Related Research

Objective: Parents’ Evaluation of Developmental Status (PEDS^®) is a validated tool used to assess child development that has not previously been tested in Australian general practice. We examined the effect of a Quality-Improvement intervention in a single general practice in Melbourne, Australia, that aimed to use this tool to improve the documented assessment of child developmental surveillance during vaccination visits.

Methods: Mixed methods incorporated audits of clinical records of children aged 1-5 years, before and after intervention, written questionnaires and a focus group (informed by the theoretical domains framework and Capability, Opportunity, Motivation-Behaviour (COM-B model)) with clinical and non-clinical staff.

Results: After 6 months, developmental surveillance more than doubled and was documented in more than one in three visits (34.1%). Almost one in five (18.6%) vaccination visits included the PEDS^® tool. Overall, the tool was positively received with staff expressing high levels of comfort asking parents to complete it (92.8%), increasing development of professional skills (71.4% staff) and confidence (55% clinicians) detecting developmental delays. Thematic analysis of the focus group transcript revealed underlying barriers arising from the practice environment, staff capabilities and motivation.

Conclusions: In a whole of practice Quality-Improvement intervention that applied PEDS^® training and implementation, including the receptionist in the medical team more than doubled documented rates of child developmental surveillance during vaccination visits. Solutions to underlying barriers could be incorporated into a revised training module. Future studies need to test the tool in more methodologically robust studies that include analysis of the outcomes of developmental surveillance.

Objective: We examined the parental perception and accuracy of Mandarin translated Parents’ Evaluation of Developmental Status, a screening questionnaire for parents’ concerns on their child’s various developmental skills.

Methods: The questionnaire was translated into Mandarin. Upon enrollment, caregivers completed the Mandarin PEDS^® and answered four questions about its acceptability and usefulness, and its ease of understanding and completing. The Mandarin PEDS^® were independently evaluated by a pediatrician and a community nurse, and classified as ‘high’ risk (> 2 predictive concerns), ‘medium’ risk (1 predictive concern), ‘low’ risk (any non-predictive concerns) or ‘no’ risk (if no concern) for developmental delays. The caregivers repeated Mandarin PEDS^® at a 2-week interval for test-retest reliability, while their children underwent testing for accuracy using a developmental assessment test.

Results: The majority (> 85%) of the 73 caregivers recruited perceived the Mandarin PEDS^® as acceptable and useful, as well as easy to understand and complete. Fifteen (20.5%) and 24 (33.9%) responses were classified as high and moderate risks respectively. The test-retest and inter-rater reliabilities were excellent, with intra-class correlation coefficients of 0.812 (95% CI: 0.701, 0.881, p < 0.001) and a kappa value of 0.870 (p < 0.001) respectively. Mandarin PEDS^® was 80.0% sensitive and 83.8% specific for those in high risk category (adjusted OR = 64.68; 95% CI 1.33, 3139.72; p = 0.035).

Conclusions: The Mandarin PEDS^® was well received by the caregivers, and it was reliable and accurate in detecting developmental delays among the Mandarin-speaking population. We recommend it for early detection of children with developmental and behavioral problems. This article is protected by copyright. All rights reserved.

The Supplemental Nutrition Assistance Program (SNAP) helps working families meet their nutritional needs. Families whose earned income increases in a given month may have their SNAP benefits abruptly reduced or cut off in the following month. Using sentinel sample data from 2007–15 for families with children younger than age four, we investigated how SNAP benefit reductions or cutoffs resulting from increased income were related to economic hardships (food and energy insecurity, unstable housing, forgone health and/or dental care, and health cost sacrifices) and to caregiver and child health. PEDS^® was used to measure developmental-behavioral status. After we controlled for covariates, we found that the groups whose SNAP benefits were reduced or cut off had significantly increased odds of household and child food insecurity, compared to a group with consistent participation in SNAP. Reduced benefits were associated with 1.43 and 1.22 times greater odds of fair or poor caregiver and child health/development, respectively. Policy modifications to smooth changes in benefit levels as work incomes improve may protect working families with young children from increased food insecurity, poor health, and forgone care.

Background:Only 30% of parents of children aged 9-35 months report that their child received a developmental screening in the previous year. Screening rates are even lower in low-income households, where the rates of developmental delays are typically higher than those in high-income households. Seeking to evaluate ways to increase developmental screening, Text4baby, a national perinatal texting program, created an interactive text message-based version of a validated developmental screening tool for parents.

Objective: This study aimed to assess whether a text message-based developmental screening tool is usable and acceptable by low-income mothers.

Methods: Low-income mothers of infants aged 8-10 months were recruited from the Women, Infants and Children Program clinics in Prince George’s County, MD. Once enrolled, participants used text messages to receive and respond to six developmental screening questions from the Parents’ Evaluation of Developmental Status: Developmental Milestones. After confirming their responses, participants received the results and feedback. Project staff conducted a follow-up phone survey and invited a subset of survey respondents to attend focus groups. A representative of the County’s Infants and Toddlers Program met with or called participants whose results indicated that their infants may be behind.

Results: Eighty-one low-income mothers enrolled in the study, 93% of whom reported that their infants received Medicaid (75/81). In addition, 49% of the mothers were Hispanic/Latina (40/81) and 42% were African American (34/81). A total of 80% participated in follow-up surveys (65/81), and 14 mothers attended focus groups. All participants initiated the screening and responded to all six screening questions. Of the total, 79% immediately confirmed their responses (64/81), and 21% made one or more changes (17/81). Based on the final responses, 63% of participants received a text that the baby was “doing well” in all six developmental domains (51/81); furthermore, 37% received texts listing domains where their baby was “doing well” and one or more domains where their baby “may be behind” (30/81). All participants received a text with resources for follow-up. In a follow-up survey reaching 65 participants, all respondents said that they would like to answer screening questions again when their baby was older. All but one participant would recommend the tool to a friend and rated the experience of answering questions and receiving feedback by text as “very good” or “good.”

Conclusions: A mobile text version of a validated developmental screening tool was both usable and acceptable by low-income mothers, including those whose infants “may be behind.” Our results may inform further research on the use of the tool at older ages and options for a scalable, text-based developmental screening tool such as that in Text4baby.

The main goal of this research was to describe the type and level of parents’ concerns about child development and behaviour according to the PEDS^® test (Parents’ Evaluation of Developmental Status). The sample included 289 parents of children from three to seven years of age, from two preschool institutions in Serbia. A significantly high correlation was determined between parents’ general concerns and expressed concerns with regard to behaviour (χ2 = 17.86, df = 2, p < .001) and getting along with others (χ2 = 22.57, df = 2, p < .000). A marginally significant correlation was determined between parents’ general concerns and manifested concerns with regard to fine motor skills (χ2 = 5.90, df = 2, p = .052), as well as expressive language (χ² = 5.858, df = 2, p = .053). According to the criteria of PEDS^® test, this research identified 56.4% of children whose development needed to be monitored, 27.7% of children who needed to be referred for detailed diagnostic procedures, and 1.7% who needed to be included in treatment or special education support.

Background: Developmental delays are more prevalent in low-income countries and access to developmental screening is severely limited.

Introduction: This study evaluated an m-Health version of a standard developmental screening tool, Parents Evaluation Developmental Status (PEDS^®) and PEDS^®: Developmental Milestones (PEDS:DM^®) for use by community health workers (CHWs) in terms of

1. correspondence with conventional paper-based testing by a speech language pathologist (SLP) and
2. interrater reliability compared to an SLP.

Method: CHWs were trained in a primary healthcare (PHC) setting to administer the newly developed smartphone application version of the PEDS^® tools. One SLP and two CHWs recruited 207 caregivers who were attending a baby wellness clinic. Caregivers were tested by one CHW using the smartphone application of the PEDS^® tools; a qualified SLP simultaneously recorded and scored the PEDS^® tools on the same participants.

Results: High positive (100%) and nega- tive correspondence (96%) was found between the paper- based PEDS^® tools and the smartphone application PEDS^® tools and between the SLP and CHW. Almost perfect (Cohen’s Kappa) inter-rater agreement between conditions was dem- onstrated (j = 0.873 to j = 0.961).

Conclusions: Outcomes of the smartphone application, operated by a CHW, corre- sponded closely to the gold standard PEDS^® tools operated by a health professional. Trained CHWs can conduct accurate developmental screening using the smartphone version of the PEDS^® tools.

Methods:

• Cognitive stimulation during the first five years of life is critical for proper childhood development.
• Prior community evaluations in rural Ghana have demonstrated that children in the Bibiani-AnhwiasoBekwai (BAB) district receive inadequate cognitive simulation.

Objectives:

• To characterize baseline child development in the BAB district.
• To obtain formative data for developing a mentorship program for first-time mothers and their children.

By 2014, 59.5 million people worldwide were forcibly displaced from their homes and living as refugees or stateless people. Over 50% of these individuals were children.

1. Of the nearly 70 000 refugees annually resettled to the United States, ∼30% are children.
2. The United Nations High Commissioner for Refugees reports that refugee and resettlement experiences may impact critical stages of intellectual, social, emotional, and physical child development.
3. Disruption to families and education and witnessed traumatic events impact the presentation of development concerns.

World-wide it is important to recognize Indigenous children’s speech and language competence and their language learning environments. Indigenous Australian children participated in the child cohort of Footprints in Time: Longitudinal Study of Indigenous Children, a national study supported by Indigenous Australians and the Australian Government collected annually (in waves). There were 692 3–5-year-old children in wave 1, and two years later, 570 5–7-year-old children were in wave 3 (77.0% of children in wave 1 were also in wave 3). Data were obtained via parent interviews and direct assessment. The children spoke between one and eight languages including: English (wave 1: 91.2%, wave 3: 99.6%), Indigenous languages (wave 1: 24.4%, wave 3: 26.8%), creoles (wave 1: 11.5%, wave 3: 13.7%), foreign languages (non-Indigenous languages other than English) (wave 1: 2.0%, wave 3: 5.1%), and sign languages (wave 1: 0.6%, wave 3: 0.4%). Children who spoke an Indigenous language were more likely to live in moderate to extreme isolation than their English-speaking counterparts. Parental concern about speech and language skills was similar to data for non-Indigenous children with approximately one quarter of parents expressing concern (wave 1: yes = 13.9%, a little = 10.4%). Children’s language environments were rich, with many family members and friends telling oral stories, reading books, and listening to the children read. Almost a third of families wanted to pass on their cultural language, and many indicated that they would like their child to learn an Indigenous language at school. Overall, Indigenous Australian children have rich cultural and linguistic traditions and their speech and language competence is promoted through family, community, and educational experiences.

This large-scale longitudinal population study provided a rare opportunity to consider the interface between multilingualism and speech-language competence on children’s academic and social-emotional outcomes and to determine whether differences between groups at 4–5 years persist, deepen, or disappear with time and schooling. Four distinct groups were identified from the Kindergarten cohort of the Longitudinal Study of Australian Children (LSAC)

1. English-only + typical speech and language (n = 2012);
2. multilingual + typical speech and language (n = 476);
3. English-only + speech and language concern (n = 643); and
4. multilingual + speech and language concern (n = 109).

Two analytic approaches were used to compare these groups. First, a matched case-control design was used to randomly match multilingual children with speech and language concern (group 4, n = 109) to children in groups 1–3 on gender, age, and family socio-economic position in a cross-sectional comparison of vocabulary, school readiness, and behavioral adjustment. Next, analyses were applied to the whole sample to determine longitudinal effects of group membership on teachers’ ratings of literacy, numeracy, and behavioral adjustment at ages 6–7 and 8–9 years. At 4–5 years, multilingual children with speech and language concern did equally well or better than English-only children (with or without speech and language concern) on school readiness tests but performed more poorly on measures of English vocabulary and behavior. At ages 6–7 and 8–9, the early gap between English-only and multilingual children had closed. Multilingualism was not found to contribute to differences in literacy and numeracy outcomes at school; instead, outcomes were more related to concerns about children’s speech and language in early childhood. There were no group differences for socio-emotional outcomes. Early evidence for the combined risks of multilingualism plus speech and language concern was not upheld into the school years.

To assess whether age of initial parent developmental concern differs between children with autism spectrum disorder (ASD) vs other developmental conditions, and to assess whether provider response to initial parent concerns is associated with earlier diagnosis.

Objective: This study determined the feasibility and validity of a Chinese-translated Parents’ Evaluation of Developmental Status (PEDS^®), a questionnaire for parents to report concerns involving language, motor skills, learning, behavior, and social skills of children.

Method: The PEDS^® questionnaire was translated to Chinese and underwent testing for reliability and validity (sensitivity and specificity) against a diagnostic reference-standard developmental assessment test, Griffiths Mental Development Scales – Extended Revised. Parents / caregivers completed the questionnaire twice within a two-week interval. The scores were assessed separately by a pediatrician and a community nurse. Respondents also answered four study-designed questions about PEDS^® on acceptability and usefulness as screening tool, and ease of understanding and completing.

Results: Sixty-eight (84.0%) respondents thought the Chinese PEDS^® was acceptable to screen for children with developmental and behavioral concerns. They rated it as very easy or easy to understand (n = 79, 97.5%) and very easy or easy to complete (n = 79, 97.5%). There was a 71.6% agreement [intra-rater (test-retest) reliability of 0.615 (p < 0.001)] between the first and second PEDS^® for two predictive concerns, one predictive concern, non-predictive concern or no concern. There was an 88.9% agreement [inter-rater reliability with kappa value 0.849 (p < 0.001)] for the score assessment between pediatrician and community nurse. PEDS^® had 75.0% sensitivity and 86.2% specificity for two or more predictive caregivers concerns (with adjusted OR 14.53; 95% CI 2.00, 105.83; p = 0.008).

Conclusions: PEDS^® can be used for early detection of children with developmental problems in the Chinese speaking population.

211 is a national telephone helpline focused on non-medical emergencies, i.e., addressing the challenges of people with unstable housing, food insufficiency, lack of money to pay for utilities or health care, etc. With help from the Robert Wood Johnson Foundation, 211LA added a screening and referral service for young children with autism and other developmental disabilities. After addressing the immediate issues raised by callers, 211LA staff asked parents if they would also like to discuss and assess their children’s development and behavior. Almost all parents were interested. Since its beginning in September 2009, the program has screened nearly eight thousand children under the age of five; nearly half were found to be at moderate to high risk of a development delay—rate much greater than found in general pediatric samples including low-income, Medicaid eligible families. 211LA’s referral coordination efforts (e.g., live call transfers to early intervention providers) ensures that this vulnerable population actually received services: 211LA’s families are ~ twice as likely to be enrolled in early intervention than are families screened in primary care. Thus 211LA serves as a national and replicable model for detecting and addressing the needs of high risk families and for supporting early identification efforts in primary care.This link provides more information on the Robert Wood Johnson Foundations efforts with 211LA and contact information for the program.

This meta-analysis of 37 PEDS^® studies included a total of 210,242 children/parents. The studies were conducted in the US, Canada, Australia, Thailand, The Philippines, Indonesia, Spain, India and Tanzania. Dr. Woolfenden and colleagues found that parental concerns indicating high developmental risk were associated with multiple risk factors: male gender, low birth weight, poor/fair child health rating, poor maternal mental health, lower socioeconomic status (SES), minority ethnicity, not being read to, a lack of access to health care and not having health insurance. Thus PEDS^® ensures both developmental-behavioral screening plus psychosocial risk assessment, i.e., surveillance. The authors conclude, “given [that] the prevalence of parental concerns increased with biological and psychosocial adversity, the service response needs to be one of proportionate universalism where the greater the disadvantage, the more services available.”

The goals of this study are to (a) inform clinicians embarking on evidence-based screening initiatives about what to expect when using quality tools, including provision of information on identification rates by age, patient mix, and well-visit uptake, and (b) describe the various implementation methods used by other clinics. Participants were professionals in 79 clinics across 20 U.S. states and elsewhere in North America, collectively serving 20,941 families via a Web-based screening ervice, PEDS Online^®, which offers developmental-behavioral/mental health and autism screens with automated scoring, report writing, and a mineable database. Problematic screening results were found in more than 1 out of 5 children, and rates of screening test failures increased with children’s ages. Children screened outside the well-child visit schedule were more likely to have screening test failures. Personnel at 22 of the 79 clinics were either interviewed or observed in person to identify implementation strategies. Clinics, even those serving families with limited education or lack of facility with English, found a variety of ways to make use of online screening services.

Drs. Cleave et al viewed the impact of the 2007 Mass Medicaid’s requirement for use of quality screening tools in primary care in order to best identify children with developmental-behavioral/mental health problems. Providers were motivated to comply with the mandate and most practices reported implementing screens routinely, whether for Medicaid patients or not, i.e., practices found it easiest to establish a consistent process across well-visits regardless of insurance). PEDS^® together with the M-CHAT were the most commonly selected measures due to their brevity and numerous translations (both are included in PEDS Online^®). The authors conclude that mandates are an effective way to improve evidence-based practice but that: a) physician champions are needed to promote solutions to implementation; and b) referral coordination and service capacity building are needed to make sure that children identified by screens receive intervention.

PEDS^® has been re-standardized and validated and its technical manual, Collaborating with Parents includes an enormous range of studies on PEDS^®.

Objective: To study the relationship between parent concerns about development in the first year and a half of life and later autism diagnostic outcomes.

Method: Parent concerns about development were collected (via PEDS^®) for infants at high and low risk for autism, using a prospective, longitudinal design. Parents were asked about developmental concerns at study intake and when their infant was 6, 12, and 18 months. Infants were then followed up until 36 months, when diagnostic status was determined.

Results: By the time their child was 12 months, parents who have an older child with autism reported significantly more concerns in autism spectrum disorders-related areas than parents of children with typical outcomes. These concerns were significantly related to independent measures of developmental status and autism symptoms and helped predict which infants would later be diagnosed with autism or autism spectrum disorders. At 6 months, however, the concerns of parents who have an older child with autism do not predict outcome well.

Conclusions: Explicitly probing for parent concerns about development is useful for identifying children in need of closer monitoring and surveillance, as recommended by the American Academy of Pediatrics.

Comment: This invaluable study shows that parents may worry unnecessarily about their young children when an older child has an ASD diagnosis. That seems totally understandable and worth attending to with vigilant monitoring. Risk of ASD, just as with any developmental-behavioral problem increases as children age and the genetic correlates of ASD are high. Thus parents should be worried early on and it is our job as providers to address those worries, dispel when needed and watch carefully the development of all children at risk.

Introduction: PEDS^® is a 10 questions tool used to elicit parental developmental concerns across a number of domains and hence to identify high risk children.

Objective: Testing the validity and reliability of translated PEDS^® and its use in Malaysia as a developmental screening tool.

Method: PEDS^® was translated into Malay and Mandarin by linguistics and medical professionals, followed by focussed group discussion. A cross sectional study involving 120 children between 1 and 6 years of age was conducted between 15 February and 31 May 2012 in Sibu. Caregivers completed the translated PEDS^® and answered questions regarding the acceptability and usefulness. PEDS^® was repeated 2 weeks later while the children underwent Griffiths Mental Development Scales.

Result: Till 3 May 2012, a total of 86 caregivers were recruited (46 used Malay PEDS^®, 40 for Mandarin). Preliminary data showed 26% of caregivers reporting 2 or more significant concerns and 17% have no concern. Preliminary analysis showed significant correlation between PEDS^® and global developmental disabilities and/or language disorder as assessed by the gold standard test (p <0.001), with sensitivity 73.5% and positive predictive value of 67.9%. Agreement test showed high correlation of the intra-raters reliability. Almost all (97.7%) caregivers rated the PEDS^® as very easy or easy to understand and complete; 90.7% found it acceptable as a developmental screening tool, and 62.1% believe it is very useful for Malaysian health professional.

Conclusions: Final result will be presented and relevant recommendation made to help improving the early detection of children at risk in Malaysia.

Methods: 133 Newborn infants admitted longer than 3 days to private-sector neonatal intensive care units were enrolled. 113 of these parents were contacted when their infants were 6-months corrected-age. They completed the ASQ (n=60) and the PEDS^® COMBINED (n=65) questionnaires at home. Returned questionnaires were compared using an in-subject design. Concordance between the questionnaires was determined with the kappa coefficient (κ) and Test of Symmetry.

Results: Concordance between the ASQ and PEDS^® COMBINED was 90.7% (κ = 0.82, ρ = 0.05).

The ASQ and PEDS^® COMBINED identified 40% and 42% of the cohort with developmental concerns. The ASQ and PEDS^® COMBINED showed excellent interrater agreement, identifying the same infants requiring further developmental assessment. When there was discordance, it was non-significant in the direction of the ASQ being more likely to identify an infant as delayed overall and statistically significant in the direction of the PEDS^® COMBINED being more likely to identify communication delays (ρ = 0.01)

Conclusions: The ASQ and PEDS^® COMBINED identify the same infants with developmental concerns. The PEDS^® COMBINED is more sensitive to communication delays.

Objective: This study explored the potential roles and utility of the Parents Evaluation of Developmental Status (PEDS^®) to screen children for developmental delays in a Southeast Asian clinical sample of preschool children. The PEDS^® is a 10-item questionnaire instrument used in pediatric settings for reporting parents’ concerns for their children’s development, learning, and behavior. Clinicians use it to make decisions about clinical pathways for high-, moderate-, and low-risk categories of concerns, but its utility in cross-cultural contexts has not been well documented.

Methods: Participants in this study were 1806 parents, teachers, and child care workers of preschool children in Singapore. Of these, 47.2% were English speaking, 21.2% were Mandarin Chinese speaking, and 31.6% were Malay speaking. PEDS^® was translated into Chinese and Malay for parents using these languages predominantly.

Results: Only parent results were analyzed. The reporting of significant parental concern was considerably higher than US norms and Australian pilot figures when western cutoff scores were applied. When cutoff scores were adjusted, similar patterns of reporting of high, medium, and low risk for disability could be captured.

Conclusions: Parents’ interpretation of the concept of “concern” varies across language and culture. Findings highlight the importance of evaluating a screening tool’s use in local contexts before its widespread implementation to yield clinically meaningful results.

Comment from Frances Page Glascoe: Culture does matter. Quality translations do too. We’ve been working with Dr. Kiing and colleagues since she sent us the above data in 2001, where we mutually concluded that the Mandarin translation was problematic. It isn’t enough to translate and back-translate. Wording has to be tested by providers and parents to make sure it works as intended. In 2005, after much machinating and vetting, we generated a new translation using an alternative Chinese terms for “Do you have concerns…” that was not synonymous with “Do you care…?”. Back-translated, the phrasing for the Chinese translation is “Are you worried….?” Although we know this doesn’t work in English (only about 2% of English speaking parents will respond and we know that rates of problems are much higher than that), the new translation works well with Chinese speaking parents and ensures their rates of “worries” are commensurate with parents speaking other languages. We thank Dr. Kiing, her colleagues and especially Dr. Teck-Hock Toh for working with us on this issue. We’ve also shared the revised translation with researchers using Survey PEDS^® within National Survey of Early Childhood Health (NSECH) who found similar problems with their original translation.

Ideally, journal editors/reviewers should ask about the time frame for data collection and if old, should also ask what is known and has been done since then. If such had occurred, this paper would surely not have been published.

So, please also read the subsequent study using better translations of Mandarin by Lim Boon Chuan and colleagues.

Parents’ concerns about their children’s development or behaviour predicted clinically significant levels of parenting stress on the PSI (Parenting Stress Index) even though parents who requested medical evaluations for their children didn’t have PSI or PEDS^® scores that were associated with the requests. Primary Care providers need to consider this relationship when they’re interpreting screening results and to provide support and referrals to families.

Objectives: This study investigated the sensitivity and specificity of two brief, parent-completed developmental screening measures—the Ages and Stages Questionnaire (ASQ) and the Parents’ Evaluation of Developmental Status (PEDS^®)—in children presenting to their primary care providers.

Method: A sample of 334 children aged 12 to 60 months was recruited. Parents completed the PEDS^® and the ASQ in their home or the primary care clinic of one of the investigators. The presence of >1 predictive concerns or abnormal domains was considered a positive screen. All children underwent evaluation (administered by a psychologist) with the following criterion measures: the Bayley Scales of Infant Development—Third Edition or the Wechsler Pre- school and Primary Scale of Intelligence—Third Edition, the Preschool Language Scale—Fourth Edition, and the Vineland Adaptive Behavior Scales—Second Edition.

Results: The mean age of children was 32.3 months. Developmental delay was identified in 34 children (10%). The PEDS^® had moderate sensitivity (74%) but low specificity (64%); comparatively, the ASQ had significantly higher sensitivity (82%) and specificity (78%). The ASQ had moderate sensitivity and specificity across age subgroups, whereas the PEDS^® had either low sensi- tivity or specificity in each of the age subgroups, except for the <30 month group, where there was moderate sensitivity (78%) and specificity (75%). Using >2 predictive concerns on the PEDS^® or >2 abnormal domains on the ASQ significantly improved specificity of both tests (89% and 94%, respectively) but resulted in very low sensitivity (41% and 47%, respectively).

Conclusions: These findings support the guidelines of the American Academy of Pediatrics, demonstrating that both the ASQ and, to a lesser extent, the PEDS^® have reasonable test characteristics for developmental screening in primary care settings. Although the ASQ seems to have higher sensitivity and specificity across a variety of age groups, the choice of which measure to use should be determined by the practice setting, population served, and preference of the physician.

Comment from Dr. Glascoe: In response to the above paper, several researchers including the author of PEDS^® and the ASQ, raised concerns about the overly strict definition of developmental delay. PEDS^® is designed to identify children with milder delays, i.e., not just high risk but also at risk and this explains its lower specificity in comparison with the ASQ. In addition, it is not clear that the researchers dealt appropriately with PEDS^® Response Forms on which nothing was written–these should either be met with a readministration by interview or discarded from studies. The in-press letter to the editor is below.

Glascoe FP, Marks KP, Squires J. Improving the Definition of Developmental Delay. JDBP. 2011, in press

To the Editor:

We compliment Drs. Limbos and Joyce on their careful and well-written study (Comparison of the ASQ and PEDS^® in Screening for Developmental Delay in Children Presenting for Primary Care. The authors’ research was exemplary in viewing how well the ASQ and PEDS^® performed in the identification of children with probable disabilities, i.e., those scoring below the 10th percentile and ostensibly eligible for early intervention/special education.

But the term ‘developmental delay’ also embraces those likely to fail in school—those performing above the 9thth percentile and below the 25th percentile. Such at-risk children rarely qualify for Early Intervention or special education but that does not mean they don’t need to be identified by screens as in need of other kinds of intervention (e.g., Head Start, Reach Out and Read, parent training, etc.).

Screens should identify not only disabled but also at-risk children and provide clinicians appropriate guidance for selecting diverse resources needed to help both groups. We encourage the authors to review their findings in order to speak to the complete meaning of developmental delay. Such an analysis seems likely to render different levels of sensitivity and specificity for both PEDS^® and the ASQ.

Frances Page Glascoe, Ph.D.

Professor of Pediatrics
Vanderbilt University
Nashville, Tennessee

Kevin P. Marks, M.D., FAAP
PeaceHealth Medical Group
1162 Willamette
Eugene, Oregon 97401

Jane Squires, Ph.D.
Professor, College of Education
Director, Center on Human Development
Director, Early Intervention Program
University of Oregon
Eugene, Oregon

Purpose: Quality screens are standardized on a sample of children and families whose socio-economic and demographic characteristics represent those of an entire nation (e.g., in the US by creating a normative group that reflects Census Bureau population parameters). Standardization of tests on such a sample defines what is typical performance and, in the case of screening tests, predicted frequencies of referral rates. Should researchers and clinicians working with Medicaid, NICU follow-up, or other at-risk groups expect their referral rates to differ from national norms?

Methods: Referral rates based on national norms for Parents Evaluation of Developmental Status (PEDS^®) (N = 771) were compared to those from a pediatric clinic serving mostly Medicaid patients in Milwaukee, Wisconsin (N = 744), and to 211LA, a warm line serving mostly ethnic minority families (47% Latino and 30% Arican-American) in non-medical crisis (e.g., housing or food instability)(N = 257).

Results: Chi-square comparisons among the three groups revealed that clinics serving families with elevated rates of psychosocial risk (e.g., poverty, less than a high school education, limited English proficiency, etc.) had significantly higher rates of children with problematic performance on PEDS^® (p < .0001). These results are corroborated by other studies of at-risk children administered different screening tests.

Conclusions: The impact of psychosocial risk on development is well known to developmental-behavioral specialists. Helping trainees and generalist pediatricians anticipate increased referral rates when working with at-risk populations is needed. Screening test authors should help by reporting, not only the frequency of problematic performance on nationally representative samples, but also frequencies for various at-risk populations (e.g., children in foster-care, NICU follow-up, etc.).

The number of foster children and their psychological and medical morbidity are growing. To gain insight into how to recruit and retain foster homes, characteristics of 64 foster families were determined by interview. Foster parents had low-to-moderate incomes, were approaching middle age, had underutilized home space, and wanted more children. Most enjoyed foster care and planned to continue. Twenty-three percent of the 64 had half of all foster children in the study in their homes at interview and had cared for seven times as many children in the past, including 66% of all the teens and 83% of all the handicapped children who had been in the 64 homes. These “high providers” functioned like group homes for mentally handicapped individuals. Adapting the group-home concept to foster homes could improve care, especially for children with special needs.

One of the oldest and best known developmental screening tests was recently restandardized and revised as the Denver-II. Because it was published without evidence of its accuracy, the present study was undertaken with 104 children between 3 and 72 months of age attending one of five day-care centers. To determine the presence of developmental problems, children were administered individual measures of intelligence, speech-language, achievement, and adaptive behavior. A second psychological examiner, blind to the outcome of the diagnostic battery, administered the Denver-II. Developmental problems including language impairments, learning disabilities, mild mental retardation, and/or functional developmental delay were found in 17% of the children. The Denver-II identified correctly 83% and thus had high rates of sensitivity. However, more than half the children with normal development also received abnormal, questionable, or untestable Denver-II scores. Thus the test had limited specificity (43%) and a high overreferral rate. The alternative scoring method, categorizing questionable/untestable scores as normal, caused sensitivity to drop to 56% although specificity rose to 80%. Since neither scoring method produced acceptable levels of accuracy, an effort was made to locate the sources of accuracy and inaccuracy within the test. Only items in the language domain were modestly helpful in discriminating children with and without difficulties. The findings suggest that the authors of the Denver-II need to engage in further development of the instrument including revising scoring criteria and item placement in relation to children’s ages. In the interim, test users should employ screening tests which are more accurate such as the Minnesota Inventories or the Battelle Developmental Inventory Screening Test.

Developmental screening tests are widely used for early identification but few are studied for their accuracy—the percentage of children with and without problems correctly detected. The absence of such data makes it difficult for professionals to choose measures wisely and to avoid those that under-detect or over-refer. In this article, the accuracy of three developmental screening tests was assessed. Measures included the Academic Scale of the Developmental Profile-II (DP-II), the Denver II, and the Battelle Developmental Inventory Screening Test (BDIST). Each was administered, along with a criterion battery of intelligence, adaptive, language, and achievement measures, to 89, 7- to 70-month-old children, enrolled in one of five day care centers. Twenty percent of the children tested were found to have developmental disabilities, including language delays, mental retardation, developmental delay, and autism. The Academic Scale identified fewer than one in four of the children with diagnoses, although under-referrals were minimal. The Denver-II detected the majority of children (if questionable/untestable scores were grouped with abnormal) with difficulties, but most children without problems also failed the measure. The BDIST, using the 1.5 cut-offs, was more accurate than the other screening tests and identified correctly 72% of the children with difficulties, and 76% of the children without diagnoses.

Comment: The BDIST has been revised since this article was written. The Developmental Profile is now out in its 3rd edition (but without evidence that it works as a screening measure, i.e., no cutoff scores but is helpful for NICU follow-up and EI intake as is the more recently published PEDS^®: Developmental Milestones. The Denver-II remains as it was in 1992 and continues to under-detect if questionables/untestables are not referred and over-detected if they are referred. Work on this tool is needed!

Recent research and legislation support the importance of early identification and intervention for children with developmental and behavioral or emotional problems. Detecting these children often depends on medical professionals, especially pediatricians. However, few pediatricians use developmental screening tests to help them identify children. Rather, physicians usually rely on their clinical impressions to discriminate children with and without difficulties. Research on the accuracy of clinical impressions, although sparse, suggests that only half the children in need are identified. The most obvious reasons, such as severity of the problem or the type of clinical information physicians select (e.g., parents’ concerns, observations of the child, history, etc.), do not fully explain why some children are identified and others are not. More complete explanations are found in research on clinical impression formation that suggests physician’s selection from the array of clinical data is mediated by their unique experiences, beliefs, and attitudes. These qualities provide a set of judgment heuristics for sorting seemingly relevant from irrelevant information. Judgment heuristics, depending on their content, may lead to accurate or inaccurate impressions. This article suggests a model of ideal impression formation that may help physicians learn to more accurately identify children with developmental and behavioral or emotional problems.

Comment: Almost 20 years later, we are still not finding a way for clinical judgment to detect young children with delays and disabilities without the support of accurate screening tools. This isn’t a slight on clinical acumen but rather that professional judgment is enhanced by and needs to depend on evidence. Problems are often subtle and quality measurement is critical (and informal milestones checklists, even if drawn from standardized measures, fail to provide a sufficient threshold of suspicion).

To determine whether parents’ estimates of children’s developmental ages can function as a prescreening technique.