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Available from:

Child Development Review

Call: (612) 850-8700

Behavior Science Systems, Inc.


Box 19512
Minneapolis, MN 55419-9998

Fax: (360) 351-1374


Web: http://www.ChildDevelopmentReview.com
Email: Heidi@childdevrev.com

Copyright 2004, 1996 by Harold R. Ireton and Heidi Vader


All rights reserved. No part of this manual may be reproduced in any form of printing
or by any other means, electronic or mechanical, including, but not limited to,
photocopying, audiovisual recording, and transmission and portrayal or duplication in any
information storage and retrieval system without permission in writing from the author.
Printed in the United States of America

CHILD DEVELOPMENT REVIEW ...............................................................................................................................................1


CHILD STUDY.................................................................................................................................................................................2
USING THE CHILD DEVELOPMENT REVIEW PARENT QUESTIONNAIRE.............................................................5
Interpreting Responses ...........................................................................................................................................................5
CHILD DEVELOPMENT CHART.................................................................................................................................................8
Child Development Interview ............................................................................................................................................... 10
Using the Child Development Chart for Observation.....................................................................................................11
Child Development Chart: Educating Parents and Professionals................................................................................ 12
Cultural Sensitivity.................................................................................................................................................................. 13
WORKING WITH PARENTS .................................................................................................................................................... 14
Connecting Parents With Community Resources............................................................................................................. 15
USES IN EDUCATION, INCLUDING RESEARCH ............................................................................................................ 16
Preschool Screening: CDR Validity For Screening.......................................................................................................... 16
Wisconsin's Child Development Days: Parent Education and Screening.................................................................. 18
Parent Teacher Conferences Using the CDR Parent Questionnaire ........................................................................ 22
Appreciating Childrens Development By Integrating Parents and Teachers Observations ........................... 24
Ongoing Assessment: Integrating Assessment with Education ................................................................................ 26
USES IN HEALTH CARE, INCLUDING RESEARCH ........................................................................................................ 28
Primary Care Pediatrics and Child Development Review.............................................................................................. 28
Well Child Visit Schedule for Child Development Review ........................................................................................... 30
Child Development Chart for Developmental Screening in a Family Practice Clinic ............................................. 31
Developmental Monitoring at the Community-University Health Care Center ..................................................... 32
Increasing Pediatric Residents' Discussion of Behavioral Problems ....................................................................... 35
Pediatric Screening for Developmental Disabilities in Armenia................................................................................ 35
References .................................................................................................................................................................................... 40
Appendix A: Infant Development Inventory ........................................................................................................................ 41
Appendix B: Child Development Inventory Profile............................................................................................................. 43

Appreciation
If the revised expanded Child Development Review Manual is an improvement over the
original, I have a lot of people to thank, including parents as well as professionals. The
following education and health care professional contributed experience and critique, articles
and research. I appreciate them as colleagues and friends.

Thank you all,


Harold Ireton

From Education:

From Health Care:

Arlene Wright
Kathy Ofstedal
Kate Horst
Sheri Goldsmith
Terri Heiserman

Robert Chesky
Frances Glascoe
Terri Kolrusch
Mary Jordan
Tenna Pflum
Barbara Felt
Mary OConnor
William Barberisi

Parents Concerns
Childs Development
Talking With Parents

CHIL

D DEVELOPMENT REVIEW

Child Development Review is a researchbased system for obtaining information


from parents, making your own
observations of the child and integrating
these two sources of information to
appreciate the childs functioning and
needs.

and preschoolers. It includes a Parent


Questionnaire and a Child Development
Chart. The parent questionnaire is brief yet
comprehensive. It saves time by helping
you focus your talk with parents to identify
their concerns. There is a similar
questionnaire and chart for parents of
infants called the Infant Development
Inventory (see Appendix).

Child Development Review helps you:

Obtain information from parents


about their child - including strengths
and any concerns the parents may
have about the childs health,
development and behavior.

The CDR helps you answer questions


such as the following:

Determine whether a childs


development is typical for age or is
delayed in some regard.

How satisfied or concerned is the


parent about the childs health,
development and/or behavior?

Childs Health: Are there any health,


sensory or physical problems that
could compromise the childs ability
to learn?

Childs Development: How well is


the child doing in the major areas of
development? What are the childs
abilities, strengths and possible
problems?

Childs Behavior: Is the childs


behavior and adjustment a concern?

Talk with parents and involve them


more effectively.

Child Development Review describes


the process of integrating information from
parents with your own observations of
their child. It is also the name of the tool
described in this manual.
The Child Development Review (CDR) tool
is for developmental screening of toddlers
1

How satisfied or concerned is the


parent about his or her own
functioning as a parent?

Using the CDR to involve parents makes it


easier to talk and work with them to
benefit their children.

The CDR Parent Questionnaire asks


parents of toddlers and preschool age
children to briefly describe their child and
report any questions or concerns. The
parent responds briefly to six questions
and a 25-item Problems Checklist.

If a parents ability to read is in question,


the information requested in the parent
questionnaire may be obtained by
interviewing the parent.

Research Base: The CDR format and


content are the result of over thirty years of
research and clinical experience with
longer Child Development Inventories
(Ireton 1972, 1992), followed by briefer
screening inventories including the Infant
Development Inventory (Ireton, 1988) and
the Preschool Development Inventory
(Ireton, 1987).

The Child Development Chart on the


backside of the questionnaire covers
development in the first five years in five
areas: social, self-help, gross motor, fine
motor and language. This chart can be
used to interview the parent and record
information about the childs present
development, and to directly observe the
childs skills.

Research using these inventories with


typical children, children at risk, and
children with developmental disabilities
has demonstrated the validity of parents
reports of their childrens development.
This includes international research. See
pages 16-39.
.

The CDR is used in a variety of educational


and health care settings. In Early
Childhood Education, schools use the CDR
as a screening tool. Teachers also use it for
conferences and as a parent education tool.
In Health Care, the CDR is commonly used
for screening at Well Child visits.

CHI

LD STUDY

The following pages display the CDR


Parent Questionnaire and Child
Development Chart and show the results
for a three-year-old boy.

Parents Concerns include speech and


overly aggressive behavior.
Parents Functioning: My hectic schedule
gets pretty crazy, but I will survive.

CDR Parent Questionnaire: This child is


described as Friendly, affectionate, but
sometimes very aggressive, and Talking
a lot more, asking for things. Sits still
longer.

Child Development Chart: Results suggest


development typical for age except for
language, which is borderline at the twoyear level.

Childs strengths include: Usually happy,


good helper, good physical coordination.

Recommendation: Check hearing and


assess language development. Talk with
mother about childs aggressive behavior.
2

USIN

G THE CHILD DEVELOPMENT REVIEW

Most often, the CDR is used for brief


screening to help identify children with
health problems, developmental delays
and behavior problems. It may also be used
for a more thorough review of a childs
developmental skills, including strengths
as well as weaknesses.

centered point of view for screening and


parent conferences.
Combining parents
Parent Questionnaire
status information
Development Chart
powerful option.

For screening, use the Parent Questionnaire


and/or the Child Development Chart. The
Chart is used to ask the parent about the
childs present development and for direct
observation.

concerns from the


with developmental
from the Child
provides the most

The comprehensive Child Development


Review approach starts with the parents
picture of their child, including the childs
abilities, strengths and possible problems.
It considers the parents functioning as well
as the childs. It is parent education and
community resource focused, providing
information to parents about both child
development and community resources for
parents of young children. It provides
information and support to parents and is
less intimidating than the traditional
screening for deficits approach. For more
details, see Child Development Days article,
page 18, in Uses in Education section.

Many physicians use the Child


Development Chart for screening (and no
Parent Questionnaire) because it is similar
to the Denver and they are not accustomed
to using parent questionnaires. However,
the questionnaire can help them save time
by acquiring valuable information from
parents before a Well Child visit.
Schools and teachers also value the Parent
Questionnaire because it provides a parent-

Parent Questionnaire: Interpreting Responses


When reviewing the parents answers to
the six questions, do the answers suggest
that . . .

The parents responses to the six questions


may be marked accordingly with one of the
following symbols:

The child and parent are doing well


or okay?
Some possible problem or cause for
concern exists?
A major problem may be present?

OK
?
P

No problems or doing well


Possible Problem ask for more
information
Possible Major Problem ask for
more information and consider
referral

identified by the parent or some


professional as a significant, possibly
major, problem or disability.

Question Ratings, including frequencies:


1) Please describe your child briefly:
Parents descriptions range all the way
from very positive, enthusiastic
descriptions that suggest the parents
delight in the child to very negative
descriptions, i.e. aggressive, stubborn
children who may be provoking strong
negative reactions from their parents.
Strongly negative child descriptions may
express a parents frustration and be a risk
factor for potential child abuse.

In the CDR research, this question was


answered with some reported problem by
15% of parents. Only 3% of parents
described a problem that was classified as a
major problem or disability. Reported
problems or disabilities ranged from lefthanded to allergies to hearing to
multiple disabilities attending a
developmental learning center. The
majority were physical-health problems
that could interfere with learning.

In one preschool screening study1 of the


CDR, only 2% of parents descriptions of
their children were classified as strongly
negative.

5) What questions or concerns do you


have about your child?
The purpose of this question is to obtain
information about the childs less serious
problems and the parents concerns. Thirtyeight percent of parents indicated that they
had some question or concern about their
child. Only 4% expressed concerns that
were rated as a possible major concern. The
majority of concerns were about behavioral
problems, speech, attention, motor
coordination, or pre-academic skills.

2) What has your child been doing lately?


This question asks the parent to describe
their childs present skills and is most
useful when you decide to do a
developmental interview (see page 10).
3) What are your childs strengths?
The parents description of the childs
strengths helps you get a more balanced
picture of the childs functioning, ie,
strengths vs. problems and concerns.

6) How are you doing as a parent and


otherwise, at this time?
This question gives parents an opportunity
to report any problems of their own. They
may choose to ignore this question, say
fine or report distress. Including this
question recognizes the fact that childrens
and parents functioning are intimately
related and that parents also need support
and assistance.

4) Does your child have any special


problems or disabilities?
Some children may have major health
problems or physical or sensory
disabilities. Others may have serious
developmental
disabilities
or
behavioral/emotional disorders. Still more
children have lesser problems such as
speech, attention, or behavioral problems
that are developmental in nature.

Unfortunately, the parents functioning is


seldom asked about in screening. It is
probably as important as the childs
functioning, as it affects the child directly.

The purpose of the questions, Does your


child have special problems or disabilities?
What are they? is to identify any
condition of the child that has been
1

Based on results for 220 3 and 4 year-olds. See


page 16.

Problems Checklist:

Health: Parents report relatively few health


problems (45 percent).

The Problems Checklist helps parents


systematically report their concerns and the
childs possible problems. This 25-item list
covers health, development and behavioral
concerns.

Development: When parents are


concerned about their child's development,
it is most often that the child does not talk
well (9 percent) and more often for boys
than girls.

Parents of one to five-year-olds commonly


check one or more problems regarding
their childs health, development and
behavior.

Behavior: Starting at age two, behavior


problems are the most commonly reported
concerns, more often for boys than girls.

CDR Problems Checklist - with Freq./Percentages reported for 1 to 5 Year-Olds

(N=411)

1. Health Problems

4.5

14. Clumsy, walks or runs poorly,


stumbles or falls (ages 2 or older)

1.5

2. Growth, height or weight problems

5.5

15. Clumsy in doing things with his


hands

2.5

16. Immature; acts much younger


than age

2.5

3. Eating problems eats poorly or


too much, etc.

10.5

4. Bowel and bladder problems, toilet


training

6.5

17. Dependent and clingy

5.0

5. Sleep problems

4.5

18. Passive; seldom shows initiative

3.0

6. Aches and pains: earaches, stomach


aches, head aches, etc.

11.5

19. Disobedient; does not mind well

6.5

7. Energy problems; appears tired and


sluggish

<1.0

20. Temper tantrums

No
data

8. Seems to have trouble seeing.

<1.0

21. Overly aggressive

10.0

9. Seems to have trouble hearing

1.5

22. Cant sit still; may be hyperactive

6.5

10. Does not pay attention; poor


listener

3.5

23. Timid, fearful, or worries a lot

3.0

11. Does not talk well for age

9.0

24. Often seems unhappy

5.5

12. Speech is difficult to understand

6.0

25. Seldom plays with other children

4.5

13. Does not seem to understand well,


slow to catch on

2.5

26. Other?
7

<1.0

CHI

LD DEVELOPMENT CHART

Use the Child Development Chart to determine WHAT and HOW WELL the child is doing in
five areas of development social, self help, gross motor, fine motor and language. Use the
parents report of the childs present skills along with your own observations.
After you have determined the childs skills, compare them to the AGE NORMS for young
children. The behaviors on the chart are placed at the age level during which at least 75% of
children display the skill, for example, walks without help (13-14months).
Use the Infant Chart (see Appendix) to age 18 months, then 5 Year Chart up to kindergarten.
Directions: Draw a line across the chart at the childs exact age, including years and months.
For each area of development, start with behaviors just below the childs age. Ask the
parent, Is your child doing this regularly, just beginning to do this, or not doing this yet?
Also, make your own observations when possible.
Check (!) the behaviors that describe the things that the child does regularly or pretty well.
Mark B for behaviors that the child is just beginning to do or only does sometimes.
If the child is doing things around age level in an area, you may want to ask about more
mature behaviors to determine just how well the child is doing. If the child is well below age
level in an area, ask about younger age behaviors to determine the childs highest level of
functioning.
If the child is lagging behind in an area of development, draw a line across the chart at the
below-age cutoff line, which is 70% of the childs age (Child Development Chart Below-Age
Cutoff Conversion Table on next page).
Results:
For screening, use the checked behaviors to appreciate the childs highest level of function in
an area. Use the Bs as additional information about anticipated development.
For each area of development, classify the results as suggesting typical, borderline or delayed
development.
Delayed = development below the below-age cutoff line (70% of age)
Borderline= development on the below-age cutoff line or just above
Typical = development around age level
Try to appreciate the childs profile of development, ranging from doing well in all 5 areas to delayed in one or more areas - to delayed in all 5 areas. Consider strengths as well as
weaknesses. Use these results in relation to any parental concerns about Health,
Development or Behavior.
8

This Below-Age Cutoff Conversion Table shows where to draw the cutoff line on the CDC.
Current Age
6m
7m
8m
9m
10 m
11 m
12 months
13 m
14 m
15 m
16 m
17 m
18 m
19 m
20 m
21 m
22 m
23 m
Two Years Old
2 y, 1 m
2 y, 2 m
2 y, 3 m
2 y, 4 m
2 y, 5 m
2 y, 6 m
2 y, 7 m
2 y, 8 m
2 y, 9 m
2 y, 10 m
2 y, 11 m
Three Years Old
3 y, 1 m
3 y, 2 m

70% of Age
4m
5m
5.5 m
6.5 m
7m
7.5 m
8.5 m
9m
10 m
10.5 m
11 m
12 m
12.5 m
13 m
14 m
14.5 m
15 m
16 m
16.5 m
17.5 m
18 m
19 m
19 m
20 m
21 m
21 m
22 m
23 m
23 m
2y, 0 m
2 y, 1 m
2 y, 2 m
2 y, 2 m

Current Age
3 y, 3 m
3 y, 4 m
3 y, 5 m
3 y, 6 m
3 y, 7 m
3 y, 8 m
3 y, 9 m
3 y, 10 m
3 y, 11 m
Four Years Old
4 y, 1 m
4 y, 2 m
4 y, 3 m
4 y, 4 m
4 y, 5 m
4 y, 6 m
4 y, 7 m
4 y, 8 m
4 y, 9 m
4 y, 10 m
4 y, 11 m
Five Years Old
5 y, 1 m
5 y, 2 m
5 y, 3 m
5 y, 4 m
5 y, 5 m
5 y, 6 m
5 y, 7 m
5 y, 8 m
5 y, 9 m
5 y, 10 m
5 y, 11 m

70% of Age
2 y, 3 m
2 y, 4 m
2 y, 4 m
2 y, 5 m
2 y, 6 m
2 y, 6 m
2 y, 7 m
2 y, 8 m
2 y, 9 m
2 y, 9 m
2 y, 10 m
2 y, 11 m
2 y, 11 m
3 y, 0 m
3 y, 1 m
3 y, 1 m
3 y, 2 m
3 y, 3 m
3 y, 4 m
3 y, 4 m
3 y, 5 m
3 y, 6 m
3 y, 6 m
3 y, 7 m
3 y, 8 m
3 y, 8 m
3 y, 9 m
3 y, 10 m
3 y, 11 m
3 y, 11 m
4y, 0 m
4 y, 1 m
4 y, 1 m

Child Development Interview


Review the CDR Parent Questionnaire
before interviewing the parent. When
reviewing the parents answers, determine
whether this is a child about whom the
parent has no particular concern or
whether the parent is concerned or worried
about the child. Then review the parents
responses with them, giving them a chance
to clarify or add to what they have written.
Identify the childs strengths and special
abilities as well as any problems, along
with the parents questions and concerns
about the child.

1. Please tell me what (childs name) has


been doing lately.
Preview the parents response to this
question on the Parent Questionnaire
and/or ask the parent this question as a
first step in the developmental interview.
The parents spontaneous report gives the
parent a chance to talk about their child in
her own way. It also gives the interviewer
an opportunity to note behaviors that are
reported and to tentatively determine the
age level behaviors that may need to be
surveyed. When a parent mentions a
behavior from the developmental chart,
check (!) the behavior on the chart.

If the parent has not completed the


questionnaire, offer them a chance to do so,
or the alternative of simply talking to you
about these questions. If you are aware that
the parent has a limited educational
background (less than high school) or that
there are cultural or language factors that
may cause difficulty completing the
questionnaire, simply include the questions
on the questionnaire as the initial part of
your developmental interview.

2. Please tell me more about . . .


Begin the second level of questioning by
asking for more information in the area of
development that the parent has
mentioned the most. For example, if the
area is gross motor: Tell me more about
how your child is getting around from
place to place. If it is in language: How
much is your child talking? What is he
saying?

The parent interview may be limited to


reviewing and discussing the parents
answers to the questionnaire. Alternatively,
the interviewer may proceed to do a full
developmental interview.

The language area is the most complex area


to review. You need to determine:

The purpose of the developmental


interview is to determine what the child is
doing in the five areas of development
listed on the back of the questionnaire.
The developmental interview is keyed to
the parents description of what your
child has been doing lately and to the
behaviors on the chart.

how much the child is talking.


how understandable his or her speech is.
how much he or she understands.
3.Does your child______________? or
Is your child ________________?

The specific wording of your questions is less


important than a natural approach that is
comfortable to the parent.

At the third level of questioning, within


each area of development, you need to ask
10

specific questions about the behaviors


listed on the chart. Ask Does your
child..? then state the behavior. Check the
behaviors to which the parent answers
yes. You may also mark some behaviors
with a B for just beginning. Repeat this
process in all five areas.

my child doesnt do that. In this regard, it


is encouraging to parents to end by briefly
summarizing some of the childs
developmental achievements.
When to stop: For each area of
development, there is no point in asking
about developmentally more mature items
when the child is reported as not doing
less mature items. STOP when all items
within a given age interval are answered
No. STOP when three items in a row are
answered No. STOP when the child has
demonstrated functioning at least at age
level, unless you are interested in
evaluating advanced development. STOP
when you think it makes sense to stop.

When asking about specific behaviors, be


careful not to create expectations or to ask
leading questions that would influence the
parent to answer based on what they think
the child should be doing. Ask these
questions in a Does? or Is? form. Do
not ask, Can your child . . .?
Where to begin the Developmental
Interview: You may use the childs age as
your guide and begin with items that are
one age interval below the childs actual
age. For example, for an eighteen-monthold, start at age twelve months. This is less
threatening to parents who then have some
opportunity to report on their childs
achievements before they have to say, No,

The full developmental interview is


conducted in this three-step fashion.
*To save time, the interviewer may omit
steps one and two, refer to the Child
Development Chart, and simply ask about
behaviors in each area around the childs
age level.

Using the Child Development Chart for Observation


You may also use the Child Development
Chart to observe what a child is doing.
Whether you observe the child in your
office, a child care setting, or at home, the
childs spontaneous behavior provides
critical information about his or her
development, adjustment, and well-being.

drawing and printing. Similarly, when a


child follows directions or answers
questions, she reveals her level of
understanding.
The areas of development and the
behaviors described in the CDR Child
Development Chart can be used to assist
your observation of the childs behavior.
They also function as indicators of what to
ask the child to do or say at various ages.

When age-appropriate play materials are


available, the child will naturally seek them
out and use them in different ways,
depending on their level of development.
Small play blocks may be picked up,
stacked, used to build, or play cars and
trucks. Crayons and pencils will be used in
very simple, complex, or even symbolic
ways from marking and scribbling to

You can use the Parent Questionnaire


questions to ask parents to describe the
child as you observe him or her, making
special note of the childs social behavior
and response to the parent or to you.
11

Child Development Chart: Educating Parents and Professionals


The Child Development Chart can also be
used as a handout to parents and
professionals in order to provide them with
an overview of child development in the
first five years. The following information
describes the major areas of development
and guidelines for appreciating a range of
normal. If a child is functioning below this
range in some area of development, this is
a basis for concern and referral.

comprehension. Simple expressive


communication may be exhibited by
gestures (pointing), sounds and words, or
simple and complex sentences. Speech
refers to how understandable the child is
and how well the child articulates speech
sounds. Comprehension or understanding
of language, from simple instructions to
concepts, is a critical issue. Low language
comprehension may reflect a hearing
problem or a problem in understanding.

Areas of Development First Five Years


Numbers and Letters from age two to
three years, children show a beginning
understanding of quantity, numbers and
counting, letters and reading. These are the
readiness skills we look for in
preschoolers as they approach
kindergarten age, along with language
comprehension.

Social
Self Help
Gross Motor
Fine Motor
Language
Numbers and Letters (Age 2, 3+)
Social Development includes response to
and interaction with parents, other
caregivers and children from individual
interaction to group participation.

Developmental Milestones The


Developmental skills listed in each area of
the Child Development Chart are placed in
the age range by which children have
typically developed these skills (75% of
children). For example, 75% of children are
walking independently by age 12-15
months, so this behavior sits in the chart in
the 12-15 month range.

Self Help skills include eating, dressing,


bathing, toileting, independence and
responsibility.
Gross Motor skills include moving about
by rolling over, walking, running, jumping
or riding. Balance and coordination are
important. Clumsiness for age can be a
symptom of a physical problem.

Range of Normal - How Well is This


Child Doing? This is the question that
parents and professionals all want to
answer. Is this child doing well, doing and
learning the things that you would expect
for a child this age? Or is this childs
development in some area(s) less than
would be expected for his/her age? For
example, is this three-year-old talking like
a three-year-old, or like a two-year-old, or
less than a two-year-old?

Fine Motor includes eye-hand coordination


visually following objects, reaching for
and picking up objects (small toys, blocks,
cereal bits), scribbling and drawing
pictures.
Language includes three components:
talking, speech intelligibility, and language
12

Cultural Sensitivity
The Child Development Chart, including
the developmental skills and norms, is
based on a sample of children from South
Saint Paul, Minnesota. The majority of
these children were white (95%). School
age children in this community, as a group,
demonstrate average ability.

and forks, or different norms, for example:


the age toilet training is attempted.
Social games vary widely in different
cultures, so that games in the chart such a
peek-a-boo and patty-cake do not
occur or have different names. Examples at
older ages are playing board games or card
games. Here it is important to recognize the
developmental skill that is being identified,
not the specific game. For example, pattycake involves stimulating the baby to
imitate the parents behavior and the
babys ability to imitate. At older ages,
social games involve understanding simple
rules, taking turns, and accepting direction.

Using this Chart in other communities and


with children of diverse cultural
backgrounds should be preceded by a
careful review of its contents. For some
communities/cultures, modifications in the
Chart may be necessary (see below).
It is important to know each childs
language background. What is the childs
primary language? What about the parents
language?

The challenge for each child and family is


to help the childs parents identify and
stimulate the major developmental skills
that emerge in young children and to
reinforce
their
development.
Understanding child development, cultural
variations of expression, and individual
parent/family interests and needs provides
the basis for being helpful to them and
their children.

Some of the behaviors in the Child


Development Chart involve the use of
materials that may not be available in some
homes. Examples are blocks, scissors, and
drawing materials. For these behaviors,
mark No Opportunity (NoOp). If possible,
provide parents with safe, age appropriate
materials that stimulate learning, such as
blocks and drawing materials.

If a child appears to be behind in some area


of development, it is important to do a
proper assessment and not be too quick to
explain away the apparent delay.

In some cultures, Self Help skills such as


eating involve the use of different utensils,
for example: chopsticks, rather than spoons

13

Parents are the experts on their children.


Recognizing this fact, and letting parents know how we value their knowledge
of their children, sets the stage for working effectively with them.

WOR

KING WITH PARENTS

Your knowledge of child development and


your experience in talking with parents
about their children provide the basis for
making effective use of the CDR. The CDR
is one means to help you organize what
you are already doing. It provides a
systematic method for gathering
information, for creating a record of the
childs development, and for talking with
parents.

judgment can ensure that questions such as


these are answered accurately and
helpfully. You may also have questions
that you need to raise about the child.
Just how you use the Child Development
Review with parents depends on who they
are and on your own situation. You may
want to have the parents fill it out prior to
meeting with them. You may want to
provide them with a copy of the Child
Development Chart after your discussion
with them, including their childs
developmental achievements, or use it as a
part of your discussion.

Most parents welcome the opportunity to


talk about their children and what they are
doing. Often they worry about how their
child is doing or at least have some
questions about their child. Starting with
what they have told you about their child
and adding your own observations works
well.

In doing the review, remember that what


parents need most is affirmation of their
childs achievement and recognition of
their efforts as parents. This is especially
true when their child has a problem or
disability or they are discouraged.

Key in on their expectations, their


questions and their concerns, then use
what they know and what you know about
the child in relation to their questions. For
example, the mother of a four-year-old may
be concerned about her childs speech and
language development and also may not
know how articulate children this age
usually are. Using the CDR Parent
Questionnaire and your professional

Parents who recognize that their child has a


problem are usually easier to communicate
with than parents who are hearing about
their childs possible problems for the first
time. Sensitivity, tact and timing are
important when discussing a childs
problems and needs.

14

Connecting Parents With Community Resources


Parents need information from
professionals about community resources
and how to access them.
Health
professionals and child care/education
professionals who see children early in
their development need to be informed
about, and to inform parents about,
community resources available for parents
and children.

in the Twin Cities and surrounding


communities. The Warmline addresses
concerns such as toilet training, sleep
disruptions, discipline, feeding, and eating
difficulties. The volunteer professional staff
specializes
in
early
childhood
development, provides support for stressed
parents and directs parents to additional
community resources as needed.

The following are examples of resources in


Minnesota and nationwide that benefit
young children and their parents. Other
states have similar resources.

Head Start and Early Head Start Head


Start early intervention programs have
benefited millions of preschool age
children from low-income families. More
recently, Early Head Start programs
provide educational and related services
for infants and toddlers and their parents.
Head Start, more than any other early
education programs, has stressed parent
involvement and parent education.
Participating parents learn about child
development and learning and about
educating young children. To find Head
Start in your area, visit their web site:
http://www.nhsa.org.

Early Childhood Family Education


Programs Minnesota offers parent
education to all families with children from
birth to kindergarten. Available in most
communities (parents contact their local
school), it provides a variety of programs
for parents and children including: parent
discussion groups, activities for children,
parent-child interaction activities, special
events for families, home visits, screening
for health and developmental problems,
lending libraries with books for parents
and toys and learning materials for
children.

Early Childhood/Special Education The


public schools are required to provide early
intervention services to infants, toddlers
and preschoolers with physical, sensory, or
developmental disabilities. Early
identification of these children is
accomplished by outreach programs,
which let parents know that their childs
vision, hearing and development can be
screened through their local school system.
Screening serves to identify children in
need of further assessment. Then the
schools specialists direct parents to
resources to assist them and their children.

The Parent Warmline Sponsored by


Childrens Hospitals and Clinics in
Minneapolis/St. Paul, Minnesota, this free
telephone consultation service provides
support, information, practical advice and
resource referral about parenting, child
development, and behavior.
Parent Warmline is available to parents of
young children, day care providers, family
members and other interested professionals

15

16

USES

IN EDUCATION, INCLUDING RESEARCH

The first two articles in this section describe the validity of the CDR Parent
Questionnaire for screening.
The articles in this and the following section are brief descriptions of some uses and
studies. More examples can be found in the book, The Child Development Inventories
in Education and Health Care (Ireton et al, 1997). Many of the following articles can
also be found there in a more detailed form.

Preschool Screening: CDR Validity For Screening


Harold Ireton, Ph. D.
University of Minnesota
Three and Four-year-olds (N=220)

education services (11% of children


screened).

This study determined the accuracy of


parents CDR reports for screening for
developmental and related problems
among three and four year olds. These
children were being screened for health,
vision and hearing, and development as
past of the South Saint Paul, Minnesota
schools preschool screening program.

Parents CDR reports were obtained


independent
of
the
standard
developmental testing.
The frequencies of parents responses to the
six CDR questions and problems checklist
that suggested possible problems were
already described on pages six and seven
of this manual.

South Saint Paul is a working class


primarily white community that is
representative of many communities.
Children in this community have an
average IQ of 100. Most parents are high
school graduates (83%), some are college
graduates (14%) and a few have not
competed high school (3%).

Here we describe the accuracy of parents


reports of problems or no problems as
indicators of childrens needs for special
education services. Parents CDR reports of
problems/no problems were compared to
childrens subsequent placement in early
childhood special education.

Two-hundred-and-twenty children were


screened using the D.I.A.L. developmental
test: 53 children (24%) were referred for
follow-up assessment based on test results.
Forty-one children were assessed. As a
result, 25 received preschool special

CDR Parent Questionnaire results


(questions 1, 4, 5 plus problems checklist)
were classified as indicating 1 = No
problem; 2 = Possible problem; and 3 =
Possible major problem. The CDR overall
17

results for each child were similarly


classified.
Results: CDR overall results (questions
plus problems list) identified the majority
(68%) of special education students and
indicated no significant problems for the
large majority (88%) of the other children
who passed screening. In technical terms,
sensitivity is .68; specificity is .88.

Does not seem to understand well.

Clumsy, awkward; runs poorly.

Clumsy doing things with hands.

Immature; acts much younger than


age.

Passive; seldom shows initiative.

Parents of special education students


(n=25), when compared to parents of other
children (n=195), more often reported signs
of problems on the PQ as follows:

The two items in bold print above were


strong predictors of future poor
performance in kindergarten, based on
teachers ratings.

CDR Questions and Problems List:

These results indicate that parents CDR


reports provide accurate indicators of
childrens developmental problems and
need for follow-up assessment. Most
parents recognize and report their
childrens problems. Parents should be
more systematically involved in screening
and assessment to determine their
childrens functioning and needs.

1. Negative child description: 4% vs. .5%


4. Major Health/Disability: 8% vs. 2.5%
5. Major Concern: 12% vs. 3%
Problems (1 or more): 44% vs. 10%
Eight CDR problems items were more
common among the 25 children placed in
special education. These include:

Does not seem to see well.

Does not talk well for age.

Speech is difficult to understand.

18

Wisconsins Child Development Days: Parent Education and Screening


Arlene Wright
Chippewa Falls, Wisconsin

Harold Ireton, Ph.D.


University of Minnesota

Three-year-olds (N=2,225 from 29 School Districts)


This article describes a comprehensive
approach for supporting and educating
parents of young children, age 2 1/2 to 3
1/2, and for identifying those children who
need further evaluation for exceptional
education needs. Professionals from
education, public health, social services,
and child care collaborate to provide
parents with information about child
development and community resources;
have early childhood teachers observe
children in a play setting; respond to
parents questions and concerns; and talk
with parents about the teachers
observations of the child. Parents concerns
and teachers observations are used to
identify children for follow-up assessment
for possible early childhood/special
education services, or to refer parents to
other services.

areas of education, child care,


medical/health, and family support
and services.

Child Development Days Goals: In an


effort to meet the needs of families,
children, school districts, agencies, and
ultimately the community, the following
goals for Child Development Days were
established.
Educate parents about early child
development

Provide parents with information


about community resources in the

those children who


need of further
the following areas:
vision and hearing,

Model Description: Public and parochial


schools, Head Start, birth-to-3 early
intervention programs, childcare, social
services, public health, and other
community service providers collaborate to
plan, implement, and evaluate community
Child Development Days. Parents of 2 1/2to 31/2-year-old children are located and
identified through a school census. A mass
media campaign including school flyers,
local TV, and radio advertising is used to
locate children not on the current school
census. Parents are sent an invitation to
attend Child Development Days and are
asked to call the community coordinator of
the project (local school district or other
community coordinator) to make an
appointment for their child. A letter is sent
to the parent confirming the time of their
appointment, along with the CDR Parent
Questionnaire to be returned when they
attend the onsite review.

Developed through community schools


and other agency collaboration, this
program takes the same positive approach
to screening as Child Development Review.
It emphasizes childrens strengths as well
as possible problems and special needs.

Help identify
may be in
assessment in
development,
health.

The onsite screening review includes

19

Parent questions and concerns


regarding
childs
health,
development, adjustment, addressed
by screening staff

Childs development by early


childhood teachers observation in a
play setting

Hearing screening by an audiologist


or another trained individual

Vision and health screening by a


nurse

concerning services they can offer to young


children and their families.
Parent Teacher Exit Conference: Following
the play-based observation of the child, the
parents have an opportunity to talk to the
early childhood teacher who has observed
their child. The discussion includes the
parents report of the childs present
development, the parents questions and
concerns, the teachers observations of the
child, and the hearing, vision, and health
screening results. First, the teacher reviews
the CDR Parent Questionnaire results.

Parent/Child Friendly Atmosphere: Child


Development Days is parent and child
friendly by design. Parents are invited to
Child Development Days as a positive
opportunity to talk about their childs
development and needs and to learn about
community resources. Children are
observed at play in a natural setting rather
than tested.

The discussion begins with the parents


offering their perception of their child,
including any questions and concerns the
parent may have. Using the CDR Child
Development Chart, the teacher asks
parents, What has your child been doing
lately?

Community Resource Fair: While the child


is being observed in the play setting,
parents have an opportunity to meet with
representatives of the community agencies.
The agency displays are located in or near
the room used for the childrens play, so
parents are never far from their children.
The displays are an important part of
developing an awareness of the resources
available in the community in the areas of
early childhood education, childcare,
health care, and family support.
Participating agencies include family/child
guidance clinics, childcare resource and
referral agencies, social service agencies,
public library, county public health
department, the police and fire
departments, the Red Cross, YMCA, and
the United Way.

Next, the teacher describes his or her own


observations of the child. The discussion is
balanced between the parents comments,
questions and concerns and the teachers
observations. At the end of the conference
some parents are provided with
information regarding referral for early
childhood/special education assessment or
for other services. All parents are given a
copy of the CDR Child Development Chart,
which shows what their child is doing in
the development of skills. The conference
takes about 15 minutes.
Program Evaluation: In 1990, the Child
Development Days program was initiated
in two Wisconsin communities, Chippewa
Falls and Cornell. Currently, the program
is being used in over 100 Wisconsin
communities. The results described here
are for 29 school districts. Two thousand,
two hundred twenty-five 2 1/2 to 3 1/2year-old children participated. The
population size of this age group ranged
from 40 to 350. The impact of Child
Development Days was evaluated by

Public and parochial school kindergarten


teachers are on hand to answer parents
questions and concerns. The display tables
are filled with materials and examples of
developmentally appropriate activities that
parents can provide for their children. The
local Head Start and Birth-to-3 early
intervention services provide information
20

questions or concerns, and (c) educating


and supporting parents. Parents responses
to the program evaluation questionnaire
indicate that they benefited from the
process and that it was more useful to them
that a traditional screening for disabilities
program.

reviewing the results in terms of (a)


parent/child participation, (b) referral rates
of children for various services, and (c)
results of questionnaires completed by
parents and professionals.
Program Benefits:

The validity or accuracy of screening


decisions based on the Child Development
Days model cannot be conclusively defined
by the available data. The referral rate for
assessment for early childhood/special
education of 8% seems to be reasonable;
73% of the children referred and assessed
were found to be eligible for special
education services.

Among the 2,225 children seen, 8% (n=173)


were referred for multidisciplinary team
evaluation to determine eligibility for early
childhood/special education service.
Thirteen parents declined to participate.

Of the 160 children who were assessed,


73% (n=123) were determined to be eligible
for early childhood/special education
services and received early intervention.

However, the children who passed the


screening received no subsequent
assessment. Therefore, no measure or index
of the number of children with special
education needs who passed the screening
is available. Results of a one-time
observation of a childs functioning,
whether by testing or professional
observation, are open to question. A onetime screening may not be representative of
the childs typical functioning. Because the
Child Development Days model combines
information from parents with teacher
observations, the data are more likely to be
accurate.

An additional nine percent (n=213) of


children/families who were not referred
for assessment, were, however, directed
toward other community resources
including Head Start, social services, public
health or audiologists.
Implications: Broadening our view of early
childhood screening using the Child
Development Days model provides more
opportunities to benefit parents and
children in general. Modifying our
methods to focus on parents and early
childhood teacher observations of
childrens behavior instead of depending
primarily on developmental screening tests
creates a more natural parent- and childfriendly experience and still provides a
mechanism to help identify children with
special education needs. Child
Development Days provides parents with
an opportunity to discuss their childs
development and to learn more about child
development and community resources.

Child Development Days makes parents


more community-wise by providing a
Resource Fair where parents learn about
available resourced and how to use them.
Based on parents and professional
evaluations, Child Development Days
appears to be a successful collaborative
multi-community effort. Perhaps the
greatest strength of Child Development
Days is its collaboration at all levels; (a)
between the Wisconsin Department of
Public Instruction and the 30 school
districts served by Cooperative Educational
Service Agency #10 through an IDEA 99457 Discretionary grant award, (b) between

The Child Development Review system


provides for an integrated approach for (a)
reviewing childrens development with
parents, (b) responding to parents
21

an early childhood educator (first author)


and a child psychologist (second author),
(c)
among
community
agency
representatives who organized local Child
Development Days programs, and (d)
between early childhood teachers and
parents working together to review
childrens development and needs.

Development Days provides an


opportunity for family and child services
providers to get to know one another and
to convey to the community and to parents
their common concern for the wellbeing of
both children and parents.
This community service project
demonstrates the value of enlarging the
concept of screening to include
Developmental Review. This systematic
method combines parent reports with
teachers observations, and provides a
parent education and support focus as
well as a child-centered focus.

Collaboration among some agencies and


school districts who were initially involved
in the Child Development Days model has
expanded to include initiation of integrated
programs for young children, development
of joint community councils working
toward improved services for families, and
funding proposals and grant awards to
establish family/child resource centers.
The process of forming collaborative efforts
within the community becomes as
important as the day itself. Child

Wright, A. & Ireton, H. (1995). Innovative Practices


Child Development Days: A New Approach to
Screening for Early Intervention. Journal of Early
Intervention, Vol. 19, No. 3, 253-263.

22

Parent Teacher Conferences Using the CDR Parent Questionnaire


Kathy Ofstedal, Ed.D.
Early Childhood Educator,
St. Cloud State University,
St. Cloud, Minnesota

Ann and Andy Preschool Parent Teacher Conferences


Dear Parents,
Conference time is a fun time for me. It gives me the chance to get to know your child
through your eyes. It also gives me the chance to let you know the exciting things your child has
discovered this fall at school.
Please fill out the attached CDR Parent Questionnaire and send it back with your child the
next time we have school. The questions can be answered in only a few words or sentences.
Conferences are not required, but are very important. I would like the input of both parents
(if possible) on both the CDR and at our conference.
Together we will work to plan a rich and creative program for your child!
Kathy

When I was teaching preschool I held


parent teacher conferences twice a year.
After several years of experience, I realized
I was not really zeroing in on problem
areas that needed to be dealt with, and
immediately started to look for a tool to use
to help me.

First of all, the parents were excited to tell


me all about their children, and were
touched that I would care enough to ask!
This immediately established a rapport
between the parents and me that continued
to build all year long. This was invaluable
to me the children already trusted me,
now the parents did too.

After attending a presentation describing


the CDR Parent Questionnaire, I decided to
use it to help me prepare for my parent
teacher conferences. I had never asked
parents, before a conference, to tell me
about their child, and the idea intrigued
me. I sent out the questionnaire in October
and asked the parents to fill it out and
return it one week before their scheduled
conference in November (see above letter).
I was overwhelmed with the response I
received.

Secondly, many more issues were talked


about and dealt with than I had ever
experienced before. I found out that most
of the parents really enjoyed and loved
their children. I also found that many
wanted to do a better job of parenting and
wanted advice about improving parenting
skills
One of the most beneficial outcomes of this
review, however, was parents sharing with
23

me real concerns they had about their


children. In many cases I had carefully
considered how to approach parents about
these same concerns, but now I didnt have
to bring them up they approached me!
The parents never became defensive as we
both worked toward the common goal of
helping their child.

CDR Parent Questionnaire:


Parents Questions and Concerns
Question/Concern

As I read the statements describing


possible problems their child might have, I
looked up information for them in our
Parent Resource Library and in my
personal resources, or directed them to
others who could help. We caught some
problems early on and many parents
developed some great new parenting skills.
I believe my whole year of teaching went
smoother and I accomplished more because
I learned so much about my children and
their families early in the year.

Childs School Adjustment

15

Development/Maturity

Kindergarten Readiness

Speech/Language Problems

15

20

43

Routines Sleeping, Eating,


Toileting

11

Health Concerns

Explanations (Why does s/he?)

How Tos (Promote self-esteem,


discipline, etc.)

Behavior Problems/Discipline
(from shy to aggressive)

Parents Concerns Research


Parents responses to the CDR question,
What questions or concerns do you have
about your child? were classified to
determine the frequencies of various
concerns and questions (N=46 parents of
three-, four- and five-year-olds). As shown
on right, parents are more often concerned
about their childs behavior than with their
development and learning. Childrens
adjustment to preschool and their speechlanguage development are common
concerns or at least questions. Parents are
also asking for explanations and advice
from their childs teacher. They wish to be
taught how to help their child in various
ways.

24

Appreciating Childrens Development


By Integrating Parents and Teachers Observations
Harold Ireton, Ph.D.
University of Minnesota

Sheri Goldsmith, M.A.


University of Minnesota Child Care Center

The University of Minnesota Child Care


Center provides early childhood education
and child care services to children of
University students, staff and faculty
parents. The center, located near the main
campus, is designed to serve 155 children
age three months to kindergarten. A
companion program provides child care
resource and referral information to
parents. The center is under the University
College of Education. The program is an
educational resource to University faculty
and students for purposes of observation,
training and research. The center has ties
with the University Center for Early
Education and Development and the
Institute of Child Development, including
their laboratory nursery school program.

development and learning of each


child? What can others and I do to
assess and help those children who
are not doing well?
We prefer to speak of Appreciation rather
than assessment because Appreciation
means to value or admire, to be fully aware
of something, to have an understanding of
that thing, such as a work of art or a child.
Appreciation is a more positive, richer,
subtler idea than assessment. To harmonize
the two, if your assessment of a young
child is done with a full appreciation of
child development and the complexity of
each child, then the assessment will be
developmentally appropriate.
The following describes the three main
elements of the assessment system at the
University of Minnesota Child Care Center.
This system was designed to be parent,
child and teacher-friendly (Ireton and
Goldsmith, 1994). Comments and
suggestions of parents and teachers
contributed to the development of this
system. This system is described in detail in
the Teachers Observation Guide Manual.

The system described here is based on the


following principles:
A. The Teacher stands at the center of
the assessment and educational
planning process.
B. Making best use of information from
parents and working closely with
them benefits children, parents and
teachers.

A. Teachers Observations: Teachers


observe children to learn about each
childs interests, adjustment to the
Center, development, learning,
personal style and educational needs.
To assist them in their observations,
teachers use an observation guide:
either the Cataldo Early Childhood
Competencies Profile (Cataldo, 1983)
or the CDI Teachers Observation

C. Parent teacher conferences provide a


means for educational planning with
parents.
D. Teachers need to answer two main
questions about children in their
program: How do I appreciate the
25

Guide (Ireton, Goldsmith, 1995). Use


of these observation tools encourages
a systematic approach to observation.
Teachers
observations
are
summarized on the Teachers
Observation Guide Summary Sheet.

If parent teacher conferences are held twice


a year, the CDR Parent Questionnaire is
used in the fall and the longer, more indepth Child Development Inventory may
be used in the spring. Whatever
alternatives fit your program, a system for
assessment and educational planning can
be developed using some of these methods.
If a childs development is questionable,
the longer Child Development Inventory
provides more information.

B. Parents Observations: Parents


complete
the
CDR
Parent
Questionnaire or Infant Development
Inventory before their scheduled
parent teacher conference to describe
their child and their childs interests,
strengths, and social adjustment.
They are also asked, What questions
or concerns do you have about your
child?

What Teachers Say About the CDR Parent


Questionnaire:

C. Parent Teacher Conference: The


teacher reviews the parent responses
to the parent questionnaire prior to
the conference. This helps the teacher
anticipate the parents questions and
concerns. The teacher begins the
conference by keying in on the
parents questions and concerns, and
then adds her own observations of the
child. The parent teacher conference
then becomes a partnership in which
the special knowledge of both parents
and teacher contributes to planning
for the childs education and care.

26

It gives parents an opportunity to


express their concerns.

It gives teachers information about


whether the parents and teacher are
on the same wavelength.

It eliminates surprises for the teacher.

It helps determine the focus of the


conference. It reveals the parents
interests.

It provides teachers with an


opportunity to educate parents . . .For
example, What is normal for age?

Ongoing Assessment: Integrating Assessment with Education


Terri Heiserman
Director, Christ Memorial Tender Learning Center
Plymouth, Minnesota
Christ Memorial Tender Learning Center is
owned by Christ Memorial Lutheran
Church in Plymouth, Minnesota. Our child
care center serves families and their
children ages six weeks through fourth
grade. Currently our program is licensed to
serve 99 children (14 infants, 21 toddlers, 40
preschoolers and 24 school-age children).
We offer full day child care as well as a
nursery school program for preschool-aged
children. For the most part the families that
we serve are middle to upper class. We do
serve four children who receive county
funding and we serve six children through
the Wayzata School Districts Learning
Readiness program. We also have
scholarship money available and currently
four children are receiving those funds.

Prior to the actual conference, we send


parents the Infant Development Inventory
or the CDR Parent Questionnaire. We ask
that parents complete and return the parent
questionnaire to us prior to the conference.
This allows the staff the opportunity to
research information if there are concerns
from the parent prior to the conference (an
example may be toilet training tips for a
child who is not showing any signs of
interest by age three).
In a couple of instances, this process has
affirmed some of the gut feelings the
staff had about children with delays. At
conference time we are able to show the
parent the items their child should be
performing. We then have suggested
making referrals to doctors or to the school
districts early intervention program.
Several children are now receiving special
services.

Tender Learning Center has been using an


Integrated Assessment System, including
the Infant Development Inventory, The
CDR Parent Questionnaire and the
Teachers Observation Guide since October
of 1995. We use these items as tools for
parent teacher conferences, which are held
twice a year. Previously we had struggled
with several different forms used for
conferences.

The staff and parents seem to really


appreciate this process of tracking each
childs development. Conferences now see
a collaboration of information gathering
rather than teachers doing most of the
reporting.

The teachers track the childrens


development in the Teachers Observation
Guide Booklet periodically and then use
the information gained to set goals for each
child. It is shown to the parents at
conference time and we gain information
from the parents then as to items that they
may see being performed at home. It works
well as a partnership between the center
and home.

The parents are able to see what they


should be expecting from their childs
development. This directly benefits the
child as parents and teachers are working
on the same goals.
The following lists parent and teacher
comments about the CDR Parent
Questionnaire and about parent teacher
conferences, including the Teachers
Observation Guide.
27

CDR Parent Questionnaire

Conferences allow me to take


comfort in the fact that for the most
part my child is developing
normally.

The comments seemed to be more


personal to who we think Zachary is.

I like that the forms are ongoing.

Parent Comments:

I like that this form is personal.

It gave us time before the conference


to think about it.

Provided opportunity for more


specific feedback.

Teacher Comments:

Made me think about different areas


of development.

On a daily basis there are usually 20


other things on my mind and the
review encouraged me to process the
developmental areas that my child is
in.

I like that the Teachers Observation


Guide is continuous (carries over
from conference to conference can
see improvements).

The breakdown of ages is very


informative.

I liked having the parents input


before the conference.

Gives parents a chance to see what


besides academics can help their
child learn.

Parents appreciated the conference


more because they were asked their
opinion ahead of time.

The last page was nice so that I could


add anecdotes and anything else
important about the particular child.

Helps me as a teacher learn more


about each child and shows me what
to work on.

Shows areas where children are


behind. It helps me to plan activities
to help get them up to speed.

Gives a wonderful summary of a


child both from the parents and
teachers perspective.

I wish that the booklet continued to


a higher age group (school age).

Teacher Comments:

Parent Teacher Conference, Including the


Teachers Observation Guide
Parent Comments:

The forms are similar to my


pediatricians forms.

It gave me ideas for what I can work


on at home.

I like that it compares what I saw


versus what you saw.

Conferences are an opportunity for


me to tell you how wonderful Alex
is.

28

SES IN HEALTH CARE, INCLUDING RESEARCH

Primary Care Pediatrics and Child Development Review


Robert H. Chesky, M.D.
Ann Arbor, Michigan
I am a solo pediatrician practicing in a
rural-suburban edge city north of the
Detroit metropolitan area. I have a special
interest in developmental-behavioral
pediatrics and am a member of that section
of the American Academy of Pediatrics.

cases where I distrust maternal literacy


skills. All new parents in my practice
receive a Child Development Chart so they
can better anticipate and appreciate the
course of normal development in the first
five years.
Children with problems on any of the brief
screening questionnaires are subsequently
assessed by means of the longer Child
Development Inventory. Low scores in the
Child Development Inventory are usually
followed up, after discussion with parents,
by referral to the public school
infant/toddler-preschool evaluation team,
with special attention called to the specific
patterns of low scores on the various
development scales of the instrument.

Experiences with Child Development


Review
In the past fifteen years, I have employed
or experimented with the Child
Development Inventory and its briefer
screening forms, such as the Infant
Development Inventory and the Child
Development Review. The Infant
Development Inventory and CDR Parent
Questionnaire are used at well child visits.
Occasionally, I also use the CDR Parent
Questionnaire for a structured interview in

Without any detailed analysis having been


done, I think it is fair to say that those
29

children identified in this scheme were


found to be either truly handicapped in
some way, or were borderline in their
development.

discovery (later usually confirmed by


school performance and/or testing) of a
small but significant number of
problematic patients who had been in my
practice for several years or from birth
without suspicions on my part. In these
patients, problems were sometimes in the
developmental domains; however, in other
cases, the MPI problem lists alerted me to
an array of other behavioral concerns that
parents had not voiced during previous
visits.

Parental Reactions
I explained my use of the Child
Development Review screening and
assessment tools to parents on the basis of
three principles:

My
commitment
to
early
identification of children with special
needs related to either developmental
or behavior problems.

Parents superior knowledge and


expertise about their childrens
development and learning.

Instruments like the Infant Development


Inventory, CDR and Child Development
Inventory offer pediatricians something of
an insurance policy against certain
important developmental and behavioral
concerns being lost in the shuffle of busy
high-volume practices.
Also, pediatricians are loath to convey to
parents the bad news that their children
may have problems that could interfere
with later performance in school and in life.
On this account, pediatricians may refrain
from raising developmental issues without
hard evidence to substantiate their
concerns. Standardized screening tools like
the Child Development Review tools, while
never substitutes for clinical judgment, are
one means of providing concrete
justification for raising such emotional
issues with parents and attempting to face
and resolve them by means of more
comprehensive assessments.

The increasing availability of publicly


supported free preschool early
intervention programs.

These principles of explanation appear to


be effective. I would estimate compliance
with both the brief, in-office tools and the
more time-consuming, at-home completion
of the Child Development Inventory, has
exceeded 95 percent.
Several parents have balked at referral to
public school teams for more detailed
evaluations, however, out of concerns
about their children being categorized and
labeled during the preschool years. Private
alternatives, both for evaluation and early
intervention, would seem to me to be
highly desirable, if not essential.

Parents are rarely offended or resistant to


opening up subjects for discussion when
the reasons for so doing are their own
concerns and observations about their
own children, treated with professional
respect and accorded a central place in
referral decisions.

I first became convinced of the utility of the


Child Development Review tools by
surveying, over two years, all entering
kindergartners from my practice by means
of the no longer extant Minnesota
Prekindergarten Inventory (MPI). My
personal, aha experience was the
30

Well Child Care Schedule for Child Development Review


At all visits parents are asked certain Key Questions. At some ages parents also are asked to
complete a parent questionnaire before the visit. Finally, the Child Development Chart can be
used as an observation guide at all well child visits. CDR procedures by age are described
below.

Procedures by Age:
All Visits:

Key Ages for


Parent Questionnaires:

Ask for parents questions and


concerns about childs health,
development, behavior, other.

Infant Development Inventory:


Ages 6 months and 15 months
Child Development Review:
Ages 2 years, 3 years and at
Pre-kindergarten visit (4 5 years)

Ask the parent, What has your


baby/child been doing lately?
Observe the infants/childs
behavior, using the appropriate Child
Development Chart, checking for
behaviors around the childs age level.

Concern: When you or the parent has


some concern about the childs
development or behavior, ask the
parent to complete one of the parent
questionnaires and obtain more
history.

Ask the parent how she/he is


doing?

Suspected Developmental Problems


For children with suspected developmental problems, a more detailed developmental interview
may be done using the instructions in the Child Development Review manual. Or the parent
may be asked to complete a Child Development Inventory. The Child Development Inventory is
an assessment level questionnaire that includes 270 developmental items and provides a profile
of the childs development in the following areas: social development, self-help, gross motor, fine
motor, expressive language, language comprehension, letter knowledge and number knowledge.
It also includes 30 problems items, similar to the CDR Parent Questionnaire.
See Appendix B: Child Development Inventory.

31

Child Development Chart for Developmental Screening


In a Family Practice Clinic
Terri Kohlrusch, R.N., C.P.N.P.
Health Partners/Ramsey-Amery Clinic
Amery, Wisconsin
Health Partners/Ramsey-Amery Clinic is a
Family Practice clinic in rural
Northwestern Wisconsin. It provides
health services to the surrounding
community along with the 35 bed attached
hospital. The clinics professional staff
includes nine family practice physicians, a
surgeon, a physicians assistant, and
myself, a pediatric nurse practitioner.

the local Public Health Departments back


into private clinic settings. This well-child
screening requires child developmental
screening as one of its components.
Over the past year I have worked to
standardize well baby/well child care in
our clinic. This has included implementing
a tool that we could use in the clinic setting
for screening and monitoring of child
development. I had experience working
with a variety of developmental screening
tools in my previous job as a consultant for
the Comprehensive Child Development
Program, a federally funded program out
of the Department of Health and Human
Services. I found the Child Development
Chart First Five Years to be
comprehensive, yet easy to use. The one
page sheet was preferable to the PreScreening Developmental Questionnaire,
which added an additional sheet in the
chart each visit.

Prior to my joining the staff in 1996, child


development was monitored in a variety of
ways, depending on the individual
practitioner. Two physicians used the
Denver forms in the chart as a checklist
monitor. Another used it in the drawer as a
guide, and the others would include
discussion of milestones in the historytaking session of well-child exams to
varying degrees.
Shortly after I began my practice, I
contacted the Birth to Three- Early
Intervention Program consultant, and the
Special Education Director from the Amery
School District.

We have been using the Child


Development Chart during well child visits
since 1996. At a recent meeting where this
was discussed, the providers were
generally pleased. Some suggestions that
we have to make this a better tool for a
clinic practice are:

The Birth to Three Program reported


referrals from the clinic were rare. The
School District also had concerns
regarding children with delays,
particularly speech, that were not being
picked up at an earlier age when
interventions would be most effective.
In addition, the State Health Check
Program (EPSDT) was being moved from
32

Lessen the areas where there are


gaps in the chart

Strengthen the tool in the speech


area, especially expressive language

is turn has led to more referrals also after


age three to the school district, and this
year they have hired an additional staff
person in the Special Education Program. I
am committed to working toward early
intervention services for children. It is more
cost-effective, but more important, it is
what is best for children. I would like to
use this opportunity to thank you for your
work and your commitment.

Checking three-year-olds on
prepositions, most do very well with
three, but many fail to understand
beside. Would behind be an
acceptable substitute?

Results: Since we started using the Child


Development Chart, the Birth to Three
Program has reported a significant increase
in referrals for developmental delays. This

Developmental Monitoring at the


Community-University Health Care Center
Mary Jordan, M.S., R.N., P.N.P.
Teena Pflum, M.A., R.N., P.N.P.
University of Minnesota
The Community University Health Care
C e n t e r is a partnership between the
University of Minnesota and various
community, county, and state resources.
The clinic was established in South
Minneapolis serving the poorest
neighborhoods of Phillips, Powderhorn,
and Longfellow in addition to serving
others from the four county regions.

Developmental Monitoring at CUHCC has


been done with Dr. Iretons screening tools.
These tools include the Child Development
Chart and two parent questionnaires the
Infant Development Inventory and the
Child Development Review Parent
Questionnaire. The Child Development
Chart is used to track childrens
developmental progress at each well child
visit and provide the necessary
documentation. The Denver II was the
previous screening tool used at the clinic.

The clinic offers medical, dental, and


mental health services for adults and
children. The majority of the
reimbursement is through medical
assistance. The diverse cultural population
served ranges from South East Asian (30%),
African American (30%), Native American
(20%), with the remainder being European
American, Somalian, Ethiopian, Russian,
and Mexican/Hispanic, Hmong, Laotian,
Vietnamese, and Cambodian. Interpreters
are on the staff with accessible Somali and
Spanish interpreters at the University. All
the care delivered at CUHCC is offered in a
culturally sensitive environment.

Parents of infants through 18 months of age


complete the Infant Development
Inventory (sometimes as an interview).
Parents of two- to five-year-olds complete
the CDR Parent Questionnaire. The
questionnaire is usually given to the
parent/care giver during the work-up
period prior to the well child visit with the
pediatrician or pediatric nurse practitioner.
The practitioner previews the parents
responses to the questionnaire to help focus
the visit. Information gained from the
33

questionnaire is recorded on the standard


well child form, as the questionnaire is not
currently a permanent part of the chart.

Denver when the two are done at the


same time, or closely

Our pediatric staff has been very happy


with the change from the Denver to Dr.
Iretons developmental screening tools. As
is well known, the Denver II is somewhat
time consuming with questionable yields of
anything except obvious delays. The
questions on the Infant Development
Inventory/CDR Parent Questionnaire are
direct and effectively illicit information on
how the infant/child and family are doing.
Both parent questionnaires immediately
identify issues that often deserve more
discussion and possibly more evaluation.

Like that it is all on the same sheet for


tracking

Much quicker and easier to use than


the Denver, especially if it does the
same thing

Easier for parents to understand.


Seems to correlate well with the

Good education tool for families

Easy and Quick Efficient way to do


overall screen

We now feel very confident assessing


childrens development with the Ireton
Child Development Review tools for two
reasons. First, we are identifying children
with developmental delays without
needing to perform a structured test. The
beauty of this tool is the ease with which it
can be used at each well child visit to
monitor young childrens development
over time. Also, this tool recognizes the
value of the parents knowledge of their
child. Parents are not threatened by
testing and are eager to talk about the
developmental progress of their children.
This leads to the second main reason for
valuing this tool, which is its educational
value for parents. This tool, especially the
Child Development Chart, provides a
complete, compact guide that parents can
use to monitor the development of their
own child. This guide, along with the
screening procedure, allows parent
education and anticipatory guidance to
flow during the well child visit.

Comments from Community University


Health Care Clinic Staff:
Very specific, age-related questions
for each group

Certainly an easier test for the


provider

Some concerns on checking the


language skills for preschoolers. Some
providers use the Denver for this part

Most importantly, Dr. Iretons


developmental tools are family friendly.
They are easy to read and understand and
readily lend themselves to educating the
parents/care givers on what to expect with
their childs development. Child
Development Charts can be handed out to
families, taken home and hung on the
refrigerator for easy reference. These
educated parents can then more readily
become active partners with pediatric
practitioners in ensuring growth and
development of their children.

In sum, this tool helps us to make sound


professional judgments about childrens
development, make referrals or intervene
when appropriate, as well as help parents
learn to monitor their childrens
development.

34

Following are examples of parents


responses to the parent questionnaires for
their infants, toddlers, and preschool age
children. These responses highlight the
range of issues that parents raise at well
child visits.

lately? Copying me, talking a lot, asking a


lot of questions . . .watching movies.

Infants:

Questions-concerns. I want to know what


to do because she is constipated a lot
since age two.

Childs strengths. Talking and explaining


everything also describing everything.
Problems or Disabilities? None.

Mother of a two-month-old boy: Describe


your baby. He likes to look around. Looks
at the animals. Looks at colors. Likes when
his sister picks him up. Cries at night.
Happy during the day.

How are you doing? Okay, I guess.


Working now and she is not used to that. I
think I get nervous also.

How are you doing as a parent? Im


tired.

Mother of a four-year-old, who is


concerned about her childs speech
problems.

Mother of nine-month-old girl: Describe


your baby. Bossy. She knows what she
wants. She likes people.

Describe your child. Hes smart. Always


want to do activities. He learns easily.

How are you doing as a parent? Two kids


are a lot to get around. Nice that they need
me. Nice having an older child to talk to
me now.

What has he been doing lately? Activities


in a book, singing school songs, and
playing.
Strengths? ?

Toddler:
Special problems/disabilities? I think he
has a small speech problem.

Mother of a sixteen-month-old girl:


Describe your baby. Her attitude has
changed! Likes to do stuff herself. Very
active. Climbs onto everything!

Questions concerns? Is he going to grow


out of the small speech problem?

Questions-concerns? Why does she throw


up cheese? Im getting a little worried
about having another baby (is pregnant).

How are you doing? Good.


Possible problems mother checked.

Preschoolers:

Mother of a three-year-old girl: Describe


your child. Energetic. I think shes
growing well. Talking a lot now. Becoming
independent. Whats she been doing

35

Does not talk well for age


Speech is difficult to understand
Cant sit still; may be hyperactive

Increasing Pediatric Residents' Discussion of Behavioral Problems


Barbara T. Felt, M.D.
Mary E. OConnor, M.D., M.P.H.
Division of General Pediatrics
University of Michigan School of Medicine
Ann Arbor, Michigan
Parents of Toddlers and Preschoolers
(N=257)

group (135). Physicians having the CDR


Parent Questionnaire results at the start of
the visit were more likely to identify and
discuss behavioral concerns and problems
with parents.

This study examines whether the use of a parent


questionnaire (the CDR P a r e n t
Questionnaire) before health maintenance
exams increases parent reporting and increases
resident discussion and documentation of
behavioral concerns for toddler and preschool
age children.

The authors conclude that Use of the CDR


Parent Questionnaire increased the rate of
identification and discussion of behavioral
issues . . . The parents were readily able to
complete the CDR Parent Questionnaire . . .
The use of the parent questionnaire may
have helped parents organize their
concerns and given them the message that
the doctor was interested in such issues.

Parents of toddlers and preschoolers in a


primary care clinic serving inner city, lowincome families completed the CDR Parent
Questionnaire prior to the well child visit
with the pediatric resident. Identification of
parents concerns regarding their childs
behavior was higher for parents
completing the CDR (122) than for a control

Ambulatory Pediatrics. 2003;


Vol. 3, 1. Pp.2-8 , 1998

Pediatric Screening for Developmental Disabilities in Armenia


William J. Barbaresi, M.D.
Community Pediatrics
Mayo Clinic
Rochester, Minnesota
In the former Soviet Republic of Armenia
and in the first years of the independent
Republic of Armenia, children with
developmental disabilities were largely
excluded from the mainstream of society.
Families were encouraged by pediatricians
to accept the fact that developmentally
disabled children were unlikely to lead a
happy, productive life. Children with
moderate to severe disabilities were

excluded from schools and shunted to


orphanages or institutions for the
developmentally disabled.
Primary pediatric care was, and still is,
delivered exclusively by pediatricians,
pediatric nurses and midlevel practitioners
similar to pediatric nurse practitioners in
the U. S. Pediatric health centers are
organized as large multi-specialty groups
36

called polyclinics, or, in rural communities,


as smaller units called ambulatories or
medical health posts. In the Soviet era,
children were to be seen an astounding 22
times for well child care during the first
year of life. The emphasis of these visits
was to accumulate and record a large
amount of data regarding physical growth
and development. There was little or no
attention paid to cognitive, behavioral or
social development.

expressed a desire to design a pilot project


to modernize and reform the Armenian
primary pediatric health care system.
Surprisingly, the Armenian officials
emphasized the need to include a program
of developmental screening. The initial
meetings were followed by a weeklong
educational and planning symposium
conducted by several U. S. physicians and
nurses and a group of leading Armenian
pediatricians.

Formal developmental screening was


conducted only between the ages of 6 and 8
years and consisted of a two-part test.
The first part required the child to draw a
person, copy a sentence, and copy a design
of dots. The second part required the child
to pronounce a series of difficult sounds
based on the Russian language. Outcomes
of this screening were to allow the child
to enter school, to suggest a series of fine
motor or speech articulation exercises or to
simply exclude the child from school.
Children with developmental, behavioral
or learning problems who managed to pass
the screening and enter school were
typically expelled from school once their
difficulties became apparent.

Subsequently, the U. S. group developed a


series of protocols for the pilot project. This
was followed by a six-month-long training
program with a goal of training 100
Armenian pediatricians and pediatric
nurses who practice in several urban and
rural sites. At the time that this report is
being written, the educational phase of the
project is ending with project
implementation set to begin in the next
several months. The two-year project will
include formal evaluation and monitoring,
and, if successful, will be used as a model
for modernizing the entire primary
pediatric care system.
In designing a program of developmental
screening and basic early intervention
services for the pilot project, several criteria
were considered. First, the tools used in
screening needed to be comprehensive,
including assessment of all major areas of
development and based on scientifically
sound norms for developmental
attainment. Second, the screening tools had
to be organized in a way that could be
taught to a group of physicians and nurses
who had virtually no experience or training
regarding child development. Third, the
tools needed to be translatable into
Armenian. Finally, the screening tools
needed to be cost and time efficient in
order to allow for their incorporation into a
primary care pediatric practice in a country
with limited financial resources. These
criteria led to the decision to employ the
Child Development Review developmental

After the dissolution of the Soviet Union,


Armenia was faced with a severe economic
crisis based on the almost total loss of
reliable energy sources. In the past several
years, as economic conditions have
gradually improved, the government has
solicited help from other countries to
modernize services provided to its citizens,
including health care.
Americares, a non-profit organization that
provides medical services to underserved
populations in the U. S. and abroad,
received
a
grant
from
an
Armenian/American foundation with a
request to develop a medical service project
in Armenia. Officials from the Armenian
ministry of health, during preliminary
meetings with Americares representatives,
37

screening and assessment instruments in


the Armenian Primary Care Pilot Project.

while also acknowledging that is would be


impossible, in the short term, to train the
Armenian staff to administer individual
psychometric and speech and language
tests.

The project protocols are divided into First


Stage Screening, Second Stage Screening,
and Early Intervention. Nurses and
pediatricians will use developmental
interviews, observation of the child, and
the parent-reported Infant Development
Inventory and the Child Development
Review Parent Questionnaire to complete a
developmental assessment at each wellchild visit. This information will be
recorded on the Child Development Chart,
which will be maintained in each childs
medical record.

Children with significant delays on the


Child Development Inventory become
eligible for a basic program of Early
Intervention. The specific criteria are
similar to those used in deciding to refer
the child for Second Stage Screening. In
essence, the Second Stage Screening
process is intended to confirm the presence
of developmental delays and to better
define the delays so that a basic Early
Intervention program can be designed for
the child. The criteria for referral for
Second Stage Screening and for receiving
Early Intervention services are based on
similar criteria used in early intervention
programs in the U.S.

Specific criteria have been established for


referral for Second Stage Screening. These
criteria include the presence of medical
conditions known to hinder normal
development (e.g. Downs Syndrome) or
demonstrating developmental concerns
during First Stage Screening.

Both the staff nurse and the childs parents


or guardian writes early intervention
services on a formal document that is
signed. The specific services vary
depending on the childs age and
problems. Children from ages 0 to 3 years
will receive services in the home while
children from 3 to 6 years will participate
in small Developmental Playgroups at the
local pediatric health center. Service plans
and goals will be formally reviewed every
6 months. Formal assessment with the CDI
will be conducted on an annual basis to
monitor progress, determine eligibility for
continued services and write a service plan
for the following year.

Developmental concerns are defined as


gross motor delays on three successive well
child visits in children under the age of 18
months, language delays in children
between the ages of 2 and 6 years and
children between the ages of 6 months and
6 years who have delays in any two or
more areas of development on two
successive well child visits. Delays are
defined according to the recommendations
contained in the Child Development
Review Manual.
Second Stage Screening and Early
Intervention are provided by a core group
of nurses who received an intensive
educational seminar conducted by U.S.
early childhood educators. Second Stage
Screening employs the Child Development
Inventory as the formal screening
instrument. The Child Development
Inventory was chosen with the recognition
of a need to obtain more detailed data
regarding the childs developmental status

The system of developmental screening


and early intervention in the Armenian
Primary Pediatric Pilot Project represents a
major step forward for the children of
Armenia. If successful, it may contribute to
a change in attitudes and practices
regarding developmentally disabled
children and adults. Clearly, if this
program is to be successful in the long
38

term, it will need to evolve beyond the


basic protocols which are outlined above.
Entirely new professional training
programs will need to be established for
early childhood educators, psychologists
and developmental pediatricians.
Eventually, the Armenians will need to
learn to provide more in-depth assessment
of
children
with
complicated
developmental problems.

Development Review instruments, may


remain as the foundation of an organized
system for providing high quality
scientifically sound developmental services
to the children of Armenia.
In September 2001, the pediatric protocols
introduced during the implementation of
the Armenian Primary Pediatric Pilot
Project were formally adopted by the
federal government of Armenia and now
serve as the national guidelines for all
pediatric primary health care and child
development.

However, the initial monitoring and


assessment of children during pediatric
encounters, employing the Child

39

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42