Early Childhood Mental Health and Improving Early Identification of Developmental Delay and Autism

Spectrum Disorder

Friday, September 22, 2017

1:15 PM-2:45 PM

Rhonda Rairden-Nelson

Rachell Swanson-Holm

• Understand the importance of early childhood mental health.

• Define Autism Spectrum Disorders, symptoms, social, behavioral, and communication differences, causes and diagnosis.

• Name possible diagnoses other than Autism Spectrum Disorder

• Increase awareness and knowledge of the CDC’s Learn the Signs. Act Early. program, materials and online trainings available.

• Describe ways to integrate Learn the Signs. Act Early. materials into early education and child care sites

• Increase existing developmental screening by engaging families and staff in monitoring milestones as part of the assessment process

• Understand how the LTSAE materials can support referral of infants, toddlers and young children for eligibility evaluation by Part C and Part B Services

Objectives

• Mute your phones please

• There will be time for questions and answers following the presentation

• If you would like more resources by email and other information, please leave your request and email address on clipboard provided

Welcome and Thank You For Attending!

Housekeeping Items

Who We Are

Early Childhood Mental Health

What do we

mean by

INFANT AND

EARLY

CHILDHOOD

MENTAL

HEALTH?

Otherwise known as

SOCIAL or EMOTIONAL

DEVELOPMENT

early childhood mental health

refers to a young child’s ability

to….

Form Close Relationships

Explore New Environments

Express and Manage their Emotions

Social and emotional wellbeing

includes the development of:

• SELF-WORTH

• SELF-CONFIDENCE

• SELF-REGULATION

Healthy social, emotional

development is

FOUNDATIONAL

to success in

school and in

life.

Approximately

17% of all

children

experience a

mental health

concern before

the age of 6.

(Source: Klitzing K von, Doehnert M, Kroll M, Grube M:

Mental disorders in early childhood. Dtsch Arztebl Int 2015;

112: 375–86. DOI: 10.3238/arztebl.2015.0375)

• Relationship Disorders (Attachment)

• Mood Disorders such as Anxiety and Depression

• Feeding Disorders

• Motor Dysregulation (ADHD)

• Post Traumatic Stress Disorder

• ASD

Mental Health Concerns

ASD is classified as a neurodevelopmental disorder with onset during early development, often before a child enters grade school.

• Characterized by:

1. Persistent deficits in social communication,

2. Social interaction, and

3. Presence of restricted, repetitive patterns of behavior, interests, or activities.

Autism Spectrum Disorder

Deficit in Social-Emotional Reciprocity exists across various social situations: Ability to engage with others and share thoughts and feelings:

Struggle to know when and how to join a conversation and identify what to say,

Difficulty maintaining a conversation; back and forth exchanges are challenging or absent,

Difficulty or lack of sharing thoughts and feelings with others,

Impaired joint attention as displayed by a lack of pointing, showing, or bringing objects to share interest with others,

Lack of shared social play and imagination, and insistence of playing with very fixed, defined rules,

Preference to play on their own or with much younger or older people, and

Imitation of others’ behavior is absent or reduced.

Communication & Social interaction Deficits

• Repetitive motor movements, use of objects, or speech

• Inflexible adherence to routines, insistence of sameness, or ritualized patterns of verbal or non-verbal behavior

• Highly restricted, fixated interests

• Hyper or hypo reactivity to sensory input or unusual interest in sensory aspects of their environment

Restrictive, Repetitive Behaviors & Interests

• Deficits in nonverbal communication behaviors, such as atypical use of eye contact, gestures, facial expressions, body orientation, or speech intonation.

• Delay in language development and comprehension, ranging from complete lack of speech to delays, echoed speech, and overly literal speech.

• Intellectual impairment, motor deficits (e.g., clumsiness, odd gait, walking on tiptoes), self-injury behavior (e.g., head banging, biting the wrist), and anxiety and depression.

Other Associated Features

• There is no one medical test that can diagnosis autism.

• Diagnosis should only be made by specially trained physicians and psychologists who will administer autism-specific behavioral evaluations.

• A typical diagnostic evaluation will involve a multi-disciplinary team of doctors, that may include a developmental pediatrician, psychologist, speech and language pathologist, and occupational therapist.

• A diagnosis can open access to therapies and assistive technologies that can improve function in areas of difficulty.

• Diagnosis can provide relief to families who have struggled to find answers. However, it can also be very anxiety provoking as they come to terms with the diagnosis especially if the next steps aren’t identified.

• https://www.autismspeaks.org/family-services/tool-kits/100-day-kit

Diagnosis of ASD

Each individual with autism is unique so each autism intervention plan should be tailored to address specific needs.

• Medications

• Speech therapy

• Occupational therapy

• Psychiatrist/Psychologist sessions

• Behavioral and social skills therapy programs

• Applied Behavioral Analysis (ABA)

Treatment

• Intellectual Disability (ID ) Global Developmental Delay

• Speech and Language Disorders

• Attention Deficit Hyperactivity Disorder

• Disruptive Behavior Disorder/Oppositional Defiant Disorder

• Anxiety Disorders

• Nonverbal Learning Disorder

• Social Communication Disorder

Is It ASD or Something Else?

• Total Population=3,134,693

• Percent of population under 5 years of age =6.4%

• Median Household income=$53,183

• Poverty Rate=12.2%

• State Ranking of Child Well-Being=5 out of 50

• Largely agricultural state with large rural geographical areas

• Significant underserved populations with a limited amount of providers

Iowa

• Developmental disabilities are common

• About 1 in 6 children ages 3-17 has a developmental disability1

• In the United States, about 1 in 68 children has an autism spectrum disorder2

• Median age of ASD diagnosis is 4 years

• 12-16% U.S. children have a developmental or behavioral disorder

• Prompt identification can spur specific and appropriate therapeutic early interventions

• Fewer that 50% of pediatricians use valid and reliable screening tools.

• 30% of Primary Care Providers follow the AAP Screening Guidelines

Issues

Developmental Monitoring

and Screening: Activities

• Milestones are things most children can do by a certain age

– How a child plays, learns, speaks, acts, and moves

• You see these every day

• They offer important clues about each child’s developmental health

• Parents may need guidance in recognizing them

Developmental Milestones

All children develop at their own pace. Some will reach milestones slightly late or early.

• Parental concerns about child development are highly predictive of true developmental problems (Poon, LaRosa & Pai, 2010).

• Parents of low Social Economic Status (SES) are less likely to bring up concerns, but when asked they were accurate with concerns similar to parents with moderately-high SES. (Glascoe, 2012).

• Preliminary data suggests that when developmental monitoring and screening occur simultaneously, identification and access to services increases (National Survey of Children’s Health; 2007; 2011-2012).

Caregivers are Important Partners

• Recent research tells us as many as 1 in 4 children

in the United States, ages 0-5, are at moderate

or high risk for developmental, behavioral or social delays

• 1 in 6 children has an identified developmental disability and/or delay

• 1 in 68 children are identified with autism

Why Track Milestones?

Reference: (Blumberg, Boulet, Boyle, Cohen, Kogan, Schieve, & Yeargin-Allsopp,

2011)

• Early identification (before school age) can have a significant impact on a child’s ability to learn new skills as well as reduce the need for costly interventions over time

• Less than half of these children are identified before entering school, and miss opportunities to benefit from early intervention

• Early intervention can have a significant impact

Why Track Milestones?

• Understand each child’s developmental progress

• Determine if a child needs extra help or has additional challenges in a particular area

• Gather objective information for talking with parents

• To build relationships with families

Tracking Milestones Helps You…

• Understand that watching for milestones is important

• Better understand child development

• Pinpoint any potential developmental concerns

Tracking Milestones Helps Parents…

• A brief, standardized assessment procedure designed to identify children at risk who should receive more intensive diagnosis or evaluation.

• Typically administered by:

– Early childhood educators

– Mental health providers

– Health care providers

• Screening tools do not provide conclusive evidence of developmental delays and do not result in diagnoses. A positive screening result should be followed by a thorough assessment.

Developmental Screening

• Developmental monitoring is done at ALL well-child visits

• In the absence of established risk factors or parental or provider concerns, developmental and behavioral screening should be done using a standardized screen tool when the child is:

9, 18, and 24/30** months

18 and 24/30 month visit ASD specific screening

AAP and CDC Guidelines

9-Month-Old Child

18-Month-Old Child

24-Month-Old Child

Learn the Signs. Act Early.

www.cdc.gov/ActEarly 34

Developmental

Surveillance/Monitoring

Done by parents, teachers, health professionals Ongoing process-begins at birth Sample tool: “Learn the Signs. Act Early.” Milestone Checklists

Formal process

Recommended by the American Academy of

Pediatrics at 9, 18, and 24 or 30 months

Done by health professionals

and may be done by teachers with special training

Uses a validated screening tool

Sample tool:

Ages and Stages Questionnaire

Developmental

Screening

Look for

developmental

milestones

Important for

tracking signs

of development

and identifying

concerns

• General Developmental Screening Tools (approved by AAP)

– Ages and Stages Questionnaire (ASQ-3)

– Parents’ Evaluation of Developmental Status (PEDS)

– Parents’ Evaluation of Developmental Status- Developmental Milestones (PEDS-DM)

– Brigance Screens

– Developmental Assessment of Young Children

• Language Screening Tools

– Communication and Symbolic Behavior Scales - Developmental Profile

• Social-Emotional Screening Tools

– Ages and Stages Questionnaire: Social-Emotional (ASQ-SE-2)

For in-depth profiles of many of the tools, see the Birth to 5: Watch

Me Thrive! Compendium of Screening Measures.

Commonly Used Developmental Screening Tools

• Validated Autism Screening Tools

-Modified Checklist for Autism in Toddlers (M-CHAT-R/F)

-Childhood Autism Spectrum Test (CAST)

-Social Communication Questionnaire (SCQ)

• Secondary Autism Screening Tools

-Screening Tool for Autism in Toddlers and Young Children (STAT)

Commonly Used ASD Specific Screening Tools

Detection Rates

Without Tools

With Tools

Developmental Disabilities

30% identified Palfrey et al. J Peds. 111:651-655, 1987.

70-80% identified Squires et al. JDBP. 17:420-427, 1996.

Mental Health

Problems

20% identified Lavigne et al. Pediatr.

91:649-655, 1993.

80-90% identified Sturner. JDBP. 12:51-64, 1991.

• Parents can detect problems with development in approximately 70-80% of children with a delay.

• When parents reported concern of emotional or behavioral issues, physicians were 13 times more likely to identify psychiatric problems and make needed referrals.

• Parents of low Socio-Economic Status(SES) were less likely to bring up concerns, but when asked they were accurate with concerns similar to parents with moderately-high SES. (Glascoe, 2012).

Accuracy of Caregiver Report

How Can I Increase Family Engagement in Developmental Monitoring and

Screening?

To improve early identification developmental disabilities and delays, including autism, so children and their families can get the services and support they need as early as possible.

“Learn the Signs. Act Early” Mission

• Developed by CDC, in conjunction with the AAP

• Help parents become better partners in monitoring development

• Objective, research-based information may make visits more productive

• Free and available in English and Spanish

Tools to Make Your Work with Families Easier

• Milestone Checklist

• Milestone Moments Booklet

• Milestone Brochure

• Milestone Growth Chart

• Fact Sheets

• Screening Passport

• Milestones Tracker

Materials to Help You

• Complete checklists address – Four domains of development

– Developmental “red flags”

• How to use – At beginning of each school

year, print two copies. Complete one at school and encourage parents to print the other.

– Use at parent-teacher conferences

• Can be printed with Spanish translation on reverse

Milestone Checklists

• Throughout the year encourage the caregiver to, pay attention to how their child is meeting milestones and mark the checklist accordingly.

• Includes:

– Complete milestone checklists (2mo – 5yrs)

– List of developmental “red flags”

– Activities to try at home

– Space to write down questions

• Intended for parent use throughout a child’s early years

• Provide one to every family when they enroll

• Helps parents prepare for well-child visits; gives you a parent-friendly reference

• Try activities in the booklet in your home/classroom at least monthly

• Include activities in your monthly newsletter

Milestone Moments Booklet

Select milestones at a glance

for ages 6 months to 4 years

Milestone Brochure/Poster

Measure each child’s height on the growth chart. As you measure, mentally check the developmental milestones for his or her age.

Growth Chart

Ask parents to order a free

parent kit, so they can track

their child’s development at

home using Milestone

Moments and the Growth

Chart.

Parent Kit

Materials specially packaged for

parents - includes one growth chart

and one Milestone Moments booklet

(English or Spanish).

• Tips for Talking With Parents

• Tips for Talking With Your Doctor

• Developmental Screening

• Condition-specific fact sheets

Fact Sheets

• The app is available for iPhone and includes the following:

– Add a child to get personalized information on your child

– Milestone Tracker

– Milestone Photos/Videos

– Tips and Activities

– Alerts when you need to “Act Early”

– Appointment reminders

– Milestone results that can be emailed to providers (or parents)

CDC Milestone Tracker

• Milestones in Action Digital Library

• Watch Me Training!

• Autism Case Training

Other Resources from the CDC

Go Out and Play! Kit

A resource to help early educators monitor development through play

https://www.cdc.gov/ncbddd/actearly/pdf/ccp_pdfs/GOP_kit.pdf

Early Educator Tool Kit

• Milestone checklists are not validated screening tools.

• The American Academy of Pediatrics recommends that all children receive a developmental screen using a formal, scientifically tested screening tool at 9, 18, and 24 or 30 months, or whenever there is a concern.

• Using milestone checklists will not satisfy this recommendation.

• Milestone checklists cannot be used to diagnose any developmental disability.

Warning

Why monitor and screen in

Early Care and Education Settings?

Most parents who bring up the possibility of developmental delays want to be heard, not just reassured

that their child is normal.

(Slices & Egbert, 2009)

Although early intervention has been shown to help…

…...most will not be identified before they enter school.

Why “Learn the Signs. Act Early.”?

U.S. children aged 3-17 has a developmental disability

1 in 6

Parents want to talk to their child's doctor and early education and care provider regularly about development.

Developmental Concerns

86%

81%

expect to talk to the doctor about their child's development during every well-child visit.

would like their child's early education provider to discuss development at least every few months.

However…. Parent knowledge is often limited to

physical and language development

Many parents are reluctant to bring

concerns to their child’s doctor

Learn the Signs. Act Early. Can fill this gap!

Parent Concerns about a child’s development are reliable predictors of delays

Past Studies have shown that LTSAE Materials…… help parents understand and appreciate Can help validate a parents concern the broad range of developmental milestones Reliably teach parents something new about Reduce barriers to parents sharing development concerns with the doctor

In intercept interviews with parents in clinics...

LTSAE changes parent behavior

91%

87%

86%

said LTSAE encouraged them to take action if they ever had a concern about development

said LTSAE made them more likely to contact their child’s doctor if they had a concern

said LTSAE made them more likely to contact early intervention services if they had a concern

Feasibility of integrating LTSAE has been demonstrated across many settings and systems • Early eduction and childcare

settings

• Childcare sites

• Pediatric clinics

• Home visiting

• Early Head Start and Head Start centers

• For education purposes (e.g. medical residency training programs)

LTSAE offers more than other lists of developmental milestones. LTSAE milestones...

• Cover the complete range of developmental domains

• Are adapted from milestones developed by the American Academy of Pediatrics (AAP), considered the “gold standard”

• Are written in plain language

• Are based on what most children can do by each age, instead of what the average child can do *

• Include information about when and how to act early

Benefits of LTSAE Materials

Next Steps

– Learning more about LTSAE resources/trainings

– Learning from others

– Building community

Technical Assistance

Contact Information

Contact E-mail Phone

Rhonda Rairden-Nelson Rhonda-rairdennelson@idph.gov

515-281-4926

Rachell Swanson-Holm rachell-swanson-holm@uiowa.edu

Iowa-Act-Early@uiowa.edu

515-955-8326 866-219-9119 press 4

Questions?