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Winter
2007
Recommendations for
Implementing Iowa Medicaid Guidelines:
Identifying Young Children
with Developmental or Behavioral Concerns
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LEVEL 1: Surveillance for ALL
Children |
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Guideline: Every EPSDT
well-child exam for a child 0-3 years must include:
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Surveillance of cognitive, motor, language, adaptive, and social-emotional
development
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A
review of:
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Developmental milestones
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Social,
emotional, and behavioral health, including early signs of autism
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Family
risk factors, including parental stress and maternal depression
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Eliciting and addressing parental concerns about the child’s growth and
development
Level 1
goals can be accomplished using either option below: |
Option 1
Meets current AAP recommendation
for surveillance at each well-child visit.
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Recommended protocols and
tools
Either of the tools below may be administered in the office by the health care
provider and nurse teams. Each of these tools:
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Is
age-specific for each standard well-child visit up to age 5
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Provides a checklist of developmental and social-emotional milestones, and
screens for family risks
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Can be
downloaded free at the link provided
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Is easy
to insert into an electronic medical record
Health Maintenance Clinical Notes (HMCN)
HMC Notes gather information
on such topics as nutrition, medications, immunizations, and lead screening. The
checklist format makes it easy to gather information and to provide anticipatory
guidance. HMC Notes also contain the Iowa Developmental and Behavioral
Surveillance Instrument below.
Iowa
Developmental and Behavioral Surveillance Instrument
Administration and interpretation of this tool take
3-5 min. If a child cannot execute an activity that
about 90% of other same-age children are able to perform,
this is a “red flag” that signals the need to refer
the child for further assessment.
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Option
2
Health care
providers who do not choose to use either of the tools
in Option 1, above, should complete a comprehensive surveillance
in all three domains below during the well-child exam.
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1. Domain:
Development |
One of the developmental
questionnaires below can be completed by a paraprofessional
with the parent, or by the parent alone, and then reviewed
by the primary health care provider. All children with
speech delay should be referred for audiological evaluation.
Recommended tools include:
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2. Domain:
Social-emotional and behavioral, including autism
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Administer a screening
questionnaire at intervals determined by the health
practitioner. Please note that the AAP also recommends
specific screening for autism at 18 months.
Recommended tools include:
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3. Domain:
Parenting stress and family risk factors
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The practitioner should
review for postpartum depression during the first few
newborn visits and periodically check for parenting
stress, parental depression, and other family risk factors.
Recommended tools include:
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At the first visit:
Pediatric
Intake Form, available from Bright Futures
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At subsequent visits,
at least annually:
Pediatric Intake Form
In
addition to the routine Level 1 surveillance described
above, the AAP recommends periodic screening using a
standardized tool at 9, 18, and 24-30 months.
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Level 2: Screening for Children at
Risk |
Health
care providers must provide Level 2 screening specific
to the domain of concern for any child 0-3 years old
identified as at-risk during a well-child exam, as well
as any child the provider feels should have additional
screening. The provider may complete the screening in
the office, refer the child to another provider, or
refer a child directly for Level 3 assessment. Select
domain-specific tools for additional screening. If a
tool recommended below was used in the initial screening,
proceed to diagnosis-specific tools for further evaluation.
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1. Developmental
Screening |
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A health professional
should provide screening; paraprofessionals may assist
with administration of parent report scales. The AAP
recommends developmental screening for all children
at 9, 18 and 24-30 months. All children with speech
delay should be referred for audiological evaluation.
Recommended
tools include: |
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Ages and Stages
(ASQ,
2nd ed.) |
Sensitivity
Specificity
Age
Administration
Time
Languages
Cost
Comments |
70-90%
76-91%
0-60 mo.s
Parents complete
10-15 min, less if parent completes alone
English, Spanish, French, Korean
$12.41-16.68*; $4.60 if parent completes alone**
Single, pass/fail scoring;
reading level varies per question from
grade 4-12 |
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Bayley Infant Neurodevelopmental Screen
(BINS
1995) |
Sensitivity
Specificity
Age
Administration
Time
Languages
Cost
Comments |
75-86% across ages
75-86%, across ages
3-24 mo.s
Direct elicitation
10-15 min
English
$22.22-$26*; $10.45 for materials**
Cut scores for low, moderate, or high risk in domains;
training helpful for checking reflexes and tone.
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Brigance Screens
(2002) |
Sensitivity
Specificity
Age
Administration
Time
Languages
Cost
Comments |
70-82% across ages
70-82% across ages
0-90 mo.s
Infant/toddler: parent report. Early preschool: direct
elicitation
10 min
English, Spanish
$11.68 for materials and time**
Helpful scoring software; cutoffs indicate potential
giftedness,
psychosocial risk
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| Denver
II (1992) |
Sensitivity
Specificity
Age
Administration
Time
Languages
Cost
Comments |
56-83%
30-80%
0-72 mo.s
Direct elicitation
15-20 min
English, Spanish
Complete kit $90; 100 test forms for $25
Uses risk groups; classifies children as normal, suspect,
or
delayed
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2.
Social-Emotional and Behavioral Screening |
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Screening by a health professional; paraprofessionals
may assist with administration of parent report scales.
Recommended
tools include:
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Ages
and Stages Social- Emotional (ASQ-SE, 2002)
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Sensitivity
Specificity
Age
Administration
Time
Languages
Cost
Comments |
71-85%
90-98%
6-60 mo.s
Parent completes
10-15 min, less if parent completes alone
English, Spanish, French
$4.60 for materials if parent completes alone
See ASQ, above
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Brief
Infant and Toddler Social and Emotional Assessment (BITSEA,
2000) |
Accuracy Age
Administration
Time
Languages
Cost
Comments |
Fair to good
12-36 mo.s
Parent completes 60 items
Unknown
English
$99; $35 for 25 test forms
Normed on diverse population
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Infant Development Inventory
(IDI) |
Accuracy
Age
Administration
Time
Languages
Cost
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Good
18 mo.s
Parent complete one page, both sides
Unknown
English, Spanish
$65 starter kit; $11 replacement materials |
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Child Development Review
(CDR, 1994) |
Accuracy
Age
Administration
Time
Languages
Cost
Comments |
Not known
18-60 mo.s
Parent completes 6 questions, 25-item checklist
Unknown
English, Spanish
$65 starter kit; $11 replacement materials
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3.
PDD/Autism Screening |
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AAP recommends screening all children for autism at
18 months by a health professional; para-professionals
may help administer parent report scales. If an autism
screen is positive or a high degree of concern exists,
refer for diagnostic assessment. Refer children with
speech delay for audiological evaluation.
Recommended tools include:
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M-CHAT
(2001) |
Sensitivity
Specificity
Age
Administration
Time
Languages
Cost
Comments |
87%
99%
16-48 mo.s
Parent completes
5-10 min
English, Chinese, Japanese, Spanish,
Turkish
Materials free; administration cost
unknown
Risk categorization scoring (pass/fail)
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4.
Parenting Stress/Family Risk Factors
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Screening by health professional.
Recommended tools include:
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Level 3: Assessment for children with developmental or
social-emotional concerns |
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Guideline:
Refer
for systematic, comprehensive assessment all children
0-3 years who do not pass standardized screening or
who, in your opinion, require further evaluation.
Screening should include standardized measures of the
child and family functioning, and should provide a diagnosis
as well as a treatment plan.
Recommended protocols/tools:
Professionals who provide testing as authorized by their
scope of practice should determine domains to be tested.
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Notes
*Resource-Based
Relative Value Scale (RBRVS) used to calculate Medicare
rates, as reported in "Estimating the Cost of Developmental
and Behavioral Screening of Preschool Children in General
Pediatric Practice," Peds 108:4 (Oct 2001).
** http:/www.dbpeds.org
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