RESULTS

INTRODUCTION

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Comparison of the ASQ and PEDS in Screening for Developmental Delay in Primary Care Settings

Marjolaine M. Limbos1,2, PhD & David P. Joyce2, MD, CCFP1Department of Psychology, Sunny Hill Health Centre for Children & 2Department of Family Medicine,

University of British Columbia, Vancouver, BC

ABSTRACT

Primary care physicians provide health care services to young children on a regular basis and may be ideally suited to screen for developmental delay.

There is mounting evidence that early intervention improves outcomes for children and their families in terms of behavioral, social and cognitive competence.

The Parents’ Evaluation of Developmental Status (PEDS) and Age and Stages Questionnaire (ASQ) are parent-completed developmental screening tools that are increasingly being recommended for use in clinical practice.

While there is growing research demonstrating the accuracy of both tests in research settings, generalization of the findings to primary care settings is limited by several factors including:

A scarcity of study in primary care settings Conflicting results for those studies that have used primary care samples Failure to administer an adequate criterion measure

The purpose of this study was to :

Compare the sensitivity and specificity of the ASQ and PEDS in identifying developmental delay in preschool children presenting for primary care.

Examine the agreement between the ASQ and PEDS in classifying children with and without developmental delay.

Objectives: The purpose of this study was to investigate the sensitivity and specificity of two brief, parent-completed developmental screening measures, the Ages and Stages Questionnaire (ASQ) and the Parents Evaluation of Developmental Status (PEDS) in children presenting to their primary care provider.

Method: A sample of 334 children aged 12-60 months was recruited. Parents completed the ASQ and the PEDS in their home. The presence of ≥1 predictive concern or abnormal domain was considered a positive screen. All children underwent evaluation with the criterion measures, administered by a psychologist: the Bayley Scales of Infant Development or the Wechsler Preschool and Primary Scale of Intelligence, the Preschool Language Scale and the Vineland II.

Results: The mean age of children was 32.4 months. Developmental delay was identified in 34 children (10%). The PEDS had moderate sensitivity (74%) and reasonable specificity (64%). In comparison, the ASQ had significantly higher sensitivity (82%) and specificity (78%). Using ≥2 predictive concerns on the PEDS or ≥2 abnormal domains on the ASQ significantly improved specificity of both tests (89% and 94%, respectively) but resulted in very low sensitivity (41% and 47%, respectively).

Conclusions: These findings support the guidelines of the American Academy of Pediatrics and others, demonstrating that both the PEDS and ASQ have reasonable test characteristics for developmental screening in primary care settings. Although the ASQ appears to have higher sensitivity and specificity, the choice of which measure to use should be determined by the practice setting, population served and preference of the physician.

This study adds to the growing literature supporting the use of the ASQ and PEDS for developmental screening in primary care.

Both the ASQ and PEDS have reasonable test characteristics to be used for screening for developmental delay in preschool children.

Although the ASQ appears to have higher sensitivity and specificity, the choice of which measure to use should be determined by the:

Practice settingPopulation servedPreference of the provider

The findings support the guidelines of the AAP and others to institute regular developmental screening using standardized screening tests.

Future research should replicate this study engaging actual primary care physicians in the administration, scoring, interpretation, and follow up to better understand the performance of these tests in real world settings.

DISCUSSION

334 Children Aged 12-60 months (Mean = 32.4 months)Presenting for Routine Primary Care

Screening Tests:

• Ages and Stages Questionnaire (ASQ)• ≥ 1 Abnormal Domain• ≥ 2 Abnormal Domain

• Parents Evaluation of Developmental Status (PEDS)

• ≥ 1 Predictive Concern• ≥ 2 Predictive Concerns

CONCLUSIONS

The PEDS had moderate sensitivity and reasonable specificity.

The ASQ had significantly higher sensitivity and specificity. Use of ≥ 1 predictive concerns (PEDS) & ≥ 1 abnormal domain (ASQ) is the preferred cut-off.

Use of ≥ 2 predictive concerns/ abnormal domains had higher specificity (>90%) but very low sensitivity (<50%) for both ASQ and PEDS.

Disagreement in classification between the ASQ and PEDS was seen in over 1/3 of children (slight to fair agreement).

80 Primary Care Providers :70 Family Physicians 7 Nurse Practitioner

3 Pediatricians

Criterion Measures:

Cognition/Development:

Bayley III (12-30 months)WPPSI III (30-60 months)

Speech and Language:

Preschool Language Scale IV

Adaptive Functioning:Vineland II

Clinical Assessment by Registered Psychologist

Accuracy of PEDS and ASQ:

Sensitivity = TP/TP+ FN Specificity = TN/TN+FP

Table 2. Demographic Characteristics of Study Participants (N=334)All

ChildrenN(%)

Developmental Delay*N(%)

No Developmen

tal Delay N(%)

Comparison†

χ 2, p value

Total Sample

Child Age, mo 12-18 19-24 25-36 ≥37

334

90(27)57(17)75(22)

122(37)

34

8(24)13(38)10(29)13(38)

300

82(27)44(26)65(22)

109(36)

NA

χ2=1.64p=0.65

Characteristics

Gender Female

Race/Ethnicity (Mother) White Black Aboriginal Other

Languages of Testing English French

Maternal Education Less than high school High school More than high school

147(44)

284(85) 1(<1)42(12)

7(2)

254(76)80(24)

60(18)59(18)

196(59)

9(27)

29(85)0

5(15)0

23(68)11(32)

9(27)7(21)

14(41)

138(46)

255(85) 1(<1)37(12)

7(2)

231(77)69(33)

51(17)52(17)

182(61)

χ2=4.73p=0.03

χ2=1.04 / 5.25

p=0.79 / 0.15

χ2=1.47p=0.23

χ2=3.75p=0.15

Annual Income < 15 000 15 000-30 000 30 000-60 000 >60 000 Refused Community TypeUrban ClinicRural Clinic

42(13)54(16)73(22)

131(39)32(10)

198(59)136(41)

10(29)10(29)5(15)4(12)4(12)

26(74)9(26)

32(11)44(15)68(23)

127(42)28(9)

173(58)127(42)

χ2=21.4p=0.0001

χ2=3.18p=0.07

0

10

20

30

40

50

60

70

80

90

100

ASQ 1† PEDS 1 ASQ 2 PEDS 2

Sensitivity (%)

Specificity (%)

Figure 1. Sensitivity and Specificity of the ASQ and PEDS in Detecting Developmental Delay (N=334)*

*DD refers to developmental delay based on a score of ≤ 10th percentile on adaptive function and one other criterion measures.

†ASQ1 and PEDS1 refer to a cutoff of one or more abnormal domains or predictive concerns. ASQ2 and PEDS2 refer to a cutoff of 2 or more abnormal domains or predictive concerns.

%

Table 1. Two by Two Matched Sample Tables for PEDS and ASQ for Children With and Without

Developmental Delay*†

Children Without

Developmental Delay

Children with

Developmental Delay

PEDS

≥ 1 Predictive Concerns

No Concerns

≥ 1 Predictive Concerns

No Concerns

≥ 1 Failed Domains

ASQ

21 45 20 8

No Concerns

68 160 1 5

*Developmental delay refers to children with a score of ≤10 % on adaptive function and one other criterion measure.†The presence of ≥1 predictive concern on the PEDS or ≥1 failed domain on the ASQ was the cutoff for an abnormal screen.

METHODS