Developmental Screening Tools

Michelle M. Macias, MD
D-PIP Training Workshop
June 16, 2006

I have no relevant financial relationships with the manufacturer(s) of any commercial product(s)
and/or provider of commercial services discussed in this CME activity.

Learning Objectives
Understand

properties of good
screening tools
Review the screening tool grid

What is screening?
Use of a brief, objective, and validated instrument
Goal to help differentiate children that are probably
ok vs. those needing additional investigation- those
with unsuspected deviations from normal
Performed at a set point in time

9, 18,(24), 30 months

Objective vs. subjective impressions

Results always interpreted in context

Never in isolation
Aid to ongoing surveillance

Why Screen?
Most

obvious problems are the least

prevalent

New

morbidities

Cannot

rely solely on clinical judgment

for identification of developmental
problems

WHY SCREEN?

CLEARLY
NORMAL

CLEARLY
ABNORMAL

Benefits of Screening
Assists in sorting children into 3 categories:
Needs

screen

additional evaluation - Did not pass

Needs

close monitoring/surveillance- Passed

screen but has risk factors

Needs

ongoing monitoring in the context of

well-child care - Passed screen and has no
known risk factors

Screening Challenges

Use of informal checklists of developmental skills

Lack proof that they predict developmental status
Lack criteria to indicate when a referral is indicated

Informally eliciting parents concerns (Are you

worried about your childs development?)
Parents often not sure if they are worried
The word development is understood by only ~50% of
parents

Accuracy of clinical judgment

detects fewer than 30% of children who have
developmental disabilities

Developmental Screening Tools

Developmental

screening tools are used to

enhance the surveillance process and increase
detection rates
Parent-completed questionnaires
Directly administered instruments

Standards for Screening Tests

Standardized on national sample

Proof of reliability
ability of a measure to produce consistent results

Evidence of validity
ability of a measure to discriminate between a child at a
determined level of risk for delay (i.e. high, moderate)
from the rest of the population (low risk)

Standards for Screening Tests

Accuracy

in ability to categorize is measured

by:
Sensitivity: accuracy of the test in identifying
delayed development
Specificity: accuracy of the test in identifying
individuals who are not delayed

For developmental screening tests,

Sensitivity and Specificity of 70-80% are
acceptable

High Sensitivity Trade-off

Abnormal test result

Cutoff

Normal test result

false
positives

High Specificity Trade-off

cutoff

Abnormal test result

false
negatives

Normal test result

Standards for Screening Tests

Accuracy of the Denver-II

Developmental Diagnosis
NO

YES

PASS

69

86

FAIL

17

10

27

86
Sensitivity = 10/18 = 56%
Specificity = 69/86 = 80%

18

Denver-II

Screening Pitfalls

Relying on informal methods

Checklists!
provide no validated criteria for referral
have unknown reliability

Using a measure not suitable for primary care

(i.e. too long)
results in two things
using

tests only with selected patients, usually those

with observable problems
nonstandard administrations

Screening Pitfalls:
The Damage
Relying on informal methods
ignores the asymptomatic who are those most in
need of screening
Using a measure too time consuming for
primary care
reduces screens to the status of checklists with
their inherent lack of criteria and unproven
sensitivity and specificity

Lets Review the Developmental

Screening Tools Grid!

Developmental Screening Tools Grid:

Components

Organized from general

screening tools to
domain/disorder specific
screening tools

General Screens
Language and cognitive screens
Motor screens
Autism screens

Information

provided

Description
Age Range
Number of Items
Administration Time
Psychometric Properties
Scoring Method
Languages available
How to obtain
Key references

Developmental Screening Instruments:

General

Ages and Stages Questionnaire

Battelle Developmental Inventory (BDI) Screening Test
Bayley Infant Neurodevelopmental Screener (BINS)
Brigance Screens-II
Infant Development Inventory
Child Development Review
Child Development Inventory (CDI)
Denver-II Developmental Screening Test
Parents' Evaluation of Developmental Status (PEDS)

Developmental Screening Instruments:

Domain-specific
Gross

motor

Early Motor Pattern Profile (EMPP)

Motor Quotient (MQ)
Communication/Cognition

Capute Scales (aka Cognitive Adaptive Test/Clinical

Linguistic Auditory Milestone Scale-CAT/CLAMS)
Communication and Symbolic Behavior ScalesDevelopmental Profile (CSBS-DP): Infant Toddler
Checklist
Early Language Milestone Scale (ELMS -2)

Developmental Screening Instruments:

Disorder-specific
Autism and pervasive developmental disorders

Autism Behavior Checklist (ABC)

Checklist for Autism in Toddlers (CHAT)
Modified Checklist for Autism in Toddlers (M-CHAT)
Modified Checklist for Autism in Toddlers-23 (CHAT-23)
Pervasive Developmental Disorders Screening Test-II (PDDST-II) Stage 1-Primary Care Screener
Pervasive Developmental Disorders Screening Test-II (PDDST-II) Stage 2-Developmental Clinic Screener
Screening Tool for Autism in Two-Year-Olds (STAT)
Social Communication Questionnaire (SCQ) (formerly Autism
Screening Questionnaire-ASQ)

Examples: Parent Report Screens

Ages

and Stages Questionnaire (ASQ) 4

months to 6 years

Parents

Evaluation of Developmental
Status (PEDS) 0 to 8 years

Can parents be counted upon to give accurate

and good quality information?

YES!

Screens using parent report are as accurate as those

using other measurement methods
Tests correct for the tendency of some parents to
over-report
Tests correct for the tendency of some parents to
under-report

Can parents read well enough to

fill out screens?
Usually! But first ask,

Would you like to complete this on your

own or have someone go through it with
you?
Also, double check screens for completion and
contradictions

Ages and Stages Questionnaire

(ASQ) 4 months to 6 years

19 color-coded questionnaire for use at 4, 6, 8, 10, 12,

14, 16, 18, 20, 22, 24, 27, 30, 33, 36, 42, 48, 54, and 60
months

30 35 items per form describing skills

Completed by parent report

Taps most domains of development

Takes about 10-15 minutes, and 3 to score

ASQ-Social-Emotional works similarly and measures

behavior, temperament, etc.

Can be photocopied

ASQ Sample Items

1. When your child wants
something, does she tell you by
pointing to it?

Yes

4. Does your child say

eight or more words in
addition to Mama and
Dada?

Yes

Sometimes Not Yet

Sometimes Not Yet

ASQ Scoring
Assign a value of 10 to yes, 5 to sometimes, 0 to never
Add up the item scores for each area, and record these
totals in the space provided for area totals
Indicate the childs total score for each area by filling in
the appropriate circle on the chart below

Communication
Gross Motor
Fine Motor

Problem solving
Personal-social

Scores in shaded areas prompt a referral

PARENTS EVALUATION OF
DEVELOPMENTAL STATUS

For children 0 to 8 years

In English, Spanish, Vietnamese, Somali, Chinese
Takes 2 minutes to score
Elicits parents concerns
Sorts children into high, moderate or low risk for
developmental and behavioral problems
4th 5th grade reading level
Score/Interpretation form printed front and back
and used longitudinally

Two Directly Administered Screening

Tools
Bayley

Infant Neurodevelopmental Screener

(BINS)

Brigance

Screens-II

Bayley Infant Neurodevelopmental

Screener (BINS)
Takes 10 - 15 minutes
Assesses neurological processes (reflexes, and tone);
neurodevelopmental skills (movement, and symmetry)
and developmental accomplishments (object
permanence, imitation, and language)
Uses 10 - 13 directly elicited items per 3 - 6 month age
range
Categorizes performance into low, moderate or high risk
via cut scores. Provides subtest cut scores for each
domain
For use from 3 - 24 months

BINS Risk Scores

Brigance Screens
Takes 10 15 minutes of professional time
Produces a range of scores across developmental
domains
Relies primarily on observation and elicitation of
skills (0-2 year age range can be administered by
parent report)
Detects children who are delayed as well as
advanced
9 separate forms across 0 7 years of age
Each produces 100 points and is compared to an
overall cutoff
Available in multiple languages
Computer scoring software

How to Explain Screening Test

Results
Use

language that encourages follow-up

Avoid

Be

negative and meaningless words

sensitive to cultural meanings of words

Developmental Screening
Principles (AAP 2006)

When the results are normal:

Inform the parents and continue with other aspects of the
preventive visit
Provide an opportunity to focus on developmental
promotion

When administered due to concerns:

Schedule early return visit for additional surveillance, even if
the screening tool results do not indicate a risk of delay

When results are concerning:

Schedule developmental evaluations
Schedule medical evaluations

Developmental Screening:
Recommendations
Infants

and young children should be screened

for developmental delays using reliable and valid
screening techniques at 9,18,(24), 30 months

Use

of standardized developmental screening

tools at periodic intervals will increase accuracy

Use

parent-report questionnaires or directly

administered tools with sensitivity and specificity
of at least 70-80%