issue brief CHILDHOOD DEVELOPMENT Implementing Screening in Mississippi Pre-Kindergarten Programs PUBLISHED JUNE 2015 Children enrolled in Mississippi’s Early Learning Collaborative Pre-Kindergarten programs were screened to assess the degree to which these preschool children may be exhibiting delays in development. This brief summarizes the results of the screening study and outlines policy considerations. A detailed report of study findings can be found on the Center’s web site at mshealthpolicy.com. In 2013, the Mississippi legislature passed the Early Learning Collaborative Act which set up Mississippi’s first state-funded Pre-Kindergarten (Pre-K) programs for four year olds. Eleven Early Learning Collaboratives were established around the state as a result of this law. In fall 2014, the Center for Mississippi Health Policy (C4MHP) contracted with Mississippi State University’s Social Science Research Center (SSRC) to conduct a study to implement developmental screening in these programs, in collaboration with the Mississippi Department of Education. The goal of the study was to determine what the developmental concerns of children entering Pre-K in Mississippi are, and what policy implications these needs have ASQ-3 DOMAINS for the state. COMMUNICATION Language skills The project utilized the Ages and Stages Questionnaires, Third Edition (ASQ- e.g. Can name three items from a common category (Names of some animals, food the child likes to eat) 3) and the Ages and Stages Questionnaire: Social-Emotional (ASQ-SE). These widely used instruments are considered valid and reliable for assessing GROSS MOTOR developmental progress for children ages 1 month to 5 years. Of the 1,786 children Use of arms, legs, and large muscles e.g. Can hop on one foot who attend the Pre-K collaboratives, approximately 1,350 children were screened using the ASQ-3 and the ASQ-SE. Findings from the ASQ-3 screenings indicate FINE MOTOR Coordinated use of hands and fingers that nearly one quarter (24%) of children screened scored in the “Referral” range. e.g. Can cut paper in half using scissors Another quarter (24%) had scores in the “Monitor” range. The remaining half (52%) scored into the “On Target” group. PROBLEM SOLVING How the child plays with toys and solves problems FIGURE 1. RESULTS FROM THE ASQ-3 SCREENINGS, MISSISSIPPI PRE-K COLLABORATIVE PROJECT (2015) e.g. Can count five objects, can name five colors PERSONAL SOCIAL Self-help skills and interactions with others e.g. Can dress self, including buttons 24% Source: Ages & Stages Questionnaires, Third Edition (ASQ- 3). (2009). Squires & Bricker Paul H. Brookes Publishing Co. RESULTS FROM ASQ-3 SCREENINGS NUMBER OF CHILDREN WITH 52% ASQ-3 RESULTS ARE GROUPED INTO 3 CATEGORIES: SCORES INDICATING POSSIBLE DELAY ON TARGET Communication: 173 children Score meets or exceeds cutoff for typical development Fine motor: 124 children Gross motor: 103 children MONITOR Score falls outside range of typical; Problem solving: 89 children Targeted intervention and rescreening recommended Personal social: 78 children 24% REFERRAL Source: Southward, L, McKee, C, Hanna, H, & Bell, L. (2015). Mississippi Pre-K Collaboratives: Score falls outside range of monitor; Further assessment by provider recommended A Study of Developmental Screenings 1 of 4 Center for Mississippi Health Policy � Issue Brief: Childhood Development—Implementing Screening in Mississippi Pre-K Programs � JUNE 2015 Overview of Developmental Screening SURVEILLANCE Children grow in a variety of ways beginning at birth. Physical, mental, emotional The informal process of using clinical judgment and social development all factor into a child’s maturity. While the pace at which to recognize children who may be at risk for developmental delay. children advance through development may vary to a certain degree, there are ranges of achievement that are considered appropriate or typical. Developmental SCREENING screening is the use of a standardized tool to evaluate if a child is reaching these The use of a standardized tool to evaluate if a child is reaching benchmarks within a desired period of time. benchmarks within a certain period of time. EVALUATION The term “developmental delay” is used when a child under the age of five does The complex process aimed at identifying specific developmental disorders that are affecting a not meet the expected milestones in a timely manner. A distinction must be made child. While some prefer the term “evaluation” between developmental delay and developmental disability: A delay may lead to to “assessment,” the words are frequently used or indicate a disability, or not. With appropriate intervention and instruction, many synonymously, and should be considered so for the purposes of this brief. developmental delays can be resolved before developing into a lifelong condition. Risk factors associated with a developmental delay are particularly relevant to Mississippi. These include poverty, minority status, low-parental education, and low birthweight. There are a number of poor outcomes associated with an untreated developmental delay. Speech and language With appropriate treatment, many delays have been associated with an increased risk developmental delays can be resolved before of learning disabilities, difficulty reading in later school developing into a lifelong condition. years, a higher degree of academic under-achievement, and more behavioral problems, and possibly contribute to lower IQ scores. A sibling study indicates that speech problems in childhood may be linked with obtaining lower-skilled jobs as adults. Research shows that physicians tend to rely on clinical judgment, rather than the use of standardized screening tools, which contributes to the low rate of children with developmental delay being identified and referred to services. As a result of low screening rates, only 10 percent of children with delays are linked to the appropriate intervention needed. Between 12 and 16 percent of children in the U.S. are estimated to experience a developmental delay, but up to half of these are not identified before entering kindergarten. In Mississippi, approximately 18 percent of children under six years of age have received a standardized screening for developmental or behavioral problems, compared with 31 percent nationwide, although Mississippi children are at greater risk of delay. The results from the SSRC study of the children enrolled in the Pre-K collaboratives share similarities with other recent findings. Data from Mississippi’s statewide Kindergarten Readiness Assessment in the fall of 2014 indicate that 65 percent of students are not ready for kindergarten. By third grade, 50 percent of students are scoring below proficient on standardized reading tests. It is possible that early identification of and intervention for developmental delays might impact these later outcomes. North Carolina has documented success in using early childhood education to significantly decrease placement In Mississippi, approximately 18 percent of in special education. One study in that state showed children under six years of age have received a reduction of 39 percent in the likelihood of a student a standardized screening for developmental being placed in special education in third grade. A or behavioral problems, compared with 31 key to the program’s success was raising preschool percent nationwide, although Mississippi developmental screening rates to 98 percent. The children are at greater risk of delay. same study found that certain early childhood programs might benefit children by reducing the disparities in special education placement associated with income and racial background. 2 of 4 Center for Mississippi Health Policy � Issue Brief: Childhood Development—Implementing Screening in Mississippi Pre-K Programs � JUNE 2015 Policy Options for Improving Developmental Screening States have implemented a variety of strategies to increase developmental screening rates and identify children with developmental delays. Most have worked through the Medicaid program to provide incentives to screen earlier. One route many states have taken involves using the Early and Periodic Screening, EPSDT EPSDT is a Medicaid service mandated by the federal Diagnosis, and Treatment (EPSDT) program. EPSDT screenings are required to government to provide comprehensive preventive be conducted on a regular basis and include developmental screenings (although health care to children from birth through age 21. it is left to state Medicaid programs to define what qualifies as a “developmental State Medicaid programs are given flexibility in setting EPSDT services, which must include covered screening”). See Figure 2. Some states, like North Carolina, require that EPSDT screenings in the following categories: medical, screening incorporates developmental screenings. Other states, like Illinois, have mental health, vision, hearing and dental. worked with Medicaid managed care companies to use financial incentives or penalties to ensure children receive appropriate developmental screening. FIGURE 2. MEDICAID REQUIREMENTS AND REIMBURSEMENT POLICIES ON DEVELOPMENTAL SCREENING. (2011). STATE MEDICAID PROGRAM ACTION ON DEVELOPMENTAL SCREENING: Requires in well-child exam; Pays additional fee Requires in well-child exam; Does not pay additional fee Does not require in well-child exam; Pays additional fee Does not require in well-child exam; Does not pay additional fee No response Source: NASHP. (2011). State Medicaid Requirements and Reimbursement Policies on Developmental Screening. In addition to utilizing Medicaid to implement policy that encourages developmental screening, states can foster partnerships between agencies with programs that relate to screening and referral, like the Title V Maternal and Child Health and Part C Early Intervention programs housed at the Mississippi State Department of Health, or the Child Find program at the Mississippi Department of Education. Strengthening partnerships and coordinating resources are often prioritized in developing a statewide plan to improve developmental screening rates. The medical community also has a role to play in increasing the early identification of developmental delays. The American Academy of Pediatrics (AAP) has incorporated recommendations on developmental screening into its own program, Bright Futures, an evidence-based guide for preventive care. AAP recommends developmental surveillance be incorporated into all well-child visits throughout infancy and early childhood, and that formal developmental screenings be conducted at 9 months, 18 months, and 30 months, as well as any time developmental surveillance indicates a potential problem. The National Academy for State Health Policy (NASHP) has worked extensively with many states across the country to address increasing developmental screening rates among young children. NASHP emphasizes in its work that while screening is a critical component to addressing healthy child development, subsequent follow up and referral to appropriate treatment is indispensable to the process. Without connecting children whose screens indicate a need for follow up with those services, screening will not improve child health and educational outcomes. 3 of 4 Center for Mississippi Health Policy � Issue Brief: Childhood Development—Implementing Screening in Mississippi Pre-K Programs � JUNE 2015 Summary Developmental screening is an important tool used to identify developmental delay in infants and children. Screening rates for young children, however, are low, particularly in Mississippi where only 18 percent of children under six are screened. If developmental problems in preschool children can be identified and treated early enough, many can be resolved before the child enters school, improving the child’s chance to succeed academically. Where children in Mississippi’s Early Learning Collaborative Pre-Kindergarten programs were screened for developmental delays, the study results documented that nearly one-quarter of children needed a comprehensive evaluation to confirm the presence of one or more developmental delays, another quarter needed targeted intervention and periodic re-screening to monitor for possible delays, and a little more than half of the children exhibited developmental patterns that were on target and typical for their age. These results are not surprising given that many risk factors associated with developmental delay (e.g. poverty, low birthweight, minority status, and low- parental education) are prevalent in Mississippi. The study’s results point to potential opportunities for early identification and treatment of developmental delays in preschool children in order to reduce the percentage of children considered not ready to enter kindergarten (65%) and scoring below proficient levels on standardized reading tests in the third grade (50%). There are a variety of policy options states have used to improve developmental screening rates. North Carolina, for example, which made developmental screening a required component of Medicaid EPSDT screens and achieved a 98 percent screening rate, demonstrated that early identification and treatment as part of early childhood education greatly reduces the likelihood of students later being placed in special education. Resources Ages & Stages Questionnaires, Third Edition (ASQ-3). (2009). Squires & Bricker Paul H. Brookes Publishing Co. American Academy of Pediatrics. (2009). Developmental screening in early childhood systems: summary report. American Academy of Pediatrics. (2006). Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics 118 (1): 405-420. Retrieved from: http://pediatrics.aappublications. org/content/118/1/405.full.pdf+html Centers for Medicare and Medicaid Services. (2014). EPSDT: a guide for states: coverage in the Medicaid benefit for children and adolescents. Retrieved from: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/early-and-Periodic- Screening-Diagnostic-and-Treatment.html Kaye, N, May, J, & Abrams, M. (2006). State policy options to improve delivery of child development services: strategies from the eight ABCD states. National Academy for State Health Policy. Retrieved from: http://www.nashp.org/sites/default/files/ABCD_state_policy_ options.pdf Mackrides, PS. & Ryherd, SJ. (2011). Screening for developmental delay. American Family Physician 84 (5). 544-549. Retrieved from: http://www.aafp.org/afp/2011/0901/p544.html Mississippi KIDS COUNT. (2015). 2015 Fact Book. Available at: http://kidscount.ssrc.msstate.edu/data/mississippi-kids-count/ms- data-books/ Mississippi Department of Education. (2014). Kindergarten Readiness Assessment Results October 2014. Available at: http://www. Plaza Building, Suite 700 mde.k12.ms.us/docs/student-assessment/k-readiness-results-public_20141021113851_378676.pdf?sfvrsn=2. 120 N. Congress Street Muschkin, CG, Ladd, HF, & Dodge, KA. (2014). Impact of North Carolina’s early childhood initiatives on special education placements in third grade. Educational Evaluation and Policy Analysis. doi: 10/2102/0162373714559096 Jackson, MS 39201 National Academy of State Health Policy. (2011). State Medicaid Requirements and Reimbursement Policies on Developmental Screening. Retrieved from: http://nashp.org/sites/default/files/abcd/ABCDresources.org/abcd3.devscreeningmap.052011.pdf Phone 601.709.2133 National Survey of Children’s Health 2011/2012. (2013). Available at: http://www.childhealthdata.org/ Fax 601.709.2134 Nelson, HD, Nygren, P, Walker, M & Panoscha, R. (2006). Screening for speech and language delay in preschool children: systematic evidence review for the US preventative services task force. Pediatrics 117 (6): e298-e319. www.mshealthpolicy.com 4 of 4 Center for Mississippi Health Policy � Issue Brief: Childhood Development—Implementing Screening in Mississippi Pre-K Programs � JUNE 2015