ASQ-3 and ASQ:SE A Screening Tool For Pennsylvania’s Early Learning Practitioners

Definitions Screening Assessment Evaluation Refer to agenda handout…. Screening, assessment and evaluation are 3 very different activities – yet we often use them interchangeably--- let’s take some time to discuss their definitions.

Screening is… A brief process that allows teachers, parents, or practitioners to determine whether a child is developmentally “on track” or not Ask Participants to define screening…what do they think that it is? You may consider recording answers on a flip chart. Developmental screening is the practice of systematically looking for and monitoring signs that a young child may be delayed in one or more areas of development. Screening can be completed by anyone who is familiar with a child. No special training is necessary. Screening is not intended to be diagnostic, but can help to focus referrals, which children indicate a need for further evaluation? . 3 3

Screening… DOES help to identify children who should receive a more intensive evaluation DOES NOT lead to a decision about whether a child has a developmental delay! Ask Participants to define screening…what do they think that it is? You may consider recording answers on a flip chart. Developmental screening is the practice of systematically looking for and monitoring signs that a young child may be delayed in one or more areas of development. Screening can be completed by anyone who is familiar with a child. No special training is necessary. Screening is not intended to be diagnostic, but can help to focus referrals, which children indicate a need for further evaluation? .

Assessment is… An ongoing process conducted by trained personnel, along with families, to identify a child’s strengths and needs and to create learning opportunities that will encourage developmental progress. Again…you can ask participants to define Assessment and record responses. Note the Ounce Scale and Work Sampling as assessment tools… In quality ECE programs teachers conduct assessment continually, observe and design daily plans and curricula to address individual and group needs/goals.

Multi-disciplinary evaluation (MDE) is… An in-depth evaluation of one or more developmental areas to: determine the nature and extent of a physical or developmental problem and determine if the child is eligible for more intensive services (early intervention) Designed to be completed by those with specialized training in special education or mental health. Emphasize the expense and time involved in diagnostic assessment. Good (e.g., valid) screening tools ensure that children requiring diagnostic assessments be referred while reducing the number of unnecessary referrals.

Evaluations are completed by specialized programs: Early intervention (EI) Mental health/social service Health systems Children who are referred for further assessment, MAY or MAY NOT be determined to have a delay or diagnosable condition. Research has shown that early detection of developmental delays leads to better outcomes.

Typically, screening involves… Information gathering activities Ask participants to share some of the ways that they gather info about a child– answers may include: Discussion with a parent Review of professional records Direct observation of the child Formal screening tools What are some ways that you gather info about children??

Tests don’t make decisions. People do!!!! (Neisworth and Bagnato) Final thought…regardless of the results of a screening, assessment or evaluation, it is important to keep in mind that tests don’t make decisions, people do. Gather all the necessary info and use the results to inform your decision, that should be a team decision that involves parents and teachers in the process.

Why screen? Screening young children is an effective, efficient way for professionals to catch problems and start treatment http://www.zerotothree.org/site/PageServer?pagename=ter_util_babybrainflash Now we will move on to discuss why screening is important… when it does the most good—during the crucial early years when the child’s brain and body are developing so rapidly. This link to Zero to Three’s webpage provides a look at a baby’s brain, shows what areas of the brain are developing with relationship to particular behaviors found in very young children. It includes questions, answers, and ideas for enhancing development of infants/toddlers at various stages. This is a great resource for parents and staff. It demonstrates all the development that occurs in a short amount of time.

Early detection is critical “Compensating for missed opportunities, such as the failure to detect early difficulties...often requires extensive intervention, if not heroic efforts, later in life.” —From Neurons to Neighborhoods This quote further emphasizes the critical need to identify and treat difficulties in young children early in their lives.

Formal Screening Tools Are based on the performance of a representative sample of young children Identify children who may have a developmental delay and need referred for further evaluation. So screening is important…why formal screening tools? Because delays can be subtle and can occur in children who appear to be developing typically, most children who would benefit from early intervention are not identified until after they start school. Even pediatricians fail to detect delays more than 70% of the time when they rely on clinical judgment alone. Studies show that when professionals use reliable and valid screening instruments, they are able to identify 70% to 80% of children with developmental delays.[8]

Why the ASQ System… Is quick and easy to use Sound research base Requires little training Fits well with PA’s standards Flexible and can be used in various types of programs Why this particular screening tool? Refer to Handouts…Top 10 Reasons for Using the ASQ, and Keystone STARS Standards that relate to using formalized screening process. Used across systems – EI, OCYF The ASQ was standardized on a large research sample of 12,695 children that mirror that population of the US in terms of geography, ethnicity and socioeconomic status. This data was used to establish cutoffs and study reliability and validity. Excellent validity is .82 to .88; test-retest reliability is .91 and inter-rater reliability is .92 The sensitivity, or the ability to correctly identify those children with delays, ranged from 75% to 100%, with 86% overall agreement. The specificity, or the ability to correctly identify typically developing children, ranged from 70% to 100%, with 85% overall agreement. *Given the complexity of measuring child development, the American Academy of Pediatrics considers high quality developmental screening tests to have sensitivities and specificities of 70% to 80%. For more information, download the ASQ-3 Technical Report. Or Appendix C of the User’s Manual

Ages and Stages Questionnaires:2 Components Review slide. ASQ-3 focuses on overall development ASQ:SE focuses on social emotional development Explain the ASQ: SE developed as a companion tool the ASQ to address the need for age-appropriate tools to monitor very young children’s behavior and address parental concerns.

Let’s look at the ASQ Divided into 5 developmental domains Communication Gross motor Fine motor Problem-solving Personal-social Communication includes both receptive language – how the child understands others and expressive – how child communicates with others to get his needs met Gross motor - large muscles – movement and coordination: arm, body and leg movements Fine motor – Small muscles – hand and finger movements Problem-solving – Interaction with items and learning – Learning and playing with toys Personal-social – focuses on solitary social play and play with toys and other children.

Features of the ASQ 21 questionnaires between 4 and 60 months of age 2, 4, 6 , 8, 9, 10, 12, 14, 16, 18, 20, 22, 24 months 27, 30, 33, 36 months 42, 48, 54, 60 months Ages covered = 2, 4, 6, 8, 9, 10,12,14,16, 18, 20, 22, 24, 27, 30, 33, 36, 42, 48, 54, and 60 months Can be used alone or in combination

Features of the ASQ Each questionnaire includes a checklist of 30 items And an Information Summary page with a section for plotting scores and an area for general concerns. 30 questions- 6 within each domain Parents/practitioners score each item as yes, sometimes or not yet General concerns– section to describe

The items… Written at 4th to 6th grade reading level, some illustrations Ordered from easy to average skill level

Cultural considerations Adaptations can be made for cultural backgrounds Substitute alternative items that will assess the targeted skill Or Omit the item and follow directions for scoring with unanswered questions (User’s guide page 72) (If an item needs to be omitted due to cultural consideration the solution can be found on pg 72 in manual) There may be situations in which test items are not appropriate for a given family, culture geographic area. A child may not have had opportunities to perform a behavior not provided by the family due to cultural preferences. Families also may not have access to certain materials. There may also be times when English is not the child’s native language and it is recommended that the questionnaire be administered in the child’s native language. Websites to help with translation: babelfish.com One example related to food – can a child pick up a cheerio? Perhaps child is not yet eating finger foods (cultural preference), what adaptations might you make to accommodate? For information about additional translations that are available in previous editions or currently under development for ASQ 3, please visit www.agesandstages.com

Selecting the appropriate questionnaire… Through 24 months, administer within 2-month (16 month is valid from 15-17 months) Over 24 months, the window is stretched so there are no gaps See Handout: Guide for selecting appropriate questionnaire Ex.-12 month questionnaire can be used for a child between the ages of 11-13 months. If a child falls outside of the 2-month window, use the younger questionnaire. Ex – If a child is 44 months old, use the 42 month questionnaire first and if the child passes all items then go to the 48 month.

Adjusting for Pre-maturity For infants up to 24 months of age who were born 3 or more weeks pre-mature, adjust their age by: Subtracting weeks of pre-maturity from present age to determine “adjusted age” Use the questionnaire that corresponds to “adjusted age”. If a baby was born 3 or more weeks premature and is less than 24 months of age, the baby’s age is adjusted to determine which questionnaire to administer. Adjusted age is calculated by subtracting the number of weeks premature from the child’s age. Ex. – A 6-month old baby is being screened and was born 2 months premature. The appropriate ASQ interval to administer is the 4 month. More information abut this can be found on pages 65-67 of the User’s Manual.

The User’s Guide For more information: Suggested readings Activity Sheets Complete technical information

Scoring Review the questionnaire for items with missing responses. Items are scored as: Yes – 10 points Sometimes – 5 points Not yet – 0 points If responses are missing, determine why and if appropriate gather the missing info. If this is not possible or the item is not appropriate due to the culture of the family, omit the item and adjust the score in that area. All completed items should be scored and this total score should be divided by the number of items completed. This will give you an average. This average score should be added to the total score. A child should not be penalized for not completing 1-2 items. If more than 2 items were not completed the section cannot be scored. Ex. – In the Fine Motor domain, a child’s score was 20 and one item was omitted. The child’s adjusted score for Fine Motor is 24. 20 / 5 = 4 ; 20 + 4 = 24 To score the questionnaire, the items yes = 10 pts; sometimes = 5 points; and no = 0 points. Total scores within each section, then transfer score to bubbles/scoring summary shaded section on back page. A total score may be above cutoffs, in the monitoring zone, or below cutoffs. The lightly shaded monitoring zone was developed to address concerns about careful monitoring of a child whose performance falls close to the cutoff. If a child’s score fall in the monitoring zone, the child may be referred for further evaluation, provided learning activities in that particular area and/or monitored and re-screened over the coming weeks. Take time to review the tool with participants…info page, discuss corrected date of birth, address not necessary (intended to be sent to parents to complete), Open ended questions (may be helpful to discuss with parents), summary page includes all info from other pages.

Scoring Total the points for each developmental area (Gross Motor, Fine Motor, Communication, Problem-Solving, Personal-Social). Transfer each total to the Information Summary sheet. Record the scores on the scoring grid and fill in the appropriate bubbles on the bar graph. Record the total on the line provided at the end of each area

Scoring Transfer responses and any notes from the Overall section. Record any follow-up decisions Optional – Record individual item responses on the Information Summary sheet. This can serve as a one-page summary of the questionnaire’s information.

Interpreting Results Review the Summary sheet (the five total scores and the Overall responses). Review any additional information that you may have (discussions with family, notes).

Interpreting Results A score above the cutoff (the white area of the bar) indicates that the child appears to be doing well Providing an enriched environment will promote continued healthy development. Intervention activities Ages and Stages activities

Interpreting Results Each developmental area has a “cutoff point”. A score in the light gray shaded area in the bar graph is close to the cutoff. A score in this area means that the child may need practice in this area and development should be closely monitored. The child with a score in the gray shaded area should be monitored closely and re-screened within a period of time to be determined by the child care and the family. All information about the child should be considered and a decision could be made to refer the child for further evaluation at this time.

Interpreting Results A score below the cutoff or in the dark shaded section of the bar graph indicated that the child may need further assessment.

Interpreting Results Review the responses to the Overall section of the questionnaire. These responses may indicate the need for further assessment, even if total scores are well above cutoff points.

Practice scoring: Michael’s ASQ Discuss findings - Scores-cut offs - Overall section Discuss recommendations

The Ages & Stages Questionnaires: Social-Emotional This may be good time to allow participants time to take a break! The ASQ:SE takes the ASQ a step further by concentrating on the importance of socal-emotional competence in young children.

The ASQ and ASQ:SE Relationship ASQ:SE was designed to focus on the social and emotional behaviors of children Should be used in conjunction with the ASQ or other screening tool Complement to ASQ

ASQ:SE Focuses on Social competence Emotional competence The ability to engage in positive interactions with peers, siblings, parents and other adults Emotional competence The ability to effectively regulate emotions to accomplish one’s goals

ASQ:SE Completed by the child’s parents or primary caregivers Completed in 10-15 minutes

ASQ:SE 8 questionnaires that can be used with children from 3 to 66 months of age Questionnaires vary in length English and Spanish versions available Ages covered = 6, 12, 18, 24, 30, 36, 48, and 60 months Questionnaires # - varies by age, range from 19 to 33 questions. (remember ASQ has 30 questions at each level) Makes sense since we would expect children to have developed more SE skills as they get older.

ASQ:SE Covers 7 areas Includes general concerns area Self-regulation Compliance Communication Adaptive functioning Autonomy Affect Interaction with people Includes general concerns area Self-regulation – child’s ability to calm, adjust to environmental conditions or stimulation (lights, noises)- reading and responding to baby’s cues helps them learn to self regulate Compliance – ability to conform to directions or others or to follow rules Communication – communicate feelings, affect or internal status- talk about what this means in SE development Adaptive functioning – ability to cope with physiological needs Autonomy – self-initiate or respond without guidance, become independent Affect – demonstrate feelings or empathy for others Interaction with people – social responses to parents, other adults, children

Ability/success in coping with physiological needs Autonomy Behavioral area Definition Self-regulation Ability/willingness to calm, settle, or adjust to physiological or environmental conditions Compliance Ability/willingness to conform to the direction of others and follow rules Communication Verbal/nonverbal signals that indicate feelings, affect, and internal states Adaptive Ability/success in coping with physiological needs Autonomy Ability/willingness to establish independence Affect Ability/willingness to demonstrate feelings and empathy for others Interaction with people Ability/willingness to respond to or initiate social responses with caregivers, adults, and peers These behavioral areas are somewhat arbitrary but may help providers understand the organization of the ASQ:SE and the intent of individual questions. If you have a question about the intent of an item, you can refer to page 14 of The ASQ:SE User’s Guide to see how that item is categorized. Items are not evenly distributed across areas. The number of items and content of items change over age intervals. Activity Material: “Intent Activity” handout In small groups, have participants categorize questions into the areas listed on the handout. If you use the 6-month questionnaire and the 36- or 48-month questionnaire, you will cover most of the questions across the ASQ:SE series. See pages 14 and 15 in The ASQ:SE User’s Guide for guidance as to how the authors classified the items. It is important to remember, however, that these areas are arbitrary and items can often fit in more than one area. Have a discussion with participants about questionable items or items they were not able to categorize. ASQ and ASQ:SE Training Materials by Jane Squires, Jane Farrell, Jantina Clifford, Suzanne Yockelson, and Elizabeth Twombly Copyright © 2008 by Paul H. Brookes Publishing Co., Inc. All rights reserved. For more information about the ASQ and ASQ:SE, see http://www.agesandstages.com 38

ASQ:SE User’s Guide Case Studies Sample letters Similar to ASQ in the way that it is organized. Case studies, sample letters and forms, phasing in the system, etc.

Let’s look at a questionnaire! Louis’ 6 month questionnaire There is a completed ASQ:SE in the handout folder in order to discuss and practice scoring.

Scoring Items are scored as Most of the time = 0 or 10 points Sometimes = 5 points Rarely or never = 0 or 10 points Is this a concern? Yes = 5 points X=10 pts; V=5 pts; Z=0 pts. Why does scoring happen this way? Because both competence AND problem behaviors are targeted within the tool Review with participants: Roman numerals- not in order on the questionnaire

Scoring Scores for each item are combined for a total score which is recorded on the last page. A high score may be indicative of concerns. Each questionnaire has an age-specific cutoff score. Additional 5 points may be added if item indicates a concern. Opposite of ASQ –high score on ASQ indicates typical development, high score (score higher than the cutoff) on ASQ:SE indicative of concern.

What have we learned about Louis from his ASQ:SE screening What have we learned about Louis from his ASQ:SE screening? What recommendations might we make?

Reminder: The results from the ASQ and the ASQ:SE will not identify which children have delays and which do not. It simply suggests which children need to be referred on for further in-depth evaluation. Remember that the decision to refer should come from the team- parents, teachers, director, not only the test.

Discussing results with families Share the completed screener with family as quickly as possible Review the purpose of screening Listen to families’ perspective Remind family that screening only indicates the need for further assessment and is not diagnostic Developmental milestones completed, what expect next, how to encourage next developmental step Reference handout- Partnering with parents. If time permits, you may allow participants to work in groups to practice sharing info with parents based on the ASQ and SE sample screeners that they scored.

Discussing results with families Discuss the scoring section On target - discuss & share activities In the shaded area- consider referral or monitor and follow up soon Beyond cutoff – consider referral for further evaluation, i.e. Early Intervention Use terms like above cutoff, close to cutoffs or below cutoffs

Discussing Results with Families Avoid terms such as “test”, “fail”, “normal” or “abnormal” Together make a decision about next steps

Discussing Results with Families Provide parents with appropriate follow-up information such as Learning activities (intervention activities are included in the ASQ-3 box and Appendix C of the ASQ: SE User’s Guide) Referral options Information about community resources Reminders about when to schedule follow-up The ASQ-3 and the ASQ:SE haves suggestions for developmentally appropriate activities. These would be great resources for parents and staff.

Making a referral Where to call – contact information CONNECT- Early Intervention Helpline 1-800-692-7288 Parent permission to share information Participate in planning process, with parent permission Mention contact pages, systems, child resides in- If concern is Social Emotional only and/or questions about mental health, you may consider contacting County CASSP Coordinator In order to share info with other programs, you must get parent permission (Release of information form) Can tell parent that you can participate as much or as little as they want…let them know that you are interested in being a part of the team, to attend important meetings, etc. Services can happen at the center, you can use the plan in your program… Reference handout---STARS standards related to obtaining/using IEP in ECE setting Mention ECMH Consultation program STARS specialists can help to link to resources

Early Intervention is: Free Voluntary A system of supports to the family and child in order to enhance the child’s developmental capacities Research underscores the importance and effectiveness of early intervention: Developmental delays, learning disorders, and behavioral and social-emotional problems are estimated to affect 1 in every 6 children.[3] Only 20% to 30% of these children are identified as needing help before school begins.[4] Intervention prior to kindergarten has huge academic, social, and economic benefits. Studies have shown that children who receive early treatment for developmental delays are more likely to graduate from high school, hold jobs, live independently, and avoid teen pregnancy, delinquency, and violent crime, which results in a savings to society of about $30,000 to $100,000 per child.[5]

Early Intervention Evaluation A comprehensive look at a child’s skills and behaviors Determines eligibility for further early intervention services Makes recommendations to address areas of concern

Resources for Early Education Practitioners about EI An Early Education Provider’s Guide to Early Intervention Services in PA http://www.pattan.net/category/Resources/PaTTAN%20Publications/Browse/Single/?id=4dc09560cd69f9ac7f4b0000

Resource for Families A Family’s Introduction to Early Intervention in PA http://pattan.net-website.s3.amazonaws.com/images/2011/08/05/what_is_EI_rack_card7_11.pdf

Activity Case Study and role play- Emily Part 1- Part 2- Use the scored screening tools Read the Background info that is provided on child/family Discuss with group possible recommendations for the family Part 2- Engage in a role play (groups of 5) Be prepared to share your experience with the group

Implementation in ECE program Share this training with your staff Decide how screening will be implemented Who, when, how often, how will results be shared with families Document your process in parent handbook Before beginning to screen, get parent permission (see pg 35/36 in manual for sample) Who- person who spends most time with child When- at program entry (within 45 days) how often thereafter Effective programs screen children at frequent intervals. HANDOUT- Implementation considerations

Consider your next steps? What are your plans as you leave the session? What support may you need to get started, or for follow up once you have started?

Questions?? Need assistance? Contact … Jennifer Murphy 484-955-8264 jenmur@berksiu.org This information can be changed to reflect local resources.