Screening & Prevention - Infant Social-Emotional Screening

Learning disabilities, language delays, mental retardation, and social-emotional problems affect up to 18% of children. Social-emotional, or infant mental health, problems may include attachment disorders, feeding problems, and behavior problems. Less than 1/3 of these children with disabilities are identified before they begin school, delaying appropriate and helpful interventions. Low enrollment rates, at about 80%, in early intervention programs indicate the need for primary care providers to improve screening services to identify these children. Early intervention programs can help improve long-term outcomes including improving the likelihood of graduating from school and avoiding teenage pregnancy. [www.dbpeds.org Tutorials]

Improving social-emotional screening requires the use of standardized screening tools rather than relying on identifying possible delays or problems from parent's questions or clinical observations during a busy well- or sick-child visit. While some experts recommend implementing social-emotional screening at every well-child visit, choosing key visits at critical ages can be a way to introduce standardized screening with manageable changes to office procedures. An alternative method to implement social-emotional screening is to introduce the screening when scores on a standardized developmental screening tool indicate the need for further evaluation. Additionally, screening tools should be used when parents or providers have concerns about behavior issues. [www.dbpeds.org Tutorials] [American: 2006]

The pediatrician is the best-informed professional with whom many families have contact during the first 5 years of a child's life. Parents look to the pediatrician to be the expert not only on childhood illnesses but also on child development and child behavior. [Committee: 2001]

As a field of study, infant mental health is "concerned with the optimal physical, social, emotional, and cognitive development of the human infant within the context of his family." In screening for healthy mental health development, the infant is best evaluated within the "primary caregiving relationship - usually with his mother- and the pair is the focus of assessment and intervention." [Frederick H. Leonhardt Foundation]

The ability to attach to a significant adult fosters a child who is trusting, confident, and capable of regulating stress and distress. "Children who develop insecure attachments are at risk for developing learning delays, relationship dysfunction, difficulty expressing emotions, and future mental health disorders, including poor self-control, aggression, poor peer relationships, and difficulty in school." [Onunaku: 2005].

Other Names

Infant mental health

Early Signs

The following behaviors may indicate mental health problems:

Infants and toddlers:

Displays very little emotion: rarely coos, babbles, or whimpers;
Sad affect; rejects being held or touched;
Unusually difficult to soothe or console;
Extremely fearful or on guard;
Does not turn to familiar adults for comfort or help;
Rare eye contact with caregiver;
Unable to comfort or console self;

Pre-school children:

Cannot play with others or objects;
Very sad or flat affect, withdrawn, expressionless;
Absence of language or communication;
Extreme mood swings;
Inappropriate responses to situations (laughs instead of cries when hurt);
Loss of earlier skills like toileting, language, or motor skills; and
Reckless behavior, accident prone, destructive to self or others, frequently fights.

Adapted from [Graham: 2001].

ICD-9

783.4, Lack of expected normal physiological development in childhood

V20.2, Routine infant or child health check

V70.0, Routine general medical examination at a health care facility

V79.3, Screening for developmental handicaps in early childhood

V79.8, Screening for other specified mental disorders and developmental handicaps

V79.9, Screening for unspecified mental disorder and developmental handicap

The listed ICD-9 and V codes may be used for screening. The list does not include codes for diagnosed conditions.

CPT

96110, Developmental Screening

96111, Developmental Testing

In 2003, "two codes specifically relating to 'developmental and behavioral' pediatrics were approved by CMS and thereby setting the path for reimbursement for the services these codes cover." [www.dbpeds.org]

"Billing code 96110 covers a physician or non-physician administering a standardized screening instrument (broadband or autism-specific) to a child's guardian or other observer, and reflects only the physician time reviewing the scores and interpreting the findings with the family (rather than the actual work of giving the survey). Using this code requires documentation that the screen was given and the actions taken." [www.developmentalscreening.org]

"When adding the 96110 screening code to an evaluation and management visit, American Medical Association CPT (Current Procedural Terminology) codes guide providers to append the modifier "-25" to the E/M code. Given that the evaluation is a significant, separate service from the screening procedure, it's acceptable to bill 96110 for every screening tool used. However, individual payers may contract with participating providers to include the screen within preventive care or E/M, or may direct their providers to bill differently from the AMA's CPT guidelines." [www.developmentalscreening.org]

Guidelines

Conduct developmental surveillance for all children at well-child visits; [AAP Periodicity Schedule] [Committee: 2001]

Use standardized screening tools for low-risk children at the 9-, 18, and or 30-month well-child visits. [Committee: 2001] [American: 2006] [American: 2007]

Tools

A brief list of suggested screening tools is provided. Contact your state's Medicaid agency for other possible recommended tools.

Ages and Stages Questionnaire (ASQ)

Description: A developmental screening tool that can be filled out by parents or providers and is designed for children from birth to 60 months of age. Sensitivity= 67-90%; specificity= 39-91%. [Rydz: 2006] [Descriptions of Screening Tools from dbpeds.org]

Source: Questionnaires are available in English, Spanish, and other languages from the Brookes Publishing Company at Ages and Stages Questionnaire. Scoring instructions are available in the User's Guide. The costs range from $175.00 for the ASQ Questionnaires only to $199.00 for the Complete ASQ System. Other items are available for purchase including the User's Guide, Learning Activities, Questionnaire Manager software, videos, and materials kit. Paper questionnaires are photocopiable. Questionnaires from the CD-ROM can be posted to password-protected web sites.

Ages and Stages Questionnaire: Social-Emotional (ASQ:SE)

Description: A screening tool for social-emotional developmental screening that can be filled out by parents or providers and is designed for children from 6 to 60 months of age. Sensitivity= 71-85%; specificity= 90-98%. [Overview of the ASQ:SE]

Source: Questionnaires are available in English and Spanish from the Brookes Publishing Company at Ages and Stages Questionnaire: Social-Emotional. Scoring instructions are available in the User's Guide. The costs range from $125.00 for the ASQ:SE Questionnaires only to $149.00 for the Complete ASQ System. Other items are available for purchase including the User's Guide and videos. Paper questionnaires are photocopiable. Questionnaires from the CD-ROM can be posted to password-protected web sites.

Parent's Evaluation of Developmental Status (PEDS)

Description: A developmental screening tool that can be filled out by parents and is designed for children from birth to 8 years of age. Sensitivity= 74-79%; specificity= 70-80%. [Descriptions of Screening Tools from dbpeds.org]

Source: Forms are available in English and Spanish from Ellsworth & Vandermeer Press at Parent's Evaluation of Developmental Status. Scoring instructions are available in the Brief Administration and Scoring Guide. The costs range from $15.00 for a pad of 50 PEDS Response Forms to $30.00 for the Complete Set. Other items are available for purchase including the Comprehensive PEDS Manual and a Discounted Bulk Order Package. Paper forms are can not be photocopied. Replacement forms must be purchased. Online options are available for purchase.

Temperament and Atypical Behavior Scale (TABS)

Description: A developmental screening tool that can be filled out by parents and is designed for children from 11 to 71 months of age. Sensitivity= 98%; specificity= 85%. [The Evidence for Clinical Judgment in Early Intervention]

Source: Forms are available in English from Brookes Publishing Company at Temperament and Atypical Behavior Scale (TABS). Scoring instructions are in the Manual. The costs range from $25.00 for the Screener to $85.00 for the Complete TABS System. Other items are available for purchase including the Manual and the Assessment Tool.

Response to a Positive Screen

Primary Care

Well-child exams in the first years of life offer opportunities for early detection of problems with a child's development. Screening with a standardized instrument is the most reliable method of identifying developmental problems. Screening at well child visits should identify early disruptions in the attachment process.

When a delay is uncertain or not yet confirmed:
- Help parents by recommending activities and resources to enhance development in the home;
- Continue to monitor the child's development closely and to address concerns of parents;
- If the screening tool indicates a possible delay, additional assessment may be needed and may be provided by the following service(s): see all Early Intervention Programs services providers (34) in our database.
If delay is confirmed, make a referral to an early intervention program.
- Know what a quality Early Intervention Program should provide:
  - full assessment of a child's current health and developmental status;
  - service coordination among providers, programs, and agencies;
  - strategies to build on family concerns, priorities, and resources;
  - services including Occupational Therapy, Physical Therapy, and Speech Language Therapy.
- Fill out any necessary referral/release forms (see Resources) and refer to the following service(s): see all Early Intervention Programs services providers (34) in our database.
- If possible, establish etiology of delay to determine:
  - Risk of recurrence;
  - Prognosis;
  - Need for follow-up of known complications;
  - If there are available therapeutic interventions (available in rare cases).
- Offer support to parents: One of the most difficult tasks in identifying a potential delay is sharing the concern with the parent. The following quote highlights the importance of focusing on the child not the potential label.
  - " Whenever I hear something "new" about Becca's condition or abilities, I have to remind myself that it didn't change her right then. We just now have a name for it. We have to take all of those labels and realize that all of those together are the beautiful child that we love so much and that it can be helpful to name the problem so that we can work on it, but it doesn't change her or our love for her." Diana S.
- Coordinate care: Link children with special health care needs and their families to services and resources in a coordinated effort to maximize the potential of the children and provide them with optimal health care (AAP, Committee on Children With Disabilities, 1999). For additional information, see the following page(s): About>>Care Coordination.

Specialty Care

Initial consultation and ongoing collaboration with the following service(s): see all Early Intervention Programs services providers (34) in our database; see all Mental Health, Infant/Pre-school services providers (31) in our database.

Resources

Links

For Professionals

Utah Medicaid Provider Manual for CHEC
The Utah Medicaid Provider Manual for Child Health Evaluation and Care (CHEC) Services provides regulations for the Early Periodic Screening, Diagnosis and Treatment (EPSDT) Program including a list of recommended developmental screening tools.

Utah Public Mental Health Practice Model
The Utah Public Mental Health Practice Model for Infants and Toddlers (Birth to Five), approved by the Utah Division of Substance Abuse and Mental Health, was developed for providers and agencies serving young children in Utah.

Utah Association for Infant Mental Health
Hosted by Utah State University, this site includes: an overview of infant mental health; announcements; and tool kits (with documents, presentations, sample agreements, patient education materials).

Developmental Screening from the CDC
This site gives an overview of screening, the pros and cons of screening tools and a link to the CDC recommendations for screening, plus links to federal resources and tips for parents.

Parent's Evaluation of Developmental Status
This site is published by Ellsworth & Vandermeer Press. It links to parent/patient handouts (pdf files)and questionnaires concerning physical social and academic development. Includes a pediatric symptom checklist and screening tools for physicians.

Early Childhood Mental Health: What is it all about?
This 2001 paper by Cindy Oser, RN, MS at Zero To Three discusses a framework for the context, content, and cornerstones of infant mental health and includes references, links, and resources.

The Infant Mental Health Specialist
This 2000 paper by Deborah J. Weatherston provides information about the skills, clinical strategies, role, and training of an infant mental health specialist.

For Parents

Early Developmental Guide for Parents
From the Utah Department of Health, an easily printable list of milestones for ages 1-2 months, 3-4 months, 6 months, 9 months, 12 months, 18 months, 2-3 years. Includes development, nutrition, communication/hearing/vision, and guidance for parents

Parenting Children Aged Zero to Three
A webpage from the Zero to Three national, nonprofit organization dedicated to supporting families and communities in the care of young children. This site has links to FAQs; parenting tips; and reproducible handouts for parents. Topics range from preschools, play, physical activity and more.

Practice Guidelines

American Academy of Pediatrics.
Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening.
Pediatrics. 2006;118(1):405-20. PubMed abstract / Full Text

Services

Early Intervention Programs

See all Early Intervention Programs services providers (34) in our database.

Mental Health, Infant/Pre-school

See all Mental Health, Infant/Pre-school services providers (31) in our database.

For other services related to this condition, browse our Services categories or search our database.

Helpful Articles

Pinto-Martin JA, Dunkle M, Earls M, Fliedner D, Landes C.
Developmental stages of developmental screening: steps to implementation of a successful program.
Am J Public Health. 2005;95(11):1928-32. PubMed abstract / Full Text

Authors

Contributing Author:

Alfred Romeo RN, PhD, 3/2008

Reviewing Authors:

Sarah Winter M.D., 3/2008
Paul Carbone MD, 3/2008

Compiled and edited by:

Kathleen Smart LCSW, 9/2006

Content Last Updated:

3/2008

Page Bibliography

American Academy of Pediatrics.
Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening.
Pediatrics. 2006;118(1):405-20. PubMed abstract / Full Text

American Academy of Pediatrics.
Recommendations for preventive pediatric health care.
Pediatrics. 2007;120(6):1376. PubMed abstract / Full Text

Committee on Children with Disabilties.
Developmental surveillance and screening of infants and young children.
Pediatrics. 2001;108(1):192-6. PubMed abstract / Full Text
This article encourages physicians to use standardized developmental screening tools and suggests that testing children at periodic intervals will increase accuracy and further early intervention.

Graham, MA; White, BA; Clarke, CC; Adams, S.
Infusing infant mental health practices into front-line caregiving
Infants and Young Children. 2001;14(1):14-23.

Onunaku, Ngozi.
Improving maternal and infant mental health: Focus on maternal depression.
National Center for Infant and Early Childhood Health Policy at UCLA. July. / http://www.healthychild.ucla.edu/PUBLICATIONS/Maternal%20Depression%20...

Rydz D, Srour M, Oskoui M, Marget N, Shiller M, Birnbaum R, Majnemer A, Shevell MI.
Screening for developmental delay in the setting of a community pediatric clinic: a prospective assessment of parent-report questionnaires.
Pediatrics. 2006;118(4):e1178-86. PubMed abstract / Full Text

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