Universal Screening Panel Report

September 2019

October 30, 2019 1

Introduction

Iowa has been working diligently on the care and nurturance of its most vulnerable citizens for

over 150 years

. The goal of providing “safe, healthy, and successful lives with their families

and friends” shows the value and importance of social emotional behavioral health to the

community.

The Iowa Children’s System State Board convened the Universal Screening Panel

(herein the

Panel) in the spring of 2019 to provide recommendations based on Board consensus to develop

a universal screening plan for Iowa’s children. The Strategic Plan

of the State Board provides

a vision, mission, reason to act, and core value statements as a guide for the Universal

Screening Panel’s work.

It is strongly recommended that implementation of universal screening is approached as a

learning process with opportunities to reflect, improve, and correct in response to lessons

learned as it unfolds. The Panel recommends three broad goals for the implementation of

universal screening in Iowa:

1. Provide public education about the critical need to attend to social and emotional

behavioral health and well-being.

2. Implement universal screening informed by Panel tool and practice guidance,

capitalizing on existing efforts and the natural opportunities to engage families.

3. Provide enhanced family support, targeted training, and funding support and

throughout the state.

Using parameters and guidelines that can be found in the needs assessment section of this

report, the Panel developed the following set of specific recommendations for the

implementation of universal screenings:

 Universal screening activities use existing programs of strength, supply strong

communication tools, and activates care coordination functions of the Children’s System;

 Leverage the strength of the Iowa EPSDT (Early, Periodic, Screening, Diagnosis, and

Treatment) program, 1

Five, Children’s Health Insurance Program

, and Department of

Education activities including the use of the MTSS framework for supplying and

broadcasting the message of social emotional behavioral health and well-being;

 Public education about universal screening as a proactive strategy for maximizing

healthy social emotional behavioral development and building family and community

strength;

 Provide screening in the environments naturally engaging with families: healthcare and

schools, as well as innovative strategies like placing healthcare clinics in or alongside

schools, daycares, early childhood programs;

 Provide families, in various contexts, with resource navigators who serve to support,

educate, and accompany families through the identification of need to intervention and

resolution. Examples of resource navigators are found in 1

Five

and Scott County

;

https://idph.iowa.gov/Portals/1/Files/LPHS/LBOH%203_history.pdf

Membership found in Appendix/Additional Resources

https://dhs.iowa.gov/sites/default/files/ChildrensStateBoard_StrategicPlan_Nov2018.pdf?071120191534

https://dhs.iowa.gov/hawki

http://www.iowapeds.org/home/about-us/programs/1st-five-initiative/

October 30, 2019 2

 Provide training for all screeners/practitioners and to use existing stakeholders and

relationships (Systems of Care, AAP Iowa, EPSDT, Family Physicians, 1

Five, and the

Department of Education including Areas Education Agencies) to ensure broad capacity,

competence, and networks are developed;

 Training includes specific training and support about choosing best screening tools for

the various contexts in which screening will happen;

 The State Board endorses the Practice Parameters and Suggested Matrix of Tools

supplied here and institutes a robust periodic review of suggested tools;

 A diligent analysis of barriers to universal screening including funding, payment,

personnel, and referral network adequacy. Education and healthcare communities

presently manage extraordinary expectations often with competing demands and limited

time. Removal of impediments and creating efficiencies for these providers is strongly

recommended. Additionally, equity across insurance types (and for the uninsured), in

access to quality care, and of service and provider capacity is a significant concern and

removal of these barriers will be necessary.

Background

Social and emotional behavioral health (SEBH) affects how we think, feel, communicate, act,

and learn. It includes the process by which children and adults acquire and effectively apply the

knowledge attitudes, and skills necessary to understand and manage emotions set and achieve

positive goals, feel and show empathy for others, establish and maintain positive relationships,

and make responsible decisions.

Flexible and competent social and emotional behavioral health is developed through responsive

and nurturing caregiving and relationships. It contributes to resilience, how we relate to others,

respond to stress and emotions, and make choices

. Families need essential resources,

support, and attentive care in order to nurture children’s health: mind and body.

The consequences of inadequate care and insufficient

resources on the brain development of young children

can be dire to individuals and the community. Toxic

stress and adverse childhood experiences

, especially

in the early years, impact a person’s overall health,

ability to maintain healthy relationships, make wise

choices, and meaningfully contribute to their

community. Many parts of the community that touch

families – childcare and education, healthcare, housing,

nutrition, and economic support – are essential for

helping families to nurture and support optimal social

emotional behavioral health. Iowa’s Innovation Model

and investment in community health is an excellent

https://www.scottcountyiowa.com/health/care-kids/developmental-screenings

https://www.cdc.gov/hrqol/wellbeing.htm

https://www.cdc.gov/ncbddd/childdevelopment/early-brain-development.html

https://www.iowaaces360.org/

https://dhs.iowa.gov/ime/about/initiatives/newSIMhome/social-determinants-health

A toxic stress response can occur

when a child experiences strong,

frequent, and/or prolonged adversity—

such as physical or emotional abuse,

chronic neglect, caregiver substance

abuse or mental illness, exposure to

violence, and/or the accumulated

burdens of family economic hardship—

without adequate adult support.

https://developingchild.harvard.edu/scien

ce/key-concepts/toxic-stress/

October 30, 2019 3

example of committed leadership and resources in addressing the social determinants of health

(aka unmet social needs).

The Innovation Model describes five unmet social needs:

 Economic Stability

 Education

 Social and Community Context

 Health and Health Care

 Neighborhood and Built Environment

Unmet social needs should remain a

consideration in system design and

implementation of universal screening. Panel

members cited how identifying an unmet social

need and lacking a viable option for addressing

the need frustrates the opportunity to stabilize a

vulnerable family. The 1st Five

program was

highlighted as a powerful engine for connecting

families to resources that can meet material needs

while simultaneously attending to social and

emotional health of all members of the family.

Learning environments are a powerful place to

strengthen social emotional behavioral health. The

Iowa Department of Education has employed the

Multi-Tiered System of Support (MTSS

)

framework to help ensure that students are

provided a rich and attentive context in which to

learn and grow. Iowa educational innovators like Scott County Kids

use universal screening to

appropriately identify and attend to needs that impact students’ learning and social/emotional

health. The MTSS framework supports accurate knowledge about the needs of individuals,

schools, and communities in support of the sound allocation of resources.

Needs assessment

The Panel initiated its work with an assessment and review of the present practices and

opportunities for universal screening across Iowa and national practices and guidance. At

present, schools, healthcare professionals, and the early childhood community supported by the

Department of Health provide excellent structure to build upon.

The Panel gathered, shared, and reviewed information about the areas of strength in Iowa’s

efforts to attend to children’s social and emotional needs. Innovative and strong efforts include

the work of Scott County Kids

, Iowa 1

Five

, and the medical home model many pediatric

http://www.iowapeds.org/home/about-us/programs/1st-five-initiative/

https://educateiowa.gov/pk-12/learner-supports/multi-tiered-system-supports-mtss

https://scottcountykids.org/

http://idph.iowa.gov/1stfive

Unmet social needs are the complex,

integrated, and overlapping social structures

and economic systems that are responsible

for most health inequities. These social

structures and economic systems include the

social environment, physical environment,

health services, and structural and societal

factors. Social determinants of health are

shaped by the distribution of money, power,

and resources throughout local communities,

nations, and the world.

https://www.healthypeople.gov/2020/t

opics-objectives/topic/social-

determinants-of-health

October 30, 2019 4

practices employ

. Each of these is unique in its attention to sensitive and timely engagement

with families, evidence-based practices of identifying needs and strengths, attention to unmet

social needs, and deliberate coordination of care in the service of attending to needs.

Paramount in successful implementation and efforts at sustaining universal screening is the role

of care coordination and communication between and among families, practitioners, educators,

and service providers. The Panel recommends ensuring universal screening activities use

existing programs of strength, supply strong communication tools, and activates care

coordination functions of the Children’s System.

The Panel was charged with and responded to the following parameters for universal screening:

Screenings shall be:

 Accessible to all children in Iowa;

 Administered at key developmental stages of childhood by qualified individuals after

informed consent is given by the child’s parent or guardian;

 Developmentally, age, gender, and culturally appropriate for the child or adolescent

being screened;

 Linked to appropriate assessments and services;

 Valid and reliable in identifying children and adolescents in need of further

assessment;

 Administered at multiple locations including, but not limited to schools, primary care

clinics, and detention centers.

Children and youth in Iowa are commonly screened through schools and healthcare providers.

In the educational setting, panel members evaluated the tools used across early childhood and

through high school and found them to be useful and appropriate. Screening in healthcare

satisfies the objective of EPSDT and is detailed in Iowa’s robust EPSDT program found here:

http://www.iowaepsdt.org/ .

The Panel advocated for the following guidelines for universal screening:

 Build on the existing system of already established screenings;

 Screening tools are simple, easy to administer checklists or questionnaires used for

identifying biological and environmental factors that put some children at a higher risk for

social emotional behavioral health conditions;

 Screening tools are intended to be predictive in nature for assessing strengths and areas

of concern;

 Screening tools identify the need for a referral for an appropriate, in-depth assessment

to determine if social emotional behavioral health services are needed;

 Periodic screenings are essential for the early detection of social emotional behavioral

health conditions since conditions can present at different stages of development.

Matrix of suggested tools

The matrix of suggested tools and practice parameters are the basis for a universal screening

program in Iowa. The Panel developed a matrix of suggested tools (found in Appendix) having

evaluated each for:

https://medicalhomeinfo.aap.org/national-state-initiatives/State-Profiles/Pages/Iowa-State-

Profile.aspx

October 30, 2019 5

a. Appropriateness: the fit of the tool to the screening context, the purpose, and the need of

screening;

b. Technical adequacy: the validity, reliability, and accuracy of the screening tool;

c. Usefulness: the tool generates new and useful information supplemental to existing

information;

d. Feasibility: the ease of implementation and clarity of the referral pathway of the tool;

e. Beneficial properties: the cultural sensitivity and responsiveness and the absence of

harm of the tool.

There is no single tool appropriate for all children or screening situations. All the tools chosen

through expert consensus of the Panel are presently used in Iowa, typically in educational or

healthcare settings. The Panel cautions that the on-going process of suggesting screening

tools should include a rigorous evaluation of psychometric properties, usefulness, cultural

sensitivity, and supporting evidence of effectiveness.

The recommended tools are the best choices to ensure that tools used in Iowa are appropriate

to the child with regard to age, gender, ethnicity, cultural background, sexual orientation,

disability, or any other factor that would influence the developmental appropriateness of the

instrument being administered. The tools are research-informed and evidence-based to ensure

validity and reliability in identifying children and adolescents in need of further assessment.

The Panel recommends the following screening tools:

 Modified Checklist for Autism (M-CHAT)

 Survey of Wellbeing of Young Children (SWYC)

 Patient Health Questionnaire (PHQ)

 Ages and Stages Questionnaires (ASQ)

 Strengths and Difficulties Questionnaire (SDQ)

 Social Academic Emotional Behavior Risk Screener (SAEBERS)

 CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble)

Practice Parameters

Practice parameters are outlined by the Panel’s guidance on the following questions:

o When screenings will occur;

o Where screenings will be provided;

o Who will provide screenings; and;

o What will be included in the screenings.

The existing screening practices within Iowa provide a framework and sound rationale for

adopting the EPSDT-approved Bright Futures periodicity schedule (found in Appendix/Additional

Resources). This schedule has been married with the recommended schedule of screenings in

Iowa schools.

WHEN

The Panel recommends including key events in the periodicity schedule detailed here for

healthcare and education. These are the two places that encounter children most frequently

however the Panel encourages inclusion of all available settings (childcare and home visiting,

for example) in universal screening efforts. For both, there is an expectation of on-going

monitoring of development and the periodicity noted here is intended for the use of screening

tools.

October 30, 2019 6

Primary and Pediatric care:

o Developmental screening (note this includes screening for Autism): 9, 18, 30, and 36

months;

o Yearly developmental monitoring until age 21;

o Annual screening of substance use and depression screening beginning (minimally)

age 12.

Educational setting: Minimally an annual screening with attention to the following

vulnerable times in a child’s life:

o School entry: Kindergarten or 1

grade

o 4

grade

o 6

grade

o 9

grade

WHERE

The Matrix of tools includes information about where screenings typically occur. Multiple

opportunities for screening, i.e.: healthcare, school, early childhood setting, ensure that families

and youth engage comfortably and frequently in optimizing social and emotional health, a

breadth of practitioners are involved in collaborative monitoring of social emotional behavioral

health with families, and that screening occurs with more vulnerable families who are often not

as routinely interacting with professionals.

Essential to the implementation of sustainable universal screening practices is the link to follow

up care. Healthcare, ideally as a health home that coordinates care and communication for

families, is the place where most children will be encountered. Healthcare providers will make

appropriate follow up recommendations for care for area(s) of concern identified from any

screening practice employed

WHO

Screenings should be provided by professionals and paraprofessionals appropriately supported

and trained in screenings and the referral network. Appropriate training is determined by the

screening setting and tool. Efficient and accessible communication tools across settings (for

example school and physician), and clear referral pathways for areas of concern ensure

adequate support of screeners. Screeners should have clear parameters for obtaining consent,

engaging families in the process of screening and discussing area for growth where found, and

be appropriately aware of and connected to pathways to care for addressing concerns.

The Panel encourages the broad use of paraprofessionals in early childhood settings

particularly where their utility and expertise are proven (in Head Start and home visiting

programs for example.)

The Panel also strongly encourages engagement with the primary care community of providers

who see most children and youth in healthcare settings and influence families’ engagement with

supportive services and interventions when these are needed. The development and spread of

health homes throughout Iowa would serve to strengthen the universal screening network.

This practice is also best for the 12,000 estimated home-schooled children in Iowa.

October 30, 2019 7

Equally, the role of the Area Education Agencies

in early access to screening and care are an

asset to this effort.

WHAT WILL BE INCLUDED

The Matrix reflects the Panel’s recommendation that screenings be appropriate for the age,

developmental needs, and culture of the child and family. Screenings should gather information

about a child’s developmental status, social emotional behavioral strengths and needs, unmet

social needs, and cultural context to supply information about area for growth when identified.

Areas of specific attention like substance use, domestic violence, and depression in the family

are also recommended.

Conclusion

The Panel’s recommendations aim to light the pathways to health for Iowa families. The Panel

is grateful for the opportunity to provide valuable guidance in promoting social emotional

behavioral health early and wisely in Iowa. Promoting the social emotional behavioral health of

children through universal screening as recommended here capitalizes on the existing strengths

of the health, education, and healthcare communities. The care and nurturing of social and

emotional health of Iowa children strengthens schools, families, and communities.

http://www.iowaaea.org/

October 30, 2019 8

Definitions and terms

Adverse Childhood Experiences (ACEs): The original study evaluated 10 types of adverse

childhood experiences:

 Abuse: physical, sexual, psychological

 Neglect: emotional, physical

 Household dysfunction: substance abuse, divorce, mental illness, battered

mother, and criminal behavior

The ACE Study revealed that adverse childhood experiences are common. Nearly two-thirds of

participants reported at least one ACE and more than one in five reported three or more ACEs.

The study also linked childhood trauma to a range of health and social outcomes including:

 Alcoholism

 Chronic obstructive pulmonary disease

 Depression

 Illicit drug use

 Ischemic heart disease

 Liver disease

 Smoking

 Adolescent pregnancy

 Sexually transmitted diseases

 Intimate partner violence

 Health-related quality of life

In addition, as the number of ACEs increase, so does the level of risk for each of these health

issues in a strong and graded fashion

EPSDT (Early, Periodic, Screening, Diagnosis and Treatment): A program for children who are

enrolled in Medicaid. The focus of this program is to assure that eligible children ages birth

through 20 years receive preventive health care services, including oral health care. In Iowa, the

EPSDT program is called Care for Kids. EPSDT Care for Kids services are free to children

enrolled in Medicaid. Care for Kids: http://www.iowaepsdt.org/.

The acronym EPSDT stands for:

 Early

o Children should receive quality health care beginning at birth and continuing

throughout childhood and adolescence including the identification, diagnosis and

treatment of medical conditions as early as possible.

 Periodic

o Children should receive well child check-ups at regular intervals throughout

childhood according to standards set by the American Academy of Pediatrics.

Health care may be provided between regularly scheduled check-ups.

 Screening

o Children should be screened for health and developmental problems. Services

shall include health history, developmental assessment, physical exam,

immunizations, lab tests, health education, dental exam, and vision and hearing

screenings.

 Diagnosis

o Children should receive further evaluation of health or developmental problems

identified during check-ups that may require treatment.

October 30, 2019 9

 Treatment

o Children should receive treatment for health or developmental problems

identified during check-ups.

Following the Iowa EPDST Care for Kids Periodicity Schedule, screenings provide the

opportunity to identify concerns through comprehensive assessment of the child and family; and

develop a care plan that is responsive to the family’s strengths, needs and choices.

Screening: The use of a standardized tool to identify risk and determine the need for further

evaluation. Screening includes:

 Determining whether your child has any health concerns

 Offering ways to keep your child from developing health concerns

 Providing support for your child’s overall health and well-being

 Talking through health information and offering advice

https://brightfutures.aap.org/Bright%20Futures%20Documents/BF_Family_Tipsheet.pdf:

Surveillance (AKA monitoring): A longitudinal, continuous process based on clinical judgement

that includes eliciting and attending to concerns, maintaining a history of findings, making

observations, and identifying risk and protective factors.

https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Screening/Pages/Definitions-of-

Key-Terms.aspx

Toxic Stress: Prolonged exposure to adverse experiences that activate the stress response

system, potentially disrupting a child’s development and increasing the risk of poor health

outcomes into adulthood.

https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Screening/Pages/Definitions-of-

Key-Terms.aspx

Unmet Social Needs (AKA social determinants of health): The social determinants of health

(SDH) are the conditions in which people are born, grow, work, live, and age, and the wider set

of forces and systems shaping the conditions of daily life. These forces and systems include

economic policies and systems, development agendas, social norms, social policies and

political systems (https://www.who.int/social_determinants/en/). SDH include the opportunity to

work, access quality childcare, healthcare, and education, have safe housing, and access to

food and nutrition.

October 30, 2019 10

APPENDIX

Working Matrix

BLUE:

SCHOOLS

GREEN:

HEALTHCARE

Tier 1 or 2

Tool

ACCESSIBILITY

ADMINISTRATION

DETAILS

AGES

CULTURAL

SENSITIVITY

M-CHAT: (screening tool for autism in toddlers)

Free online; instant score

https://m-chat.org/

Quick online

administration by any

caregiver

16 to 30

months

Translations underway:

https://mchatscreen.co

m/m-chat/translations/

SWYC: Survey of Well Being of Young

children: The SWYC covers 3 domains of functioning

(Behavior and Emotion, Family Risk Factors, and

Development), and it is composed of 6 questionnaires:

Preschool Pediatric Symptom Checklist, Baby Pediatric

Symptom Checklist, Family Questions, Parents

Observation of Social Interaction, Developmental

Milestones, and Parent’s Concerns. It is comprehensive,

including cognitive, language, motor, and social-emotional

development as well as family risk factors (parental

depression, conflict, or substance abuse, and hunger).

Free: SWYC was created in order

to provide a screening instrument

that is free of cost and easily

accessed by parents,

pediatricians, preschool teachers,

nurses, and other professionals

involved in child care and

education

10 minutes or less

https://www.floatinghospital.or

g/-/media/Brochures/Floating-

Hospital/SWYC/SWYC-

Manual-v101-Web-Format-

33016.ashx?la=en&hash=E0C

2802F003ED312E9D5268374

C540A112151FB3

1 to 66

months

Spanish, Khmer,

Burmese, Nepali,

Portuguese, Haitian-

Creole, Arabic, Somali

and Vietnamese.

Patient Health Questionnaire (PHQ): The

PHQ, a self-administered version of the PRIME-MD,

contains the mood (PHQ-9), anxiety, alcohol, eating, and

somatoform modules as covered in the original PRIME-

MD. The GAD-7 was subsequently developed as a brief

scale for anxiety. The PHQ-9, a tool specific to depression,

simply scores each of the 9 DSM-IV criteria based on the

mood module from the original PRIME-MD. The GAD-7

scores 7 common anxiety symptoms.

Free

https://www.phqscreeners.com/se

lect-screenere:

Seems most useful for

parents

0-13

years

ASQ: General psychosocial screening Sensitivity: 63%

to 94% for emotional symptoms, Specificity: 88% to 98%

conduct problems, hyperactivity/inattention, peer

relationship problems, and pro-social behavior (not

included in score); a separate scale assesses impact of

symptoms on global functioning.

About .50c per screen

Parents, caregivers,

teachers, clinicians10 min;

25 items; self-

administered for 11-17

1 month

to 5.5

years

40 languages

ASQ-SE2 & 3: “highly reliable, parent-completed tool

with a deep, exclusive focus on children’s social and

emotional development, it’s easier than ever to screen

important areas of social-emotional competence, pinpoint

behaviors of concern, and identify any need for further

assessment or ongoing monitoring.”

10–15 minutes to

complete, 1-3 minutes to

score;

https://agesandstages.com/free-

resources/articles/using-asq-3-and-

asqse-2-together/

1-72

months

40 languages

SDQ: 1) Emotional symptoms; 2) conduct problems; 3)

hyperactivity &/or inattention; 4) peer relationship

problems; 5) prosocial behavior.

Used in research and clinically worldwide

$.25/screen

Additional information:

https://www.cebc4cw.org/assessment-

tool/strengths-and-difficulties-

questionnaire/

https://depts.washington.edu/dbpeds/S

creening%20Tools/Strengths_and_Diffi

culties_Questionnaire.pdf

https://www.nctsn.org/measures/strengt

hs-and-difficulties-questionnaire-child-

report

Self-screener; Parent,

teacher, clinician, youth

3-16

years

Abundant languages

available

SAEBRS: The SAEBRS is a brief tool supported by

research for use in universal screening for behavioral and

emotional risk. The measure falls within a broad class of

highly efficient tools, suitable for teacher use in evaluating

and rating all students on common behavioral criteria

(Severson, Walker, Hope-Doolittle, Kratochwill, &

Gresham, 2007). The SAEBRS is designed for use in the

K-12 setting

$7 a student

1-3 minutes;

Online portal

5-18

years

Multiple languages

CRAFFT: (screening tool for substance-related risks)

Free -

https://www.integration.samhsa.g

ov/clinical-

practice/sbirt/CRAFFT_Screening

_interview.pdf;

https://www.integration.samhsa.g

ov/clinical-

practice/sbirt/adolescent_screeni

ng,_brieft_intervention_and_referr

al_to_treatment_for_alcohol.pdf

6 questions; designed for

primary care

ages 14-

Spanish, Portuguese,

Hebrew, French,

Czech, Khmer,

Russian, Vietnamese,

Haitian Creole,

Laotian, Chinese, and

Japanese

October 30, 2019 11

APPENDIX

Membership

Member

Agency

Dr. Joyce Vista Wayne

Chair/ Mercy Hospital

Ben Barry

Carlisle School District

Brad Niebling

Department of Education

Dana Miller

Central Rivers AEA

Dr. Amanda Boeke

YSS

Dr. Amy Shriver

Blank Children’s Hospital

Dr. Marguerite Oetting

University of Iowa Hospital and Clinics

Dr. Stephen R. Mandler

Orchard Place

Kay Augustine

Department of Education

Kelly Betsworth

ChildServe

Marcus Johnson-Miller

Department of Public Health

Melanie Cleveringa

Sioux Center School District

Nicole Mann

Scott County Kids

Rick Shults

Department of Human Services

Sally Oudekerk

Department of Human Services

Shanell Wagler

Early Childhood Iowa

Grant funds provided by Mid-Iowa Health Foundation were used to support the Panel

and their work.