# “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 --- 1. Early intervention relies heavily upon early identification 2. Early identification relies heavily upon medical homes 3. 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 1. How can we better incorporate evidence-based DB promotion with the process of DB screening? *Do: Reach Out and Read program* 2. How can we integrate or co-locate early childhood developmental or mental health specialists into our medical home setting? *Do: Healthy Steps Program* 3. 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!*