Team Approaches to Assessment

1
Team Approaches to Assessment

• Cindy Oser, R.N., M.S.
• ZERO TO THREE
• Washington, DC

Evelyn Shaw, M.Ed. NECTAC Chapel Hill, NC
2
Overview

• What is screening, assessment, and informed
  clinical opinion
• Principles and purpose of assessment
• Examples of assessment approaches (autism,
  DC0-3)
• Partnering with teams and team models
• Putting it all together

3
Screening

• A brief assessment procedure designed to identify
  children who should receive more intensive
  diagnosis or evaluation
• Early intervention (EI)
• Early childhood special education (ECSE)
• Mental health/social service
• Health systems

.
4
Diagnostic Assessment

• An in-depth assessment 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 early
  intervention or mental health services.

5
Curriculum-Based Assessment(Programmatic,
On-going Assessment)

• An in-depth assessment that helps to determines a
  childs current level of functioning. This type
  of assessment can
• Provide a useful child profile
• Help with program planning
• Identify targeted goals and objectives
• Be used to evaluate child progress over time

6
Monitoring

• Developmental surveillance
  (screening at frequent intervals) of at-risk
  infants and toddlers not known to be eligible for
  special health,educational or mental health
  services
• Similar in theory to a person with diabetes
  monitoring blood sugar

7
Informed Clinical Opinion

• What does informed clinical opinion mean?
• What is the role of informed clinical opinion in
  assessment?
• Why is it necessary to document informed clinical
  opinion?

Shackelford, J. (2002) Informed Clinical Opinion.
NECTAC Notes, Issue No. 10.
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Defining Informed Clinical Opinion

• Informed clinical opinion makes use of
  qualitative and quantitative information to
  assist in forming a determination regarding
  difficult-to-measure aspects of current
  developmental status.
• Appropriate training, previous experience with
  evaluation and assessment, sensitivity to
  cultural needs and the ability to elicit and
  include family perceptions are all important
  elements of informed clinical opinion.

9
Role of Informed Clinical Opinion in Assessment

• Informed clinical opinion is especially
  important if there are no standardized measures,
  or if the standardized procedures are not
  appropriate for a given age or development area.
• Informed clinical opinion is used at the
  individual team member level and at the team
  level.

10
Role of Informed Clinical Opinion in Assessment

• Individual team member level
• Clinical interviews with parents
• Evaluation of the child at play
• Observation of parent-child interaction
• Information from teachers or child care
  providers and
• Neurodevelopmental or other physical examinations

11
Role of Informed Clinical Opinion in Assessment

• Team Level
• Multidisciplinary team, including the family,
  synthesizes and interprets all available
  information.
• This opportunity to integrate observations,
  impressions, and evaluation findings facilitates
  a whole child approach.
• The functional impact and implications of noted
  delays or differences in development can be
  discussed and considered by the team in
  determining eligibility and developing a plan for
  services (such as the IFSP).

12
Documenting Informed Clinical Opinion

• Provides a baseline against which to measure the
  progress and changing needs of the child and
  family over time. Assessment is an on-going
  process. Perceptions and impressions of team
  members may change over time.
• Facilitates communication during transitions when
  families move, changes service providers or enter
  additional or new service deliver systems.

13
Principles of Assessment

1. Assessment must be based on an integrated
   developmental model.
2. Assessment involves multiple sources of
   information and multiple components.
3. An assessment should follow a certain sequence.

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Principles of Assessment (cont.)

1. The childs relationship and interactions with
   his or her most trusted caregiver should form the
   cornerstone of an assessment.
2. An understanding of sequences and timetables in
   typical development is essential for
   understanding developmental differences.
3. Assessment should emphasize attention to the
   childs level and pattern of organizing
   experience and to functional capacities.

15
Principles of Assessment (cont.)

• The assessment process should identify the
  childs current competencies and strengths, as
  well as the competencies.
• Assessment is a collaborative process between
  clinicians and parents.
• The process of assessment should always be viewed
  as the first step in a potential intervention
  process.
• Reassessment of a childs developmental status
  should occur in the context of day-to-day family
  and/or early intervention activities.

16
Practices to Avoid in Assessment

• Child is separated from parents or familiar
  caregivers during the assessment.
• Assessment by a strange examiner.
• Assessments that are limited to areas that are
  easily measurable, such as certain motor or
  cognitive skills.
• Formal tests or tools as the cornerstone of the
  assessment.

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Assessment Approaches
18
Barriers to Assessing Social-Emotional Development

• Lack of screening tools
• Lack of knowledge
• Variety of terminology
• Complexity of issues
• Lack of services
  
  

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Types of Behavioral/Social Emotional Assessment

• Parent (e.g, ASQSE) or professional report of
  childs behavior (e.g., PKBS)
• Parent stress assessments (e.g, PSI)
• Parent/child interaction scales (e.g., N-CAST)
• Combination tools (e.g., FEAS)
• Structured environmental scales (e.g., HOME)

20
Examples of Child-focused Screening Tools
(Infant/Toddler)

• Infant Toddler Symptom Checklist
• Temperament and Atypical Behavior Scale (TABS)
• Ages and Stages Questionnaire Social Emotional
  (ASQSE)

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Examples of child-focused screening tools
(Preschool)

• Conners Rating Scale
• Carey Temperament Scale
• Social Skills Rating System (SSRS)
• Early Screening Project (ESP)
• Preschool Kindergarten Behavior Scales (PKBS)

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Assessment of Autism Spectrum Disorders

• Practice Parameter Screening and Diagnosis of
  Autism Report of the Quality Standards
  Subcommittee of the American Academy of Neurology
  and the Child Neurology Society
• www.aan.com/professionals/practice/pdfs/gl0063.pdf
  
• Reviews the empirical evidence and establishes
  recommendations for an approach to screening and
  diagnosis of autism spectrum disorders (ASD)

23
Autism Spectrum Disorders

• Autism or Autistic Spectrum Disorders (ASD) and
  Pervasive Developmental Disorders (PDD) (term
  used in the Diagnostic and Statistical Manual IV)
  are often used synonymously.
• ASD refers to a wide continuum of associated
  cognitive and neuro-behavioral disorders,
  including, but not limited to, three
  core-defining features impairments in
  socialization, impairments in verbal and
  nonverbal communication, and restricted and
  repetitive patterns of behaviors. (Filipek, et
  al, 1999)

24
Autism Spectrum Disorders

• It is particularly appropriate to use ASD to
  describe younger children because diagnoses
  within the spectrum have been found to be quite
  stable over time, but distinctions within the
  spectrum are not very reliable at these young
  ages.

25
Variability of children with ASD

• Wide range of symptoms from severe to mild.
• Individual variability (e.g. child may have some
  characteristics but not all that have been
  identified as part of syndrome).

• It is a developmental diagnosis the symptoms
  vary with the age of the child.
• It is a lifelong disability even though symptoms
  may fluctuate or vary.

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Variability of Children with ASD

• Autism co-occurs with other syndromes (i.e.
  mental retardation, epilepsy, tuberous sclerosis,
  Fragile X)
• Approximately 50 of all autistic persons
  function in the retarded range. (Freeman, Ritvo,
  Needleman, and Yokota, 1985)
• Approximately 25 of the children have normal
  intelligence (Ritvo, Freeman, Mason-Brothers,
  Ritvo, 1994).

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Variability of Children with ASD

• While cognition may be impaired, many of these
  children have strengths in certain areas (for
  example, visual spatial skills, long term
  memory).
• Children with autism can progress in all areas.

• While children with ASD may have a slow rate of
  learning, appropriate educational strategies and
  practices are needed in order to maximize their
  potential. (Rogers, S., 1999)

28
Age of Diagnosis and Early Identification

• Reliability of the diagnosis is unknown prior to
  the age of two autism can be reliably diagnosed
  between the ages of two and three.
• Currently, children are typically identified
  between the ages of 2 and 3.
• Children with Asperger Syndrome may not be
  identified until they reach elementary school.
• Many children are not identified as early as they
  could be.

29
Age of Diagnosis and Early Identification

• Why is there a reluctance to diagnose?
• Concerns regarding emotional impact on the
  family belief that ASD carries a poor prognosis
• Lack of confidence in the accuracy and stability
  of the diagnosis
• Lack of awareness of warning signs of ASD.
• Lack of knowledge regarding the availability of
  early intervention and preschool services to
  which to refer the child and family.

30
Age of Diagnosis and Early Identification

• Research in early identification is evolving
• Observations of videotapes of first birthday
  parties (children later identified as having
  autism and children that had typical development)
  has confirmed that there are behavioral warning
  signs for autism spectrum disorders that are
  present before the age of two.
• Experienced and trained clinicians have been able
  to identify children with ASD as young as 18
  months.

31
Age of Diagnosis and Early Identification

• The Quality Standards Subcommittee of the
  American Academy of Neurology and the Child
  Neurology Society has issued a report titled
  Practice parameter Screening and diagnosis of
  autism. (Endorsed by national professional
  groups as well as parent/advocacy groups.)
• It calls for a multi-level approach to
  identifying children at risk for developmental
  delays, including ASD with step-by-step
  procedures screening and diagnosing children with
  ASD.

32
Early Warning Signs of ASD

• Filipek, P.A, et. al., 2000)
• These warning signs would indicate a need for the
  child to have an immediate evaluation
• No babbling or pointing or other gesture by 12
  months
• No single words by 16 months
• No 2-word spontaneous (not echolalic) phrases by
  24 months
• Any loss of any language or social skills at any
  age

33
Assessment of Autism Spectrum Disorders

• Level 1 Routine developmental surveillance and
  screening specifically for autism
• Level 2 Diagnosis and evaluation of autism

34
Assessment of Autism Spectrum Disorders

• Level 1
• Developmental surveillance at all well-child
  visits (infancy through school-age) or at any age
  when concerns are raised about social acceptance,
  learning or behavior.
• Recommended developmental screening tools Ages
  and Stages, BRIGANCE Screens, Child Development
  Inventories and Parents Evaluation of
  Developmental Status.

35
Assessment of Autism Spectrum Disorders

• Level 1 (continued)
• Further developmental evaluation is required
  whenever a child fails to meet the following
• Babbling by 12 months
• Gesturing (e.g. pointing, waving bye-bye) by 12
  months
• Single words by 16 months
• Two-word, spontaneous phrases by 24 months
• Loss of any language or social skills at any age

36
Assessment of Autism Spectrum Disorders

• Level 1 (continued)
• Siblings of children with autism should be
  carefully monitored for acquisition of social,
  communication and play skills, along with
  maladaptive behaviors.
• Screening for autism should be performed on all
  children failing routine developmental screening
  using one of the validated instruments (CHAT or
  Autism Screening Questionnaire)

37
Assessment of Autism Spectrum Disorders

• Level 2 Recommendations
• Although educators, parents, and other health
  care professionals identify signs and
  characteristics of autism, a clinician
  experienced in the diagnosis and treatment of
  autism is necessary for accurate and appropriate
  diagnosis.
• Clinicians rely on their clinical judgment, aided
  by guides to diagnosis, as well as the results of
  various assessment instruments, rating scales and
  checklists.

38
Assessment of Autism Spectrum Disorders

• Level 2 (continued)
• Diagnostic Parental Interviews
• The Gilliam Autism Rating Scale
• The Parent Interview for Autism
• The Pervasive Developmental Disorders Screening
  Test Stage 3
• The Autism Diagnostic Interview Revised
• Diagnostic Observation Instruments
• Childhood Autism Rating Scale (CARS)
• The Screening Tool for Autism in Two-Year Olds
• The Autism Diagnostic Observation
  Schedule-Generic (ADOS)

39
Assessment of Autism Spectrum Disorders

• Level 2 (continued)
• Medical and neurologic evaluations
• Evaluation and monitoring of autism diagnosis
• Speech, language and communication evaluation
• Cognitive and adaptive behavioral evaluations
• Sensorimotor and occupational therapy evaluations
• Neuropsychological, behavioral and academic
  assessments

40
Challenges for States

• From Oser,C. and Shaw,E. in press
• Developing specific public awareness campaigns to
  alert health care providers, parents and other
  professionals of the warning signs for ASD
• Training professionals to utilize screening tools
  with greater sensitivity to detect ASD, including
  milder forms of ASD (e.g. Asperger Disorder)
• Developing a cadre of trained professionals with
  expertise in evaluating and diagnosing children
  with ASD.

41
Challenges for States

• Children are identified close to the age when
  they transition from Part C to Part B. Flexible
  policies that would enable children to transition
  more smoothly are needed.
• Developing awareness of Asperger Disorder in
  preschool and public school programs.
• Developing sufficient and appropriate early
  intervention/special education services to meet
  the needs of these children and their families.

42
A Language That WorksDiagnosing Disorders of
Infancy and Early ChildhoodUsing DC0-3
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(No Transcript)
44
Why diagnostic classification?

• A common vocabulary for professionals and
  families
• Development of clearly articulated assessment and
  treatment plans

45
Why diagnostic classification? (contd)

• Accumulation and refinement of clinical and
  research knowledge
• Securing resources for assessment and treatment
  of very young children

46
DC 0-3 as a tool in prevention

• Builds on the young childs drive toward healthy
  development
• Reframes symptoms as coping mechanisms
• Recognizes the protective, buffering power of the
  childs relationships
• Understands timing help before symptoms are
  internalized or generalized

47
DC 0-3 encourages us to

• Recognize individual differences in the ways
  infants and young children
• process sensation
• organize experience
• implement action

48
DC 0-3 encourages us to (contd)

• Observe and understand the childs behavior --
  especially in the context of interaction with
  important caregivers

49
DC 0-3 encourages us to (contd)

• Explore the impact on the childs development of
• family patterns
• cultural patterns
• community patterns

50
DC 0-3 encourages us to (contd)

• Identify the childs
• adaptive processes
• developmental challenges

51
How does DC 0-3 organize clinical observations
into

• a diagnostic profile?
• recommendations for intervention?

52
The DC 0-3 multiaxial framework

• Axis I Primary diagnosis
• Axis II Relationship classification
• Axis III Medical and developmental disorders
• Axis IV Psychosocial stressors
• Axis V Functional Emotional Developmental
  Level

53
Guidelines to selecting appropriate diagnosis

• Infants and young children have limited ways of
  responding to stress
• Primary diagnosis should reflect
  
  
  
  
  most prominent features

54
The reward -- Axis I systematically addresses
specific risk factors

• Environmental (traumatic stress, adjustment)
• Interactional (disorders of affect)
• Constitutional and interactional (regulatory)
• Constitutional (relating and communicating)

55
Jean Thomas and Roseanne Clark

• Hyperactive, aggressive and defiant behaviors as
  a final common pathway for expression of internal
  distress
• DC 0-3 identifies specific risk factors that
  guide intervention strategies

56
DC 0-3 Axis II Relationship Classification

• Used only to diagnose significant relationship
  difficulties
• When a disorder exists, it is specific to a
  relationship

57
Axis III

• Medical and developmental diagnoses

58
Axis IVPsychosocial stressors

• Severity
• Duration
• Overall impact
• Identify all sources of stress

59
Axis IV Psychosocial stressorsUltimate impact
depends on

• Severity of stressor
• Developmental level of child (age, endowment, ego
  strength)
• Adults as protective buffers

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Source of Stress

• Abduction
• Abuse - physical
• Abuse - sexual
• Abuse - emotional
• Adoption
• Birth of sibling
• Foster placement
• Hospitalization

• Loss of parent
• Two-year TANF limit
• Loss of significant other
• Medical illness
• Move
• Neglect
• Parent illness - medical

61
Source of Stress (contd)

• Parent illness -- psychiatric
• School/child care entry
• Separation from parent - work
• Separation from parent - other
• Sudden loss of home

• Sudden injury
• Trauma to significant other
• Violence in environment
• Other

• Number of stressors

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Axis V Functional Emotional Developmental Level
(FEDL)

• The way in which the infant or young child
  organizes experience, reflected in his or her
  functioning.

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Essential Capacities

• Becoming calm, attentive and interested in the
  world
• Falling in love
• Becoming a two-way communicator

64
Essential Capacities (cont.)

• Solving problems and forming a sense of self
• Discovering a world of ideas
• Building bridges between ideas

65
DC 0-3

• Developmentally informed
• Emphasizes relationships
• Identifies strengths to build on

66
DC 0-3 Cautions

• Diagnosis -- over/under
• Strengths-based approaches
• Surf n turf -- who owns IMF?
• Relationship-focused intervention,
• relationship-based work

67
DC0-3 ApplicationsDIAGNOSTIC TOOL

• Bridge between DSM-IV and the infant-toddler
  field
• Common language
• Diagnostic thinking
• Social-emotional development

68
DC0-3 ApplicationsSYSTEMS CHANGE

• Reflective supervision
• Financing
• Training
• Infuse and integrate IMH concepts
• Create MH partnerships

69
DC0-3 ApplicationsINTERVENTION STRATEGIES

• Legitimize IMH work
• Plan appropriate interventions
• Develop family-centered IFSPs

70
Partnering with a Team
71
Putting It All Together

• Assessment Planning
• Pre-Assessment Team Meeting
• Team Report Writing Process
• Looking Back What Worked? What Didnt?

72
Models of Team Interaction

• Multidisciplinary
• Interdisciplinary
• Transdisciplinary
• Cross-agency
• Inclusive

73
Guidelines for Instruments Used in Team Assessment

• Flexible enough for different disciplines
• Understood by families
• Comprehensive, from variety of domains and
  sources
• Able to measure quality and quantity of
  performance
• Linked to intervention and curriculum
• Functional help to identify strengths and
  needs and
• Consistent with the next learning and caregiving
  environment.

74
Team Report Writing Process

• Report is based on information generated at the
  post-assessment meeting.
• Written document is draft until reviewed by the
  family.
• All team members participate in development of
  the report.
• The family is not typically involved in writing
  the report.

75
Report Writing Interdisciplinary vs.
Transdisciplinary

• Interdisciplinary
• Assessment results written by each team member
  according to developmental area
• Writing done individually
• One team member has responsibility for addressing
  concerns and questions raised by the family and
  other team members
• One team member writes final report, including
  changes and obtaining signatures.

76
Report Writing Interdisciplinary vs.
Transdisciplinary

• Transdiscipinary
• Draft written by team, usually right after the
  assessment. Entire team participates one member
  serves as scribe.
• Report broken down into narrative areas that
  address child strengths and needs written
  across disciplinary boundaries.
• Team members teach and learn across disciplinary
  boundaries as they write integrated narratives
  and outcomes.
• Responsibility for obtaining family review,
  making changes and obtaining signatures rotates
  among members.

77
Using Assessment Results

• What do these findings mean for the childs
  functioning in the various settings where she
  lives her life?
• What are some ways in which this child can be
  misunderstood, given his capacities and deficits?
• What are some mismatches between this childs
  abilities and environmental demands?
• How do these findings help us understand this
  childs experiences of the world and the parents
  experiences of the child?

78
Putting It All Together

• Assessment Planning
• Pre-Assessment Team Meeting
• Team Report Writing Process
• Looking Back What Worked? What Didnt?

79
Resources

• www.nectac.org
• www.zerotothree.org
• New Visions for the Developmental Assessment of
  Infants and Young Children (ZERO TO THREE Press)
• http//www.nectac.org/pubs/pubs.asp
• NECTAC Early ID/Autism webpages
• http//www.nectac.org/topics/earlyid/idspecpops.as
  pasd
• http//www.nectac.org/topics/autism/autism.asp
• First Words demonstration and research project
  at Florida State University http//firstwords.fsu.
  edu/
• First Signs public awareness website designed
  for families, caregivers and primary referral
  sources, especially physicians http//firstsigns.o
  rg/