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Parents Shouldn’t Compare, or Should They?

Renee C. Wachtel MD FAAP, Clinical Professor of Pediatrics, UCSF School of Medicine and Chair, CAC1 AAP Committees on Development and Behavior and School Health

Miriam Rhew, MD, MPH. FAAP Medical Director, UCSF Benioff Children’s Physicians (UBCP), Pediatrician, UBCP – Bancroft Pediatrics

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What is the meaning of “to compare”

A verb- to estimate, measure or note the similarities or dissimilarities between
To examine in order to note similarities and differences
What are the purposes of comparison in medicine and public health:

To learn or understand processes that are interfering with ”normal function”
To improve the lives of individuals or groups of people

Some examples:

Prevalence of Tay Sachs in Ashkenazi Jews and Sickle Cell Disease led to the discovery of the genetic basis in specific subgroups of people
Asthma rates in different geographic areas

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Scientific Research

Much of scientific research is based upon the comparison of groups of individuals to discover, for example:

Norms and variations from normal eg LDL/cholesterol and its association with later disease
Effects of treatments eg Randomized Clinical Trials
Medical Statistics is based upon the calculated probability that the differences found in research between data obtained between subject groups is due to chance (Null Hypothesis)

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Misuse of Comparisons in Child Development

To compare “IQ scores” between races based upon biased IQ measures to demonstrate the “superiority of a race”
To compare individual children to another child and verbally use that information to shame or motivate behavioral change, eg “why can’t you be more like your sister?”

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Case example:

Gabriel’s parents bring him to your office for his 2 year old well child visit. You ask the parents how he is doing and they answer “fine”. You ask them what words he says, and they state that he only says “mama” and “dada” but “boys are late talkers in their family and turn out fine”. What do you say/do?

Would you respond differently if his older brother has autism?

Would you respond differently if he was born at 28 weeks with a complicated NICU course?

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What are the purposes of developmental surveillance?

Part of every pediatric visit should be the determination of any parental concerns about the child’s development or behavior
Many of these parental concerns may be due to a lack of knowledge about child development and can be addressed through providing parent information and educational resources eg “What to Expect…”, Help Me Grow
These questions allow the pediatrician to assess whether the parent’s concerns are about typical issues in normal child development or a “red flag” that developmental screening is indicated.

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Date of Download: 5/28/2023

From: Promoting Optimal Development: Identifying Infants and Young Children With Developmental Disorders Through Developmental Surveillance and Screening

Pediatrics. 2020;145(1). doi:10.1542/peds.2019-3449

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What are the purposes of developmental screening?

The first and most important purpose is to promote optimal child development
We accomplish this by identifying young children with developmental delays and disorders to enable appropriate evaluation and treatment
We also accomplish this by teaching parents appropriate expectations for young children at each age that we perform developmental screening
This enables us to develop a dialog with parents about developmental and behavioral concerns and provide parental support and education.

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Date of Download: 5/28/2023

From: Promoting Optimal Development: Identifying Infants and Young Children With Developmental Disorders Through Developmental Surveillance and Screening

Pediatrics. 2020;145(1). doi:10.1542/peds.2019-3449

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How often do pediatricians use developmental screening tools?

The good news is that it is increasing. According to the AAP, in 2002 only 21% of pediatricians self-reported use of formal screening tools.
BUT Lipkin et al (2020) reported that one-third of pediatricians DID NOT use formal screening tools.
Just as important, the rates of referral when developmental screens are positive are increasing, but still relatively low (59%).
Commonly reported reasons for screening gaps include:

Lack of time
Sub-optimal or no additional reimbursement
Lack of available treatment

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Comparison of Developmental Screening Questionnaires

Sheldrick etal (JAMA Peds 2020) recently conducted a comparison of three commonly used developmental screening measures in the waiting rooms of 10 primary care offices in eastern MA.
These including the Ages and Stages Questionnaire (ASQ-3), the Parent’s Evaluation of Developmental Status (PEDS), and the Survey of Well Being of Young Children (SWYC) Milestones.
There were 1495 children between 9 months and 5.5 years who participated. Parents completed all three measures in random order at the visit.
All children who screened positive on any measure, plus 10% of those who screened negative on all measures had formal developmental testing.

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How is accuracy of a test measured? Specificity and Sensitivity, PPV and NPV

Sensitivity refers to a test's ability to designate an individual with disease as positive. A TRUE POSITIVE.

A highly sensitive test means that there are few false negative results, and thus fewer cases of disease are missed.

The specificity of a test is its ability to designate an individual who does not have a disease as negative. A TRUE NEGATIVE.

Positive predictive value (PPV)reflects the proportion of subjects with a positive test result who truly have the outcome of interest. TRUE POSITIVE

Negative predictive value (NPV)reflects the proportion of subjects with a negative test result who truly do not have the outcome of interest.

TRUE NEGATIVE

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What did they find? �Surprise: nothing is perfect.

Between 20% and 30% of children screened positive on each measure
35% or 60% also screened positive on a second measure, demonstrating moderate co-occurence
Among children 42 months or younger, the ASQ and the SWYC Milestones had a high (89%) Specificity (TRUE NEGATIVES), with the PEDS being lower (80%)
Among children 43-66 months, the ASQ-3 has higher Specificity (92%) than the PEDS (73%) or the SWYC Milestones (70%)

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What were the PPV and NPV?

For all three measures the PPV were:

SWYK Milestones 60%
ASQ-3 56%
PEDS 44%

For all three measures the NPV were:

SWYK Milestones 80%
ASQ-3 78%
PEDS 77%

CONCLUSION: The SWYK Milestones and ASQ-3 were very similar, and the PEDS less so but none are perfect.

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What are some advantages and disadvantages of each measure?

The ASQ-3

It teaches parents about different activities that may be appropriate for their child to learn
It goes more in depth about developmental skills at each age
It requires the parent to use objects around the house to do activities with the child

The SWYK Milestones

It is free
It includes questions about the family, including SDOH and caregiver mental health
It only has 10 developmental questions at each age

The PEDS

It is quick to give and score but very repetitive to answer

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Screening for autism: what you need to know

The current prevalence of autism is 1 in 44 children at age 8 (CDC data)
The MCHAT (R/F)- a free 20 question screening tool in many languages that screens for autism and other developmental delays
Up to 76% of pediatricians reported use of autism specific screening
Recent article (Wieckowski et al 2023) reviewed 50 studies using the MCHAT (R/F) up to 48 months of age.

The pooled SENSITIVITY was 0.83 and the SPECIFICITY was 0.94.
The follow up portion of the MCHAT reduced false positives
There was better diagnostic accuracy if given at both 18 and 24 months
There was better accuracy in non-English samples
Conclusion: the MCHAT (R/F/) is a useful autism screener
Note that it also screens for other developmental delays

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What are we likely to find when we do developmental screening at different ages according to Bright Futures protocol?

At 9 months: motor delay

Can be signs of cerebral palsy, other motor disorders; severe developmental disabilities

At 18 months

Language delay/cognitive delay/autism

At 24 months

Autism, language delay

At 30 months

Language delay/behavior issues

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What are the developmental disorders that we are screening for?

Motor Disorders-while mild delays are common, severe delays like cerebral palsy affect 1/1500 births
Autism: current data shows prevalence of 2% in the US, with most manifesting symptoms between 12 and 30 months of age
Communication Disorders:

Language Disorders 7% of children at 5 years of age

Can be expressive, receptive or both

Speech Sound Disorders: 15% of children at 4 years

Articulation-common
Dysarthria-rare
Childhood Apraxia of Speech-rare

Voice
Stuttering and other Disfluences: 1% of children at 4 years

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Another autism screening measure: the POSI

The Parent’s Observations of Social Interactions (POSI), is a 7-item screening instrument for Autism Spectrum Disorders (ASD) developed by the SWYK team.
In a small study, 235 parents of children aged 16-36 months were enrolled from a combination of primary care and subspecialty settings. They completed the POSI, M-CHAT, and a report of their child’s diagnoses. POSI and M-CHAT scores were compared to reported diagnoses to assess validity.
The POSI’s internal reliability was high and sensitivity of the POSI compared favorably to that of the M-CHAT. More children scored positive on the POSI than on the MCHAT, and “best evidence from population samples suggests that the MCHAT is more specific than the POSI”.

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What about children 3-5 years old?

School readiness is an important issue.
Children with 2 or more ACEs were more than 2.6 times more likely to repeat a grade in school (Bethell et al 2014).
A recent report by Shah et al (2021) showed that school readiness concerns found upon screening at an average age of 4.5 years was associated with a nearly two-fold increase in the likelihood of low academic achievement at ages 9-10.
The purpose of developmental screening for school readiness in children 3-5 is to identify those children who can benefit from early intervention programs to improve their chances of school success.

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What are the components of school readiness in children?

Physical well being and normal sensory motor development including vision and hearing
Social and emotional developmental skills, such as emotional regulation, attention, impulse control, cooperation, empathy
Language development, including listening, vocabulary, intelligible speech, and pre-literacy skills such as print awareness
General knowledge and cognition
Positive approach to learning, including enthusiasm, curiosity, temperament

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How can we screen for school readiness?

Use our ongoing relationship with the parents to support development and learning
Use available screening tools at ages 3, 4 and 5 years old, to detect developmental delays, especially in speech and language or social-emotional development
Use tools like the Ages and Stages 3 and the SWYK provide good individual child data about a child’s developmental progress, and may suggest interventions
Encourage involvement in community based programs such as Head Start, Developmental Centers such as those in Oakland, and pre-Kindergarten when available

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Proposed Developmental Screening Schedule�

Maternal depression screening: 2 weeks, 2 months, 4 months, consider parental ACES
6 months PEARLS
9 months SWYC for motor delay/family issues
12 months PEARLS
18 months ASQ-3 for language delay/motor delay/autism
24 months MCHAT and SWYC for autism/language delay
30 months ASQ-3 for language delay/ cognitive delay/behavior issues
36 months PEARLS and SWYC for speech/social-emotional development
48 months SWYC for school readiness
60 months ASQ-3 for school readiness/PEARLS

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So should parents compare their child to other children? Yes, for discussion with their pediatrician and for further evaluation

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Resources for Parents

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Resources for Parents

Help Me Grow-First 5 in your county
Parent support groups such as Family Resource Navigators (Alameda County), CARE (Contra Costa County), CASE (San Francisco), MATRIX Parent Network(Marin County), Parents Helping Parents (Santa Clara)
Websites such as “What to Expect…”, CDC’s Act Early Program

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SAVE THE DATE: SEPTEMBER 6

OUR NEXT CHAPTER CHAT ON WEDNESDAY SEPTEMBER 6 AT 7 PM
TOPIC: WHAT YOU CAN DO WHEN CHILDREN 0-5 NEED HELP

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Questions and Comments?

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SO NOW WHAT??

Miriam Rhew, MD, MPH

Medical Director, UCSF Benioff Children’s Physicians (UBCP)
Pediatrician, UBCP – Bancroft Pediatrics

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Bright Futures Recommends…

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Instruments for Recommended Universal Screenings at Specific Bright Futures Visits https://publications.aap.org/toolkits/resources/15625/?_ga=2.209781653.1469549313.1685727435-1544684872.1684963055

Instruments for Recommended Universal Screening at Specific Bright Futures Visits

Abbreviation: AAP, American Academy of Pediatrics.

Recommended Visit	Recommended Screening	Tool by Author/Owner
1 Month�2 Month�4 Month�6 Month	Maternal Depression	Edinburgh Postnatal Depression Scale (EPDS)� Patient Health Questionnaires (PHQs)�PHQ-2/9 Survey of Well-being of Young Children (SWYC)
9 Month�18 Month�2½ Year	Child Development	Ages & Stages Questionnaires®, Third Edition (ASQ®-3) Survey of Well-being of Young Children (SWYC) Parents’ Evaluation of Developmental Status (PEDS®)
18 Month�2 Year	Autism Spectrum Disorder	Modified Checklist for Autism in Toddlers, Revised, with Follow-Up (M-CHAT-R/F) Survey of Well-being of Young Children (SWYC)�(Parent's Observations of Social Interactions)

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