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Developmental Screening in the Primary Care Setting
Dr Kang Ying QiAssociate Consultant
Child Development UnitNational University Hospital
28 May 2016
Content
1. Overviewofterminologyandconcepts2. ImportanceofPrimaryCaresetting3. Importanceofdevelopmentalscreening4. SingaporeHealthBooklet5. MCHAT6. Vanderbiltassessmentscale7. PediatricSymptomChecklist
OverviewofConceptsandTerminology
Culture
CommunityChildren’s servicesSupport forparentingHousing Family
FamilyrelationshipsParentingstylesandvaluesFinancialsituationParent’slevelofeducation/occupationParent’sphysicalandmentalhealthSiblings
Factorsinfluencingachild’sdevelopment
ChildGeneticinheritanceTemperamentGenderPhysicalHealth
DevelopmentalDomains
Tervo R.RedFlagsandRulesofThumb:SortingOutDevelopmentalDelay.GilletteChildren’s SpecialtyHealthcare:APediatricPerspective2009;18:1.
DevelopmentalQuotient(DQ)=DevelopmentalAge x100ChronologicalAge
• DQ=100→average• DQ<70→significantdelay
>2 domain
WHYPrimaryCareSetting?
Ongoingrelationship
Agerelateddevelopmentalmanifestation
1– 2%
8 %
Familyfactorsandtrust
1in6childrenwithdevelopmentaldelayordisorder
LianWB,HoSKY, YeoCLetal.GeneralPractitioners’KnowledgeonChildhood DevelopmentalandBehavioural Disorders.SingaporeMedJ2003;44:397.
WHYDevelopmentalscreening?
DetectionMethods
DevelopmentalSurveillance
DevelopmentalEvaluation
http://www.medmerits.com/index.php/article/developmental_delay_in_children_evaluation_and_management/P2
Halfdetectedbefore5yearsold
HamiltonS.Screeningfordevelopmentaldelay:Reliable,easy-to-usetools.JFamPract 2006;55:415.
Developmentaldisordersexistasaspectrum
Language
DevelopmentalSurveillance
DevelopmentalEvaluation
DevelopmentalScreening
http://www.medmerits.com/index.php/article/developmental_delay_in_children_evaluation_and_management/P2
EarlyInterventionMatters.
DevelopmentalSurveillance
DevelopmentalScreening
Glascoe FP.ScreeningforDevelopmentalandBehavioralProblems.Ment RetardDevDisabil ResRev2005;11:173.HamiltonS.Screeningfordevelopmentaldelay:Reliable,easy-to-usetools.JFamPract 2006;55:415.
Toolsforscreeningfordevelopmentaldelays
DenverDevelopmentalScreeningTest(DDST)developedin1989
LimHC,ChanT,Yoong T.StandardisationandAdaptationoftheDenverDevelopmentalScreeningTest(DDST)andDenverIIforUseinSingaporeChildren.SingaporeMedJ 1994;35:156.LimHC,HoLY,GohLYetal.TheFieldTestingofDenverDevelopmentalScreeningTest,Singapore:ASingaporeVersionoftheDenver IIDevelopmentalScreeningTest.AnnAcad Med
• Objective:Theaimofthisstudywastoinvestigateparents'perceptionsofdevelopmental checklistsandthechilddevelopmentmonitoring scheduleintheSingaporehealthbooklet.
• Method:Parentsofchildrenaged2years6months to3years11monthswithorwithoutdevelopmentalconcerns(n=450)completedastructured interview,andtheirchild'shealthbookletswerereviewed.
• Results:Mostparentsreported readingandusing thedevelopmental checklists.However,onlyabouthalfofthemattemptedthechecklistswithminimalhelpfromprofessionals.Approximately7in10parentsofchildrenwithdevelopmental concernsfound thechecklistsuseful foridentifying concernsabouttheirchild.Despitepositivefeedbackfromparentsaboutthechecklists,onlyabout1in4parentsbrought theirchildfora2to3yearsdevelopmentalmonitoring visitatthetimeofthesurvey,andthecompletion ratesofthechecklistswerelessthandesirable.
• Conclusions:Further revisionstothechecklistscanincludesimplifying thewordsandsentencesandproviding relevantpicturestoaidunderstanding. Ifthechecklistsaretobeusedforscreening,standardizationofhowthechecklistsaretobecompletedandhowchildrenatriskofdevelopmentaldelayscanbeidentified onthechecklistsneedtobeprovided.Parents'awarenessoftheimportanceofevaluatingtheirchild'sdevelopmentat9months, 18months,andparticularlyat2.5years,needstoberaised.Developmental screeningforchildrenatthesecriticalagescanbemademandatory.Anelectronicversionofthehealthbookletislikelytofacilitateimplementation ofdevelopmental screeninginthehealthcaresystem.
Journal ofDevelopmentalandBehavioural Pediatrics:JDBP2016May5
11timepoints fordevelopmentsurveillanceandscreening
Othersimilarscreeningtoolsareyettobecomparable
PersonalCommunication.KKHDCDPhysiciansandPsychologists.April2014.Kiing J,LowPS,ChanYHetal.InterpretingParents’ConcernsaboutTheirChildren’sDevelopmentWithTheParentsEvaluationofDevelopmentalStatus:CultureMatters.JDevBehav Pediatr 2012;33:179.
https://www.m-chat.org
Nathan Mother
ScoringinstructionsforMCHAT
https://www.m-chat.org
Nathan Mother
16points
MCHAT
• 16– 30months• AAPguidelines:18and24months• Highfalsepositiverate->otherdevelopmentaldisorder
VanderbiltScoring
Hyperactive
Inattentive
ODD
CD
CDMood
Functio
n
9/9
9/9
0/8
>6/9=sig
>6/9=sig
>4/8=sig
>3/14=sig0/14
0/7 >3/7=sig
And anyscoreof4or5
VanderbiltAssessmentScale
• 6– 12yearsold• Togetherwiththeteacherassessmentscale,usedbypaediatriciansandpsychiatrists,toaidinthediagnosisofADHD
• ParentassessmentscalecanbeusedbyGPsasscreeningtoolinclinic
Toolforscreeningformental/emotionalhealthinchildren
http://www.massgeneral.org/psychiatry/services/psc_forms.aspx
MentalHealthismorethantheabsenceofmentalillness
• A stateofwell-beinginwhicheveryindividualrealizeshisorherownpotential,cancopewiththenormalstressesoflife,canworkproductivelyandfruitfully,andisabletomakeacontributiontoherorhiscommunity.
http://www.who.int/features/factfiles/mental_health/en/
Mentalwellness
Mentalhealthproblem
Mentalillness
Case
• 11yearoldboycomesforthe4th timein3monthstoyourclinicforaseriesofnonspecificcomplainslikeabdominalpainandheadache.Eachtimeaskingtobeexcusedfromschool.
• Thechildcomesalonetoyourconsulteachtime,whenquestionedifthereareanystressorsandaskedabouthismood,hegivesyounonchalantresponses.
• Whatdoyoudo?
0 1 2
0 1 2
PediatricSymptomChecklist
PediatricSymptomChecklist
• 3to18yearsold• Psychosocialscreen:cognitive,emotional,andbehavioralproblems
• Schoolagechildren:Scoresof28orgreater• Youngerkids:Scoresof24orgreater
• ->referralforfurthermentalhealthassessment
PediatricSymptomChecklist- 17
Difficultiesfaced
TimeCost
Literacy Knowledgeabouttools
Logistics
Parentsreceptivity
Followup
Responsibilityfortheresults
Competinghealthcarepriorities
Lackoftraining
Caution
• Positivescreeningdoesnotequaldiagnosis• Negativescreeningdoesnotmeanthereisnoissues• LackofstandardizedmeasuresforSingaporeanchildren• Caregiverreportsaresubjecttobiases• Confidentiality• Crisismanagement
Resources• HEALTHPROMOTIONBOARD
• HealthyStartForYourBabyhttp://www.hpb.gov.sg/HOPPortal/health-article/12206HealthyStartForYourGrowingChildhttp://www.hpb.gov.sg/HOPPortal/health-article/12294
• EARLYCHILDHOODDEVELOPMENTAGENCY
• GrowingwithYourChildbooklethttp://www.ecda.gov.sg/growatbeanstalk/Pages/articledetail.aspx?type=4&category=Growing+With+Your+Child+Booklet
• Care&Development:AResourceforParentsofChildrenwithDevelopmentalNeedshttp://www.ecda.gov.sg/growatbeanstalk/Pages/ArticleDetail.aspx?type=4&articleid=145http://www.childcarelink.gov.sg/ccls/uploads/MSF-ChildDevelopment-Booklet.pdf
• CENTERS FORDISEASECONTROLANDPREVENTIONUSALearntheSigns.Act Earlyhttp://www.cdc.gov/ncbddd/actearly/milestones/index.html
• MINISTRYOFHEALTH
• AMS-MOHClinicalPracticeGuidelineonAutismSpectrumDisordersinPreschoolChildren2010http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical/2010/cpgmed_autism_spectrum_dis orders_preschool_children.html
• Summary
• http://www.moh.gov.sg/content/dam/moh_web/HPP/Doctors/cpg_m edical/current/2010/ASD%20CPG(Card).pdf
• PatientVersionhttp://www.moh.gov.sg/content/dam/moh_web/HPP/Doctors/cpg _medical/current/2010/Autism%20Spectrum%20D.pdf
• http://www.mentalhealthamerica.net/every-child-needs
• RECOGNISINGCHILDRENWITHDEVELOPMENTALDELAYS:ASTRATEGY FORSURVEILLANCE.THESINGAPOREFAMILYPHYSICIANVOL40(2)APRIL-JUNE2014:18
• http://www.medmerits.com/index.php/article/developmental_delay_in_children_evaluation_and_management/P2