‘Missing Maria, Identifying Anna’: Lessons on Improved Screening Questionnaires for Children and Adolescents

Posted on 23.10.2023

MD PhD Kevin Marks shares valuable lessons on improving early identification systems for developmental and mental health screening in childhood.

MD PhD Kevin Marks recently had two major articles published: ‘Associations between disordered eating behaviors and HbA1c in young people with type 1 diabetes: a systematic review and meta-analysis’, published in Current Diabetes Reviews, and Core Concepts and Resources for Community-based, Developmental-Behavioral Screening’, published in Young Exceptional Children. For the latter of these, Kevin received a special invitation from the Buffet Early Childhood Institute to co-author the article.

The Buffett Early Childhood Institute at the University of Nebraska is working to transform early childhood development – especially for children at risk – through applied research, practice, policy, and outreach. 

Kevin obtained his PhD at the Graduate School of Health, Department of Clinical Medicine at Aarhus University with a scholarship from the Danish Diabetes Academy (DDA) (now Danish Diabetes and Endocrine Academy).

‘Missing Maria’: A Path to Improved Screening

The article from Young Exceptional Children revolves around ‘Maria’, a child who did not receive regular screenings of her developmental milestones despite showing signs of special needs at an early age. While the article tackles screening procedures in the United States, Kevin Marks thinks the key points could also be relevant for the Nordic countries.

– A relevant and universal take-home point is that improving a community’s early identification system will make a community’s early intervention system more effective. A major caveat is that I suspect that Denmark needs to improve its capacity for providing high-quality early intervention services for young children with suspected developmental delays, social-emotional problems, and at-risk conditions, says Kevin Marks. 

In the article, Kevin Marks and his co-author professor Marisa Macy list six core concepts to be aware of before moving forward with implementing a national program for developmental and social-emotional screening in children ages 0-5.

The Six Concepts Are

  1. Consider your purpose for screening 
  2. Community awareness and access to high-quality early intervention services 
  3. Continue with high-quality developmental-behavioural screening and surveillance 
  4. Communication and care coordination 
  5. Continually evaluate screening procedures
  6. Collect data on overall program evaluation for feedback and accountability. 
This figure is an adaptation of the six key components discussed in the book: Bricker D, Macy M., Squires J., Marks KP. (2013) Developmental Screening in Your Community: An Integrated Approach for Connecting Children with Services. Brookes Publishing. https://brookespublishing.com/wp-content/uploads/2021/06/developmental-screening.pdf 

– Maybe in the future, Denmark would be agreeable to building multiple early identification and intervention programmes in each region. Of course, Denmark’s system will be different from the US system and have its own unique challenges. But what could be the consequences of ‘missing Maria’? How many Danish children are not receiving timely, intensive, and child/family-specific services? I think that building a national ‘early identification and intervention system’ would be a smart investment for Denmark. In that case, Denmark should discuss the six core concepts, says Kevin Marks.

‘Identifying Anna’: The Importance of Using the Right Questionnaire

‘Identifying Anna’ is meant to emphasise that selecting the best screening questionnaires for a target population is really important. This second story, with a happier ending than ‘Maria’, was inspired by a systematic review and meta-analysis, which was published in Current Diabetes Reviews. The article highlights the importance of using diabetes-adapted disordered eating behaviour (DEB) screening tools in adolescents with type 1 diabetes (T1D).

– We found that self-report questionnaires that measure DEB in young people with T1D should include diabetes-adapted questions (e.g., intentionally restricting insulin for the purpose of maintaining or losing weight). Our analysis illustrated that the diabetes-adapted DEB screening questionnaires were more strongly associated with HbA1c than the generic DEB screening questionnaires. HbA1c is a blood test that measures the average blood glucose levels over the past two to three months. Higher Hgb levels over time increase the risk of long-term diabetic complications in the eyes, kidneys, brain, nerves, and cardiovascular system, explains Kevin Marks.

A Subject Deserving of a Wider Audience

Susan Buffet, philanthropist and the first wife of American businessperson Warren Buffet, gifted the Buffet Early Childhood Institute to the University of Nebraska at Kearney.

It was Community Chair Marisa Macy, who is also a professor at the University of Nebraska at Kearney, who extended the invitation to Kevin to be the co-author of the article ‘Core Concepts and Resources for Community-based, Developmental-Behavioral Screening’.

– Marisa and I have previously co-authored a book together with Diane Bricker and Jane Squires, who are both academic legends in the field of developmental and social-emotional screening. Writing that book together was a good experience. I think that Marisa reached out to me because we felt like the main themes of our book needed to be condensed into an article. We want these six core concepts to reach a wider audience, says Kevin Marks.

Susan Buffett passed away in 2004. But if Warren Buffett were to read the article, what might Kevin Marks hope for him to take away from it?

– We believe that improving a community’s early identification system will make a community’s early intervention system more effective. Warren Buffet really should read our article because the Buffett Early Childhood Fund has awarded many millions of dollars in grants for early childhood research and developmental programmes. Mr. Buffet knows that investing in early childhood has a very favourable ROI or returns on investment. However, Marisa and I did not receive any funding for writing this journal article. We only did it because we genuinely care about this topic, answers Kevin Marks.

Core Concepts and Resources for Community-based, Developmental-Behavioral Screening’

Young Exceptional Children, https://doi.org/10.1177/1096250623119404

Marisa Macy, Kevin P. Marks

Associations between disordered eating behaviors and HbA1c in young people with type 1 diabetes: a systematic review and meta-analysis’
Current Diabetes Reviews, DOI: 10.2174/1573399820666230822095939

Kevin P. Marks, Jori Aalders, Shengxin Liu, Melanie Broadley, Mikael Thastum, Morten B. Jensen, Else Helene Ibfelt, Niels H. Birkebæk, Frans Pouwer

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