Early childhood developmental screening differs in the U.S., Scandinavia

 

Nearly every parent gets excited about their child’s first smile, steps, and words. Developmental and behavioral screening helps to better track young children’s progress in areas like communication, motor, cognitive, and social/emotional skills. Approximately one in four or five children are at risk for a developmental/behavioral delay, which might indicate an emerging developmental disability or mental health disorder.

Regular screenings raise awareness of children’s development, which makes it easier for parents to expect and celebrate milestones. They encourage parents and doctors to avoid the common pitfall of taking a “wait and see” approach. Regular screenings might even help doctors more easily diagnose co-occurring conditions like autism, sleep disorders, iron deficiencies, hearing impairment, metabolic disorders, genetic disorders, in utero drug/alcohol exposure, or child maltreatment.

High-quality interventions for children aged 0-5 years can decrease rates of special education, substance abuse, criminality/incarceration, suicidal attempts, and unemployment or welfare dependency. The trick is to swiftly identify and refer at-risk and delayed children to the most effective resources in a family-centered manner.

Our new study, which has been published online in Developmental Medicine and Child Neurology, investigated early childhood screening practices across the United States and Scandinavia (Denmark, Norway, and Sweden), which lie relatively far apart on the spectrum of preventive care models (2018 Sep 23. doi: 10.1111/dmcn.14044).

Just like many other developed areas of the world, the United States and Scandinavia are increasingly using two accurate, parent-reported screening tools – the Ages & Stages Questionnaire (ASQ) and ASQ:Social-Emotional (ASQ:SE) – to measure developmental and behavioral skills in children aged 0-5 years. We found that routine and periodic ASQ and/or ASQ:SE screening is low cost, feasible, and increases early detection and referral rates, plus they connect at-risk children to early intervention programs at significantly younger ages.

Surprisingly, the United States and Scandinavia tend to use these same two screening questionnaires quite differently. U.S. pediatricians and family physicians commonly use the ASQ and/or ASQ:SE in clinic settings to swiftly identify developmental/behavioral red flags in children from general and at-risk populations (See video at end of article). Scandinavian studies more commonly report the use of the ASQ and ASQ:SE to track developmental/behavioral differences in children in an intervention/exposure group and how they compare with children in a control group over time. In other words, the United States uses these screens clinically, and Scandinavia mostly uses them for research purposes.

In Scandinavia, home visit nurses and general practitioners commonly administer more narrowly focused, “hands-on” screens during infancy. Different municipalities use different screens. Language-focused screening typically is not performed until ages 2.5-3 years in preschools or child health centers. That’s probably too late. Scandinavian countries, which boast bountiful and equitable early childhood resources, are not routinely using parent-centered screening tools that measure all of a child’s developmental domains, including social/emotional skills. One reason is probably that Danish and Swedish ASQ and ASQ:SE norming (standardization) and validation (reliability and accuracy) studies are lacking and because Norwegian norms are out-of-date. Therefore, they are primarily used just for research. Every decade, the “good” screening questionnaires have to be scientifically tweaked and improved as the characteristics of populations (like ethnicity, socioeconomic status, or percentage of new immigrants) and cultural norms (like rotary versus cell phones) change over time.

 

Scandinavia likely would benefit from nationwide screening initiatives, which played key roles in implementing and sustaining developmental and social/emotional screening in numerous U.S. states. The American Academy of Pediatrics recommends routinely administering a standardized developmental screening tool at ages 9, 18, and 24-30 months, along with many other action steps and decision-making points. In reality, only 30% of U.S. children received a parent-centered, standardized developmental screening, and state-level screening rates varied wildly from 59% (Oregon) to 17% (Mississippi) in 2017-2018 (JAMA Pediatr. 2018;172[9]:857-66). Statewide screening initiatives made a big difference.

One implementation lesson is that U.S. and Scandinavian health care clinics probably should not bother mailing out the ASQ or ASQ:SE paper questionnaires to family’s homes. They will end up getting suboptimal return rates, most especially for preschoolers. Instead, clinics should instruct parents to complete the online ASQ or ASQ:SE at home 1-2 weeks before the office visit or, alternatively, the paper ASQ or ASQ:SE about 20 minutes before the clinician walks into the exam room. A number of study results support this.

According to U.S. studies, when primary care doctors share office space with developmental specialists or psychologists, children with concerning screens are more reliably connected to early interventions. Children and families can benefit from care coordinators, who supervise and bring doctors together with different specialists while monitoring and evaluating the care delivered.

According to Scandinavian studies, when mothers screen positive for depression, their at-risk children generally benefit from a social-emotional/behavioral (ASQ:SE) screening at 2 years old or younger. Currently, this is not routinely happening in U.S. primary care practices. Too many at-risk children are not identified with mental health problems until their elementary or high school years.

America could do a much better job of screening, and as it turns out, ditto with Scandinavia. We hope our systematic review inspires policy makers, medical professionals, early childhood educators, mental health providers, social workers, and parents, to learn more about developmental and behavioral screening and to perform ongoing, high-quality research in the United States, Scandinavia, and many other developed nations.

Here is a video Dr. Marks has developed showing how to integrate ASQ screening into your practice.

 

Dr. Marks is a pediatrician, clinical researcher, and coauthor of Developmental Screening in Your Community. Dr. Madsen Sjö is a certified pediatric neuropsychologist in Copenhagen. Dr. Marks and his family moved from the United States to Denmark in 2017. Email him at [email protected].

 

Nearly every parent gets excited about their child’s first smile, steps, and words. Developmental and behavioral screening helps to better track young children’s progress in areas like communication, motor, cognitive, and social/emotional skills. Approximately one in four or five children are at risk for a developmental/behavioral delay, which might indicate an emerging developmental disability or mental health disorder.

Regular screenings raise awareness of children’s development, which makes it easier for parents to expect and celebrate milestones. They encourage parents and doctors to avoid the common pitfall of taking a “wait and see” approach. Regular screenings might even help doctors more easily diagnose co-occurring conditions like autism, sleep disorders, iron deficiencies, hearing impairment, metabolic disorders, genetic disorders, in utero drug/alcohol exposure, or child maltreatment.

High-quality interventions for children aged 0-5 years can decrease rates of special education, substance abuse, criminality/incarceration, suicidal attempts, and unemployment or welfare dependency. The trick is to swiftly identify and refer at-risk and delayed children to the most effective resources in a family-centered manner.

Our new study, which has been published online in Developmental Medicine and Child Neurology, investigated early childhood screening practices across the United States and Scandinavia (Denmark, Norway, and Sweden), which lie relatively far apart on the spectrum of preventive care models (2018 Sep 23. doi: 10.1111/dmcn.14044).

Just like many other developed areas of the world, the United States and Scandinavia are increasingly using two accurate, parent-reported screening tools – the Ages & Stages Questionnaire (ASQ) and ASQ:Social-Emotional (ASQ:SE) – to measure developmental and behavioral skills in children aged 0-5 years. We found that routine and periodic ASQ and/or ASQ:SE screening is low cost, feasible, and increases early detection and referral rates, plus they connect at-risk children to early intervention programs at significantly younger ages.

Surprisingly, the United States and Scandinavia tend to use these same two screening questionnaires quite differently. U.S. pediatricians and family physicians commonly use the ASQ and/or ASQ:SE in clinic settings to swiftly identify developmental/behavioral red flags in children from general and at-risk populations (See video at end of article). Scandinavian studies more commonly report the use of the ASQ and ASQ:SE to track developmental/behavioral differences in children in an intervention/exposure group and how they compare with children in a control group over time. In other words, the United States uses these screens clinically, and Scandinavia mostly uses them for research purposes.

In Scandinavia, home visit nurses and general practitioners commonly administer more narrowly focused, “hands-on” screens during infancy. Different municipalities use different screens. Language-focused screening typically is not performed until ages 2.5-3 years in preschools or child health centers. That’s probably too late. Scandinavian countries, which boast bountiful and equitable early childhood resources, are not routinely using parent-centered screening tools that measure all of a child’s developmental domains, including social/emotional skills. One reason is probably that Danish and Swedish ASQ and ASQ:SE norming (standardization) and validation (reliability and accuracy) studies are lacking and because Norwegian norms are out-of-date. Therefore, they are primarily used just for research. Every decade, the “good” screening questionnaires have to be scientifically tweaked and improved as the characteristics of populations (like ethnicity, socioeconomic status, or percentage of new immigrants) and cultural norms (like rotary versus cell phones) change over time.

 

Scandinavia likely would benefit from nationwide screening initiatives, which played key roles in implementing and sustaining developmental and social/emotional screening in numerous U.S. states. The American Academy of Pediatrics recommends routinely administering a standardized developmental screening tool at ages 9, 18, and 24-30 months, along with many other action steps and decision-making points. In reality, only 30% of U.S. children received a parent-centered, standardized developmental screening, and state-level screening rates varied wildly from 59% (Oregon) to 17% (Mississippi) in 2017-2018 (JAMA Pediatr. 2018;172[9]:857-66). Statewide screening initiatives made a big difference.

One implementation lesson is that U.S. and Scandinavian health care clinics probably should not bother mailing out the ASQ or ASQ:SE paper questionnaires to family’s homes. They will end up getting suboptimal return rates, most especially for preschoolers. Instead, clinics should instruct parents to complete the online ASQ or ASQ:SE at home 1-2 weeks before the office visit or, alternatively, the paper ASQ or ASQ:SE about 20 minutes before the clinician walks into the exam room. A number of study results support this.

According to U.S. studies, when primary care doctors share office space with developmental specialists or psychologists, children with concerning screens are more reliably connected to early interventions. Children and families can benefit from care coordinators, who supervise and bring doctors together with different specialists while monitoring and evaluating the care delivered.

According to Scandinavian studies, when mothers screen positive for depression, their at-risk children generally benefit from a social-emotional/behavioral (ASQ:SE) screening at 2 years old or younger. Currently, this is not routinely happening in U.S. primary care practices. Too many at-risk children are not identified with mental health problems until their elementary or high school years.

America could do a much better job of screening, and as it turns out, ditto with Scandinavia. We hope our systematic review inspires policy makers, medical professionals, early childhood educators, mental health providers, social workers, and parents, to learn more about developmental and behavioral screening and to perform ongoing, high-quality research in the United States, Scandinavia, and many other developed nations.

Here is a video Dr. Marks has developed showing how to integrate ASQ screening into your practice.

 

Dr. Marks is a pediatrician, clinical researcher, and coauthor of Developmental Screening in Your Community. Dr. Madsen Sjö is a certified pediatric neuropsychologist in Copenhagen. Dr. Marks and his family moved from the United States to Denmark in 2017. Email him at [email protected].

 

Nearly every parent gets excited about their child’s first smile, steps, and words. Developmental and behavioral screening helps to better track young children’s progress in areas like communication, motor, cognitive, and social/emotional skills. Approximately one in four or five children are at risk for a developmental/behavioral delay, which might indicate an emerging developmental disability or mental health disorder.

Regular screenings raise awareness of children’s development, which makes it easier for parents to expect and celebrate milestones. They encourage parents and doctors to avoid the common pitfall of taking a “wait and see” approach. Regular screenings might even help doctors more easily diagnose co-occurring conditions like autism, sleep disorders, iron deficiencies, hearing impairment, metabolic disorders, genetic disorders, in utero drug/alcohol exposure, or child maltreatment.

High-quality interventions for children aged 0-5 years can decrease rates of special education, substance abuse, criminality/incarceration, suicidal attempts, and unemployment or welfare dependency. The trick is to swiftly identify and refer at-risk and delayed children to the most effective resources in a family-centered manner.

Our new study, which has been published online in Developmental Medicine and Child Neurology, investigated early childhood screening practices across the United States and Scandinavia (Denmark, Norway, and Sweden), which lie relatively far apart on the spectrum of preventive care models (2018 Sep 23. doi: 10.1111/dmcn.14044).

Just like many other developed areas of the world, the United States and Scandinavia are increasingly using two accurate, parent-reported screening tools – the Ages & Stages Questionnaire (ASQ) and ASQ:Social-Emotional (ASQ:SE) – to measure developmental and behavioral skills in children aged 0-5 years. We found that routine and periodic ASQ and/or ASQ:SE screening is low cost, feasible, and increases early detection and referral rates, plus they connect at-risk children to early intervention programs at significantly younger ages.

Surprisingly, the United States and Scandinavia tend to use these same two screening questionnaires quite differently. U.S. pediatricians and family physicians commonly use the ASQ and/or ASQ:SE in clinic settings to swiftly identify developmental/behavioral red flags in children from general and at-risk populations (See video at end of article). Scandinavian studies more commonly report the use of the ASQ and ASQ:SE to track developmental/behavioral differences in children in an intervention/exposure group and how they compare with children in a control group over time. In other words, the United States uses these screens clinically, and Scandinavia mostly uses them for research purposes.

In Scandinavia, home visit nurses and general practitioners commonly administer more narrowly focused, “hands-on” screens during infancy. Different municipalities use different screens. Language-focused screening typically is not performed until ages 2.5-3 years in preschools or child health centers. That’s probably too late. Scandinavian countries, which boast bountiful and equitable early childhood resources, are not routinely using parent-centered screening tools that measure all of a child’s developmental domains, including social/emotional skills. One reason is probably that Danish and Swedish ASQ and ASQ:SE norming (standardization) and validation (reliability and accuracy) studies are lacking and because Norwegian norms are out-of-date. Therefore, they are primarily used just for research. Every decade, the “good” screening questionnaires have to be scientifically tweaked and improved as the characteristics of populations (like ethnicity, socioeconomic status, or percentage of new immigrants) and cultural norms (like rotary versus cell phones) change over time.

 

Scandinavia likely would benefit from nationwide screening initiatives, which played key roles in implementing and sustaining developmental and social/emotional screening in numerous U.S. states. The American Academy of Pediatrics recommends routinely administering a standardized developmental screening tool at ages 9, 18, and 24-30 months, along with many other action steps and decision-making points. In reality, only 30% of U.S. children received a parent-centered, standardized developmental screening, and state-level screening rates varied wildly from 59% (Oregon) to 17% (Mississippi) in 2017-2018 (JAMA Pediatr. 2018;172[9]:857-66). Statewide screening initiatives made a big difference.

One implementation lesson is that U.S. and Scandinavian health care clinics probably should not bother mailing out the ASQ or ASQ:SE paper questionnaires to family’s homes. They will end up getting suboptimal return rates, most especially for preschoolers. Instead, clinics should instruct parents to complete the online ASQ or ASQ:SE at home 1-2 weeks before the office visit or, alternatively, the paper ASQ or ASQ:SE about 20 minutes before the clinician walks into the exam room. A number of study results support this.

According to U.S. studies, when primary care doctors share office space with developmental specialists or psychologists, children with concerning screens are more reliably connected to early interventions. Children and families can benefit from care coordinators, who supervise and bring doctors together with different specialists while monitoring and evaluating the care delivered.

According to Scandinavian studies, when mothers screen positive for depression, their at-risk children generally benefit from a social-emotional/behavioral (ASQ:SE) screening at 2 years old or younger. Currently, this is not routinely happening in U.S. primary care practices. Too many at-risk children are not identified with mental health problems until their elementary or high school years.

America could do a much better job of screening, and as it turns out, ditto with Scandinavia. We hope our systematic review inspires policy makers, medical professionals, early childhood educators, mental health providers, social workers, and parents, to learn more about developmental and behavioral screening and to perform ongoing, high-quality research in the United States, Scandinavia, and many other developed nations.

Here is a video Dr. Marks has developed showing how to integrate ASQ screening into your practice.

 

Dr. Marks is a pediatrician, clinical researcher, and coauthor of Developmental Screening in Your Community. Dr. Madsen Sjö is a certified pediatric neuropsychologist in Copenhagen. Dr. Marks and his family moved from the United States to Denmark in 2017. Email him at [email protected].