Patricia Gellasch, The College of New Jersey
Marisa Macy, University of Nebraska at Kearney
AnnMarie Alvarado, Children’s Home Society of Florida Early Head Start, Orlando, Florida
All children need access to equitable opportunities for developmental screening. The COVID-19 pandemic has resulted in gaps in well-child visits, and greater inequities in overall health. Young children who show signs of a delay or disability need effective screening practices so that prevention and/or early intervention can begin as soon as possible. This article shares professional strategies on conducting developmental screening. The authors describe the importance of re-imagining developmental screening and provide a vignette to illustrate common challenges. They share their top 10 screening strategies in conducting effective developmental screening and coordinating services during challenging times.
The first 3 years of a child’s life include rapid progression in cognitive development, language, motor skills, and social and emotional skills (Lipkin et al., 2020; Marks et al., 2011). All children need access to equitable opportunities for developmental screening of early identification of risk, delay, or disability (UNICEF, 2020; United Nations Children’s Fund, 2020). The process of conducting a developmental–behavioral screening involves gathering information to make decisions about whether further assessment is warranted.
The American Academy of Pediatrics (2006, 2010) recommends developmental screening for all children in the early years of life. Screening practices are multidisciplinary and can be done by professionals who are pediatricians (Guerrero et al., 2011; Marks et al., 2013), nurses (Gellasch, 2016), social workers (Macy, 2013), early childhood educators, and more (Bricker et al., 2013; Dreu et al., 2012). Developmental screening is a recommended practice across all these professional sectors during specific and critical periods of child development (e.g., newborn, early months of life, every 2 or 3 months for infants and toddlers, and every 3–6 months for preschoolers until formal schooling). In addition to professionals, parents can provide input into developmental–behavioral screening assessments (Bruder & Dunst, 2015; Squires et al., 2013). Although it is a recommended practice to conduct developmental screening of young children, professionals and families may find the process challenging.
Children may be more vulnerable during challenging times due to short- and long-term risks resulting from a crisis like the global pandemic (Yoshikawa et al., 2020). Since the start of the COVID-19 pandemic there has been a significant drop in well-child encounters, which has resulted in delays in appropriate developmental screening (American Academy of Pediatrics, 2021). Data show that during the COVID-19 pandemic there have been 44% fewer child screening services, which are the foundation to providing early detection of developmental delays (Center for Health Care Strategies, 2020a; Centers for Medicare & Medicaid Services, 2020).
Professionals, for example home visitors, serve in an essential role addressing the needs of young children to support families and connect them to programs, supports, and needed services. The COVID-19 pandemic has pushed many professionals working with young children (e.g., service coordinators, home visitors) to adjust their in-person services by accommodating virtual home encounters and tackling various barriers as families grapple with new or expanding challenges (Johns Hopkins, 2020).
This article will introduce screening practices and highlight effective methods to screen, observe, interpret findings, and coordinate services during challenging times. We will also discuss what can happen when equitable access to screening supports young children and their families despite the obstacles encountered by highlighting how programs may be adapted to continue providing families with essential services.
Screening Through Virtual Home Visits
Lexi is an 18-month-old child who lives with her family. She was born full-term and has no health concerns. Her parents noticed Lexi was developing differently from her brothers and sister when she was about 10 months old. They were concerned about her developmental skills (e.g., weak legs, fussy/irritable). By 15 months, Lexi was still not walking, and her language appeared delayed. Just when they were ready to seek help, the COVID-19 pandemic began adding health concerns and limitations, as well as social distancing orders. Lexi’s parents turned to the early childhood educational program and early intervention services within their community for support where Lexi was able to have access to developmental and behavior screenings.
Daria is a home visitor at an early childhood educational program. Like many early childhood educators, Daria was faced with modifying her practices from in-person home services to remote learning. This included conducting developmental–behavioral screenings in a remote fashion. Daria was nervous and scared during this transition. She was confident with conducting in-person screenings, but second-guessed how to navigate screening through a virtual conversation with a parent and how to conduct child observations. Daria shared these fears and concerns with her direct supervisor. Daria was not alone. Her feelings were echoed by others and many team members had the same concerns.
The early childhood education program leadership team put a plan in place to address the team members’ concerns, provided training, and revisited service practices and procedures to adopt implementations to meet the needs of the community caused by the pandemic. The education program partnered with local early childhood programs and early intervention programs to add a validated developmental screening parent-completed tool. Daria received remote training on how to conduct research-based developmental screening remotely. Daria feels valued by the program, confident to conduct a remote screening, and equipped to successfully perform her duties.
Daria’s supervisor informed her that she has been matched with a newly enrolled family with an 18-month-old child named Lexi. During her first virtual visit, Daria provided the family with a warm welcome and orientation into the program. Daria discussed program expectations and family commitment. Together, they created a weekly schedule and confirmed technology access to the internet and devices. The family has access to a stable internet, a computer, and a live video conference platform.
During the second visit, Daria prepared and educated the parents on developmental and behavioral screenings. Lexi’s parents felt relief and shared their concerns related to Lexi’s development. The parents eagerly signed the consent to conduct the developmental screening. During the pandemic, the program modified practices of obtaining parent signatures by accepting digital signatures and/or email confirmation.
Daria used her newly learned skills of preparing families for virtual screening. She presented a short overview of developmental milestones, screening benefits, expectations, and next steps. The parents and Daria scheduled a follow-up visit to complete the screening questionnaire. Daria suggested to the parents that the next visit take place at a time when there would be minimal interruptions and Lexi would be able to participate (avoiding interruptions from siblings, Lexi’s nap time, or times of irritability).
On the third visit, Daria partnered with the parent to conduct a remote screening on Lexi. Daria used the live video conference platform to complete the screening questionnaire and gather observations of play. Daria and the family successfully completed the questionnaire virtually, which took about 30 minutes. Daria interpreted the results of the screening and consulted with the program specialist education/disability coordinator. The screening results indicated possible developmental concerns. The coordinator recommended that Daria refer the family to the local Part C early intervention program.
Daria shared results and recommendations with the family, and she gave them a digital summary of the findings (mailed or hand delivered as needed) to share with the child’s primary health care provider. The family agreed with Daria’s recommendations and consented to the referral. The early intervention Part C program conducted a remote developmental evaluation with the child and family. The results indicated that Lexi met early intervention eligibility. The family approved telehealth services during the pandemic social distancing order.
Developmental Screening During Challenging Times
Challenging conditions may include geopolitical strife/war, weather-related disasters (e.g., hurricane, tornado, fire, or earthquake), and health crisis. During the global pandemic resulting from COVID-19, it was necessary to implement risk mitigation strategies, such as social distancing and mask wearing, which led to many professionals and organizations re-imagining how they conduct their everyday practices. State programs had to quickly and efficiently rethink their home visiting programs to support families and provide continuity of care. Telehealth services were implemented to allow for virtual visits and to comply with state-level social distancing regulations (National Academy for State Health Policy, 2020). Due to social distancing measures, Daria transitioned her practice to an interactive video format, which required support from her leadership and training. Daria’s ability to connect with Lexi’s family and provide appropriate developmental screening was the result of using effective implementation strategies. The following 11 strategies for the early identification of child delays may help connect children and their families to service delivery when conditions prevent more traditional modes of service delivery.
Assess Internet and Device Access
In Lexi’s case, her family had access to an internet connection and digital device, but a recent study of more than 1,300 home visiting programs showed that over half of families do not have adequate access to the internet or a device (Home Visiting Applied Research Collaborative, 2020). When a device or an internet connection is not available, programs may consider conducting a phone conference. To optimize a phone conference, families should be encouraged to record and share specific child activities/interactions in advance to capture and document child outcomes.
Some programs may also explore using devices that may be assigned to families with no access to devices or the internet for program participation and returned at the end of their enrollment term or school year. Virtual formats limit the ability of home visitors to easily provide parents with educational materials or summaries. Parents may not have a printer readily available to them to print digital copies. Programs should consider these challenges and develop plans, such as mailing materials to parents in need.
Challenging times may find families and their children sequestered and unable to participate in face-to-face service delivery. It may be necessary to implement strategies that promote engagement during virtual visits. Families and professionals alike may experience “virtual fatigue”—tiredness, worry, and burnout associated with using video/audio platforms to substitute face-to-face encounters (Lee, 2020). Best practices for engaging families in a virtual home visit may include: scheduling the visit, being fully present, establishing the objective of the virtual encounter, observing the child, using the curriculum, administering appropriate screening tools, and supporting the family (Healthy Families America, n.d.). It is also important to ask open-ended questions and observe body language during the virtual encounter to detect signs of emotional or physical discomfort (Pruski-Clark, 2020). Although most patients report being satisfied with telehealth services, data also identify several barriers, such as difficulty speaking up and challenges establishing a rapport (Gordon et al., 2020).
Professionals should consider strategies to reduce their own distractions if working from their home environment, as well as ways to reduce parent distraction when completing the parent-completed screening tool, such as parents being busy with young children, parents being preoccupied with something else during the visit, or even surfing the web or checking their mobile device (Hackett, 2020). A survey found that 73% of men and 39% of women reported being distracted during telehealth visits (Hackett, 2020). Working with the family, Daria scheduled the screening visit during a time when there would be minimal interruptions. It is important for professional to consider the impact of the challenging condition on their own lives, and how this may impact the delivery of services (Center for Health Care Strategies, 2020b).
Choose the Appropriate Research-Based Tool
Daria’s agency selected a developmental screening tool that requires the parent to answer questions about Lexi’s development. Daria is able to facilitate the administration of the tool by providing the family with a rationale for the screening and going through each of the screening questions using the virtual format. The parent-completed tool allows for minimal interaction with the child during the actual screening and is best suited for a virtual encounter. Several developmental–behavioral screening tools have been validated (Macy, 2012), but for the tool to identify children at risk for developmental delays, professionals must be able to appropriately facilitate the administration of the measure.
Some tools require the professional to personally administer them, which would likely be challenging during a video visit. Other developmental–behavioral screening tools fall into the category of parent-completed instruments, meaning that the parent reads and answers the questions on the validated tool with the help of the home visitor (Macy, 2016). Although validated parent-completed developmental tools are often referred to as questionnaires or surveys, they are not considered informal methods of screening.
Validated parent-completed developmental screening tools are research-based and have been developed using a rigorous validation process. Currently available parent-completed tools offer moderate to high sensitivity and specificity. Sensitivity is the tool’s ability to correctly identify those individuals with a potential developmental delay (true positive rate), while specificity is the tool’s ability to correctly identify those without an issue (true negative rate; Trevethan, 2017). During challenging times when face-to-face health care screenings are being delayed, it is important to identify screenings that accurately identify children and that are able to connect them to services in a timely manner.
Training and Education Are Key
Effective training and education are essential to fully implement or modify an early identification system. A virtual program is only as strong as the training the professionals receive around engaging families virtually (Pruski-Clark, 2020). The early childhood education program leadership provided Daria and other team members with training. Not everyone will be comfortable using video options to connect with families. Training should include how to use the digital platform and how to modify or adopt new tools that are to be used during the visit (Eapen et al., 2021). Professionals should be given the opportunity to practice using the digital platforms and incorporating any materials or screening measures into the encounter. Supports can be established using the community of practice approach and coaching (Thompson et al., 2021). Time should be allotted for colleagues to engage in role playing activities to help improve their competence and performance (Barrera et al., 2020; Moreno-Guerrero et al., 2020).
Daria also received training and education about the tool she would be using during video visits. Her training including information about the validity of the tool, administration time, any electronic databases associated with the tool, language translations, cultural appropriateness, and health care literacy. The effectiveness of Daria’s training on the tool was apparent in her ability to apply the information from her training to the virtual visit. She presented parents with a short overview of developmental milestones, screening benefits, and expectations.
Maintain a Team-Based Approach
Clear communication with families and other team members is important and even more critical when using virtual formats (Macy et al., 2019). Many professionals already operate in their own silos and interprofessional communication is often lacking. To connect early child educators, early childhood education professionals, health care providers, and parents, even virtually through virtual technology bridges need to be built to enhance communication. Identify management support mechanisms for the early detection system (Macy et al., 2017). Written communications, such as referral letters or a report summarizing the findings of the screening, should be used. The other important part of a team-based approach is providing support to the home visitors, such as engaging them in conversations about their own obstacles during the pandemic and supporting them as they reflect on their practice during these unprecedented times (Center for Health Care Strategies, 2020b; Thompson et al., 2021).
Listen! The Parent Knows Their Child
Parents may report they had an intuition that something was different with their child’s development before a developmental–behavioral delay was identified. Many parents experience frustration throughout the process of identification because they are often ignored, their concerns are commonly dismissed, and they often receive false reassurance (Marks & Glascoe, 2010). Some parents even fear they will be viewed as neglectful if they voice their concerns about their child’s development. In contrast, some parents do not have a sense that anything is wrong with their child’s development (Gellasch, 2016). It is important to listen to parent concerns. Listening is a skill that is even more necessary when practitioners cannot be face-to-face during visits. Face-to-face interactions allow for easily observed body language and emotional response. These may not be so evident during a virtual visit.
Delivering Difficult News to Parents From a Distance
A positive result on screening indicates the need for further evaluation, and can take parents by surprise. They may enter a state of denial and not follow through with recommendations (Gellasch, 2016). During the pandemic it may be even more stressful for parents to hear that their child has a developmental issue. Parents may already be struggling to meet the demands of their daily responsibilities and they may also worry that they will not be able to access the services that will help their child due to social distancing measures. Many families experience significant changes to their employment situations during a crisis that adds extra stressors due to financial issues (U.S. Dept. of the Treasury, 2021).
Best practices for communicating difficult news to parents include: highlight the child’s strengths, discuss areas of weaknesses, facilitate a shared perspective, confirm observations, state recommendations for a further evaluation in a positive way, document the findings in writing (i.e., referral letter for other professionals, parent summary report), and offer ongoing support to families (Glascoe, 2013). Information should be shared using short sentences, terms parents can easily understand, and time should be allotted for pauses to allow parents time to process the information they are receiving and formulate the questions they may have (Philpot et al., 2020). Daria clearly communicated the results with the family. She allowed time to answer questions and she provided the family with a digital copy of the summary of the findings to share with the child’s primary health care provider. The family were in agreement and consented to the referral.
Know Your Local and State Resources
Formal evaluation, the next step after a screening test is positive, can be costly. To ensure referrals are valid and children are identified in a timely manner, professionals need to use quality screening measures, as described previously (Bricker et al., 2013). Improving awareness of local and state resources for comprehensive evaluation through IDEA Part C or Part B, Section 619 is a must for all professionals and families (Adams et al., 2013). Daria was aware of these resources, and as a result she was able to appropriately connect Lexi to the early intervention Part C program.
Unfortunately, about 50% of parents with children identified as needing further evaluation after the developmental screening do not follow through with the referral (Schonwald et al., 2009). Some parents wish to rely on their private insurance for evaluation but long wait times for such evaluations are abundant in the current health care system–an identified barrier to timely diagnosis and intervention (Harrison et al., 2017). Bidirectional communication between professionals, shared databases, and working with organizations, such as Help Me Grow, are needed to help facilitate timely referral and improve communication and collaboration between various professional groups (Dworkin & Garg, 2019). Daria followed up with the family to reflect on the challenges, accessibilities, and next steps in completing a developmental evaluation. The discussion goal would be to explore solutions and strategies to achieve this goal.
Implement an Adaptable Approach
Coping during difficult times requires a significant amount of flexibility. It is important to adopt a practice that can be easily adapted and used in both virtual and face-to-face encounters. Daria’s agency selected a tool that is appropriate for both settings, which will allow her to easily transition her practice when local guidance changes. It is also important to maintain public awareness of developmental screening programs that are in place during the pandemic. Parents may be misinformed that screening or early intervention services are unavailable to them because of social distancing measures. Announcements can be placed in the community’s local newspaper sharing information about who to call if parents have a developmental concern. Media can be used to inform the public about early identification and developmental behavioral screening. Public service announcements can be shared on the radio and television.
Keep Up to Date With Policy Changes and Modifications
Policy changes and modifications are inevitable during challenging conditions. It is helpful to remain abreast of changes for at least two reasons: (1) to stay in compliance with regulations and guidelines and (2) so that children and families can be served in optimal ways. For example, on July 6, 2020, the Office of Special Education Programs within the United States Department of Education made a change to the policy requiring that face-to-face screening occurs within a specified timeframe. The two allowable exceptions to the timeline were: (1) if the child or parent were not able to complete the screening, and (2) if the parent has not provided consent. By following changes in guidelines, programs can remain in compliance and provide current and updated services to children (U.S. Department of Education, 2020). Policies change, and keeping up with the changing policy landscape will be important for children and their families.
Evaluate Your Approach and Make Appropriate Adjustments
System-wide engagement is needed to successfully implement screening, evaluation, and services. Initially, programs will need to gain feedback from their staff on the virtual encounters, including successes, failures, and areas in need of improvement. Observations of the virtual encounter may also help improve staff members’ performance and reduce anxiety when navigating this new practice environment. After the home visitor has mastered the virtual encounter, they will be a valuable resource and mentor to less experienced team members (Pruski-Clark, 2020). Daria will also want to work with her team to gather data on which children were screened, referred, evaluated, and received services. Because virtual visits are a newer practice, Daria will also want to ask her families for feedback through an anonymous survey to determine how to improve the virtual encounters. Maintaining such data can help evaluate a program, identify ongoing gaps, and identify strategies needed to improve the program.
Early identification of young children with special needs can help empower parents and connect children and families to quality early intervention services as early as possible, which will help children reach their full potential. Time is of the essence for children with developmental delays (Macy et al., 2014; Marks et al., 2013). Sitting idle and waiting for a crisis, like the global pandemic, to end is not an option when considering the value of early intervention services. Developmental screening for the early identification of risk, delay, or disability must continue, and both professionals and families can adapt to change when adequately supported.
Patricia Gellasch, PhD, APN-C, is adjunct faculty at The College of New Jersey in Ewing, NJ. Dr. Gellasch received her doctorate from Villanova University’s College of Nursing. She is a board-certified family nurse practitioner with clinical experience in primary care and the neonatal intensive care unit. Dr. Gellasch owns an education and research consulting company where she provides services to medical education companies in the area of grant writing and education design. She has conducted research in the area of developmental screening behaviors of primary care clinicians, compared screening completion when broad- vs narrow-band screens are used, and has assessed the success of state-level screening initiatives. She is currently collaborating on a study exploring the lived experience of raising a child with cerebral palsy.
Marisa Macy, PhD, is the Cille and Ron Williams Endowed Community Chair of Early Childhood Education at the University of Nebraska Kearney. She is an associate professor in the College of Education. Dr. Macy does research with the Buffet Early Childhood Research Institute. Her research interests include authentic assessment of children birth to 8 years old with and without delays/disabilities, developmental screening, play, and workforce development.
AnnMarie Alvarado, MA, ITDS, has invested her professional skills and career path for the past 27 years in Head Start and Early Head Start programs. Under her leadership role as a certified infant toddler development specialist, she is committed to and passionate about scaffolding systematic approaches that ensure all children have access to services that support positive school readiness outcomes. As a coach-of-coaches in early childhood, she has the opportunity to promote positive changes in home visitors/teachers toward their professional development goals and gain skills that impact family and children outcomes. As a mother raising a teenager with unique learning needs, Ms. Alvarado embraces the journey and lessons to instill the love of being a life-long learner.
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