Kevin P. Marks, MD FAAP; General Pediatrician at PeaceHealth Medical Group; Clinical Assistant...
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Kevin P. Marks, MD FAAP; General Pediatrician at PeaceHealth Medical Group; Clinical Assistant Professor at OHSU School of Medicine, Division of General
Kevin P. Marks, MD FAAP; General Pediatrician at PeaceHealth
Medical Group; Clinical Assistant Professor at OHSU School of
Medicine, Division of General Pediatrics Identifying &
Addressing Developmental-Behavioral Conditions : Early
Interventioners Assemble!
Slide 2
I do not intend to discuss an unapproved/ investigative use of
a commercial product. Financial conflict of interest: I will
provide information about a book which was co-authored by myself
(but I do not receive any royalties for the ASQ-3 or
ASQ:SE-2).
Slide 3
Part I: How can PCPs swiftly identify & address DB problems
& better collaborate with early interventionists and other
early childhood educators prior to kindergarten entrance?
Slide 4
15-17% of U.S. children (under 16 years of age) have a
developmental disability 15-17% of U.S. children (under 16 years of
age) have a developmental disability 11-21% of U.S. children have a
mental health disorder (as defined by the DSM-V) at any given point
in time 11-21% of U.S. children have a mental health disorder (as
defined by the DSM-V) at any given point in time 37-39% of U.S
children will be diagnosed with a mental health disorder by 16
years of age 37-39% of U.S children will be diagnosed with a mental
health disorder by 16 years of age 25-40% of U.S children with a
mental health disorder will have at least 1 additional mental
health diagnosis at a given point in time. 25-40% of U.S children
with a mental health disorder will have at least 1 additional
mental health diagnosis at a given point in time. Developmental and
Behavioral Problems Are Very Common Conditions in the USA
Slide 5
1. Early intervention relies heavily upon early
identification.
Slide 6
1. Early intervention relies heavily upon early identification.
2. Early identification relies heavily upon those working in the
medical, social and educational sectors
Slide 7
1. Early intervention relies heavily upon early identification.
2. Early identification relies heavily upon those working in the
medical, social and educational sectors 3. We must wield mighty or
evidence-based DB screening tools in a planned and periodic manner
for children 0 to 5 years of age.
Slide 8
1. Early intervention relies heavily upon early identification.
2. Early identification relies heavily upon those working in the
medical, social and educational sectors 3. We must wield mighty or
evidence-based DB screening tools in a planned and periodic manner
for children 0 to 5 years of age. 4. And, after 5 years of age,
educators must collaborate closely with PCPs to better address
children with DB problems.
Slide 9
Why is Early Intervention So Important? Early Intervention (EI)
has been proven to improve long-term developmental outcomes (most
especially in children who are disadvantaged or have mild delays or
early signs of autism)
Slide 10
Why Else is Early Intervention So Important? Improved outcomes
at 18 years = higher achievement in math & reading + less
antisocial/criminal behaviors, less suicidal thoughts/attempts,
less smoking, alcohol & marijuana use (McCormick et al,
Pediatrics, 2006)
Slide 11
With behavioral/mental health disorders, theres an
approximately 2- to 4-year window of opportunity between symptom
appearance and when the child meets DSM-V criteria for a disorder.
With behavioral/mental health disorders, theres an approximately 2-
to 4-year window of opportunity between symptom appearance and when
the child meets DSM-V criteria for a disorder. Evidence strongly
suggests there are opportunities for secondary prevention or early
intervention. Evidence strongly suggests there are opportunities
for secondary prevention or early intervention. Source: U.S.
National Research Council and U.S. Institute of Medicine Committee
on Prevention of Mental Disorders and Substance Abuse Among
Children, Youth and Young Adults Why Else is Early Intervention So
Important?
Slide 12
Early intervention relies upon early identification: What is
the best setting(s) for early identification with periodic
developmental-behavioral (DB) screening? a. Nurse home visits
(social sector) b. Primary care providers (medical sector) c. Early
childhood educators (education sector) d. All of the above
Slide 13
Early identification relies heavily upon those working in the
medical, social and educational sectors And, we must collaborate
together because for every $1 invested in an early childhood
developmental program, there is a 6-10% annual return rate in there
is a 6-10% annual return rate in cost savings to society! ~Dr.
James Heckman, a Nobel Laureate in Economics & many other
well-respected economists
Slide 14
Pediatrician impression alone (DB surveillance without periodic
screening) fails to timely identify & refer 60 80% of children
with developmental-behavioral delays Only 30% of developmental
disabilities identified without screening tools (Palfrey et al.
JPEDS. 1994) Only 30% of developmental disabilities identified
without screening tools (Palfrey et al. JPEDS. 1994) 70-80% with
developmental disabilities correctly identified with screening
tools (Squires et al., JDBP 1996) 70-80% with developmental
disabilities correctly identified with screening tools (Squires et
al., JDBP 1996) Only 20% of mental health problems identified
without screening tools (Lavigne et al. Pediatrics. 1993) Only 20%
of mental health problems identified without screening tools
(Lavigne et al. Pediatrics. 1993) 80-90% with mental health
problems correctly identified with high- quality screening tools
(Sturner, JDBP 1991) 80-90% with mental health problems correctly
identified with high- quality screening tools (Sturner, JDBP 1991)
We must wield mighty or evidence-based DB screening tools in a
planned & periodic manner for children 0-5 years.
Slide 15
Many PCPs Use Screening Tools to Measure DB Risk Factors 2 wks:
Survey of Well-being of Young Children (SWYC) Family Questions
Screens parents for: a) tobacco & drug abuse, b) food
insecurity, c) depression, d) intimate partner violence Screens
parents for: a) tobacco & drug abuse, b) food insecurity, c)
depression, d) intimate partner violence 2, 4 or 6 mo: Edinburgh
Post Natal Depression Scale (EPDS) Screens for maternal
depression/anxiety Screens for maternal depression/anxiety Score =
12? Question #10 concerning? Score = 12? Question #10 concerning? 4
mo: ACE Questionnaire: (score >3 means action needed??) Screens
for parental adverse childhood experiences Screens for parental
adverse childhood experiences Not commonly being used in our
community. Not commonly being used in our community.
Slide 16
AAP General Developmental Screening Periodicity Schedule (0 to
5 years) PCPs administer a pre-visit, broad-band developmental
screen (e.g., ASQ-3) routinely at 9, 18, 24 or 30 months + 4 years
to measure kindergarten readiness + as needed when at risk for a
developmental delay Dr. Marks: 6, 9, 12, 18, 24 & 36 mo. + as
needed
Slide 17
Beyond identifying DDs, we must swiftly identify & refer
children with emerging social-emotional problems to EI/ECSE, mental
health providers & high-quality preschools!
Slide 18
AAP Social-Emotional Screening Periodicity Schedule (0 to 5
years) PCP administers a pre-visit, social-emotional screen (e.g.,
ASQ:SE-2) routinely at 5 years + as needed Dr. Marks: 18 months
& 4 years + as needed.
Slide 19
Medical assistant (MA) makes sure that caregiver(s) complete
the DB screening tool before the PCP walks into the exam room.
Slide 20
Super Hero PCPs Take Action on (+) Screens Discusses the childs
areas of strength first. Discusses the childs areas of strength
first. Discusses the childs suspected challenges second. Discusses
the childs suspected challenges second. Initially resists using
diagnostic labels. Initially resists using diagnostic labels. Does
NOT take a wait and see approach with a concerning ASQ result or
clinical impression. Does NOT take a wait and see approach with a
concerning ASQ result or clinical impression. DOES say lets play it
safe and give them a call (i.e., links child to EI/ECSE when
indicated). DOES say lets play it safe and give them a call (i.e.,
links child to EI/ECSE when indicated). DOES reliably communicate
their recommendations with parents in a culturally appropriate
manner. DOES reliably communicate their recommendations with
parents in a culturally appropriate manner.
Slide 21
DB Screening Must Be Paired with Care Coordination! For
children needing a referral, PCP sends a care coordinator an
electronic or lightning bolt encounter about their interpretation
of the ASQ-3 or ASQ:SE-2 results & a care coordinator links
children/families to the most effective community resource.
Slide 22
Part II: After kindergarten entry, how can educators
collaborate closely with PCPs to better identify & address
children with DB problems?
Slide 23
The First Interventioner Recognizes a potentially impairing DB
concern & contacts the childs caregiver(s) to get their get
signed consent (HIPPA & FERPA) to exchange information between
the school & medical home or PCP.
Slide 24
Then, (written or verbal) information is exchanged in a timely
manner between the medical home and school.
Slide 25
PCPs should do evaluations and/or refer to mental health. Then,
the PCP should complete medical or health assessment statements in
a timely manner.
