Screening and Follow-up of Young Children’s Development: Ages and Stages Questionnaires

Jane Squires, Ph.D.University of

OregonEarly Intervention

Program jsquires@uoregon.

edu

Brazilia, BrazilDecember, 2011

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Objectives

Define and discuss benefits of developmental screening.

Describe Ages & Stages Questionnaires.

Describe Ages and Stages: Social-Emotional.

Discuss and compare screening approaches. 2

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Poor environments during early childhood can be like shifting the course of an ocean liner two degrees at the beginning of a voyage. Over a thousand mile trip (or a 70 year life span) you wind up in a different port. Or you may crash into rocky shores.

Myers, 2006, American Project

Why screen?

2.53% 11.36 %5.74%

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Incidence of children identified as having disability (2009)http://www.ideadata.org

Cumulative effects of riskSameroff et al, 1987

Earlier age for receiving services and supports

Improved child and family outcomes

Reduced stress

Cost effective6

Benefits of early, universal screening

3 to 1 benefit-cost ratio Better health and academic outcomes $3-9 for every dollar invested 16% annual return

• http://epinet.org

• http://brookings.edu

• http://minneapolisfed.org/

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Early childhood programs save money

Biomedical/PsychiatricMorbidities& Health Care Utilization

Nonrandom Distribution of Childhood Morbidities

1 in 5 children are responsible for over ½ health cost, morbidity

W. T. BoyceUniversity of British Columbia

Childhood experiences of adversity/trauma predict leading causes of adult mortality(Felitti et al, 1998)

Investment

Cost effective to intervene earlier

Less use of community resourcesHealth/mental healthSocial serviceSchoolLegal system

Large pay off for services for each dollar spent

Cost-Benefits of Early Child Development Programs

Participants in programs• Have higher scores on reading and math

achievement tests• Better language and cognitive abilities• Improved social emotional development• Better prepared to succeed in elementary

school• More likely to pursue secondary

education

Cost-Benefits of Early Child Development Programs

Participants in programs• Have less need for special education and other

remedial services• Have lower dropout rates and higher graduation

rates• Have better health and• Experience less child abuse and neglect

These children are less likely to become teenage

parents, more likely to be employed as adults, have

less rates of drug use, lower rates of delinquency and

adult crime, and lower incarceration rates.

Screening Assessment

A brief assessment procedure designed to identify children who should receive more intensive diagnosis or evaluation from local early intervention, early childhood special education, health, mental health agencies.

Similar in theory to health screenings such as a quick hearing or vision screen. 14

Screening

Not near cutoffBelow Cutoff

Eligible

Near Cutoff

Professional

Assessment

Not Eligible

Continue to monitor (re-screen) & use curriculum-based assessment to develop learning plans

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Informal checklists or tests without psychometric data

Expensive professionally administered tests

“Islands” of screeningNo system for referral, follow up

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Barriers to effective screening systems

Detection rates of children with existing delays

Without Screening Tools

With Screening Tools

Developmental Disabilities

30% identifiedPalfrey et al, 1994

70-80% identified

Squires et al, 1996

Mental Health Problems

20% identifiedLavigne et al, 1993

80-90% identified

Sturner, 1991Courtesy of START

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Parent or caregiver completed Quick and easy to administerLow costValid and reliableAble to be used in a variety of ways

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Effective screening tests

What are effective measures?

Qualities of assessment toolsValidity

Reliability

Adequate normative

population

Cultural sensitivity

Comprehensiveness

Attractiveness to children

Types of screening instruments

Professionally-administered

Parent-completed

Information on screening tools http://www.dbpeds.org/ http://www.fpnotebook.com http://www.cimh.org Individual publishers

Professionally-administered

Battelle Developmental Inventory Screen, 2nd (http://www.assess.nelson.com)

Bayley Scales of Infant Development Screen, 3rd (http://harcourtassessment.com)

Brigance Screens (http://www.curriculumassociates.com)

Denver II (http://www.denverii.com/DenverII.html)

Early Screening Inventory (www.pearsonearlylearning.com)

Parent-Completed

Pediatric Evaluation of Developmental Status PEDS--Glascoe• www.pedstest.com

MacArthur Communicative Development Inventory--Fenson et al.

Minnesota Child Development Inventories• http://www.childdevrev.com/cdi.html

Ages & Stages Questionnaires• http://www.brookespublishing.com• http://agesandstages.com

Assessment

“the science of examining the strange behaviors of children in a strange situation with strange adults for the briefest possible periods of time”

(Bronfenbrenner, 1979)

Advantages of Parent-Completed Screening Measures

Engaging families in the assessment of their child

Parents are reservoirs of rich information about their children

Parental involvement reduces cost

Screening structures observations, reports and communications about child development

Screening may become a teaching tool for parents and teaching staff

Information/communication can be useful for primary health care providers and communication based rehabilitation center

Effective and efficient method of early identification

Engaging families in the assessment of their child

Research on parent report of child developmental level

As accurate as formal measures for identifying cognitive delay (Glascoe, 1989, 1990; Pulsifer, 1994)

As accurate as formal measures for identifying language delay (Tomblin, 1987)

As accurate as formal measures for identifying symptoms of ADHD and school related problems (Mulhern, 1994)

More accurate than Denver for predicting school-age learning problems (Diamond, 1987)

Dinnebeil & Rule (1994) 23 studies High reliability in parent report

Area specific studies Cognitive (Glascoe, 1999) Communication (Ring and Fenson,

2000) Attention deficit and school related

problems (Mulhern, 1994) Gross motor (Bodnarchuk & Eaton,

2004)29

Accuracy of parent report

Low cost, economicalOften know child bestNatural environment for child

Accurate, if based on current, observable behavior 30

Parent, caregiver report

Accuracy of low and middle income parents

Agreement between parent-completed ASQ andprofessionally administered standardized

assessment:

Low income parents .85 (N = 54)(below federal poverty level)

Middle income parents .89 (N = 42)No statistical significance between groups

Squires, Potter, & Bricker, (1998) Early Childhood Research Quarterly,13, 2, 345-354.

Advantages of parent-completed screening tests

Parents/caregivers can provide rich information about child across settings

Parent involvement reduces cost• 3-10 times less

Screening structures observations, reports, communications about child development

Parent-completed assessments range between $1.25-10 per assessment (U.S. interview/mail models)

Professionally-administered cost 3-10 times more(Chan & Taylor, 1998; Dobrez Lo Sasso, Holl et al., 2001;

Glascoe, Foster, & Wolraich, 1997)

Cost Effective

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ASQ vs. Bayley Scales

24 month olds, 52 infants/mothersBayley administered by psychologistCommunication and personal social

—moderately correlated .55Gross motor & motor .46Sensitivity = 100%Specificity = 87%Recommended, as cost effectiveGollenberg, Lynch et al., 2010

What are the Ages and Stages Questionnaires? Identify children at risk for

developmental delays

Series of questionnaires for children ages 1 month to 5 ½

Parent- or caregiver-completed screening tool that

encourages parental/ caregiver involvement

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ASQ History

ASQ initiated in 1980 at University of Oregon by Diane Bricker and colleagues.

Authors reviewed standardized tests, literature.

ASQ skills selected were: Easily observed or elicited by

parents in home. Adopted by pediatric, child care, early

intervention, child welfare programs for early identification

Most widely tool by pediatricians (70%)

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ASQ Evolution

Follow-up of medically at risk infants

Developmental screening for infants/toddlers living in poverty, other risk conditions

Universal screening

Translated, used internationally

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ASQ Domains

ASQCommunicatio

nGross motorFine motorProblem

solvingPersonal-

social 38

Example of 4-month ASQ

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Example of 24-month ASQ

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Features: ASQ-3 intervals

21 Questionnaire intervals:

• 2*, 4, 6, 8, 9*, 10, 12, 14, 16, 18,

20, 22, 24

• 27, 30, 33, 36 (spaced 3 months

apart)

• 42, 48, 54, 60 (spaced 6 months

apart)

*New intervals included in ASQ-3 system

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Features: ASQ-3

5 developmental areas (e.g., Communication)

6 questions in each area Questions are in hierarchical

order Questions #5 and #6 are

average skills for children of that age interval (i.e., a 12 month skill for a 12 month child).

Response options: Yes, Sometimes, Not Yet

Written at 4th to 5th grade reading level

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Features: ASQ-3 Overall Section

Un-Scored Section Looks at quality of skills (e.g.,

speech) Example: “Does your baby use both

hand equally well?” “No” response indicates possible

cerebral palsy. Important to follow up.

Parent concerns very predictive. Any concerns or questionable

responses require follow-up43

Scoring the ASQ-3

Not yet = 0 points

Sometimes = 5 points

Yes = 10 points

Domain scores are totaled and compared to cutoff points

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Features: ASQ-3 cultural adaptability Alternative administration methods

for individuals from different cultural backgrounds.

Alternative materials for individuals from different cultural backgrounds.

Normative sample includes diverse populations.

Scoring permits omission of inappropriate items.

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The Ages and Stages Questionnaires: Social Emotional

Ages & Stages Questionnaires: Social Emotional

ASQ companion tool

Focused on social emotional, behavioral, self regulation competencies

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ASQ:SE features

6, 12, 18, 24, 30, 36, 48 & 60 month intervals

3-6 month administration window on either side

4th to 5th grade reading level

Competence and problem behaviors targeted

From 19 items (6-month interval) to 33 items (60-month interval)

Behavioral Areas DefinitionSelf-Regulation Ability/willingness to calm, settle, or adjust to

physiological or environmental conditions orstimulation

Compliance Ability/willingness to conform to the directionof others and follow rules

Communication Verbal/nonverbal signals that indicatefeelings, affect, internal states

Adaptive Ability/success in coping with physiologicalneeds

Autonomy Ability/willingness to establish independence

Affect Ability/willingness to demonstrate feelingsand empathy for others

Interaction withPeople

Ability/willingness to respond or initiatesocial responses with caregivers, adults andpeers.

ASQ:SE behavioral areas

Features of ASQ:SE

Open-ended questions Questions related to eating, sleeping,

toileting. All intervals include question “Is there

anything that worries you about your baby (child)? If so, please explain.”

Tell me what you enjoy most about your baby (child)?

Features of ASQ:SE

Scoring Options Points

Most of the time 0 or 10 Sometimes 5 Never or Hardly Ever 0 or 10 Is this a concern? Yes= 5

Scores are totaled and compared with empirically-derived cutoff points.

High scores indicative of problems

12 month ASQ:SE

Does your baby laugh or smile at you and other family members? (z)Most of the time (v) Sometimes

(x) Rarely or neverDoes your baby like to be picked up

and held? (z)Most of the time (v) Sometimes (x) Rarely or never

30 month ASQ:SE

Does your child destroy or damage things on purpose?

Does your child hurt himself on purpose?

Does your child play alongside other children?

Most of time SometimesRarely/Never

ASQ-3 Concurrent Validity

ASQ-3 N Sens.% Spec.%

2-12 mo. 108 84.691.3

14-24 mo.78 89.2 77.9

27-36 mo. 90 85.985.7

42-60 mo.103 82.5 92.1Normative sample = 18,572

ASQ-3 Concurrent Validity

Overall (2-60 months) Sensitivity: 86.1% Specificity: 85.6% Percent agreement: 85.8% Under-identified: 6.0% Over-identified: 8.1% Test retest reliability: 92%

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ASQ:SE Research

Validity Reliability Utility Conducted

between 1995-2001

Sample of 3014

ASQ:SE Sensitivity and SpecificityN = 1043; 3000 in total sample

N Cutoff Sens Spec % Agree6 71 45 78.6 98.2 94.012 85 48 71.4 97.2 93.0

18 99 50 75.0 96.6 93.9

24 152 50 70.8 93.0 89.5

30 115 57 80.0 89.5 87.8

36 179 59 77.8 93.0 89.9

48 174 70 76.9 94.6 92.0

60 171 70 84.6 95.8 94.0

Overall 78.0 94.5 91.8

Test-retest reliability = 94%Utility = parents said easy to understand,

appropriate, helped think about child’s behavior

Uses for the ASQ

Developmental screeningMonitoring course of

developmentCaregiver/teacher toolPrevention—target low areasGeneral overview of

development of classroomResearch

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Screening/monitoring

Identify children with potential delays in development 5-18% may have scores below cutoff

points

Monitoring Follow-along screening 9, 18, 24, 36, 48 months (pediatric

guidelines) Make sure development on course

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ASQ vs. Parents’ Eval of Developmental Status

334 children 12-60 monthsASQ and PEDS and Bayley, Wechsler,

or VinelandPEDS = .74 sensitivity, .64 specificityASQ = .82 sensitivity, .78 specificity

Limbos & Joyce, 2011, Dev & Behavioral Peds

Equador

Flower growing regionASQ administered to children as well

as growth measurement, blood testChildren 24-61 months residing in

high-exposure communities scored significantly lower on gross motor skills compared to low exposure group

Handal, Lozoff, Breilh, & Harlow, 2007

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Percentage of children displaying developmental delay for 5 ASQ domainsrelated to proximity to flower fields

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Prob

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ASQ:SE Screening

Minnesota--statewide Large Hmong and Somali populations

ASQ:SE on small PDAs, paperwww.patienttools.org

Screened 10,000 children Extremely low cost—start up was most High satisfaction by programs and parents Identified between 5-28% of children Foundationforsuccess.org

ASQ Research: Online vs. Paper

Currently on line and paper versions

Over 10,000 on-line questionnaires completed.

http://asq.uoregon.edu Initial “DIF” Analysis conducted

Few differences found between on-line versus paper completed ASQ’s.

Differential item functioning = 45/500 items

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Caregiver/teacher tool

Provides feedback on general development of individual children

Allows monitoring of classroom, school

Can target skills or areas that are in need of practice

Prevent further delaysCan compare curriculum with needs

in classroom

ASQ related follow-up- activities Prevention

Intervention

ASQ User’s Guide activities

ASQ Learning Activities (available in Spanish)

Beautiful Beginnings (Raikes & Whitmer)

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ASQ Activities (User’s Guide)Put toys on a sofa or sturdy table so

that your baby can practice standing while playing with the toys.

Find a big box that your baby can crawl in and out of. Stay close by and talk to your baby about what she is doing. “You went in! Now you are out!”

Read baby books or colorful magazines by pointing and telling your baby what is in the picture. Let baby pat pictures. (8-12 months)

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Day Care Centers(Campos, Squires, & Ponte, 2010)

Galicia, Spain2-step processParents complete PEDSPreschool teachers complete ASQFocus curriculum on children’s needsProvide follow-up to individual

children with low scoresRefer children with very low scores to

specialistMonitor through ASQ 69

ASQ Research: ASQ and AutismDoes the ASQ identify children with autism?

Retrospective study on children diagnosed with ASD who had ASQ data

N = 58; 81% < 3 years100% identified

96.6% failed communication 86.2% failed personal-social 81.0% failed problem solving

100% of parents identified concerns

High sensitivity in identifying ASD 70

Magpie Study

Follow-up study (magnesium sulfate)Latin American, Africa, India (125

centers in 19 countries)Completed ASQ interview in homes

and community based health and rehabilitation centers

2600 children screened by ASQ 78% sensitivity, 79% specificity Children whose mothers received

magnesium sulfate during birth had improved outcomes (Duley at al., under review)

ASQ Research: Pediatric Office StudyDoes adding a standard screening tool to well-child check-ups increase referral and identification rates of children?

12 and 24 months 20 pediatric practitioners 76% agreement between ASQ

and pediatrician estimate of development (OK, at risk)

Pediatricians referred mostly for communication, gross motor delays

Referrals for further assessment increased 224% in one year

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ASQ Office Study

ASQ in the office or mail it from home 30 minutes of training for staff Resource staff scored the ASQ forms Itemized cost = $1.61 - $2.43 per

patient. Cost varied on the mail-back option and

practitioner f/u decisions Reception, Nurse, Doctor all said:

“The ASQ is a fun and very important part of this well-child visit. Please fill it out. If you don’t have time, take it home and mail it in.”

Control and screening year referrals

To Review

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Parent, caregiver-completed tools Low cost, effective Flexible administration Provides common platform for multiple

agencies serving young children and families

Follow up activities on “not yet” skills using activity based intervention

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ASQ-3 and ASQ:SE

ASQ & ASQ:SE ApplicationsKiosk in office with toy kitMail to home and bring in at visit

(or email back)Complete first one at office, mail

remainder to homeHome visiting--nurses, social

workers, child welfareChild care settings

Identification of delays Better outcomes for children/families Requirements of system

Valid, reliable, culturally relevant measures

Low cost methods

Coordinated systems

for follow-up and referral

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Universal screening systems

Effective systems identify children at risk for developmental delays

Benefits in terms of economic savings and investment in future

Technology offers creative and unique solutions

Use of videoconferencing, embedded video, web-based screening involving multiple agencies

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Universal screening systems

Obrigada

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