures to aid understanding. If the checklists are to be used for screening, standardization of how the checklists are to be completed and how children at risk of developmental delays can be identified on the checklists need to be provided. Parents' awareness of the importance of evaluating their child's development at 9 months, 18 months, and particularly at 2.5 years, needs to be raised. Developmental screening for children at these critical ages can be made mandatory. An electronic version of the health booklet is likely to facilitate implementation of developmental screening in the health care system. Journal of Developmental and Behavioural Pediatrics: JDBP 2016 May 5

11 time points for development surveillance and screening

Other similar screening tools are yet to be comparable Personal Communication. KKH DCD Physicians and Psychologists. April 2014. Kiing J, Low PS, Chan YH et al. Interpreting Parents’ Concerns about Their Children’s Development With The Parents Evaluation of Developmental Status: Culture Matters. J Dev Behav Pediatr 2012; 33: 179.

Nathan Mother https://www.m-chat.org

Scoring instructions for MCHAT

Nathan Mother 16 points https://www.m-chat.org

MCHAT • 16 – 30 months • AAP guidelines: 18 and 24 months • High false positive rate -> other developmental disorder

Vanderbilt Scoring

Inattentive 9/9 > 6/9 = sig 0/14 > 3/14 = sig CD Hyperactive > 6/9 = sig 9/9 > 3/7 = sig 0/7 Mood ODD 0/8 > 4/8 = sig Function And any score of 4 or 5 CD

Vanderbilt Assessment Scale • 6 – 12 years old • Together with the teacher assessment scale, used by paediatricians and psychiatrists, to aid in the diagnosis of ADHD • Parent assessment scale can be used by GPs as screening tool in clinic

Tool for screening for mental / emotional health in children http://www.massgeneral.org/psychiatry/services/psc_forms.aspx

Mental Health is more than the absence of mental illness Mental illness • A state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is Mental health problem able to make a contribution to her or his community. Mental wellness http://www.who.int/features/factfiles/mental_health/en/

Case • 11 year old boy comes for the 4 th time in 3 months to your clinic for a series of non specific complains like abdominal pain and headache. Each time asking to be excused from school. • The child comes alone to your consult each time, when questioned if there are any stressors and asked about his mood, he gives you nonchalant responses. • What do you do?

2 0 1

2 0 1

Pediatric Symptom Checklist

Pediatric Symptom Checklist • 3 to 18 years old • Psychosocial screen : cognitive, emotional, and behavioral problems • School age children: Scores of 28 or greater • Younger kids: Scores of 24 or greater • -> referral for further mental health assessment

Pediatric Symptom Checklist - 17

Difficulties faced Time Competing healthcare priorities Logistics Follow up Parents Cost receptivity Knowledge Literacy about tools Responsibility for the results Lack of training

Caution • Positive screening does not equal diagnosis • Negative screening does not mean there is no issues • Lack of standardized measures for Singaporean children • Care giver reports are subject to biases • Confidentiality • Crisis management

Resources HEALTH PROMOTION BOARD • Healthy Start For Your Baby http://www.hpb.gov.sg/HOPPortal/health-article/12206 Healthy Start For Your Growing Child http://www.hpb.gov.sg/HOPPortal/health- • article/12294 EARLY CHILDHOOD DEVELOPMENT AGENCY • Growing with Your Child booklet http://www.ecda.gov.sg/growatbeanstalk/Pages/articledetail.aspx? type=4&category=Growing+With+Your+Child+Booklet • Care & Development: A Resource for Parents of Children with Developmental Needs http://www.ecda.gov.sg/growatbeanstalk/Pages/ArticleDetail.aspx? type=4&articleid=145 • http://www.childcarelink.gov.sg/ccls/uploads/MSF-Child Development-Booklet.pdf CENTERS FOR DISEASE CONTROL AND PREVENTION USA • Learn the Signs.Act Early http://www.cdc.gov/ncbddd/actearly/milestones/index.html MINISTRY OF HEALTH • AMS-MOH Clinical Practice Guideline on Autism Spectrum Disorders in Preschool Children 2010 http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/ • doctors/guidelines/cpg_medical/2010/cpgmed_autism_spectrum_dis orders_preschool_children.html Summary • http://www.moh.gov.sg/content/dam/moh_web/HPP/Doctors/cpg_m edical/current/2010/ASD%20CPG(Card).pdf • Patient Version http://www.moh.gov.sg/content/dam/moh_web/HPP/Doctors/cpg _medical/current/2010/Autism%20Spectrum%20D.pdf • http://www.mentalhealthamerica.net/every-child-needs • RECOGNISING CHILDREN WITH DEVELOPMENTAL DELAYS: A STRATEGY FOR SURVEILLANCE. THE SINGAPORE FAMILY PHYSICIAN VOL 40 ( 2 )APRIL-JUNE2014:18 • http://www.medmerits.com/index.php/article/developmental_delay_in_children_evaluation_and_management/P2 •