Friday, February 13, 2009

Screening the Young Ones: What Makes Sense

As you have read here before, the first step of the Rosie D. settlement is universal screening for mental illness at ALL EPSDT visits.  But when do these visits occur in the life of a child?  According to the EPSDT schedule approved by MassHealth, they happen at the following times
occur at the following ages, at a minimum: one to two weeks, one month, two months, four months, six months, nine months, 12 months, 15 months, 18 months, two years, and then every year until the member’s 21st birthday.
So we see children 6 times before their first birthday and 3 more times before their second birthday.   And yet, we don't know how to diagnose a "serious emotional disturbance" in that age group;  at least, I don't.  What we know how to do at that age is diagnose developmental and behavioral problems-  developmental delay, speech delay, autism-  those I know how to diagnosis.  ADHD, depression, bipolar disorder and the like,  I do not know how to diagnose in children under the age of 3.  And yet, because of the EPSDT schedule,  that has become the focus of our early screening efforts.
Three screening tools are approved in that age group at:

The   PEDS: 10 questions that take 3-5 minutes to complete, with open answers, fuzzy criteria for referral, and are hard to score positive or negative, as it includes the "watchful waiting" middle stage.  At 2 weeks, parents think it silly to answer a question about learning preschool skills.  Even at 4 months, that question doesn't make much sense.  The two questions that would detect "emotional disturbance" ("do you have concerns about how your child behaves" and "do you have concerns about how your child gets along with others") are really not relevant in young children.  I think that the PEDS is a great way to assess child development, although I wish that the scoring was more cut and dried.  I doubt it does much for SED in the early years, because we don't know how to diagnose SED that early at that age.
The ASQ-SE:  22 to 36 questions that take 15 minutes to complete and 1-3 minutes to score, and NOT built to be used under 6 months of age.  the plan is 6/12/18/24 months.  The downside to this one is that it takes so much time, and it costs a bit more;  still, wouldn't be unreasonable.
The M-CHAT:  23 questions, easy to score, but specifically screens for autism, not SED.  Designed for use in 18 and 24 month olds.

So we are screening lots of kids with screening instruments that don't find the thing that we are looking for, and upsetting parents in the process.  What would make sense?
My 2 cents:
1)  No evidence to support screening kids under 6 months of age for SED-  we should screen them for developmental problems, and for maternal depression, if you like screening (lots of evidence that that happens).  But nothing for the remedy yet.
2)  At 6, 12, 18 and 24 month, the kids should be screened with a PEDS, an ASQ-SE or an M-CHAT.  After that annual screening will suffice.
3)  We need to continue to work to develop better screener for the younger kids.  Of prime importance is figuring out what it is we are screening for.

The Mass AAP is working on formulating some recommendations in this area.  What do you think?

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