Developmental Screening

In spite of the loss of the ECCS grant our ECCS partners continue, at their local levels, to support the promotion and expansion of the Ages and Stages Questionnaire (ASQ) across the early care and education setting.  We also continue to sustain the strong rapport with the healthcare provider community, especially through the American Academy of Pediatrics in the implementation of Parents’ Evaluation of Developmental Status (PEDS).

For the fiscal year 2023 application year, the ECCS program will continue to strengthen its partnership with the Office of Early Learning to assure a comprehensive approach to attaining universal developmental screening in all early care and education (ECE) facilities.  The ECCS Administrator serves on the recently established State Implementation Team (SIT) charged with launching the universal developmental screening legislative mandate.  Delaware is currently the first and only state in the country to require developmental screening statewide for all eligible children enrolled in child care.  This policy change was triggered by activities, over the past five years, resulting in changes in the type of screener used within early child care and education facilities which led to the ability to track population health data while lowering costs.  This effort was sparked by the ECCS grant which required an integrated approach to addressing developmental health and family well-being.  The MCH evaluator is also a member of the Core Team on this project and shares insights and outcomes of 10 years of developmental screening data tracked through the state’s (DPH-MCH) developmental screening initiative, with the group.

We will continue to collaborate with the Birth to Three program, through our centralized access point - Help Me Grow/2-1-1.  Two (2) new full-time staff provide a robust and timely follow-up to developmental screens administered within the 16 school districts and child care facilities, mandated to conduct developmental screens annually.  This is ever more significant as the state rolls out the universal developmental screening legislation by end of 2023.

The ECCS program continues to track the Ages and Stages Questionnaire (ASQ) and PEDS screens.  Memorandum of Understanding (MOU) between the Office of Early Learning (OEL) and MCH enables the sharing of ASQ data.  ASQ and PEDS data analyses is shared with the Help Me Grow (HMG) Advisory Committee which has over 30 members representing multi-sector child serving programs.  Through the Continuous Quality Improvement sub-committee of the HMG Advisory Committee, the data is analyzed for trends and further improvement activities.

Strengthened partnership with the Women Infants and Children program (WIC) this year, has resulted in a Memorandum of Understanding for more collaboration between HMG/2-1-1 and the Home Visiting program to ensure families eligible for either of those services (WIC, home visiting) are referred through the centralized access point.  We are now meeting a team on regular basis to build on the MOU and discuss opportunities to better serve our populations.

Through the ECCS program, MCH will continue to fund and provide technical assistance (through the American Academy of Pediatrics) for pediatricians and family practices that are implementing the Parents’ Evaluation of Developmental Status (PEDS) tool.  As mentioned earlier, through the MOU with the Office of Early Learning, we are able to collect and analyze ASQ screens.  Below is a record of screening results in 2021.  The results reflect the screens of the two preferred developmental instruments used by health providers (PEDS) and ECE (ASQ).

There was a total of 13,842 PEDS Online screens completed on children 0-59 months between 1/21 to 12/21, which corresponds to an estimated 9,090 unique or unduplicated children.  The previous year’s (2020) developmental screening count was about 855 more than 2021.  Of the total number of screens administered (13,842) by pediatric practices, 3.6% (321) were high risk for delays while 11.5% were of moderate risk.  Additionally, of that number of screens (13,842), 2,800 (94.9%) of children between 18 months to 24 months screened for the MCHAT passed the test while 150 (5.1%) failed.  Modified Checklist for Autism in Toddlers (MCHAT) screens for autism.

Overtime, about 20 pediatric practices have been consistent in their frequency of using a validated instrument in screening for developmental delays.  Increased outreach this year however, saw three (3) public health clinics at the State services center signing up to use the PEDS tool.  Furthermore, we also have reached out to some Federally Qualified Healthcare Centers who are still in the contemplation stage.

In the Early Care and Education setting the administration of the ASQ has been robust since most of the school districts across the state signed on to use the ASQ as the preferred tool.  The backlog of completed ASQ screens within the Birth to Three range which needed follow-up has been eliminated since the additional hiring of 2 new full-time staff to join the Help Me Grow/2-1-1 staff.

Sixteen (16) school districts, including the Birth to Three program, currently administer the ASQ on an annual basis to enrolled children.  In 2021, they administered a total of 6,821 screens, representing 6,372 unduplicated children.  There’s also a significant progress in the percent of screens that were referred to early intervention for follow-up.  The referral rate of unduplicated children “below the cut-off” among all the 16 school districts and the Birth to Three program, ranged between 6% to 84%.  Of the sixteen districts and the Birth to Three program, eleven (11) referred 30% or more of the unduplicated children (below the cut-off) to early intervention services.  Though there’s more room for improvement, it is very encouraging since it points to a progressive trend and the commitment of EC providers to follow-up to assure early detection.

We continue to partner with the Delaware Chapter of the AAP on an online education webinar targeting pediatricians and family practitioners.  The training provides an overview of developmental screening best practices, Delaware’s developmental screening initiative, PEDS online tools, the referral process, early intervention services, including care coordination and linkages to community resources (Help Me Grow/2-1-1).  This year, saw an expansion of the curriculum to include information on Lead Screening, oral health and the Reach Out and Read program.  The course will be made available on an online education platform that health providers or other stakeholders can access for professional development.  The webinar will made available on the DEAAP website including Delaware Thrives – the Family Health Systems/MCH website.

We are also in collaboration with the DEAAP to support the Reach Out and Read project to encourage pediatric practices, especially those implementing the PEDS tool, to give out books to children, following a well-child visit.  In addition to addressing early literacy, and as a result - school readiness and improved relational health, physicians are encouraged to provide information regarding early childhood development such as milestone information, lead screening and oral health, etc. as part of the anticipatory guidance.

Through Book Balls and Blocks events, we continue to foster family and community engagement to increase awareness and knowledge about developmental milestones and the importance of early detection.  As a result of the COVID-19 pandemic in-person BBB events were adapted to online versions using zoom.  Notwithstanding the challenges of the Covid-19 pandemic, which made it next to impossible to organize in-person Books, Balls and Blocks (BBB) events, the MCH/ECCS program has been successful in organizing BBB Online using zoom.  Nearly 18 BBB online events were held in the previous year (2021).  BBB events provide the opportunity for families with young children to engage in fun and educational ways to enhance their developmental milestones while providing access to developmental screens.  MCH/ECCS and its partners resorted to in-person BBBs in July 2021, with the lowering of the incidence of Covid-19.  These events were at the Delaware State Fair and a number of Head Start centers.  The recent upsurge has led to a return to virtual BBBs.  We will continue to come up with innovative ways to hold this event till in-person events are no longer a public health threat.

As more and more programs participate in screening for developmental health, the question becomes -- how many high-risk screens were referred to early intervention and what were the results of those referrals?  This is a question that has eluded most programs.  For this reason, MCH/ECCS program is engaged in the CHADIS pilot project which has a referral platform which enables users to track and respond to referrals.  The success of this pilot could be a game changer for how referrals are made in healthcare and subsequently child care across the state.  DPH will need the support and buy-in of stakeholders and gatekeepers for the scale up and spread of this project in the very near future.

Child Health and Development Interactive System (CHADIS) is a web-based patient engagement and Data collection system for comprehensive developmental/physical and mental health for all ages.  The pilot project includes the Delaware Chapter of the American Academy of Pediatrics; Medical Society of Delaware, Division of Public Health, Early Intervention programs (Child Development Watch (birth through 2 years) Child Find (3-5 years) and Help Me Grow/2-1-1- (Centralized Access Point).  These partners are working with four (4) pediatric practices representing Delaware’s 3 counties that have diverse patients and provide Medicaid and non-Medicaid services.  This project will enable physicians to screen families during well-child visits and track any referral to early intervention or other community resources, through a feedback loop.  All these efforts will strengthen follow-up services to ensure children identified at risk for delays are referred to and receive early intervention services.

The pilot is still in its implementation stages however the results will enable Delaware to promote the CHADIS platform across pediatric and early intervention programs, with the intention of scale up and eventual spread, even across early learning settings.

A great accomplishment for Delaware’s early childhood community is the passing of House Bill 202 which expands and increases the opportunity for children to undergo developmental screening at an early age to identify those who may be eligible for early intervention or special education services.  This effort is led by the Department of Education and targets the early child care and education system.  While this is a great feat and has to be applauded, it does not take into account developmental screening that occurs within the health care setting, that is led by the Division of Public Health.

This siloed approach serves as a barrier to systems integration and is not comprehensive and far reaching enough to cover the full scope and state of developmental screening in Delaware.  A comprehensive and integrated approach prevents duplicity while assuring efficiency across the board.  MCH is committed to work with its DOE partners to assure the establishment of the development screening in the early child care and education arena.  MCH will collaborate in areas such as messaging to ensure consistent messaging across the board for providers and parents alike.  A comprehensive approach is the pathway to systems integration and it is the hope that there will be “space” within the implementation of this legislation in the near future to consider what else is happening in healthcare.

We will continue to advocate for greater collaboration between early learning and child health and continue with universal developmental screening using the two preferred validated tools in the state – the Parents Evaluation of Developmental Status (PEDS) and Ages and Stages Questionnaire (ASQ).  We will continue to pursue shared measurement and the tracking of data to bridge identified gaps to improve children’s developmental milestones and the overall outcomes for children and their families.

We continue in engaging families through the development of messaging that resonates with families and are consistent.  We collaborate with our early childhood partners to assure consistency in such messaging.  Through our social media platforms, Delaware Thrives website, Instagram, You Tube Facebook, we have posted messages on the importance of developmental screening and milestones.  We have revamped the website and updated messaging to be consistent with those in the early childhood and education arena, to reduce confusion parents face when challenged with different messaging on the topic.

Plans for the Coming Year:

• Continue partnership to support the Office of Early Learning with the implementation of the universal developmental screening legislation.
• Support efforts to increase the number people/providers/parent leaders trained to use the ASQ and PEDS.  
• Continue collaboration with early intervention programs to improve referrals following high risk developmental screens to ensure families are connected to treatment services.
• Work with the AAP and Medical Society of Delaware to assist enrolled practices to address challenges and improve their performance and support appropriate utilization of PEDS Online during primary care well child visits.
• Promote early detection by encouraging physician practices to increase developmental screens and link families to community resources and services.
• Continue with the CHADIS pilot project to ensure pilot practices are fully implementing the platform. Collaborate with partners to scale up and spread use within healthcare.
• Build parent/family leadership and capacity to advocate for themselves and their communities through BBB events.
• Continue organizing community events (virtual and in-person, when appropriate) such as Books, Balls and Blocks events to increase families understanding of developmental screening and milestones.
• Continue opportunities to promote Help Me Grow/2-1-1 as a one-stop-shop for linkages to community resources and referrals.
• Support efforts by the AAP to engage health providers to sign up for the Reach Out and Read program.

Dental Visit

Delaware is tracking along with the national average of children, ages 1 through 17, who had a preventive dental visit in the past year.  According to the 2019/2020 National Survey of Children’s Health, 77.4% of Delaware children had one or more dental visit, which resembles the national average of 77.5% of children.  Unfortunately, this equals to 22.6% of Delaware’s children have not had a preventive dental visit in the past year.

MCH feels it is critical to continue to collaborate with the Bureau of Oral Health and Dental Services (BOHDS) while they develop new approaches and integrated new technology into schools and other programs to continue to provide education, dental screenings, and case management to the most vulnerable populations during the COVID-19 pandemic.

MCH (Maternal Child Health) will continue to support BOHDS (Bureau of Oral Health and Dental Services) efforts in reporting the results from the Statewide Oral Health Survey ASTDD.  The survey was completed on 2088 students in third grade and 2135 students in kindergarten, between January 2022 – April 2022.  The information will be used to produce a report to be released to stakeholders that identifies the gaps in oral health access to care, insurance, and other barriers to care which were identified through the survey.  BOHDS will develop access to care plans, preventive dental programs, and methods to reduce barriers to care to resolve inequities associated with care during the 2023 fiscal year.

BOHDS has been collaborating with Colonial School District to make oral health part of overall health and identify students who do not have dental insurance or have not had a visit to the dentist in the last 12 months.  A pilot program will begin in 2022 for BOHDS to complete a dental screening for all children in Colonial School District who indicated they have not visited a dentist in the past 12 months.  They will also provide fluoride varnish application and case manage children into a dental home.  MCH supports BOHDS in its efforts to include oral health as part of total health through the schools and see it as a critical piece of medical and dental integration and improved access through connecting students to a dental home for routine dental care.

MCH finds it beneficial for children who lack access to dental care to support BOHDS in their effort to support legislation currently in the House.  This legislation will allow alternate paths for dentists to obtain a license in Delaware when employed by a FQHC or DPH, which have been a barrier to hiring a dentist in the state.  MCH also sees the value in supporting legislation that will be presented in 2023 after the pilot at Colonial School District.  This legislation would require all newly enrolled students to receive a dental examination or screening in the 12 months prior to entering school for the first time.  It would also change screening consent forms for dental from active consent to passive, to be consistent with the requirements for medical and vision screenings.  In addition, MCH will support future legislation to expand the functions of a dental hygienist and dental assistant to be consistent with their level of training.

MCH supports BOHDS efforts to incorporate dental into school-based wellness programs across the state to improve access to care for preventive dental treatments.  BOHDS has made dental preventive services, dental cleanings, examinations, fluoride, and dental sealants into one School Based Wellness Centers (SBWC) at Warner Elementary in 2022.  BOHDS will continue to collaborate with schools interested in including dental into their school-based wellness centers across the state.

Over the past five years Delaware has struggled to maintain the Delaware Oral Health Coalition.  Changes in Directors, lack of resources, funding and COVID have prevented BOHDS from moving forward with an agenda and partners.  BOHDS has built relationships with many community partners during this time that work toward improving the health of Delaware residents.  BOHDS Dental Director is making it a priority to reestablish The Delaware Oral Health Coalition in 2023 to address oral health access issues and work on improving oral health for all residents statewide.  MCH will be supporting the reestablishment of the Coalition to continue the progress made advancing oral health care for children.

BOHDS will continue to expand their early intervention programs for pregnant women and infants.  These programs target pregnant teenagers through DAPI and women who are struggling with addiction that are pregnant through DSAMH.  Classes are designed to empower and inspire the women to self-advocate for the oral health of their children as well as themselves through receiving preventive dental treatment during pregnancy, and assuring their children receive routine preventive dental care and have a dental home by age one.  This program has proven to be successful for the women, infants, and other children in the family and MCH will continue to support the expansion of this service.

MCH finds it beneficial to support BOHDS upgrade of their electronic dental software Dentrix to a new server.  BOHDS has no other system available to enter information about patient procedures and conversations with the families regarding case management.  Dentrix is the database that holds all information related to dental services and this information is shared with Medicaid through billing to report out for the state on the 416 reports for the Medicaid population.  The data collected is not only shared with Medicaid but used to report data on our program activities to MCH and other stakeholders.

MCH sees continued interest and benefit in supporting BOHDS with early intervention for dental services through various programs that target under age 5.  BOHDS has provided training for fluoride varnish application, caries risk assessment and referrals to most pediatric providers in Delaware.  A certificate is provided to offices that completed the recommended Smiles for Life Courses, participated in oral health training for all office staff and collaborated with one of the Division of Public Health Dental Hygienists during a well child visit to demonstrate how to incorporate billing, education, application of fluoride during the visit.  BOHDS will continue with this program and expand oral health education and training to other healthcare professionals in schools, OBGYN offices and family practitioners.

BOHDS will continue collaborating with Delaware AAP Early Literacy Committee by purchasing and distributing oral health books to pediatricians enrolled in the program and providing oral health supplies and educational materials for children under age 5.

BOHDS has reorganized to dedicate a team for education that will focus on development and delivery of specialized oral health education and trainings for populations at greater risk for developing decay or injury and less likely to receive dental care.  These programs will include individuals with systemic health conditions, people who are pregnant, experiencing substance abuse, people with disabilities, people with cancer, mental health challenges, over 21 enrolled with Medicaid or uninsured.  Oral health will be promoted within the family, schools, workplace, and primary health-care system to reduce oral health inequalities, connect them to a dental home and improve oral health literacy.  MCH will support their efforts by continuing to market for their program, fairs, Storytime, education sessions, and newsletters through DE Thrives, Facebook, Twitter and over 200 Community Partners.

Once the DEThrives website is revamped, the oral health landing page will contain additional info organized into different audience types such as “children”, “teens”, “children and youth with special health care needs”, “pregnant women”, “adults”, and “oral cancer screening” info.  Each category will include information for its respective audience type and subject matter with additional resources such as external links, infographics, downloadable PDFs or booklets.  The public will still be able to enroll in virtual or in-person services, along with schools or facilities to sign up to receive “Smile Check” services.