The Use and Interpretation of the ASQSE

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• The Use and Interpretation of the ASQ-SE
• (Ages and Stages Questionnaire-Social Emotional)
•   Goals of the Training
• Define and describe the purpose of screening.
•  Describe why the use of a screening tool is
  important.
• Describe the Follow Along Program.
•  Learn how to score the Ages and Stages
  Questionnaire
  Social Emotional (ASQ-SE).
• Break
•  Learn how to use and interpret the ASQ-SE
  screening through the use of a case
  study.
•  View and discuss the ASQ-SE in Practice Video.
• Lola Jahnke, MSW
• Public Health Social Work Specialist
• MN Dept of Health
• lola.jahnke_at_health.state.mn.us
• 651-201-3644

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What is Screening?

• A brief procedure
• To determine whether a child requires
• further and more comprehensive
  evaluation/assessment.
• Not diagnostic
• To assure the timely identification and early
  intervention

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Detection Rates Without Screening Tests

• 70 of children with developmental
• disabilities not identified
• (Palfrey et al. J PEDS. 1994111651-655)
• 80 of children with mental health
• problems not identified
• (Lavigne et al. Pediatr. 199391649 - 655)

2004 Glascoe
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Detection Rates With Screening Tests

• 70 to 80 of children with developmental
  disabilities correctly identified
• Squires et al, JDBP. 199617420 427
• 80 to 90 of children with mental health
  problems correctly identified
• Sturner, JDBP . 1991 12 51-64

2004 Glascoe
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Can Parents Be Counted Upon to Give Accurate and
Good Quality Information?
YES

• Screens using parent report are as accurate as
  those using other measurement methods
• Tests correct for the tendency of some parents to
  over-report/under-report

2004 Glascoe
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Follow Along ProgramEarly Childhood
TrackingOne component of the Public Health Child
Find System
Funded and Supported byMN Interagency Early
Childhood Intervention ProgramMN Children With
Special Health NeedsMN Department of
HealthLocal Managing AgenciesFamilies
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What Is The Follow Along Program?

• Definition
• Periodic monitoring
• Screening of infants and toddlers
• At risk for health or developmental problems
• To ensure early identification, help and services
• Use the ASQ and ASQ-SE
• Contact local public health for information

• May be a resource for non-eligible
• children or siblings or families who decline
  services.

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Typical FAP Program Process
Referral
Enrollment
ASQs/ASQ-SE Mailed
Returned and Scored
Pass
Fail
Info about community resources and activity sheets
FollowUp/Referral
Graduation
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Hennepin Co. Evaluation2000

• What do you like about the FAP?
• 82 Getting child development information
• 79 Finding out where my child is in development
• 70 Finding out what normal development is
• 56 Getting reassurance about my childs
  development
• Families Learn about child development simply by
  completing the questionnaires

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Hennepin Co. Evaluation2000

• 2. What actions have you taken as a result of
  what you have learned ?
• 65 I am able to assess my childs developmental
  level
• 48 I use toys to teach my child
• 40 I am improving my parenting skills
• 40 I play more with my child
• 38 I talk with my medical provider about health
  and
  
  development concerns

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Ages and Stages Questionnaire-Social Emotional
(ASQ-SE)Resource ASQ-SE Users Guide
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Family Friendly Terminology

• Mental Health Screening
• Community perception of the term mental
  health
• FAP experience is not to use the term mental
  health
• Difference between screening for social emotional
  development and mental health screening
• Social emotional screening is looking for
  precursors for development of issues
• Mental Health screening is looking for symptoms
• Screening for Social Emotional Concerns or
  Behavioral Issues

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Why Screen For SE Issues?

• Prevalence of mental health problems
• 13 of preschool children
• 17-25 preschool children living in environment
  of risk
• Infants, toddlers and preschoolers living in
  poverty,
• Numbers have increased,
• Twice the rate of mental health problems.
• Prevalence has increased over the last 2 decades
• Children with disabilities are more than twice as
  likely to have a mental health diagnosis

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Why Screen?

• Early identification of infants and toddlers at
  risk of a social-emotional disorder is crucial
  for improving developmental outcomes.
• The earlier social-emotional issues are
  recognized, the better the outcome is likely to
  be.

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Effects of Psychosocial Risk Factors on
Intelligence
Percentiles 84th 75th
50th
IQ
25th
16th
RISKS lt HS, gt 3 children, stressful events,
single parent, parental mental health
problems, lt responsive parenting,
poverty, minority status, limited social support
Francis Glascoe PP
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Percent of Children in Worse Health by Number of
Risk Factors
Social Risk Factors No education more than high
school Family income lt200 FPL Not 2 parent
household Black/Hispanic Uninsured Family
conflict Low maternal mental health Unsafe
neighborhoods
Influence of Multiple Social Risk Factors on
Childrens Health, Pediatrics 2008121337-344
(2003 National Survey of Childrens Health
n86249)
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Early Identification Is Essential

• Once established, social and emotional problems
• Highly resistant to change and
• Likely to intensify over time.
• Strong relationship exists between
• Childhood social and emotional problems,
• Delinquency and later criminality

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Early Identification Is Essential

• The costs associated with antisocial and criminal
  behavior are staggering
• Targeted interventions
• May improve outcomes
• Save subsequent social costs such as those
  incurred in juvenile justice programs
• Early intervention is effective and saves society
  13 for each 1 spent

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Brain Development

• Quality early relationships and experience
• Have lifelong positive effects on
• Gene function,
• Neural connections
• Organization of the mind
• Interaction between genetics and early
  experiences shape brain architecture

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Description of ASQ-SE

• Empirically derived cutoffs
• Normative data based on
• 3,014 questionnaires
• 1041 children matched to census
• Validity, Reliability and Utility Studies
• Concurrent Validity (between ASQ-SE and
  concurrent measures) 81 to 95 (Average 93)
• Sensitivity (ability to identify children with SE
  disabilities) 71 to 85 (Average 78)
• Specificity ( ability to identity children
  without SE issues) 90 to 98 (Average 95)

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Why Use the ASQ-SE?

• Parents report
• 10 to 15 minutes to complete
• Helped them think about SE development of their
  children
• Helps families understand what is normal
• Easy to score
• Can be done by paraprofessionals
• Cost (149) www.brookespublishing.com
• License allows photocopying of materials
• Available hard copy or CD
• English, spanish, soon (Somalia, Hmong)

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Uses of the ASQ-SE

• Screening (To help guide decisions about
  referrals for further assessment
• Monitor childs social-emotional development
• Determine information/support services families
  may need
• Bridge communication between parents and
  professionals about childs behavior

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Who should complete it?

• Caregivers who have 15 20 hours a week contact
  with the child.
• Sometimes having multiple people in the childs
  life complete it gives a complete picture of the
  child.
• Both parents

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ASQ-SE Seven Behavioral Areas

• Self Regulation
• Compliance
• Communication
• Adaptive Functioning
• Autonomy
• Affect
• Interaction with People

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Questions on the ASQ-SE

Emotional Competence The ability to effectively
regulate emotions to accomplish ones goals.
Social Competence An array of behaviors that
permits one to develop and engage in positive
interactions with peers, siblings, parents and
other adults.
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Relationship Between ASQ and ASQ-SE

• ASQ-SE complements ASQ
• Scoring different
• ASQ Low score indicative of need for further
  assessment
• SE High Score Indicative of need for further
  assessment
• Designed for use by parents or primary caregivers
• ASQ-SE should be used in conjunction with another
  screening measure (ASQ) that provides information
  on childs general functioning such as
  communication, motor and cognitive areas.

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Description of ASQ-SE

• 8 Questionnaires
• 6, 12, 18, 24, 30, 36, 48, 60 months
• 19 to 33 scored questions per ASQ-SE
• High score is indicative of issues
• Additional set of general unscored questions
• Eating, sleeping and toileting concerns
• Overall worries about the child
• What parents enjoy about their child

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Description of ASQ-SE

• Unlike ASQ, ASQ-SE does not adjust for
  prematurity
• Larger time frame covered by each ASQ-SE interval
• Less significant relationship between SE and
  prematurity

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Description of ASQ-SE

• ASQ-SE Interval Completion Guidelines
• If child is between Use this ASQ-SE
• 3 mos, 0 days, and 8 mos, 29days 6 month
• 9 mos, 0 days, and 14 mos, 29 days 12 month
• 15 mos, 0 days, and 20 mos, 29 days 18 month
• 21 mos, 0 days, and 26 mos, 29 days 24 month
• 27 mos, 0 days and 32 mos, 29 days 30 month
• 33 mos, 0 days and 41 mos, 29 days 36 month
• 42 mos, 0 days and 53 mos, 29 days 48 month
• 54 mos, o days and 65 mos, 29 days 60 month
• Users Manual Page 32

3 month window on either side
6 month window on either side

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Questionnaire Content

• All intervals - Eating Problems
• Targeting severe eating problems
• Each question is based on developmental norms
• 6 mo - Does your baby have any eating problems
  such as gagging, vomiting or _________?
• Older Does your child have eating problems such
  as stuffing foods, vomiting, eating nonfood
  items, or _____?
• If problem noted, evaluate it in the context of
  developmental norms
• Users Guide Page 40-42

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Questionnaire Content

• 18 months and older Perseverative behaviors
• Does your child do things over and over and cant
  seem to stop? Examples are rocking, hand
  flapping, spinning or _________?
• Families may answer with a favored activity such
  as reading books, singing Etc.
• Attachment to non toys example vacuum cleaner
• Case Example
• Questions that may identify a true perseverative
  behavior
• How difficult is it for your child to stop the
  behavior?
• What happens when you try to stop your child from
  doing this behavior?

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Responses to the Questions

• Each Question followed by four columns
• Most of the time
• Indicating that the child is doing the behavior
  most of the time, too much, or too often
• Sometimes
• Indicating the child is doing the behavior
  occasionally, but not consistently
• Never or rarely
• Indicating the child rarely performs the behavior
  or has never performed the behavior
• Behavior concern to the parents?
• Parents are to check one of the scoring options
  and then indicate if the behavior is of concern

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Questionnaire Content

• All intervals - Others Concerns
• Has anyone expressed concerns about your babys
  (childs) Behavior?
• Provides information on others perception of the
  childs behavior

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Questionnaire Content

• Open-Ended Questions (Unscored)
• Serve as general indicators of parental concerns
• May serve as the basis of a referral even if
  passing score

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Questionnaire Content

• All intervals
• Final question ends on a positive note
• What does the parent enjoy most about the child?

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36, 48, 60 Months ASQ-SEDoes your child show
interest in or knowledge of sexual language and
activity?

• This question is asked because it has happened
  more than once that families have realized a
  neighbor, family member, etc might be molesting
  the child and they really didn't consciously
  acknowledge until answering this question. It's
  related to abuse or perhaps even children
  witnessing abuse of others.

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Omitted Questions?

• Contact the family
• Average Scoring Procedures (Users Guide Page
  40-41)
• No more than 2 questions on the 6 -18 months
• No more than 3 questions on the 24-60 months
• STEPS
• Total Points
• Number of items answered Average score
• 2. (Average Score X of unanswered items) Total
  points Final Total score

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Omitted Question Example

• Total Points (30)
• Number of items answered (28) Average
  score (1.07)
• 2. (Average Score (1.07) X of unanswered items
  (3) ) (3.21)
• (3.21) Total points (30) Final Total score
  (33.21)

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Scoring Guidelines Overview

• Total all points
• If some questions unanswered
• Contact Family
• Average Score
• Instructions in the Manual - page 41
• Review any parent comments
• Review all questions with scores
• Interpret the scores
• Cutoff score
• Family Comments indicating concern
• Determine next steps

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Interpretation
Setting/Time Health Development Family/Culture
Score Number
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Variables to Consider Before Referral

• 1. Setting/Time variables
• Where, when and under what environmental
  circumstances does the behavior occur?
• Childrens behavior is often different across
  environments, ie Home - School
• Due to
• Comfort and familiarity with environment
• How environment shapes behavior- ie family may
  allow it and school does not

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Variables to Consider Before Referral

• 2. Developmental variable
• What is the childs developmental level?
• Has a significant bearing on what other people in
  their environment find acceptable and
  unacceptable. Ie
• Hairpulling 6 month old vs 3 year old
• Snatching a toy 2 year old vs 4 year old
• Crying when confronted by a stranger

NOTE SE only screens for SE issues. Must use
another tool to screen for other areas of
development
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Variables to Consider Before Referral

• Health Variable
• What is the childs health status?
• Chronic Illness
• Fatigue
• Hungry
• Reacting to a medication
• Examples Asthma, Hearing Loss, Autism/Hearing
  Loss, Food Allergy

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Variables to Consider Before Referral

• Family values/culture
• Most tools are western culture based
• Review tools prior to use
• To assure appropriateness to specific culture
• Example Mirror, Peek-a-boo, Toys, Pointing
• If an issue for the family eliminate item and
  ratio score
• Availability of items
• Example Zipper, Stringing beads

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Variables to Consider Before Referral

• Family values/culture
• What family/cultural factors are potentially
  associated with the behavior?
• Family dynamics Interactions between family
  members
• Cultural values
• Eye contact
• Body language
• Family Values
• Children should be seen and not heard
• If you are not early, you are late
• The long good bye
• Respect for elders
• Primary language

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Interpretation of Score

• Score is above cutoff
• Review variables
• Refer for diagnostic SE or mental health
  assessment, or
• Provide the parent with information/support and
• monitor with ASQ-SE
• Score is near the cutoff
• Review Variable
• Consider parent concerns
• Refer for diagnostic SE or mental health
  assessment, or
• Provide the parent with information/support and
• monitor with ASQ-SE

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Telling the Family

• Important not to alarm the family but to
  emphasize that the score indicated only that
  further evaluation or follow-up is necessary.
• Avoid using terms like fail, pass, normal,
  abnormal and test
• Explain the score in relation to the cutoffs
• Emphasize the childs current skills

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Designing and Building A Successful System

• PARTNERSHIPS
• Establishment of links to resources in the
  community planning and collaboration with
  relevant community agencies including your own.
• Many agencies doing mental health screening
• Strategies to avoid duplication and gaps

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Designing and Building A Successful System

• Why Do You Need Partners?
• Complex issues surrounding young childrens
  mental health
• Need to be dealt with concurrently
• Quality of Parent-Child Interactions
• Drug and Alcohol Abuse
• Maternal Depression
• Poverty
• Domestic Violence
• Child Abuse
• No one agency prepared to address all the issues

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Partnerships

• Environmental Scan
• What services do you provide to children and
  families?
• Quality of Parent-Child Interactions
• Drug and Alcohol Abuse
• Maternal Depression
• Poverty
• Domestic Violence
• Child Abuse
• If you ask What mental health services do you
  provide the answer will probably be none.

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MN Partnership Examples

• Head Start
• Public Health Home Visiting, CTC, Follow Along
  Program, other
• Education/Special Education
• ECFE
• Physicians/clinics
• Mental Health Centers/Practitioners
• Social Services (Child Protection/Alternative
  Response)
• Child Care
• Other
• Systems to address gaps
• IEIC
• Collaboratives

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Foundations For Success DataRamsey County

• Many screeners report that children who have
  passed developmental screening have been are
  identified through the SE with a diagnosis of
  autism.
• 1/3 of the children identified through the SE
  access mental health services.
• 2/3 access parenting support and special
  education evaluations
• Some children with screening scores under the
  cutoff are in need of referrals.
• Emphasizes using the tool as a method of
  conversation with families about concerns for
  their children and that
• the screening is not a test to pass or fail.

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DC-03R

• Diagnostic Code for children Birth to Three
• Modified DSM-IV
• Currently in Minnesota Health Care Programs
• MA
• MN Care
• Possible expansion to other health care programs
  including private insurance
• Lolas theory
• Increased Funding Increased service providers
• Zero to Three website

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Case Study

• Z 0 Points
• V 5 points
• X 10 points
• Behavior concern to the parents? 5 points

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Scoring Guidelines Overview

• Total all points
• If some questions unanswered
• Contact Family
• Average Score
• Instructions in the Manual - page 41
• Review any parent comments
• Review all questions with scores
• Interpret the scores
• Cutoff score
• Family Comments indicating concern
• Determine next steps