“Early Interventioners Assemble!”

Implementing the ASQ-3 & ASQ:SE-2 in a Medical Home Setting

Kevin Marks, MD FAAP General Pediatrician & Pediatric Hospitalist at PeaceHealth Medical Group; Clinical Assistant Professor at Oregon Health and Science University School of Medicine, Division of General Pediatrics

Early intervention relies heavily upon early identification
Early identification relies heavily upon medical homes
And... medical homes must wield mighty (or evidence-based) developmental-behavioral screening tools (e.g., ASQ-3 & ASQ:SE) & developmental-behavioral promotion (e.g., Read Out and Read) to prevent future disasters

Why Become a Screening & Surveillance Champion or Superhero?

Why is High-quality Screening & Surveillance So Important?

Early Intervention (EI) improves long-term developmental outcomes (most especially in disadvantaged children with mild delays, autism or low SES/Medicaid)
Improved outcomes at 18 years = higher achievement in math & reading + less antisocial behaviors, suicidal thoughts/attempts, smoking, alcohol & THC use (McCormick et al. Pediatrics, 2006)
Pediatrician impression alone (surveillance without periodic screening) fails to timely identify & refer 60 – 80% of children with developmental delays
For every $1 invested in an early childhood developmental program, there is a 6-10% annual return rate in cost savings to society! (per Dr James Heckman, a Nobel Laureate in Economics & other well-respected economists)

How Can You Make a Difference? AAP & Bright Futures: DB Promotion

Developmental-Behavioral (DB) promotion should be re-conceptualized as a key component of high-quality DB surveillance (Marks, Glascoe & Macias, Clinical Pediatrics, 2011) & was missing in the 2006 AAP DS&S algorithm
DB promotion makes the process of ASQ-3 & ASQ:SE screening safer (an Institute of Medicine’s quality aim)
Parent-report screening tools (e.g., ASQ-3 & ASQ:SE + age-appropriate Learning Activities) enhance DB promotion by educating parents about developmental milestones & encouraging “special time” with their child
“Special time” improves parent–child interactions and is an effective strategy for preventing behavior problems

How Can You Make a Difference? AAP & Bright Futures: DB Promotion

What else makes the process of screening safer and more effective?
Reach Out and Read (ROR) has over 20 years of supportive evidence-based research & can be used in combination with the ASQ-3 & ASQ:SE
What is ROR? Clinician gives a child a brand new ROR book + gives the parents age-appropriate literacy counseling + directly observes early literacy developmental milestones during the physical exam
ROR is for every well-child visit from 6 months–5 years

AAP General Developmental Screening Periodicity Schedule (0–5 yrs)

Use a general developmental screen (e.g., ASQ-3) routinely at 9, 18, 24 or 30 months + at 4 years (to measure “kindergarten readiness”) + as needed from 0–5 years when “at risk” for a developmental delay

ASQ-3: It’s Psychometrically Sound

Standardization: nationally representative (appropriately diverse), and general/naturalistic sample
Standardization: sample size = 12,695 (with 352–2,088 children per age interval) which is really good
Inter-rater reliability = 93%
Test-retest reliability = 93%
Last re-normed in 2009 on appropriate & equivalent reference (gold) standard testing
Sensitivity: 0.86
Specificity: 0.85
Good concurrent validity that’s been closely replicated in a primary care setting (Limbos & Joyce, Journal of Developmental Behavioral Pediatrics. 2011)
Favorably cited by the American Academy of Pediatrics & recommended by the American Academy of Neurology, Child Neurology Society, and First Signs.

ASQ-3: It’s Feasible

• Parent-report (with observable test items) • Time frame: 10–20 minutes to complete & score • 30 items (scored) + 6–7 overall items per questionnaire • 21 questionnaires with age range = 1 mo–5.5 yrs • Reading level: 4 – 5 grade • Available commercially in English and Spanish. Multiple other languages in development • Clear, straight-forward scoring & interpretation guidelines • Multiple options available for online use

Impact of Implementing the ASQ at 12 & 24 mo.

Compared to “pediatrician developmental impression” alone, the ASQ led to a 5 to 6-fold increase in EI referrals at 12 mo. & a 2-fold increase at 24 mo. & EI eligibility rates soared upward. Hix, Marks et al., Pediatrics 2007

AAP Social-Emotional Screening Periodicity Schedule (0–5 yrs)

Use a SE/mental health screen (e.g., ASQ:SE) routinely at 5 yrs + as needed from 0–5 yrs. Some practices use the ASQ:SE routinely at 4 yrs to help measure “kindergarten readiness”

ASQ:SE: It’s Psychometrically Sound

Standardization: nationally representative (appropriately diverse), general/naturalistic sample
Standardization: sample size = 3,014 (with 298–471 children per age interval) which is really good
Test-retest reliability = 94%
Normed on appropriate & equivalent reference (gold) standard testing
Sensitivity: 0.71 – 0.85
Specificity: 0.90 – 0.98
Favorably cited by the American Academy of Pediatrics (AAP) & other professional organizations.

ASQ:SE: It’s Feasible

Parent-report (items based on parental recall)
Time frame: 10–15 minutes to complete & score
19–33 questions per questionnaire
8 age-specific questionnaires & age range = 3 mo–5.5 yrs
Reading level: 5 –6 grade
Available commercially in English and Spanish
Clear, straight-forward (refer/no refer) scoring
Multiple options available for online use

10. Quality Improvement Plan-Do-Study Act (PDSA) Cycle

How can we better incorporate evidence-based DB promotion with the process of DB screening? Do: Reach Out and Read program
How can we integrate or co-locate early childhood developmental or mental health specialists into our medical home setting? Do: Healthy Steps Program
How can we better organize & utilize system-wide care coordination services? Do: Help Me Grow (HMG) or Assuring Better Child Development (ABCD) III initiatives

“EARLY INTERVENTIONERS ASSEMBLE!”

Now go forth, make the necessary changes in your practice! Theme of this presentation = work as a team!