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Minnesota Department of Health Fact Sheet: Title V (MCH) Block Grant
Pregnant Women, Mothers and Infants
Children and Adolescents
September 2009
Infant and Child Developmental, Social and
Emotional Screening
About the Title V Block Grant
The federal Title V Maternal and Child Health (MCH)
Block Grant helps states ensure the health of all
mother and children. As part of Minnesota’s Title V
Block Grant activity requirements, the MDH conducts
a statewide needs assessment every five years. The
needs assessment provides guidance to Title V
activities for the next five years by identifying priority
issues. This fact sheet describes one of Minnesota’s
priority issues.
Seriousness of the Issue
In Minnesota there are almost 400,000 children age 05 years.1 Early identification/screening and referral
systems identify children’s strengths and needs in the
areas of health and development, including
social/emotional development. These systems promote
healthy child development and minimize adverse
health, social, and emotional effects on children and
their families. In addition, through culturally
appropriate screening, assessment and early
intervention services many children are supported in
reaching their full potential.
It is estimated that nationally 12-16 percent of
children have a developmental or behavioral delay or
disorder. Only 20-30 percent of these children are
detected prior to starting school. Since 1992, early
childhood screening has been required for entrance in
Minnesota’s public schools. In fiscal year 2008,
screenings generated 20,762 referrals for additional
health and educational assessment/evaluation for the
59,375 three to five year old children screened.2 The
question that must be asked is how many of these
children might have the opportunity for better
developmental outcomes had their needs been
identified and early intervention services received
prior to the age of 3?
While data specific to children under age 5 is not
available, children below 200 percent of poverty
report higher levels of behavioral and emotional
Maternal and Child Health Section
P.O. Box 64882
St. Paul, MN 55164-0882
(651) 201-3760
www.health.state.mn.us
problems compared to higher income youth.3
According to the American Community Survey, in
2006 poverty in Minnesota reached the highest point
of the decade.4
Prevalence of mental illness is similar between
racial/ethnic minorities and Whites.5 However, racial
and ethnic minority populations are less likely to have
access to available mental health services or to receive
needed mental health care and often receive poor
quality care.6
Minnesota’s population is 74.6 percent metropolitan,
12.8 percent micropolitan and 12.6 percent rural.7 The
prevalence of mental illness in rural communities is
similar to urban or suburban areas8, but many greater
Minnesota counties have been identified as Health
Professional Shortage Areas for Mental Health.9
Minnesota has about 620 licensed psychiatrists and an
estimated 93 percent practice in metropolitan area
counties. Seven percent practice in micropolitan area
counties and less than 1 percent have their principal
7
practice site in rural counties.
Although Minnesota’s system of care for children and
their families demonstrates a commitment to
promoting developmental and mental health screening
as a critical component of well-child care, consistent
screening is largely absent from routine use in the
primary care setting.
In 2001, the American Academy of Pediatrics (AAP),
Committee on Children with Disabilities, stated that
early identification of children with developmental
delays or disabilities can lead to treatment of, or
intervention for, a disability and lessen its impact on
the functioning of the child and family.
Developmental screening is a process that selects
children who will receive more extensive evaluation
or treatment. For that reason all infants and children
should be screened for developmental delays.10 In a
2006 policy statement, the AAP stated “early
identification of developmental disorders is critical to
the well-being of children and their families.” Despite
these recommendations, a national survey found
Infant and Child Screening – page 2
substantial variability in surveillance and screening
practices among pediatricians and family physicians.11
Evidence-Based Strategies
The Centers for Disease Control and Prevention has
established the following goals to help children reach
their full potential:
• Develop and test community-based model
programs in primary care settings (and potentially
other settings that care for young children) to
screen children early on, identify those with
autism and other developmental disabilities or
delays, and ensure that children with these
conditions receive appropriate care.
• Increase health care providers’ knowledge and
skills in developmental screening by
incorporating developmental screening into
professional health care training.
• Monitor the use of screening for autism and other
developmental disabilities or delays in primary
care settings.
• Raise awareness about the need for and benefits
of developmental screening to identify and care
for children with autism and other developmental
disabilities or delays.12
A 2007 study from the University of Oregon measured
the impact of implementing the Ages and Stages
Questionnaire (ASQ) developmental screening tool at
12 and 24 month well-child visits. The study found
that referrals for early intervention increased by 224
percent with the use of the ASQ. Furthermore, 68
percent of the children with delays, would have been
missed by pediatricians using clinical impression as
opposed to a screening instrument.13
Studies confirm the effectiveness of early intervention
programs. The Infant Health and Development
Program 3, a national multi-site-study, found that lowbirth weight, premature infants who received
comprehensive early intervention and preschool
services score significantly higher on tests of mental
ability, and experience lower mental disability rates
compared to children who received only health
services.14 In addition, the benefits of screening and
surveillance are not limited to children with
developmental and behavioral delays. Even for
typically developing children, families benefit by
increased awareness of appropriate developmental and
behavioral expectations.15
The Minnesota Child Heath Improvement Project
(MNCHIP) Healthy Development through Primary
Care Project was a one year collaborative started in
November of 2007 and included nine clinic practice
teams across Minnesota. The goals were to:
• Implement the use of standardized screening tools
to screen children for developmental and mental
health concerns at well child visits.
• Screen mothers for maternal depression during
pediatric visits using a standardized screening
tool.
• Identify and refer children and families in need of
services to appropriate resources.
Preliminary findings in March 2009 showed the
developmental screening rate increased from 55
percent at baseline to 89 percent after project
implementation. The mental health screening rate
for children increased from 3 to 11 percent after
project implementation.
In North Carolina, the Assuring Better Child Health
and Development (ABCD) project focused on
integration of screening in primary care practice as a
routine and consistent component of well-child visits.
This project led to new policy in South Carolina’s
EPSDT program including requiring medical
practices to use a formal, standardized developmental
screening tool at 6, 12, 18 or 24 months and 3, 4, and
5 years of age. The project was successful in
increasing screening rates to over 70 percent of the
designated well-child visits.15
Current Resources and Capacity
As demonstrated previously, comprehensive
developmental screening, including social and
emotional domains, is critical to the early
identification and subsequent referral of young
children who would benefit from early intervention
services. It is also clear that currently there is no
single system which alone can assure ongoing
screening using a valid instrument at regular intervals
for all children beginning at birth.
The Minnesota Interagency Developmental Screening
Task Force was convened in spring 2004 to provide a
standard of practice for developmental and
social/emotional screening of children birth to age
five. Criteria were established for developmental and
social/emotional screening instrument selection.
Instrument properties were evaluated based on the
established criteria, and approved or eliminated based
on ability to meet or exceed the criteria.
A website was created to provide information on the
instruments which have been approved for use in
Minnesota’s public programs. The website URL is:
Infant and Child Screening – page 3
http://www.health.state.mn.us/divs/fh/mch/devscrn/gla
nce.html. The task force continues to meet on a
regular basis.
children at risk for developmental and
social/emotional delays.
1
In Minnesota, all local health departments receive
funding to provide home visits for at-risk pregnant
women, infants and toddlers. In March 2008, each
department submitted a plan detailing their home
visiting program. As part of that plan local health
departments were asked to submit information
regarding screening tools used for developmental,
social and emotional screening. Of 91 plans
submitted, 86 used a tool for developmental screening,
while 82 indicated a tool being used for
social/emotional screening. In local public health
department home visiting programs implementing the
Nurse Family Partnership model, 85 percent of the
children reaching age 20 months had been screened
using the ASQ and 89 percent of 24 month old
children received the ASQ – Social Emotional (SE).
The Follow Along Program (FAP) is a cooperative
agreement between the MDH and local FAP
managing agencies and provides periodic tracking and
monitoring of the health and development (including
social and emotional) of children ages birth to three.
The FAP also provides parents ASQ and ASQ – SE
screening tools, information about typical child
development as well as activities parents and children
can engage in together. Parents return the completed
screenings which are scored and followed-up on as
needed. 16
Minnesota’s public health systems, including all local
public health agencies and tribal governments have
programs and strategies that promote access to wellchild care such as Child and Teen Checkup (C&TC)
Coordinators and PHN home visitors.
The MDH’s C&TC program has an online training
program “Developmental and Social-Emotional
Screening” which was updated in June 2009. This is a
joint venture of the Minnesota Department of Human
Services and the Minnesota Department of Health to
give C & TC providers the knowledge and
information they need in regard to developmental and
social-emotional screening.
Starting in May 2009, the MDH C&TC Program
began offering grand rounds style presentations to
primary care physicians on developmental and mental
health screening and referrals for children, including
screening for post partum depression in mothers. The
presentations include information from local early
intervention staff on how to collaborate on referrals of
US Census Bureau. 2000 Census. Online resource:
www.census.gov
2
Minnesota Department of Education. (2008). Early
Childhood Screening – FY 2008 Participant Data.
Retrieved August 26, 2009, from,
http://education.state.mn.us/mdeprod/groups/EarlyLearni
ng/documents/Report/014507.pdf
3
Snapshots of America’s Families II, Urban Institute.
October 2000. Data from the National Survey of
America’s Families, 1999.
4
US Census Bureau 2000 Census and 2001 Census;
2002-2007 U.S. Census Bureau American Community
Surveys
5
U.S. Department of Health and Human Services, Office
of the Surgeon General, SAMHSA. “Mental Health:
Culture, Race, Ethnicity 0- A Supplement to Mental
Health: A Report of the Surgeon General”. 2001.
6
Minnesota Department of Education. “Minnesota’s
Self-Improvement Plan”. February 2002.
7
Minnesota Department of Health Office of Rural Health
and Primary Care. Information on Minnesota’s health
care workforce is collected through surveys professionals
voluntarily complete when renewing their licenses. Aug
2009.
8
Rural Health Advisory Committee’s Report on Mental
Health and Primary Care. Minnesota Department of
Health, Office of Rural Health and Primary Care.
January 2005.
9
Minnesota Department of Health Office of Rural Health
and Primary Care. Map of Mental Health HPSA
Designations. 2008.
10
American Academy of Pediatrics, Committee on
Children with Disabilities. Developmental Surveillance
and Screening of Infants and Young Children.
Pediatrics, 2001, 108 (1): 195
11
Sices L., Feudtner C., McLaughlin J., Drotar D.,
Williams M. (2003). How do primary care physicians
identify young children with developmental delays? A
national survey. Journal of Developmental and
Behavioral Pediatrics, 24(6):409-17.
12
Centers for Disease Control, 2005. Online resource:
http://www.cdc.gov/ncbddd/child/improve.htm
13
Hix-Small, H., Marks, K., Squires, J., & Nickel, R.
(2007). Impact of Implementing Developmental
Screening at 12 and 24 Months in a Pediatric Practice.
Pediatrics, 120, 381-389.
14
Ramey C., Bryant D., Wasik B. (1992). Infant health
and development program for low birth weight,
premature infants: Program elements, family
participation, and child intelligence. Pediatrics,
89(3):454-65.
15
Earls, M.F., & Shackelford Hay, S. (2006). Setting the
Stage for Success: Implementation of Developmental
and Behavioral Screening and Surveillance in Primary
Care Practice – The North Carolina Assuring Better
Infant and Child Screening – page 4
Child Health and Development (ABCD) Project.
Pediatrics, 118, e183-e188.
16
Minnesota Department of Health. (2008). Follow
Along Program 2008 Report