Pediatric Developmental Surveillance Program Putting principles into practice for children’s health and development.

Pediatric Pediatric Developmental Developmental

Surveillance Surveillance ProgramProgramPutting principles into practice Putting principles into practice

for children’s health and for children’s health and developmentdevelopment

Developmental Developmental Surveillance: Surveillance:

Why do it & why so early?Why do it & why so early? High prevalenceHigh prevalence

~16% of children have disabilities~16% of children have disabilitiesSpeech and language delays, mental retardation, Speech and language delays, mental retardation, learning disabilities, and emotional/behavioral learning disabilities, and emotional/behavioral problemsproblems

Early intervention is criticalEarly intervention is critical

~50% of children with disabilities ~50% of children with disabilities are detected prior to school are detected prior to school entrance.entrance.

Developmental Developmental SurveillanceSurveillance

Is it ‘doable’?Is it ‘doable’?

Where do we start?Where do we start?

Importance of Being Importance of Being Objective Objective

TOUCH OR TAKE TEMP?TOUCH OR TAKE TEMP?

Objective Developmental Objective Developmental Screening ToolsScreening Tools

Good sensitivity and specificity Good sensitivity and specificity

Ideal for use in primary care settingsIdeal for use in primary care settings

Where do we start?Where do we start?

Where infants and young Where infants and young children seen on a regular children seen on a regular

basis – basis –

Well Child VisitsWell Child Visits

Educating medical Educating medical providers providers

Increasing knowledge and skills Increasing knowledge and skills

and and changing practice patterns - changing practice patterns -

Is that ‘doable’?Is that ‘doable’?

Improving Clinical Practice Improving Clinical Practice ––

Some ways it’s been doneSome ways it’s been done

Academic mentoringAcademic mentoring – – Soumerai & Soumerai & Avorn: Principles of Educational Outreach Avorn: Principles of Educational Outreach (‘Academic Detailing’) to Improve Clinical (‘Academic Detailing’) to Improve Clinical Decision Making. JAMA 263:449, 1990.Decision Making. JAMA 263:449, 1990.

Process planningProcess planning – – Ploof & Hammel: Ploof & Hammel: Originally printed in Developmental and Originally printed in Developmental and Behavioral News, published by the AAP Behavioral News, published by the AAP Section on Developmental and Behavioral Section on Developmental and Behavioral Pediatrics Publication date: Jan 4, 2005Pediatrics Publication date: Jan 4, 2005

PDSPPDSP Phases of Training Phases of Training What did we actually do?What did we actually do?

Implementation/TrainingImplementation/Training

Mentoring/ConsultationMentoring/Consultation

Surveillance/SupportSurveillance/Support

Continuous Quality ImprovementContinuous Quality Improvement

Outcomes –Outcomes –What is getting done?What is getting done?

Medical HomesMedical Homes – – Work directly in over 30 practicesWork directly in over 30 practices Over 200 staff trained in screening toolsOver 200 staff trained in screening tools More than 95% ‘pass’ CQIMore than 95% ‘pass’ CQICommunity and FamiliesCommunity and Families – – Streamline referrals to preschool and early Streamline referrals to preschool and early

intervention servicesintervention services Provide developmental information to over Provide developmental information to over

1400 families each year1400 families each year Provide additional secondary Provide additional secondary

developmental screens to over 800 children developmental screens to over 800 children each yeareach year

Barriers –Barriers –What made it hard(er) to do?What made it hard(er) to do?

Selling the ideaSelling the idea

Identifying and sustaining fundingIdentifying and sustaining funding

Lessons learned –Lessons learned –Making it easier to do in the Making it easier to do in the

futurefuture

Flexibility - Flexibility - Tailor implementation and Tailor implementation and training to each practicetraining to each practice

Practices own the process - Practices own the process - Help Help practices identify the problem for practices identify the problem for themselvesthemselves

Secure funding - Secure funding - allow Program staff to allow Program staff to productively focus energy and timeproductively focus energy and time

Monitoring Child Monitoring Child Development:Development:

Is it something Public Is it something Public Health should be Health should be

doing?doing?Nutrition/safe water supplyNutrition/safe water supply

Infection Infection control/immunizationcontrol/immunization

DevelopmentDevelopment

Developmental Surveillance Developmental Surveillance - -

What Public Health What Public Health Agencies Agencies CANCAN DODO Educate community and medical Educate community and medical

providersproviders

Provide consultation and technical Provide consultation and technical assistanceassistance

Monitor for continuous quality Monitor for continuous quality improvementimprovement

Pediatric Developmental Pediatric Developmental Surveillance ProgramSurveillance Program

REFERENCESREFERENCES

www.cdc.gov/ncbddd/chwww.cdc.gov/ncbddd/childild

www.dbpeds.orgwww.dbpeds.org

ReferencesReferences Boyle CS, Decoufle P, Yeargin-Allsoop MY. Boyle CS, Decoufle P, Yeargin-Allsoop MY.

Prevalence and healh impact of developmental Prevalence and healh impact of developmental disabilities. disabilities. PediatricsPediatrics 93:863, 1994. 93:863, 1994.

Committee on Children and Disabilities, Committee on Children and Disabilities, American Academy of Pediatrics. American Academy of Pediatrics. Developmental surveillance and screening for Developmental surveillance and screening for infants and young children. infants and young children. PediatricsPediatrics 108:192, 2001. 108:192, 2001.

Dworkin PH. Detection of behavioral, Dworkin PH. Detection of behavioral, developmental, and psychosocial problems in developmental, and psychosocial problems in pediatric primary care practice. pediatric primary care practice. Curr Opin Curr Opin PediatrPediatr. 5:531, 1993.. 5:531, 1993.

ReferencesReferences Glascoe FP, Dworkin PH. The role of Glascoe FP, Dworkin PH. The role of

parents in the detection of developmental parents in the detection of developmental and behavioral problems. and behavioral problems. PediatricsPediatrics 95:828, 95:828, 1995.1995.

Palfrey JS, Singer JD, Walker DK, Butler JA. Palfrey JS, Singer JD, Walker DK, Butler JA. Early identification of children’s special Early identification of children’s special needs: A study in five metropolitan needs: A study in five metropolitan communities. communities. J of PediatrJ of Pediatr 11:651, 1994. 11:651, 1994.

RegaladoM, Halfon N. Primary care RegaladoM, Halfon N. Primary care services promoting optimal dhild services promoting optimal dhild development from birth to age 3 years. development from birth to age 3 years. Arch Arch of Pediatr & Adol Medof Pediatr & Adol Med 155:1311, 2001. 155:1311, 2001.

ReferencesReferences

From Neurons to Neighborhoods: From Neurons to Neighborhoods: The science of early child The science of early child development. Shonkoff & Phillips, development. Shonkoff & Phillips, eds. Washington, D. C., National eds. Washington, D. C., National Academy Press, 2000.Academy Press, 2000.

““Developmental” History Developmental” History of of the PDSPthe PDSP

Two previous projects in Wake County from Two previous projects in Wake County from the mid 1990’s:the mid 1990’s:

Healthy Start project - Healthy Start project - providing PE’s and providing PE’s and developmental assessments in child care developmental assessments in child care settings with funding by Wake County settings with funding by Wake County Smart Start.Smart Start.

NC Health Choice enrollment initiative – NC Health Choice enrollment initiative – a a collaborative between Wake County collaborative between Wake County Human Services and NC Pediatric Society Human Services and NC Pediatric Society for Wake County practices.for Wake County practices.

““Developmental” History – Developmental” History –

Why was developmental surveillance Why was developmental surveillance

chosen?chosen? AAP Committee on Children with AAP Committee on Children with

Disabilities recommends the use of Disabilities recommends the use of standardized screening tests standardized screening tests periodically at well visits. periodically at well visits.

North Carolina Division of Public North Carolina Division of Public Health mandated new screening Health mandated new screening guidelines.guidelines.

““Developmental” History - Developmental” History - Lessons learned about working Lessons learned about working

with primary care practiceswith primary care practices Assessing and monitoring children’s Assessing and monitoring children’s

developmental status is a priority for developmental status is a priority for the primary practices.the primary practices.

Practices welcome assistance to Practices welcome assistance to provide quality care IF it can be provide quality care IF it can be integrated into their individual office integrated into their individual office setting.setting.

Costs of NOT screeningCosts of NOT screening

Society saves between $30,000 & Society saves between $30,000 & $100,000 for every 2 years o needed $100,000 for every 2 years o needed intervention prior to kindergarten. intervention prior to kindergarten.

Glascoe FP, Foster M, Wolraich ML. Glascoe FP, Foster M, Wolraich ML. An economic analysis of An economic analysis of developmental detection methods. developmental detection methods. PediatricsPediatrics 99: 830, 1997. 99: 830, 1997.

Cost considerationsCost considerations

Advocates of earlier & more Advocates of earlier & more intervention have an obligation to intervention have an obligation to measure their impacts & costs.measure their impacts & costs.

Skeptics, in turn, must acknowledge Skeptics, in turn, must acknowledge the massive scientific evidence that the massive scientific evidence that early childhood development is early childhood development is influenced by the environments in influenced by the environments in which children live.which children live.

From Neurons to NeighborhoodsFrom Neurons to Neighborhoods

Parents have abundantParents have abundant opportunitiesopportunities to to observeobserve and and comparecompare their children to their children to

others. others.

TestsTests correctcorrect for tendency of some for tendency of some parents to parents to over-reportover-report and some parents and some parents toto under-report.under-report.

YES!

Can parents be counted upon to Can parents be counted upon to give accurate and quality give accurate and quality

information?information?

Where are children seen?Where are children seen?Early Child Development in Social Early Child Development in Social

Context: A Chartbook, The Context: A Chartbook, The Commonwealth Fund, Sept 2004Commonwealth Fund, Sept 2004

[email protected]@cmwf.org In 2002, 84% of children < 6 years of age had a In 2002, 84% of children < 6 years of age had a well-child visit in past year.well-child visit in past year.

In 2000, almost on half of parents had concerns In 2000, almost on half of parents had concerns about young child’s speech, social about young child’s speech, social development, or behavior, but only about 45% development, or behavior, but only about 45% of parents recalled any developmental of parents recalled any developmental assessment being done. assessment being done.

Improvement, in part physician training, Improvement, in part physician training, tracking quality of care, and changes in health tracking quality of care, and changes in health care plans, and work with other community care plans, and work with other community services to improve primary care, identify services to improve primary care, identify problems, and facilitate interventions on behalf problems, and facilitate interventions on behalf of children’s development.of children’s development.