Available from:

Child Development Review Call: (612) 850-8700

Behavior Science Systems, Inc. Fax: (360) 351-1374

Box 19512 Web: http://www.ChildDevelopmentReview.com

Minneapolis, MN 55419-9998 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 theoriginal, I have a lot of people to thank, including parents as well as professionals. Thefollowing education and health care professional contributed experience and critique, articlesand research. I appreciate them as colleagues and friends.

From Education:

Arlene WrightKathy OfstedalKate HorstSheri GoldsmithTerri Heiserman

From Health Care:

Robert CheskyFrances GlascoeTerri KolruschMary JordanTenna PflumBarbara FeltMary OConnorWilliam Barberisi

Thank you all,

Harold Ireton

1Parents Concerns

Childs Development

Talking With Parents

CHILD DEVELOPMENT REVIEWChild Development Review is a research-based system for obtaining informationfrom parents, making your ownobservations of the child and integratingthese two sources of information toappreciate the childs functioning andneeds.

Child Development Review helps you:

Obtain information from parentsabout their child - including strengthsand any concerns the parents mayhave about the childs health,development and behavior.

Determine whether a childsdevelopment is typical for age or isdelayed in some regard.

Talk with parents and involve themmore effectively.

Child Development Review describesthe process of integrating information fromparents with your own observations oftheir child. It is also the name of the tooldescribed in this manual.

The Child Development Review (CDR) toolis for developmental screening of toddlers

and preschoolers. It includes a ParentQuestionnaire and a Child DevelopmentChart. The parent questionnaire is brief yetcomprehensive. It saves time by helpingyou focus your talk with parents to identifytheir concerns. There is a similarquestionnaire and chart for parents ofinfants called the Infant DevelopmentInventory (see Appendix).

The CDR helps you answer questionssuch as the following:

How satisfied or concerned is theparent about the childs health,development and/or behavior?

Childs Health: Are there any health,sensory or physical problems thatcould compromise the childs abilityto learn?

Childs Development: How well isthe child doing in the major areas ofdevelopment? What are the childsabilities, strengths and possibleproblems?

Childs Behavior: Is the childsbehavior and adjustment a concern?

2 How satisfied or concerned is theparent about his or her ownfunctioning as a parent?

The CDR Parent Questionnaire asksparents of toddlers and preschool agechildren to briefly describe their child andreport any questions or concerns. Theparent responds briefly to six questionsand a 25-item Problems Checklist.

The Child Development Chart on thebackside of the questionnaire coversdevelopment in the first five years in fiveareas: social, self-help, gross motor, finemotor and language. This chart can beused to interview the parent and recordinformation about the childs presentdevelopment, and to directly observe thechilds skills.

The CDR is used in a variety of educationaland health care settings. In EarlyChildhood Education, schools use the CDRas a screening tool. Teachers also use it forconferences and as a parent education tool.In Health Care, the CDR is commonly usedfor screening at Well Child visits.

Using the CDR to involve parents makes iteasier to talk and work with them tobenefit their children.

If a parents ability to read is in question,the information requested in the parentquestionnaire may be obtained byinterviewing the parent.

Research Base: The CDR format andcontent are the result of over thirty years ofresearch and clinical experience withlonger Child Development Inventories(Ireton 1972, 1992), followed by brieferscreening inventories including the InfantDevelopment Inventory (Ireton, 1988) andthe Preschool Development Inventory(Ireton, 1987).

Research using these inventories withtypical children, children at risk, andchildren with developmental disabilitieshas demonstrated the validity of parentsreports of their childrens development.This includes international research. Seepages 16-39..

CHILD STUDYThe following pages display the CDRParent Questionnaire and ChildDevelopment Chart and show the resultsfor a three-year-old boy.

CDR Parent Questionnaire: This child isdescribed as Friendly, affectionate, butsometimes very aggressive, and Talkinga lot more, asking for things. Sits stilllonger.

Childs strengths include: Usually happy,good helper, good physical coordination.

Parents Concerns include speech andoverly aggressive behavior.

Parents Functioning: My hectic schedulegets pretty crazy, but I will survive.

Child Development Chart: Results suggestdevelopment typical for age except forlanguage, which is borderline at the two-year level.

Recommendation: Check hearing andassess language development. Talk withmother about childs aggressive behavior.

3

4

5USING THE CHILD DEVELOPMENT REVIEWMost often, the CDR is used for briefscreening to help identify children withhealth problems, developmental delaysand behavior problems. It may also be usedfor a more thorough review of a childsdevelopmental skills, including strengthsas well as weaknesses.

For screening, use the Parent Questionnaireand/or the Child Development Chart. TheChart is used to ask the parent about thechilds present development and for directobservation.

Many physicians use the ChildDevelopment Chart for screening (and noParent Questionnaire) because it is similarto the Denver and they are not accustomedto using parent questionnaires. However,the questionnaire can help them save timeby acquiring valuable information fromparents before a Well Child visit.

Schools and teachers also value the ParentQuestionnaire because it provides a parent-

centered point of view for screening andparent conferences.

Combining parents concerns from theParent Questionnaire with developmentalstatus information from the ChildDevelopment Chart provides the mostpowerful option.

The comprehensive Child DevelopmentReview approach starts with the parentspicture of their child, including the childsabilities, strengths and possible problems.It considers the parents functioning as wellas the childs. It is parent education andcommunity resource focused, providinginformation to parents about both childdevelopment and community resources forparents of young children. It providesinformation and support to parents and isless intimidating than the traditionalscreening for deficits approach. For moredetails, see Child Development Days article,page 18, in Uses in Education section.

Parent Questionnaire: Interpreting Responses

When reviewing the parents answers tothe six questions, do the answers suggestthat . . .

The child and parent are doing wellor okay?

Some possible problem or cause forconcern exists?

A major problem may be present?

The parents responses to the six questionsmay be marked accordingly with one of thefollowing symbols:

OK No problems or doing well? Possible Problem ask for more

informationP Possible Major Problem ask for

more information and considerreferral

6Question Ratings, including frequencies:

1) Please describe your child briefly:Parents descriptions range all the wayfrom very positive, enthusiasticdescriptions that suggest the parentsdelight in the child to very negativedescriptions, i.e. aggressive, stubbornchildren who may be provoking strongnegative reactions from their parents.Strongly negative child descriptions mayexpress a parents frustration and be a riskfactor for potential child abuse.

In one preschool screening study1 of theCDR, only 2% of parents descriptions oftheir children were classified as stronglynegative.

2) What has your child been doing lately?This question asks the parent to describetheir childs present skills and is mostuseful when you decide to do adevelopmental interview (see page 10).

3) What are your childs strengths?The parents description of the childsstrengths helps you get a more balancedpicture of the childs functioning, ie,strengths vs. problems and concerns.

4) Does your child have any specialproblems or disabilities?Some children may have major healthproblems or physical or sensorydisabilities. Others may have seriousd e v e l o p m e n t a l d i s a b i l i t i e s o rbehavioral/emotional disorders. Still morechildren have lesser problems such asspeech, attention, or behavioral problemsthat are developmental in nature.

The purpose of the questions, Does yourchild have special problems or disabilities?What are they? is to identify anycondition of the child that has been

1 Based on results for 220 3 and 4 year-olds. Seepage 16.

identified by the parent or someprofessional as a significant, possiblymajor, problem or disability.

In the CDR research, this question wasanswered with some reported problem by15% of parents. Only 3% of parentsdescribed a problem that was classified as amajor problem or disability. Reportedproblems or disabilities ranged from left-handed to allergies to hearing tomultiple disabilities attending adevelopmental learning center. Themajority were physical-health problemsthat could interfere with learning.

5) What questions or concerns do youhave about your child?The purpose of this question is to obtaininformation about the childs less seriousproblems and the parents concerns. Thirty-eight percent of parents indicated that theyhad some question or concern about theirchild. Only 4% expressed concerns thatwere rated as a possible major concern. Themajority of concerns were about behavioralproblems, speech, attention, motorcoordination, or pre-academic skills.

6) How are you doing as a parent andotherwise, at this time?This question gives parents an opportunityto report any problems of their own. Theymay choose to ignore this question, sayfine or report distress. Including thisquestion recognizes the fact that childrensand parents functioning are intimatelyrelated and that parents also need supportand assistance.

Unfortunately, the parents functioning isseldom asked about in screening. It isprobably as important as the childsfunctioning, as it affects the child directly.

7Problems Checklist:

The Problems Checklist helps parentssystematically report their concerns and thechilds possible problems. This 25-item listcovers health, development and behavioralconcerns.

Parents of one to five-year-olds commonlycheck one or more problems regardingtheir childs health, development andbehavior.

Health: Parents report relatively few healthproblems (45 percent).

Development: When parents areconcerned about their child's development,it is most often that the child does not talkwell (9 percent) and more often for boysthan girls.

Behavior: Starting at age two, behaviorproblems are the most commonly reportedconcerns, more often for boys than girls.

CDR Problems Checklist - with Freq./Percentages reported for 1 to 5 Year-Olds (N=411)

1. Health Problems 4.514. Clumsy, walks or runs poorly,

stumbles or falls (ages 2 or older)1.5

2. Growth, height or weight problems 5.515. Clumsy in doing things with his

hands2.5

3. Eating problems eats poorly ortoo much, etc.

10.516. Immature; acts much younger

than age2.5

4. Bowel and bladder problems, toilettraining

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, stomachaches, head aches, etc.

11.5 19. Disobedient; does not mind well 6.5

7. Energy problems; appears tired andsluggish

8CHILD DEVELOPMENT CHARTUse the Child Development Chart to determine WHAT and HOW WELL the child is doing infive areas of development social, self help, gross motor, fine motor and language. Use theparents 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 youngchildren. The behaviors on the chart are placed at the age level during which at least 75% ofchildren 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 theparent, 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 moremature behaviors to determine just how well the child is doing. If the child is well below agelevel in an area, ask about younger age behaviors to determine the childs highest level offunctioning.

If the child is lagging behind in an area of development, draw a line across the chart at thebelow-age cutoff line, which is 70% of the childs age (Child Development Chart Below-AgeCutoff Conversion Table on next page).

Results:For screening, use the checked behaviors to appreciate the childs highest level of function inan area. Use the Bs as additional information about anticipated development.

For each area of development, classify the results as suggesting typical, borderline or delayeddevelopment.

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 asweaknesses. Use these results in relation to any parental concerns about Health,Development or Behavior.

9This Below-Age Cutoff Conversion Table shows where to draw the cutoff line on the CDC.

Current Age 70% of Age Current Age 70% of Age

6 m 4 m 3 y, 3 m 2 y, 3 m

7 m 5 m 3 y, 4 m 2 y, 4 m

8 m 5.5 m 3 y, 5 m 2 y, 4 m

9 m 6.5 m 3 y, 6 m 2 y, 5 m

10 m 7 m 3 y, 7 m 2 y, 6 m

11 m 7.5 m 3 y, 8 m 2 y, 6 m

12 months 8.5 m 3 y, 9 m 2 y, 7 m

13 m 9 m 3 y, 10 m 2 y, 8 m

14 m 10 m 3 y, 11 m 2 y, 9 m

15 m 10.5 m Four Years Old 2 y, 9 m

16 m 11 m 4 y, 1 m 2 y, 10 m

17 m 12 m 4 y, 2 m 2 y, 11 m

18 m 12.5 m 4 y, 3 m 2 y, 11 m

19 m 13 m 4 y, 4 m 3 y, 0 m

20 m 14 m 4 y, 5 m 3 y, 1 m

21 m 14.5 m 4 y, 6 m 3 y, 1 m

22 m 15 m 4 y, 7 m 3 y, 2 m

23 m 16 m 4 y, 8 m 3 y, 3 m

Two Years Old 16.5 m 4 y, 9 m 3 y, 4 m

2 y, 1 m 17.5 m 4 y, 10 m 3 y, 4 m

2 y, 2 m 18 m 4 y, 11 m 3 y, 5 m

2 y, 3 m 19 m Five Years Old 3 y, 6 m

2 y, 4 m 19 m 5 y, 1 m 3 y, 6 m

2 y, 5 m 20 m 5 y, 2 m 3 y, 7 m

2 y, 6 m 21 m 5 y, 3 m 3 y, 8 m

2 y, 7 m 21 m 5 y, 4 m 3 y, 8 m

2 y, 8 m 22 m 5 y, 5 m 3 y, 9 m

2 y, 9 m 23 m 5 y, 6 m 3 y, 10 m

2 y, 10 m 23 m 5 y, 7 m 3 y, 11 m

2 y, 11 m 2y, 0 m 5 y, 8 m 3 y, 11 m

Three Years Old 2 y, 1 m 5 y, 9 m 4y, 0 m

3 y, 1 m 2 y, 2 m 5 y, 10 m 4 y, 1 m

3 y, 2 m 2 y, 2 m 5 y, 11 m 4 y, 1 m

10

Child Development Interview

Review the CDR Parent Questionnairebefore interviewing the parent. Whenreviewing the parents answers, determinewhether this is a child about whom theparent has no particular concern orwhether the parent is concerned or worriedabout the child. Then review the parentsresponses with them, giving them a chanceto clarify or add to what they have written.Identify the childs strengths and specialabilities as well as any problems, alongwith the parents questions and concernsabout the child.

If the parent has not completed thequestionnaire, offer them a chance to do so,or the alternative of simply talking to youabout these questions. If you are aware thatthe parent has a limited educationalbackground (less than high school) or thatthere are cultural or language factors thatmay cause difficulty completing thequestionnaire, simply include the questionson the questionnaire as the initial part ofyour developmental interview.

The parent interview may be limited toreviewing and discussing the parentsanswers to the questionnaire. Alternatively,the interviewer may proceed to do a fulldevelopmental interview.

The purpose of the developmentalinterview is to determine what the child isdoing in the five areas of developmentlisted on the back of the questionnaire.The developmental interview is keyed tothe parents description of what yourchild has been doing lately and to thebehaviors on the chart.

The specific wording of your questions is lessimportant than a natural approach that iscomfortable to the parent.

1. Please tell me what (childs name) hasbeen doing lately.

Preview the parents response to thisquestion on the Parent Questionnaireand/or ask the parent this question as afirst step in the developmental interview.

The parents spontaneous report gives theparent a chance to talk about their child inher own way. It also gives the intervieweran opportunity to note behaviors that arereported and to tentatively determine theage level behaviors that may need to besurveyed. When a parent mentions abehavior from the developmental chart,check (!) the behavior on the chart.

2. Please tell me more about . . .

Begin the second level of questioning byasking for more information in the area ofdevelopment that the parent hasmentioned the most. For example, if thearea is gross motor: Tell me more abouthow your child is getting around fromplace to place. If it is in language: Howmuch is your child talking? What is hesaying?

The language area is the most complex areato review. You need to determine:

how much the child is talking.

how understandable his or her speech is.

how much he or she understands.

3.Does your child______________? orIs your child ________________?

At the third level of questioning, withineach area of development, you need to ask

11

specific questions about the behaviorslisted on the chart. Ask Does yourchild..? then state the behavior. Check thebehaviors to which the parent answersyes. You may also mark some behaviorswith a B for just beginning. Repeat thisprocess in all five areas.

When asking about specific behaviors, becareful not to create expectations or to askleading questions that would influence theparent to answer based on what they thinkthe child should be doing. Ask thesequestions in a Does? or Is? form. Donot ask, Can your child . . .?

Where to begin the DevelopmentalInterview: You may use the childs age asyour guide and begin with items that areone age interval below the childs actualage. For example, for an eighteen-month-old, start at age twelve months. This is lessthreatening to parents who then have someopportunity to report on their childsachievements before they have to say, No,

my child doesnt do that. In this regard, itis encouraging to parents to end by brieflysummarizing some of the childsdevelopmental achievements.

When to stop: For each area ofdevelopment, there is no point in askingabout developmentally more mature itemswhen the child is reported as not doingless mature items. STOP when all itemswithin a given age interval are answeredNo. STOP when three items in a row areanswered No. STOP when the child hasdemonstrated functioning at least at agelevel, unless you are interested inevaluating advanced development. STOPwhen you think it makes sense to stop.

The full developmental interview isconducted in this three-step fashion.*To save time, the interviewer may omitsteps one and two, refer to the ChildDevelopment Chart, and simply ask aboutbehaviors in each area around the childsage level.

Using the Child Development Chart for Observation

You may also use the Child DevelopmentChart to observe what a child is doing.Whether you observe the child in youroffice, a child care setting, or at home, thechilds spontaneous behavior providescritical information about his or herdevelopment, adjustment, and well-being.

When age-appropriate play materials areavailable, the child will naturally seek themout 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 andtrucks. Crayons and pencils will be used invery simple, complex, or even symbolicways from marking and scribbling to

drawing and printing. Similarly, when achild follows directions or answersquestions, she reveals her level ofunderstanding.

The areas of development and thebehaviors described in the CDR ChildDevelopment Chart can be used to assistyour observation of the childs behavior.They also function as indicators of what toask the child to do or say at various ages.

You can use the Parent Questionnairequestions to ask parents to describe thechild as you observe him or her, makingspecial note of the childs social behaviorand response to the parent or to you.

12

Child Development Chart: Educating Parents and Professionals

The Child Development Chart can also beused as a handout to parents andprofessionals in order to provide them withan overview of child development in thefirst five years. The following informationdescribes the major areas of developmentand guidelines for appreciating a range ofnormal. If a child is functioning below thisrange in some area of development, this isa basis for concern and referral.

Areas of Development First Five Years

Social Self Help Gross Motor Fine Motor Language Numbers and Letters (Age 2, 3+)

Social Development includes response toand interaction with parents, othercaregivers and children from individualinteraction to group participation.

Self Help skills include eating, dressing,bathing, toileting, independence andresponsibility.

Gross Motor skills include moving aboutby rolling over, walking, running, jumpingor riding. Balance and coordination areimportant. Clumsiness for age can be asymptom of a physical problem.

Fine Motor includes eye-hand coordination visually following objects, reaching forand picking up objects (small toys, blocks,cereal bits), scribbling and drawingpictures.

Language includes three components:talking, speech intelligibility, and language

comprehension. Simple expressivecommunication may be exhibited bygestures (pointing), sounds and words, orsimple and complex sentences. Speechrefers to how understandable the child isand how well the child articulates speechsounds. Comprehension or understandingof language, from simple instructions toconcepts, is a critical issue. Low languagecomprehension may reflect a hearingproblem or a problem in understanding.

Numbers and Letters from age two tothree years, children show a beginningunderstanding of quantity, numbers andcounting, letters and reading. These are thereadiness skills we look for inpreschoolers as they approachkindergarten age, along with languagecomprehension.

Developmental Milestones - TheDevelopmental skills listed in each area ofthe Child Development Chart are placed inthe age range by which children havetypically developed these skills (75% ofchildren). For example, 75% of children arewalking independently by age 12-15months, so this behavior sits in the chart inthe 12-15 month range.

Range of Normal - How Well is ThisChild Doing? This is the question thatparents and professionals all want toanswer. Is this child doing well, doing andlearning the things that you would expectfor a child this age? Or is this childsdevelopment in some area(s) less thanwould be expected for his/her age? Forexample, is this three-year-old talking likea three-year-old, or like a two-year-old, orless than a two-year-old?

13

Cultural Sensitivity

The Child Development Chart, includingthe developmental skills and norms, isbased on a sample of children from SouthSaint Paul, Minnesota. The majority ofthese children were white (95%). Schoolage children in this community, as a group,demonstrate average ability.

Using this Chart in other communities andwith children of diverse culturalbackgrounds should be preceded by acareful review of its contents. For somecommunities/cultures, modifications in theChart may be necessary (see below).

It is important to know each childslanguage background. What is the childsprimary language? What about the parentslanguage?

Some of the behaviors in the ChildDevelopment Chart involve the use ofmaterials that may not be available in somehomes. Examples are blocks, scissors, anddrawing materials. For these behaviors,mark No Opportunity (NoOp). If possible,provide parents with safe, age appropriatematerials that stimulate learning, such asblocks and drawing materials.

In some cultures, Self Help skills such aseating involve the use of different utensils,for example: chopsticks, rather than spoons

and forks, or different norms, for example:the age toilet training is attempted.

Social games vary widely in differentcultures, so that games in the chart such apeek-a-boo and patty-cake do notoccur or have different names. Examples atolder ages are playing board games or cardgames. Here it is important to recognize thedevelopmental skill that is being identified,not the specific game. For example, patty-cake involves stimulating the baby toimitate the parents behavior and thebabys ability to imitate. At older ages,social games involve understanding simplerules, taking turns, and accepting direction.

The challenge for each child and family isto help the childs parents identify andstimulate the major developmental skillsthat emerge in young children and tor e i n f o r c e t h e i r d e v e l o p m e n t .Understanding child development, culturalvariations of expression, and individualparent/family interests and needs providesthe basis for being helpful to them andtheir children.

If a child appears to be behind in some areaof development, it is important to do aproper assessment and not be too quick toexplain away the apparent delay.

14

Parents are the experts on their children.

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

WORKING WITH PARENTSYour knowledge of child development andyour experience in talking with parentsabout their children provide the basis formaking effective use of the CDR. The CDRis one means to help you organize whatyou are already doing. It provides asystematic method for gatheringinformation, for creating a record of thechilds development, and for talking withparents.

Most parents welcome the opportunity totalk about their children and what they aredoing. Often they worry about how theirchild is doing or at least have somequestions about their child. Starting withwhat they have told you about their childand adding your own observations workswell.

Key in on their expectations, theirquestions and their concerns, then usewhat they know and what you know aboutthe child in relation to their questions. Forexample, the mother of a four-year-old maybe concerned about her childs speech andlanguage development and also may notknow how articulate children this ageusually are. Using the CDR ParentQuestionnaire and your professional

judgment can ensure that questions such asthese are answered accurately andhelpfully. You may also have questionsthat you need to raise about the child.

Just how you use the Child DevelopmentReview with parents depends on who theyare and on your own situation. You maywant to have the parents fill it out prior tomeeting with them. You may want toprovide them with a copy of the ChildDevelopment Chart after your discussionwith them, including their childsdevelopmental achievements, or use it as apart of your discussion.

In doing the review, remember that whatparents need most is affirmation of theirchilds achievement and recognition oftheir efforts as parents. This is especiallytrue when their child has a problem ordisability or they are discouraged.

Parents who recognize that their child has aproblem are usually easier to communicatewith than parents who are hearing abouttheir childs possible problems for the firsttime. Sensitivity, tact and timing areimportant when discussing a childsproblems and needs.

15

Connecting Parents With Community Resources

Parents need information fromprofessionals about community resourcesand how to access them. Healthprofessionals and child care/educationprofessionals who see children early intheir development need to be informedabout, and to inform parents about,community resources available for parentsand children.

The following are examples of resources inMinnesota and nationwide that benefityoung children and their parents. Otherstates have similar resources.

Early Childhood Family EducationPrograms Minnesota offers parenteducation to all families with children frombirth to kindergarten. Available in mostcommunities (parents contact their localschool), it provides a variety of programsfor parents and children including: parentdiscussion groups, activities for children,parent-child interaction activities, specialevents for families, home visits, screeningfor health and developmental problems,lending libraries with books for parentsand toys and learning materials forchildren.

The Parent Warmline Sponsored byChildrens Hospitals and Clinics inMinneapolis/St. Paul, Minnesota, this freetelephone consultation service providessupport, information, practical advice andresource referral about parenting, childdevelopment, and behavior.

Parent Warmline is available to parents ofyoung children, day care providers, familymembers and other interested professionals

in the Twin Cities and surroundingcommunities. The Warmline addressesconcerns such as toilet training, sleepdisruptions, discipline, feeding, and eatingdifficulties. The volunteer professional staffspecial izes in early chi ldhooddevelopment, provides support for stressedparents and directs parents to additionalcommunity resources as needed.

Head Start and Early Head Start HeadStart early intervention programs havebenefited millions of preschool agechildren from low-income families. Morerecently, Early Head Start programsprovide educational and related servicesfor infants and toddlers and their parents.Head Start, more than any other earlyeducation programs, has stressed parentinvolvement and parent education.Participating parents learn about childdevelopment and learning and abouteducating young children. To find HeadStart in your area, visit their web site:http://www.nhsa.org.

Early Childhood/Special Education Thepublic schools are required to provide earlyintervention services to infants, toddlersand preschoolers with physical, sensory, ordevelopmental disabilit ies. Earlyidentification of these children isaccomplished by outreach programs,which let parents know that their childsvision, hearing and development can bescreened through their local school system.Screening serves to identify children inneed of further assessment. Then theschools specialists direct parents toresources to assist them and their children.

16

17

USES IN EDUCATION, INCLUDING RESEARCH

The first two articles in this section describe the validity of the CDR ParentQuestionnaire for screening.

The articles in this and the following section are brief descriptions of some uses andstudies. More examples can be found in the book, The Child Development Inventoriesin Education and Health Care (Ireton et al, 1997). Many of the following articles canalso be found there in a more detailed form.

Preschool Screening: CDR Validity For ScreeningHarold Ireton, Ph. D.University of Minnesota

Three and Four-year-olds (N=220)

This study determined the accuracy ofparents CDR reports for screening fordevelopmental and related problemsamong three and four year olds. Thesechildren were being screened for health,vision and hearing, and development aspast of the South Saint Paul, Minnesotaschools preschool screening program.

South Saint Paul is a working classprimarily white community that isrepresentative of many communities.Children in this community have anaverage IQ of 100. Most parents are highschool graduates (83%), some are collegegraduates (14%) and a few have notcompeted high school (3%).

Two-hundred-and-twenty children werescreened using the D.I.A.L. developmentaltest: 53 children (24%) were referred forfollow-up assessment based on test results.Forty-one children were assessed. As aresult, 25 received preschool special

education services (11% of childrenscreened).

Parents CDR reports were obtainedindependent o f the s tandarddevelopmental testing.

The frequencies of parents responses to thesix CDR questions and problems checklistthat suggested possible problems werealready described on pages six and sevenof this manual.

Here we describe the accuracy of parentsreports of problems or no problems asindicators of childrens needs for specialeducation services. Parents CDR reports ofproblems/no problems were compared tochildrens subsequent placement in earlychildhood special education.

CDR Parent Questionnaire results(questions 1, 4, 5 plus problems checklist)were classified as indicating 1 = Noproblem; 2 = Possible problem; and 3 =Possible major problem. The CDR overall

18

results for each child were similarlyclassified.

Results: CDR overall results (questionsplus problems list) identified the majority(68%) of special education students andindicated no significant problems for thelarge majority (88%) of the other childrenwho passed screening. In technical terms,sensitivity is .68; specificity is .88.

Parents of special education students(n=25), when compared to parents of otherchildren (n=195), more often reported signsof problems on the PQ as follows:

CDR Questions and Problems List:

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 morecommon among the 25 children placed inspecial education. These include:

Does not seem to see well.

Does not talk well for age.

Speech is difficult to understand.

Does not seem to understand well.

Clumsy, awkward; runs poorly.

Clumsy doing things with hands.

Immature; acts much younger thanage.

Passive; seldom shows initiative.

The two items in bold print above werestrong predictors of future poorperformance in kindergarten, based onteachers ratings.

These results indicate that parents CDRreports provide accurate indicators ofchildrens developmental problems andneed for follow-up assessment. Mostparents recognize and report theirchildrens problems. Parents should bemore systematically involved in screeningand assessment to determine theirchildrens functioning and needs.

19

Wisconsins Child Development Days: Parent Education and ScreeningArlene WrightChippewa Falls, Wisconsin

Harold Ireton, Ph.D.University of Minnesota

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

This article describes a comprehensiveapproach for supporting and educatingparents of young children, age 2 1/2 to 31/2, and for identifying those children whoneed further evaluation for exceptionaleducation needs. Professionals fromeducation, public health, social services,and child care collaborate to provideparents with information about childdevelopment and community resources;have early childhood teachers observechildren in a play setting; respond toparents questions and concerns; and talkwith parents about the teachersobservations of the child. Parents concernsand teachers observations are used toidentify children for follow-up assessmentfor possible early childhood/specialeducation services, or to refer parents toother services.

Developed through community schoolsand other agency collaboration, thisprogram takes the same positive approachto screening as Child Development Review.It emphasizes childrens strengths as wellas possible problems and special needs.

Child Development Days Goals: In aneffort to meet the needs of families,children, school districts, agencies, andultimately the community, the followinggoals for Child Development Days wereestablished.

Educate parents about early childdevelopment

Provide parents with informationabout community resources in the

areas of education, child care,medical/health, and family supportand services.

Help identify those children whomay be in need of furtherassessment in the following areas:development, vision and hearing,health.

Model Description: Public and parochialschools, Head Start, birth-to-3 earlyintervention programs, childcare, socialservices, public health, and othercommunity service providers collaborate toplan, implement, and evaluate communityChild Development Days. Parents of 2 1/2-to 31/2-year-old children are located andidentified through a school census. A massmedia campaign including school flyers,local TV, and radio advertising is used tolocate children not on the current schoolcensus. Parents are sent an invitation toattend Child Development Days and areasked to call the community coordinator ofthe project (local school district or othercommunity coordinator) to make anappointment for their child. A letter is sentto the parent confirming the time of theirappointment, along with the CDR ParentQuestionnaire to be returned when theyattend the onsite review.

The onsite screening review includes

Parent questions and concernsr e g a r d i n g c h i l d s h e a l t h ,development, adjustment, addressedby screening staff

20

Childs development by earlychildhood teachers observation in aplay setting

Hearing screening by an audiologistor another trained individual

Vision and health screening by anurse

Parent/Child Friendly Atmosphere: ChildDevelopment Days is parent and childfriendly by design. Parents are invited toChild Development Days as a positiveopportunity to talk about their childsdevelopment and needs and to learn aboutcommunity resources. Children areobserved at play in a natural setting ratherthan tested.

Community Resource Fair: While the childis being observed in the play setting,parents have an opportunity to meet withrepresentatives of the community agencies.The agency displays are located in or nearthe room used for the childrens play, soparents are never far from their children.The displays are an important part ofdeveloping an awareness of the resourcesavailable in the community in the areas ofearly childhood education, childcare,health care, and family support.Participating agencies include family/childguidance clinics, childcare resource andreferral agencies, social service agencies,public library, county public healthdepartment, the police and firedepartments, the Red Cross, YMCA, andthe United Way.

Public and parochial school kindergartenteachers are on hand to answer parentsquestions and concerns. The display tablesare filled with materials and examples ofdevelopmentally appropriate activities thatparents can provide for their children. Thelocal Head Start and Birth-to-3 earlyintervention services provide information

concerning services they can offer to youngchildren and their families.

Parent Teacher Exit Conference: Followingthe play-based observation of the child, theparents have an opportunity to talk to theearly childhood teacher who has observedtheir child. The discussion includes theparents report of the childs presentdevelopment, the parents questions andconcerns, the teachers observations of thechild, and the hearing, vision, and healthscreening results. First, the teacher reviewsthe CDR Parent Questionnaire results.

The discussion begins with the parentsoffering their perception of their child,including any questions and concerns theparent may have. Using the CDR ChildDevelopment Chart, the teacher asksparents, What has your child been doinglately?

Next, the teacher describes his or her ownobservations of the child. The discussion isbalanced between the parents comments,questions and concerns and the teachersobservations. At the end of the conferencesome parents are provided withinformation regarding referral for earlychildhood/special education assessment orfor other services. All parents are given acopy of the CDR Child Development Chart,which shows what their child is doing inthe development of skills. The conferencetakes about 15 minutes.

Program Evaluation: In 1990, the ChildDevelopment Days program was initiatedin two Wisconsin communities, ChippewaFalls and Cornell. Currently, the programis being used in over 100 Wisconsincommunities. The results described hereare for 29 school districts. Two thousand,two hundred twenty-five 2 1/2 to 3 1/2-year-old children participated. Thepopulation size of this age group rangedfrom 40 to 350. The impact of ChildDevelopment Days was evaluated by

21

reviewing the results in terms of (a)parent/child participation, (b) referral ratesof children for various services, and (c)results of questionnaires completed byparents and professionals.

Program Benefits:

Among the 2,225 children seen, 8% (n=173)were referred for multidisciplinary teamevaluation to determine eligibility for earlychildhood/special education service.Thirteen parents declined to participate.

Of the 160 children who were assessed,73% (n=123) were determined to be eligiblefor early childhood/special educationservices and received early intervention.

An additional nine percent (n=213) ofchildren/families who were not referredfor assessment, were, however, directedtoward other community resourcesincluding Head Start, social services, publichealth or audiologists.

Implications: Broadening our view of earlychildhood screening using the ChildDevelopment Days model provides moreopportunities to benefit parents andchildren in general. Modifying ourmethods to focus on parents and earlychildhood teacher observations ofchildrens behavior instead of dependingprimarily on developmental screening testscreates a more natural parent- and child-friendly experience and still provides amechanism to help identify children withspecial education needs. ChildDevelopment Days provides parents withan opportunity to discuss their childsdevelopment and to learn more about childdevelopment and community resources.

The Child Development Review systemprovides for an integrated approach for (a)reviewing childrens development withparents, (b) responding to parents

questions or concerns, and (c) educatingand supporting parents. Parents responsesto the program evaluation questionnaireindicate that they benefited from theprocess and that it was more useful to themthat a traditional screening for disabilitiesprogram.

The validity or accuracy of screeningdecisions based on the Child DevelopmentDays model cannot be conclusively definedby the available data. The referral rate forassessment for early childhood/specialeducation of 8% seems to be reasonable;73% of the children referred and assessedwere found to be eligible for specialeducation services.

However, the children who passed thescreening received no subsequentassessment. Therefore, no measure or indexof the number of children with specialeducation needs who passed the screeningis available. Results of a one-timeobservation of a childs functioning,whether by testing or professionalobservation, are open to question. A one-time screening may not be representative ofthe childs typical functioning. Because theChild Development Days model combinesinformation from parents with teacherobservations, the data are more likely to beaccurate.

Child Development Days makes parentsmore community-wise by providing aResource Fair where parents learn aboutavailable resourced and how to use them.Based on parents and professionalevaluations, Child Development Daysappears to be a successful collaborativemulti-community effort. Perhaps thegreatest strength of Child DevelopmentDays is its collaboration at all levels; (a)between the Wisconsin Department ofPublic Instruction and the 30 schooldistricts served by Cooperative EducationalService Agency #10 through an IDEA 99-457 Discretionary grant award, (b) between

22

an early childhood educator (first author)and a child psychologist (second author),(c ) among community agencyrepresentatives who organized local ChildDevelopment Days programs, and (d)between early childhood teachers andparents working together to reviewchildrens development and needs.

Collaboration among some agencies andschool districts who were initially involvedin the Child Development Days model hasexpanded to include initiation of integratedprograms for young children, developmentof joint community councils workingtoward improved services for families, andfunding proposals and grant awards toestablish family/child resource centers.The process of forming collaborative effortswithin the community becomes asimportant as the day itself. Child

Development Days provides anopportunity for family and child servicesproviders to get to know one another andto convey to the community and to parentstheir common concern for the wellbeing ofboth children and parents.

This community service projectdemonstrates the value of enlarging theconcept of screening to includeDevelopmental Review. This systematicmethod combines parent reports withteachers observations, and provides aparent education and support focus aswell as a child-centered focus.

Wright, A. & Ireton, H. (1995). Innovative Practices Child Development Days: A New Approach toScreening for Early Intervention. Journal of EarlyIntervention, Vol. 19, No. 3, 253-263.

23

Parent Teacher Conferences Using the CDR Parent QuestionnaireKathy 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 heldparent teacher conferences twice a year.After several years of experience, I realizedI was not really zeroing in on problemareas that needed to be dealt with, andimmediately started to look for a tool to useto help me.

After attending a presentation describingthe CDR Parent Questionnaire, I decided touse it to help me prepare for my parentteacher conferences. I had never askedparents, before a conference, to tell meabout their child, and the idea intriguedme. I sent out the questionnaire in Octoberand asked the parents to fill it out andreturn it one week before their scheduledconference in November (see above letter).I was overwhelmed with the response Ireceived.

First of all, the parents were excited to tellme all about their children, and weretouched that I would care enough to ask!This immediately established a rapportbetween the parents and me that continuedto build all year long. This was invaluableto me the children already trusted me,now the parents did too.

Secondly, many more issues were talkedabout and dealt with than I had everexperienced before. I found out that mostof the parents really enjoyed and lovedtheir children. I also found that manywanted to do a better job of parenting andwanted advice about improving parentingskills

One of the most beneficial outcomes of thisreview, however, was parents sharing with

24

me real concerns they had about theirchildren. In many cases I had carefullyconsidered how to approach parents aboutthese same concerns, but now I didnt haveto bring them up they approached me!The parents never became defensive as weboth worked toward the common goal ofhelping their child.

As I read the statements describingpossible problems their child might have, Ilooked up information for them in ourParent Resource Library and in mypersonal resources, or directed them toothers who could help. We caught someproblems early on and many parentsdeveloped some great new parenting skills.I believe my whole year of teaching wentsmoother and I accomplished more becauseI learned so much about my children andtheir families early in the year.

Parents Concerns Research

Parents responses to the CDR question,What questions or concerns do you haveabout your child? were classified todetermine the frequencies of variousconcerns and questions (N=46 parents ofthree-, four- and five-year-olds). As shownon right, parents are more often concernedabout their childs behavior than with theirdevelopment and learning. Childrensadjustment to preschool and their speech-language development are commonconcerns or at least questions. Parents arealso asking for explanations and advicefrom their childs teacher. They wish to betaught how to help their child in variousways.

CDR Parent Questionnaire:

Parents Questions and Concerns

Question/Concern N %

Childs School Adjustment 7 15

Development/Maturity 2 4

Kindergarten Readiness 2 4

Speech/Language Problems 7 15

Behavior Problems/Discipline(from shy to aggressive)

20 43

Routines Sleeping, Eating,Toileting

5 11

Health Concerns 2 4

Explanations (Why does s/he?) 2 4

How Tos (Promote self-esteem,discipline, etc.)

4 8

25

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 CareCenter provides early childhood educationand child care services to children ofUniversity students, staff and facultyparents. The center, located near the maincampus, is designed to serve 155 childrenage three months to kindergarten. Acompanion program provides child careresource and referral information toparents. The center is under the UniversityCollege of Education. The program is aneducational resource to University facultyand students for purposes of observation,training and research. The center has tieswith the University Center for EarlyEducation and Development and theInstitute of Child Development, includingtheir laboratory nursery school program.

The system described here is based on thefollowing principles:

A. The Teacher stands at the center ofthe assessment and educationalplanning process.

B. Making best use of information fromparents and working closely withthem benefits children, parents andteachers.

C. Parent teacher conferences provide ameans for educational planning withparents.

D. Teachers need to answer two mainquestions about children in theirprogram: How do I appreciate the

development and learning of eachchild? What can others and I do toassess and help those children whoare not doing well?

We prefer to speak of Appreciation ratherthan assessment because Appreciationmeans to value or admire, to be fully awareof something, to have an understanding ofthat thing, such as a work of art or a child.Appreciation is a more positive, richer,subtler idea than assessment. To harmonizethe two, if your assessment of a youngchild is done with a full appreciation ofchild development and the complexity ofeach child, then the assessment will bedevelopmentally appropriate.

The following describes the three mainelements of the assessment system at theUniversity of Minnesota Child Care Center.This system was designed to be parent,child and teacher-friendly (Ireton andGoldsmith, 1994). Comments andsuggestions of parents and teacherscontributed to the development of thissystem. This system is described in detail inthe Teachers Observation Guide Manual.

A. Teachers Observations: Teachersobserve children to learn about eachchilds interests, adjustment to theCenter, development, learning,personal style and educational needs.To assist them in their observations,teachers use an observation guide:either the Cataldo Early ChildhoodCompetencies Profile (Cataldo, 1983)or the CDI Teachers Observation

26

Guide (Ireton, Goldsmith, 1995). Useof these observation tools encouragesa systematic approach to observation.Teachers observat ions aresummarized on the TeachersObservation Guide Summary Sheet.

B. Parents Observations: Parentscomplete the CDR ParentQuestionnaire or Infant DevelopmentInventory before their scheduledparent teacher conference to describetheir child and their childs interests,strengths, and social adjustment.They are also asked, What questionsor concerns do you have about yourchild?

C. Parent Teacher Conference: Theteacher reviews the parent responsesto the parent questionnaire prior tothe conference. This helps the teacheranticipate the parents questions andconcerns. The teacher begins theconference by keying in on theparents questions and concerns, andthen adds her own observations of thechild. The parent teacher conferencethen becomes a partnership in whichthe special knowledge of both parentsand teacher contributes to planningfor the childs education and care.

If parent teacher conferences are held twicea year, the CDR Parent Questionnaire isused in the fall and the longer, more in-depth Child Development Inventory maybe used in the spring. Whateveralternatives fit your program, a system forassessment and educational planning canbe developed using some of these methods.If a childs development is questionable,the longer Child Development Inventoryprovides more information.

What Teachers Say About the CDR ParentQuestionnaire:

It gives parents an opportunity toexpress their concerns.

It gives teachers information aboutwhether the parents and teacher areon the same wavelength.

It eliminates surprises for the teacher.

It helps determine the focus of theconference. It reveals the parentsinterests.

It provides teachers with anopportunity to educate parents . . .Forexample, What is normal for age?

27

Ongoing Assessment: Integrating Assessment with EducationTerri HeisermanDirector, Christ Memorial Tender Learning CenterPlymouth, Minnesota

Christ Memorial Tender Learning Center isowned by Christ Memorial LutheranChurch in Plymouth, Minnesota. Our childcare center serves families and theirchildren ages six weeks through fourthgrade. Currently our program is licensed toserve 99 children (14 infants, 21 toddlers, 40preschoolers and 24 school-age children).We offer full day child care as well as anursery school program for preschool-agedchildren. For the most part the families thatwe serve are middle to upper class. We doserve four children who receive countyfunding and we serve six children throughthe Wayzata School Districts LearningReadiness program. We also havescholarship money available and currentlyfour children are receiving those funds.

Tender Learning Center has been using anIntegrated Assessment System, includingthe Infant Development Inventory, TheCDR Parent Questionnaire and theTeachers Observation Guide since Octoberof 1995. We use these items as tools forparent teacher conferences, which are heldtwice a year. Previously we had struggledwith several different forms used forconferences.

The teachers track the childrensdevelopment in the Teachers ObservationGuide Booklet periodically and then usethe information gained to set goals for eachchild. It is shown to the parents atconference time and we gain informationfrom the parents then as to items that theymay see being performed at home. It workswell as a partnership between the centerand home.

Prior to the actual conference, we sendparents the Infant Development Inventoryor the CDR Parent Questionnaire. We askthat parents complete and return the parentquestionnaire to us prior to the conference.This allows the staff the opportunity toresearch information if there are concernsfrom the parent prior to the conference (anexample may be toilet training tips for achild who is not showing any signs ofinterest by age three).

In a couple of instances, this process hasaffirmed some of the gut feelings thestaff had about children with delays. Atconference time we are able to show theparent the items their child should beperforming. We then have suggestedmaking referrals to doctors or to the schooldistricts early intervention program.Several children are now receiving specialservices.

The staff and parents seem to reallyappreciate this process of tracking eachchilds development. Conferences now seea collaboration of information gatheringrather than teachers doing most of thereporting.

The parents are able to see what theyshould be expecting from their childsdevelopment. This directly benefits thechild as parents and teachers are workingon the same goals.

The following lists parent and teachercomments about the CDR ParentQuestionnaire and about parent teacherconferences, including the TeachersObservation Guide.

28

CDR Parent Questionnaire

Parent Comments:

I like that this form is personal.

It gave us time before the conferenceto think about it.

Provided opportunity for morespecific feedback.

Made me think about different areasof development.

On a daily basis there are usually 20other things on my mind and thereview encouraged me to process thedevelopmental areas that my child isin.

Teacher Comments:

I liked having the parents inputbefore the conference.

Parents appreciated the conferencemore because they were asked theiropinion ahead of time.

Parent Teacher Conference, Including theTeachers Observation Guide

Parent Comments:

The forms are similar to mypediatricians forms.

It gave me ideas for what I can workon at home.

I like that it compares what I sawversus what you saw.

Conferences are an opportunity forme to tell you how wonderful Alexis.

Conferences allow me to takecomfort in the fact that for the mostpart my child is developingnormally.

The comments seemed to be morepersonal to who we think Zachary is.

I like that the forms are ongoing.

Teacher Comments:

I like that the Teachers ObservationGuide is continuous (carries overfrom conference to conference cansee improvements).

The breakdown of ages is veryinformative.

Gives parents a chance to see whatbesides academics can help theirchild learn.

The last page was nice so that I couldadd anecdotes and anything elseimportant about the particular child.

Helps me as a teacher learn moreabout each child and shows me whatto work on.

Shows areas where children arebehind. It helps me to plan activitiesto help get them up to speed.

Gives a wonderful summary of achild both from the parents andteachers perspective.

I wish that the booklet continued toa higher age group (school age).

29

USES IN HEALTH CARE, INCLUDING RESEARCH

Primary Care Pediatrics and Child Development ReviewRobert H. Chesky, M.D.Ann Arbor, Michigan

I am a solo pediatrician practicing in arural-suburban edge city north of theDetroit metropolitan area. I have a specialinterest in developmental-behavioralpediatrics and am a member of that sectionof the American Academy of Pediatrics.

Experiences with Child DevelopmentReview

In the past fifteen years, I have employedor experimented with the ChildDevelopment Inventory and its brieferscreening forms, such as the InfantDevelopment Inventory and the ChildDevelopment Review. The InfantDevelopment Inventory and CDR ParentQuestionnaire are used at well child visits.Occasionally, I also use the CDR ParentQuestionnaire for a structured interview in

cases where I distrust maternal literacyskills. All new parents in my practicereceive a Child Development Chart so theycan better anticipate and appreciate thecourse of normal development in the firstfive years.

Children with problems on any of the briefscreening questionnaires are subsequentlyassessed by means of the longer ChildDevelopment Inventory. Low scores in theChild Development Inventory are usuallyfollowed up, after discussion with parents,by referral to the public schoolinfant/toddler-preschool evaluation team,with special attention called to the specificpatterns of low scores on the variousdevelopment scales of the instrument.

Without any detailed analysis having beendone, I think it is fair to say that those

30

children identified in this scheme werefound to be either truly handicapped insome way, or were borderline in theirdevelopment.

Parental Reactions

I explained my use of the ChildDevelopment Review screening andassessment tools to parents on the basis ofthree principles:

My commitment to ear lyidentification of children with specialneeds related to either developmentalor behavior problems.

Parents superior knowledge andexpertise about their childrensdevelopment and learning.

The increasing availability of publiclysupported free preschool earlyintervention programs.

These principles of explanation appear tobe effective. I would estimate compliancewith both the brief, in-office tools and themore time-consuming, at-home completionof the Child Development Inventory, hasexceeded 95 percent.

Several parents have balked at referral topublic school teams for more detailedevaluations, however, out of concernsabout their children being categorized andlabeled during the preschool years. Privatealternatives, both for evaluation and earlyintervention, would seem to me to behighly desirable, if not essential.

I first became convinced of the utility of theChild Development Review tools bysurveying, over two years, all enteringkindergartners from my practice by meansof the no longer extant MinnesotaPrekindergarten Inventory (MPI). Mypersonal, aha experience was the

discovery (later usually confirmed byschool performance and/or testing) of asmall but significant number ofproblematic patients who had been in mypractice for several years or from birthwithout suspicions on my part. In thesepatients, problems were sometimes in thedevelopmental domains; however, in othercases, the MPI problem lists alerted me toan array of other behavioral concerns thatparents had not voiced during previousvisits.

Instruments like the Infant DevelopmentInventory, CDR and Child DevelopmentInventory offer pediatricians something ofan insurance policy against certainimportant developmental and behavioralconcerns being lost in the shuffle of busyhigh-volume practices.

Also, pediatricians are loath to convey toparents the bad news that their childrenmay have problems that could interferewith later performance in school and in life.On this account, pediatricians may refrainfrom raising developmental issues withouthard evidence to substantiate theirconcerns. Standardized screening tools likethe Child Development Review tools, whilenever substitutes for clinical judgment, areone means of providing concretejustification for raising such emotionalissues with parents and attempting to faceand resolve them by means of morecomprehensive assessments.

Parents are rarely offended or resistant toopening up subjects for discussion whenthe reasons for so doing are their ownconcerns and observations about theirown children, treated with professionalrespect and accorded a central place inreferral decisions.

31

Well Child Care Schedule for Child Development Review

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

Procedures by Age:

All Visits:

Ask for parents questions andconcerns about childs health,development, behavior, other.

Ask the parent, What has yourbaby/child been doing lately?

Observe the infants/childsbehavior, using the appropriate ChildDevelopment Chart, checking forbehaviors around the childs age level.

Ask the parent how she/he isdoing?

Key Ages forParent Questionnaires:

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)

Concern: When you or the parent hassome concern about the childsdevelopment or behavior, ask theparent to complete one of the parentquestionnaires and obtain morehistory.

Suspected Developmental Problems

For children with suspected developmental problems, a more detailed developmental interviewmay be done using the instructions in the Child Development Review manual. Or the parentmay be asked to complete a Child Development Inventory. The Child Development Inventory isan assessment level questionnaire that includes 270 developmental items and provides a profileof the childs development in the following areas: social development, self-help, gross motor, finemotor, 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.

32

Child Development Chart for Developmental Screening

In a Family Practice Clinic

Terri Kohlrusch, R.N., C.P.N.P.Health Partners/Ramsey-Amery ClinicAmery, Wisconsin

Health Partners/Ramsey-Amery Clinic is aFamily Practice clinic in ruralNorthwestern Wisconsin. It provideshealth services to the surroundingcommunity along with the 35 bed attachedhospital. The clinics professional staffincludes nine family practice physicians, asurgeon, a physicians assistant, andmyself, a pediatric nurse practitioner.

Prior to my joining the staff in 1996, childdevelopment was monitored in a variety ofways, depending on the individualpractitioner. Two physicians used theDenver forms in the chart as a checklistmonitor. Another used it in the drawer as aguide, and the others would includediscussion of milestones in the history-taking session of well-child exams tovarying degrees.

Shortly after I began my practice, Icontacted the Birth to Three- EarlyIntervention Program consultant, and theSpecial Education Director from the AmerySchool District.

The Birth to Three Program reportedreferrals from the clinic were rare. TheSchool District also had concernsregarding children with delays,particularly speech, that were not beingpicked up at an earlier age wheninterventions would be most effective.

In addition, the State Health CheckProgram (EPSDT) was being moved from

the local Public Health Departments backinto private clinic settings. This well-childscreening requires child developmentalscreening as one of its components.

Over the past year I have worked tostandardize well baby/well child care inour clinic. This has included implementinga tool that we could use in the clinic settingfor screening and monitoring of childdevelopment. I had experience workingwith a variety of developmental screeningtools in my previous job as a consultant forthe Comprehensive Child DevelopmentProgram, a federally funded program outof the Department of Health and HumanServices. I found the Child DevelopmentChart First Five Years to becomprehensive, yet easy to use. The onepage sheet was preferable to the Pre-Screening Developmental Questionnaire,which added an additional sheet in thechart each visit.

We have been using the ChildDevelopment Chart during well child visitssince 1996. At a recent meeting where thiswas discussed, the providers weregenerally pleased. Some suggestions thatwe have to make this a better tool for aclinic practice are:

Lessen the areas where there aregaps in the chart

Strengthen the tool in the speecharea, especially expressive language

33

Checking three-year-olds onprepositions, most do very well withthree, but many fail to understandbeside. Would behind be anacceptable substitute?

Results: Since we started using the ChildDevelopment Chart, the Birth to ThreeProgram has reported a significant increasein referrals for developmental delays. This

is turn has led to more referrals also afterage three to the school district, and thisyear they have hired an additional staffperson in the Special Education Program. Iam committed to working toward earlyintervention services for children. It is morecost-effective, but more important, it iswhat is best for children. I would like touse this opportunity to thank you for yourwork and your commitment.

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 CareCenter is a partnership between theUniversity of Minnesota and variouscommunity, county, and state resources.The clinic was established in SouthMinneapolis serving the poorestneighborhoods of Phillips, Powderhorn,and Longfellow in addition to servingothers from the four county regions.

The clinic offers medical, dental, andmental health services for adults andchildren. The majority of thereimbursement is through medicalassistance. The diverse cultural populationserved ranges from South East Asian (30%),African American (30%), Native American(20%), with the remainder being EuropeanAmerican, Somalian, Ethiopian, Russian,and Mexican/Hispanic, Hmong, Laotian,Vietnamese, and Cambodian. Interpretersare on the staff with accessible Somali andSpanish interpreters at the University. Allthe care delivered at CUHCC is offered in aculturally sensitive environment.

Developmental Monitoring at CUHCC hasbeen done with Dr. Iretons screening tools.These tools include the Child DevelopmentChart and two parent questionnaires theInfant Development Inventory and theChild Development Review ParentQuestionnaire. The Child DevelopmentChart is used to track childrensdevelopmental progress at each well childvisit and provide the necessarydocumentation. The Denver II was theprevious screening tool used at the clinic.

Parents of infants through 18 months of agecomplete the Infant DevelopmentInventory (sometimes as an interview).Parents of two- to five-year-olds completethe CDR Parent Questionnaire. Thequestionnaire is usually given to theparent/care giver during the work-upperiod prior to the well child visit with thepediatrician or pediatric nurse practitioner.The practitioner previews the parentsresponses to the questionnaire to help focusthe visit. Information gained from the

34

questionnaire is recorded on the standardwell child form, as the questionnaire is notcurrently a permanent part of the chart.

Our pediatric staff has been very happywith the change from the Denver to Dr.Iretons developmental screening tools. Asis well known, the Denver II is somewhattime consuming with questionable yields ofanything except obvious delays. Thequestions on the Infant DevelopmentInventory/CDR Parent Questionnaire aredirect and effectively illicit information onhow the infant/child and family are doing.Both parent questionnaires immediatelyidentify issues that often deserve morediscussion and possibly more evaluation.

Most importantly, Dr. Iretonsdevelopmental tools are family friendly.They are easy to read and understand andreadily lend themselves to educating theparents/care givers on what to expect withtheir childs development. ChildDevelopment Charts can be handed out tofamilies, taken home and hung on therefrigerator for easy reference. Theseeducated parents can then more readilybecome active partners with pediatricpractitioners in ensuring growth anddevelopment of their children.

Comments from Community UniversityHealth Care Clinic Staff:

Very specific, age-related questionsfor each group

Like that it is all on the same sheet fortracking

Much quicker and easier to use thanthe Denver, especially if it does thesame thing

Easier for parents to understand.Seems to correlate well with the

Denver when the two are done at thesame time, or closely

Certainly an easier test for theprovider

Good education tool for families

Some concerns on checking thelanguage skills for preschoolers. Someproviders use the Denver for this part

Easy and Quick Efficient way to dooverall screen

We now feel very confident assessingchildrens development with the IretonChild Development Review tools for tworeasons. First, we are identifying childrenwith developmental delays withoutneeding to perform a structured test. Thebeauty of this tool is the ease with which itcan be used at each well child visit tomonitor young childrens developmentover time. Also, this tool recognizes thevalue of the parents knowledge of theirchild. Parents are not threatened bytesting and are eager to talk about thedevelopmental progress of their children.

This leads to the second main reason forvaluing this tool, which is its educationalvalue for parents. This tool, especially theChild Development Chart, provides acomplete, compact guide that parents canuse to monitor the development of theirown child. This guide, along with thescreening procedure, allows parenteducation and anticipatory guidance toflow during the well child visit.

In sum, this tool helps us to make soundprofessional judgments about childrensdevelopment, make referrals or intervenewhen appropriate, as well as help parentslearn to monitor their childrensdevelopment.

35

Following are examples of parentsresponses to the parent questionnaires fortheir infants, toddlers, and preschool agechildren. These responses highlight therange of issues that parents raise at wellchild visits.

Infants:

Mother of a two-month-old boy: Describeyour baby. He likes to look around. Looksat the animals. Looks at colors. Likes whenhis sister picks him up. Cries at night.Happy during the day.

How are you doing as a parent? Imtired.

Mother of nine-month-old girl: Describeyour baby. Bossy. She knows what shewants. She likes people.

How are you doing as a parent? Two kidsare a lot to get around. Nice that they needme. Nice having an older child to talk tome now.

Toddler:

Mother of a sixteen-month-old girl:Describe your baby. Her attitude haschanged! Likes to do stuff herself. Veryactive. Climbs onto everything!

Questions-concerns? Why does she throwup cheese? Im getting a little worriedabout having another baby (is pregnant).

Preschoolers:

Mother of a three-year-old girl: Describeyour child. Energetic. I think shesgrowing well. Talking a lot now. Becomingindependent. Whats she been doing

lately? Copying me, talking a lot, asking alot of questions . . .watching movies.

Childs strengths. Talking and explainingeverything also describing everything.Problems or Disabilities? None.

Questions-concerns. I want to know whatto do because she is constipated a lot since age two.

How are you doing? Okay, I guess.Working now and she is not used to that. Ithink I get nervous also.

Mother of a four-year-old, who isconcerned about her childs speechproblems.

Describe your child. Hes smart. Alwayswant to do activities. He learns easily.

What has he been doing lately? Activitiesin a book, singing school songs, andplaying.

Strengths? ?

Special problems/disabilities? I think hehas a small speech problem.

Questions concerns? Is he going to growout of the small speech problem?

How are you doing? Good.

Possible problems mother checked.

Does not talk well for age Speech is difficult to understand Cant sit still; may be hyperactive

36

Increasing Pediatric Residents' Discussion of Behavioral Problems

Barbara T. Felt, M.D.Mary E. OConnor, M.D., M.P.H.Division of General PediatricsUniversity of Michigan School of MedicineAnn Arbor, Michigan

Parents of Toddlers and Preschoolers(N=257)

This study examines whether the use of a parentquestionnaire (the CDR P a r e n tQuestionnaire) before health maintenanceexams increases parent reporting and increasesresident discussion and documentation ofbehavioral concerns for toddler and preschoolage children.

Parents of toddlers and preschoolers in aprimary care clinic serving inner city, low-income families completed the CDR ParentQuestionnaire prior to the well child visitwith the pediatric resident. Identification ofparents concerns regarding their childsbehavior was higher for parentscompleting the CDR (122) than for a control

group (135). Physicians having the CDRParent Questionnaire results at the start ofthe visit were more likely to identify anddiscuss behavioral concerns and problemswith parents.

The authors conclude that Use of the CDRParent Questionnaire increased the rate ofidentification and discussion of behavioralissues . . . The parents were readily able tocomplete the CDR Parent Questionnaire . . .The use of the parent questionnaire mayhave helped parents organize theirconcerns and given them the message thatthe doctor was interested in such issues.

Ambulatory Pediatrics. 2003;Vol. 3, 1. Pp.2-8 , 1998

Pediatric Screening for Developmental Disabilities in Armenia

William J. Barbaresi, M.D.Community PediatricsMayo ClinicRochester, Minnesota

In the former Soviet Republic of Armeniaand in the first years of the independentRepublic of Armenia, children withdevelopmental disabilities were largelyexcluded from the mainstream of society.Families were encouraged by pediatriciansto accept the fact that developmentallydisabled children were unlikely to lead ahappy, productive life. Children withmoderate to severe disabilities were

excluded from schools and shunted toorphanages or institutions for thedevelopmentally disabled.

Primary pediatric care was, and still is,delivered exclusively by pediatricians,pediatric nurses and midlevel practitionerssimilar to pediatric nurse practitioners inthe U. S. Pediatric health centers areorganized as large multi-specialty groups

37

called polyclinics, or, in rural communities,as smaller units called ambulatories ormedical health posts. In the Soviet era,children were to be seen an astounding 22times for well child care during the firstyear of life. The emphasis of these visitswas to accumulate and record a largeamount of data regarding physical growthand development. There was little or noattention paid to cognitive, behavioral orsocial development.

Formal developmental screening wasconducted only between the ages of 6 and 8years and consisted of a two-part test.The first part required the child to draw aperson, copy a sentence, and copy a designof dots. The second part required the childto pronounce a series of difficult soundsbased on the Russian language. Outcomesof this screening were to allow the childto enter school, to suggest a series of finemotor or speech articulation exercises or tosimply exclude the child from school.Children with developmental, behavioralor learning problems who managed to passthe screening and enter school weretypically expelled from school once theirdifficulties became apparent.

After the dissolution of the Soviet Union,Armenia was faced with a severe economiccrisis based on the almost total loss ofreliable energy sources. In the past severalyears, as economic conditions havegradually improved, the government hassolicited help from other countries tomodernize services provided to its citizens,including health care.

Americares, a non-profit organization thatprovides medical services to underservedpopulations in the U. S. and abroad,r e c e i v e d a g r a n t f r o m a nArmenian/American foundation with arequest to develop a medical service projectin Armenia. Officials from the Armenianministry of health, during preliminarymeetings with Americares representatives,

expressed a desire to design a pilot projectto modernize and reform the Armenianprimary pediatric health care system.Surprisingly, the Armenian officialsemphasized the need to include a programof developmental screening. The initialmeetings were followed by a weeklongeducational and planning symposiumconducted by several U. S. physicians andnurses and a group of leading Armenianpediatricians.

Subsequently, the U. S. group developed aseries of protocols for the pilot project. Thiswas followed by a six-month-long trainingprogram with a goal of training 100Armenian pediatricians and pediatricnurses who practice in several urban andrural sites. At the time that this report isbeing written, the educational phase of theproject is ending with projectimplementation set to begin in the nextseveral months. The two-year project willinclude formal evaluation and monitoring,and, if successful, will be used as a modelfor modernizing the entire primarypediatric care system.

In designing a program of developmentalscreening and basic early interventionservices for the pilot project, several criteriawere considered. First, the tools used inscreening needed to be comprehensive,including assessment of all major areas ofdevelopment and based on scientificallysound norms for developmentalattainment. Second, the screening tools hadto be organized in a way that could betaught to a group of physicians and nurseswho had virtually no experience or trainingregarding child development. Third, thetools needed to be translatable intoArmenian. Finally, the screening toolsneeded to be cost and time efficient inorder to allow for their incorporation into aprimary care pediatric practice in a countrywith limited financial resources. Thesecriteria led to the decision to employ theChild Development Review developmental

38

screening and assessment instruments inthe Armenian Primary Care Pilot Project.

The project protocols are divided into FirstStage Screening, Second Stage Screening,and Early Intervention. Nurses andpediatricians will use developmentalinterviews, observation of the child, andthe parent-reported Infant DevelopmentInventory and the Child DevelopmentReview Parent Questionnaire to complete adevelopmental assessment at each well-child visit. This information will berecorded on the Child Development Chart,which will be maintained in each childsmedical record.

Specific criteria have been established forreferral for Second Stage Screening. Thesecriteria include the presence of medicalconditio