Ages Stages Questionnaires: Social-Emotional A New Tool for Identifying Social-Emotional Difficulties in Young Child

1. Ages & Stages Questionnaires: Social-Emotional A New Tool for Identifying Social-Emotional Difficulties in Young Children Jane Squires University of Oregon Eugene, OR 97403-5253 jsquires@uoregon.edu website: eip.uoregon.edu December, 2003

2. Objectives of Presentation Define screening Present issues/considerations related to assessing children�s social-emotional behaviors Describe Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) Discuss scoring/interpretation of scores and referral issues

3. What is the ASQ system ? Parent/Caregiver completed screening tools Series of questionnaires for children 3 months to 5 years Identifies children in need of further assessment Developmental concerns(ASQ) social-emotional concerns (ASQ:SE) Encourages parent involvement Ages and Stages Questionnaire Review slideAges and Stages Questionnaire Review slide

4. ASQ System: 2 Components ASQ Communication Gross Motor Fine Motor Problem solving Personal-social ASQ:SE Social-Emotional development ASQ:SE initiated in 1995, published in 2002 5 Domains of Development Review slide. Explain the ASQ: SE were 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. 5 Domains of Development Review slide. Explain the ASQ: SE were 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.

5. Ages & Stages Questionnaires: Social-Emotional Created as a result of a �call from the field� Developed by a multidisciplinary team at the University of Oregon�s Center on Human Development Originally titled the Behavior-Ages and Stages Questionnaires (B-ASQ) Research continues to be conducted on the ASQ:SE The original ASQ was developed in early 1979 and was 1st published in 1995. A second edition of the tool was published in 1999. Among other changes, the 2nd edition included a 5-year-questionnaire. While conducting outreach training on the ASQ, participants who were fans of the ASQ talked about the need for a more in depth look at the social-emotional behaviors of young children, since this was where they had many concerns about a child�s development. From this �call from the field�, a group at the University of Oregon�s Center on Human Development sat down to begin constructing questionnaires. Many devoted ASQ users, from around the country, assisted in providing feedback, using field test versions of the ASQ:SE and sending us data, and calling us up and asking, �When will it be ready?�. We sincerely appreciate all of the assistance programs provided us in the development of this tool.The original ASQ was developed in early 1979 and was 1st published in 1995. A second edition of the tool was published in 1999. Among other changes, the 2nd edition included a 5-year-questionnaire. While conducting outreach training on the ASQ, participants who were fans of the ASQ talked about the need for a more in depth look at the social-emotional behaviors of young children, since this was where they had many concerns about a child�s development. From this �call from the field�, a group at the University of Oregon�s Center on Human Development sat down to begin constructing questionnaires. Many devoted ASQ users, from around the country, assisted in providing feedback, using field test versions of the ASQ:SE and sending us data, and calling us up and asking, �When will it be ready?�. We sincerely appreciate all of the assistance programs provided us in the development of this tool.

6. Uses of ASQ:SE (Screening) To help guide decisions about referrals for further assessment Monitor child�s social-emotional development Determine information/support services families may need Bridge communication between parents and professionals about child�s behavior

7. 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 Because of all of the confusion regarding what the different purposes and types of assessments available, it is helpful to spend some time talking about definitions. Say: �There are three different types of assessments available in the early childhood field. Each type of assessment has a specific purpose they can be used for. These are the three types of assessments.� Screening assessment Diagnostic assessment Curriculum based (programmatic, on-going assessment) (Specific Examples of social-emotional/behavioral screening tools will be given further on in the presentation)Because of all of the confusion regarding what the different purposes and types of assessments available, it is helpful to spend some time talking about definitions. Say: �There are three different types of assessments available in the early childhood field. Each type of assessment has a specific purpose they can be used for. These are the three types of assessments.� Screening assessment Diagnostic assessment Curriculum based (programmatic, on-going assessment) (Specific Examples of social-emotional/behavioral screening tools will be given further on in the presentation)

8. 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. Developmental Diagnostic Tools Gesell, Baley Battelle Peabody (motor) TELD/TOLD (communication) Vineland Social-Emotional Diagnostic Tools Child Behavior Checklists (Achenbach) Vineland Social Emotional Early Childhood Scales Sara Sparrow, David Balla, & Dominic Cicchetti (1998) Infant Toddler Social-Emotional Assessment (ITSEA) Margaret J. Briggs-Gowen & Alice S. Carter. 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. Developmental Diagnostic Tools Gesell, Baley Battelle Peabody (motor) TELD/TOLD (communication) Vineland Social-Emotional Diagnostic Tools Child Behavior Checklists (Achenbach) Vineland Social Emotional Early Childhood Scales Sara Sparrow, David Balla, & Dominic Cicchetti (1998) Infant Toddler Social-Emotional Assessment (ITSEA) Margaret J. Briggs-Gowen & Alice S. Carter. 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.

9. Curriculum-Based Assessment(Programmatic, On-going Assessment) An in-depth assessment that helps to determines a child�s 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 Developmental CBA�s Hawaii Early Learning Profile (HELP) Assessment, Evaluation and Programming System (AEPS) Carolina Curriculum Portage Social-Emotional CBA�s HELP has strands related to social-emotional competence that could help you identify goals for young children. Devereaux Early Childhood Assessment Program This is a screening assessment, but it also provides some helpful programming information-especially for classroom teachers. ASQ:SE can help you identify some areas of concern that you could provide support or information to families about (e.g., feeding, sleeping, etc.) Developmental CBA�s Hawaii Early Learning Profile (HELP) Assessment, Evaluation and Programming System (AEPS) Carolina Curriculum Portage Social-Emotional CBA�s HELP has strands related to social-emotional competence that could help you identify goals for young children. Devereaux Early Childhood Assessment Program This is a screening assessment, but it also provides some helpful programming information-especially for classroom teachers. ASQ:SE can help you identify some areas of concern that you could provide support or information to families about (e.g., feeding, sleeping, etc.)

10. 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 Monitoring involves re-screening children. Best practice encourages screening children every 4-6 months. Development is so dynamic and changing during the first 5 years of life that screening every 12 months is not sufficient. Monitoring involves re-screening children. Best practice encourages screening children every 4-6 months. Development is so dynamic and changing during the first 5 years of life that screening every 12 months is not sufficient.

11. Screening This is an example of how screening fits into an assessment system to help identify and plan programs for children with potential delays. The process starts at the top by screening all children, and then children fall into 3 categories: Beyond Cutoffs (above or below) cutoffs (With ASQ, a problem is indicated with a low score, but with ASQ:SE a problem is indicated with a high score) Near Cutoffs Not near Cutoffs. Children who are beyond or near the cutoffs should both be considered for referral for a diagnostic assessment process. Children not near the cutoff should be monitored every 4-6 months to make sure they continue to make progress. Later in the training we will discuss the decision making process (to refer or not to refer) for children who are beyond or near the cut-off. One of the dilemmas you will encounter when screening for social-emotional delays is the lack of appropriate referral agencies�especially for babies and toddlers. You can start with EI/ECSE agencies, but also consider referrals to health or mental health agencies. We are pioneers in this field and need to use tools to justify our referrals, document the need for services and advocate to our agencies/government for the need for more services. This is an example of how screening fits into an assessment system to help identify and plan programs for children with potential delays. The process starts at the top by screening all children, and then children fall into 3 categories: Beyond Cutoffs (above or below) cutoffs (With ASQ, a problem is indicated with a low score, but with ASQ:SE a problem is indicated with a high score) Near Cutoffs Not near Cutoffs. Children who are beyond or near the cutoffs should both be considered for referral for a diagnostic assessment process. Children not near the cutoff should be monitored every 4-6 months to make sure they continue to make progress. Later in the training we will discuss the decision making process (to refer or not to refer) for children who are beyond or near the cut-off. One of the dilemmas you will encounter when screening for social-emotional delays is the lack of appropriate referral agencies�especially for babies and toddlers. You can start with EI/ECSE agencies, but also consider referrals to health or mental health agencies. We are pioneers in this field and need to use tools to justify our referrals, document the need for services and advocate to our agencies/government for the need for more services.

12. Barriers to Assessing Social-Emotional Development Lack of screening tools Lack of knowledge Variety of terminology Complexity of issues Lack of services 10 years ago there were no tools available for screening babies and toddlers in this area. Now programs have more choices available for screening tools. While there is a huge amount of research and literature that has documented the social-emotional development of young children, the importance and understanding of this area is not well understood by the general public. Just mention �infant mental health� to someone outside of the field of early childhood, and this lack of knowledge becomes apparent. The variety of terminology used to describe this area is immense. Depending on backgrounds and fields of training, terms such as temperament, behavior, mental health, regulation, social skills, social-emotional development etc. may be used, In general, these terms overlap in meaning. This is a very complex topic! If general development is tricky, this area is rocket science. It is a very complex dynamic of variables that sets up a young child�s emotional heath (or an adult�s for that matter)! And how to intervene, once a problem is identified is even trickier. The use of multidisciplinary teams to make decisions is vital in this area�do not work alone-do not feel that you should know what to do, regardless of how many years of experience or level of education you are coming from. The lack of services, as mentioned before is a barrier. We can only do the best we can do given the resources we have. Know that the information and support you bring to families is very helpful to that child, even if it does not seem like nearly enough. 10 years ago there were no tools available for screening babies and toddlers in this area. Now programs have more choices available for screening tools. While there is a huge amount of research and literature that has documented the social-emotional development of young children, the importance and understanding of this area is not well understood by the general public. Just mention �infant mental health� to someone outside of the field of early childhood, and this lack of knowledge becomes apparent. The variety of terminology used to describe this area is immense. Depending on backgrounds and fields of training, terms such as temperament, behavior, mental health, regulation, social skills, social-emotional development etc. may be used, In general, these terms overlap in meaning. This is a very complex topic! If general development is tricky, this area is rocket science. It is a very complex dynamic of variables that sets up a young child�s emotional heath (or an adult�s for that matter)! And how to intervene, once a problem is identified is even trickier. The use of multidisciplinary teams to make decisions is vital in this area�do not work alone-do not feel that you should know what to do, regardless of how many years of experience or level of education you are coming from. The lack of services, as mentioned before is a barrier. We can only do the best we can do given the resources we have. Know that the information and support you bring to families is very helpful to that child, even if it does not seem like nearly enough.

13. Types of Behavioral/Social Emotional Assessment Parent (e.g, ASQ:SE) or professional report of child�s 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) There are different types of tools that assess different aspects of social-emotional functioning. The ASQ:SE and other tools like it, focus on the child. Some tools are completed by parents, others by professionals. These tools focus on the level of stress the parent or family is under. Parent/Child Interaction Scales primarily focus on the quality of interaction between the parent and the child. Some tools have a child-focus component as well as a parent/child component (FEAS) Some assessments look at the quality of the caregiving environment and how that environment supports the child�s development. All of these assessments are important pieces to the puzzle. If the ASQ:SE is not appropriate in a certain situation, or if you want more information prior to making a referral, you will need to become familiar with other types of tools that can help you make decisions.There are different types of tools that assess different aspects of social-emotional functioning. The ASQ:SE and other tools like it, focus on the child. Some tools are completed by parents, others by professionals. These tools focus on the level of stress the parent or family is under. Parent/Child Interaction Scales primarily focus on the quality of interaction between the parent and the child. Some tools have a child-focus component as well as a parent/child component (FEAS) Some assessments look at the quality of the caregiving environment and how that environment supports the child�s development. All of these assessments are important pieces to the puzzle. If the ASQ:SE is not appropriate in a certain situation, or if you want more information prior to making a referral, you will need to become familiar with other types of tools that can help you make decisions.

14. Examples of Child-focused Screening Tools (Infant/Toddler) Infant Toddler Symptom Checklist Temperament and Atypical Behavior Scale (TABS) Ages and Stages Questionnaire: Social Emotional (ASQ:SE) Infant Toddler Symptom Checklist Georgia Degangi, Susan Poisson, Ruth Sickel, & Andrea Santman Wiener (1999) Temperament and Atypical Behavior Scale (TABS) Stephen J. Bagnato, John T. Neisworth, John Salvia, & Frances M. Hunt (1999) Ages and Stages Questionnaire: Social Emotional (ASQ:SE) Squires, Bricker, & Twombly, 2002 Infant Toddler Symptom Checklist Georgia Degangi, Susan Poisson, Ruth Sickel, & Andrea Santman Wiener (1999) Temperament and Atypical Behavior Scale (TABS) Stephen J. Bagnato, John T. Neisworth, John Salvia, & Frances M. Hunt (1999) Ages and Stages Questionnaire: Social Emotional (ASQ:SE) Squires, Bricker, & Twombly, 2002

15. Examples of child-focused screening tools (Preschool) Conner�s Rating Scale Carey Temperament Scale Social Skills Rating System (SSRS) Early Screening Project (ESP) Preschool Kindergarten Behavior Scales (PKBS) Conner�s Rating Scale C. Keith Conners 3-17 years Social Skills Rating System (SSRS) Frank M. Gresham & Stephen N. Elliott 3-18 years Early Screening Project (ESP) Hill M. Walker, Herbert H. Severson, & Edward Feil (1995) 3-5 years Preschool Kindergarten Behavior Scales (PKBS) Kenneth Merrell (1994) 3-6 yearsConner�s Rating Scale C. Keith Conners 3-17 years Social Skills Rating System (SSRS) Frank M. Gresham & Stephen N. Elliott 3-18 years Early Screening Project (ESP) Hill M. Walker, Herbert H. Severson, & Edward Feil (1995) 3-5 years Preschool Kindergarten Behavior Scales (PKBS) Kenneth Merrell (1994) 3-6 years

16. The Ages and Stages Questionnaires: Social Emotional Read Chapter 2 �Description and Design� of the ASQ:SE.Read Chapter 2 �Description and Design� of the ASQ:SE.

17. Features of ASQ:SE 6, 12, 18, 24, 30, 36, 48 & 60 month intervals Competence and problem behaviors targeted 3-6 month administration window on either side 4th to 5th grade reading level From 19 items (6-month interval) to 33 items (60-month interval) The ASQ:SE has approximately equal numbers of social-emotional �competence� and �problem� behaviors on each questionnaire. Competence Behaviors (e.g., ) Does your child like to be picked up and held? Does your baby let you know when she is hungry, hurt, or wet? Problem Behaviors (e.g.) Does you child hurt himself on purpose? Does your child have eating problems such as stuffing foods, vomiting, or eating nonfood items? Point out the front page of the questionnaire in participant�s packets, where the age range is indicated. There is a wider �window� of administration in the ASQ:SE than the ASQ (which has a one-month window). Many behaviors assessed on the ASQ are skills such as crawling that is present for a short period of time and than becomes something different (e.g., walking). This is different from �competence� behaviors on the ASQ:SE that once they are present, hopefully will stay with a child forever. On the flip side, �problem� behaviors you hope will not show up or at least not very often. Because of this wider window, correcting for prematurity is not necessary. However, If you are correcting a child�s age for another assessment process (e.g., the ASQ), it is fine to use that corrected date and stay consistent. The ASQ:SE has approximately equal numbers of social-emotional �competence� and �problem� behaviors on each questionnaire. Competence Behaviors (e.g., ) Does your child like to be picked up and held? Does your baby let you know when she is hungry, hurt, or wet? Problem Behaviors (e.g.) Does you child hurt himself on purpose? Does your child have eating problems such as stuffing foods, vomiting, or eating nonfood items? Point out the front page of the questionnaire in participant�s packets, where the age range is indicated. There is a wider �window� of administration in the ASQ:SE than the ASQ (which has a one-month window). Many behaviors assessed on the ASQ are skills such as crawling that is present for a short period of time and than becomes something different (e.g., walking). This is different from �competence� behaviors on the ASQ:SE that once they are present, hopefully will stay with a child forever. On the flip side, �problem� behaviors you hope will not show up or at least not very often. Because of this wider window, correcting for prematurity is not necessary. However, If you are correcting a child�s age for another assessment process (e.g., the ASQ), it is fine to use that corrected date and stay consistent.

18. Developmental-Organizational Framework (Cicchetti, 1993) This is a model of how social-emotional development progresses in children, developed by Dante Cicchetti, a Developmental Psychopathologist who works at Harvard University and has studied emotional development of children for years. Attachment: babies are regulating their bodies, including things such as basic as their body�s ability to regulate temperature and take in nourishment. Babies begin to exhibit recognizable state such as times when they are alert and ready to play or times when they are sleepy. They are primarily forming an attachment with their primary caregiver, who they completely depend on. Caregivers begin to recognize specific communicative attempts (e.g., one cry mean hungry, one cry means tired or hurt, one cry means, pay attention to me!). Autonomy: During this stage, children are beginning to see themselves as separate from their caregivers. They are beginning to use pronouns (the favorite being, �mine�). Children are starting to explore new environments after a little warm up time. They may toddle away from their caregiver, although they will look back and make sure their caregiver is watching them. They are also beginning to learn some self-control and that there are rules that should be followed (even if NO is another favorite word) Peer Relationships: Understanding empathy (that the other person has emotions. Really moving away from caregiver here, identifying friends.This is a model of how social-emotional development progresses in children, developed by Dante Cicchetti, a Developmental Psychopathologist who works at Harvard University and has studied emotional development of children for years. Attachment: babies are regulating their bodies, including things such as basic as their body�s ability to regulate temperature and take in nourishment. Babies begin to exhibit recognizable state such as times when they are alert and ready to play or times when they are sleepy. They are primarily forming an attachment with their primary caregiver, who they completely depend on. Caregivers begin to recognize specific communicative attempts (e.g., one cry mean hungry, one cry means tired or hurt, one cry means, pay attention to me!). Autonomy: During this stage, children are beginning to see themselves as separate from their caregivers. They are beginning to use pronouns (the favorite being, �mine�). Children are starting to explore new environments after a little warm up time. They may toddle away from their caregiver, although they will look back and make sure their caregiver is watching them. They are also beginning to learn some self-control and that there are rules that should be followed (even if NO is another favorite word) Peer Relationships: Understanding empathy (that the other person has emotions. Really moving away from caregiver here, identifying friends.

19. These �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 the User�s Guide, p. 14 to see how that item was categorized. Items are not evenly distributed across areas The number of items and content of items change over age intervals. ACTIVITY In small groups, have participants categorize questions in these areas. 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 pages14 and 15 in User�s Guide for guidance as to how the author�s classified the items. It is important to remember, however, that these areas are arbitrary and can fit in more than one category. Have a discussion with participants about questionable items, or items they couldn�t categorize.These �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 the User�s Guide, p. 14 to see how that item was categorized. Items are not evenly distributed across areas The number of items and content of items change over age intervals. ACTIVITY In small groups, have participants categorize questions in these areas. 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 pages14 and 15 in User�s Guide for guidance as to how the author�s classified the items. It is important to remember, however, that these areas are arbitrary and can fit in more than one category. Have a discussion with participants about questionable items, or items they couldn�t categorize.

20. Features of ASQ:SE Parent/Caregiver completed. Available in English and Spanish Companion tool to the ASQ questionnaires Each interval has a separate summary sheet, with cutoff on the page. Parent/Caregiver completed. Caregivers need to have at least 20 hours of contact with the child across the week. It may be important to consider multiple perspectives of the child�s behavior. Ask Participants, �Why is this important?� Children exhibit different behaviors in different environments People have different expectations for certain behaviors New moms, cultural differences, �goodness of fit� issues, temperament, experienced vs. new child providers The ASQ:SE is a companion tool to the ASQ. Social-emotional development, and problems that arise in a child�s development are very different from General Development (I.e., communication, motor, cognitive) domains. For example, in the motor domain we might have a concern because of the absence of a skill, if a 24 month old child is not walking. However in the social-emotional area, we may have a concern because of the presence of a behavior, or the age a child is exhibiting the behavior. For example, think about a 4 year old who bites his peers when frustrated. Both parts of a child�s development are important to assess, however, to get a full picture. Parent/Caregiver completed. Caregivers need to have at least 20 hours of contact with the child across the week. It may be important to consider multiple perspectives of the child�s behavior. Ask Participants, �Why is this important?� Children exhibit different behaviors in different environments People have different expectations for certain behaviors New moms, cultural differences, �goodness of fit� issues, temperament, experienced vs. new child providers The ASQ:SE is a companion tool to the ASQ. Social-emotional development, and problems that arise in a child�s development are very different from General Development (I.e., communication, motor, cognitive) domains. For example, in the motor domain we might have a concern because of the absence of a skill, if a 24 month old child is not walking. However in the social-emotional area, we may have a concern because of the presence of a behavior, or the age a child is exhibiting the behavior. For example, think about a 4 year old who bites his peers when frustrated. Both parts of a child�s development are important to assess, however, to get a full picture.

21. 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 Depending on whether the questions are positively or negatively stated changes the point values for each question. 24 month #4) Does your child laugh or smile when you play with her? Most of the time=0 Sometimes=5 Never or rarely=10 24 month # 8) Does your child have difficulty calming down when upset? Most of the time=10 Sometimes=5 Never or rarely=0 Depending on whether the questions are positively or negatively stated changes the point values for each question. 24 month #4) Does your child laugh or smile when you play with her? Most of the time=0 Sometimes=5 Never or rarely=10 24 month # 8) Does your child have difficulty calming down when upset? Most of the time=10 Sometimes=5 Never or rarely=0

22. 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)? Open-ended questions are not scored. The open-ended questions on the ASQ:SE, just like the Overall Section in the ASQ are very important. Referrals are often made based on an answer to an overall question, regardless of the total score of the ASQ:SE. Any concern that is brought up in this section should be addressed. Open-ended questions are not scored. The open-ended questions on the ASQ:SE, just like the Overall Section in the ASQ are very important. Referrals are often made based on an answer to an overall question, regardless of the total score of the ASQ:SE. Any concern that is brought up in this section should be addressed.

23. Research Studies Validity Reliability Utility Conducted between 1995-2001

24. ASQ:SE Sample 3014 questionnaires National sample Ethnicity 59% White 9% Black 9% Hispanic 6% Asia Pacific Islander 2% Native American 16% Mixed Attempted to match the demographics of the 2000 US census. The ASQ demographics had a choice option of �mixed ethnicity� where-as the US census did not.Attempted to match the demographics of the 2000 US census. The ASQ demographics had a choice option of �mixed ethnicity� where-as the US census did not.

25. Age N Median Means Cutoff  6 331 16.7 22.5 45 12 339 25.0 27.7 48 18 307 26.0 34.6 50 24 441 28.4 35.4 50 30 289 35.2 48.6 57 36 408 35.0 49.9 59 48 447 36.0 55.7 70 60 299 35.0 49.1 70  ASQ:SE Means, Medians, and Cutoffs The �N� refers to the number of children in the sample. The Median is the score where an equal number of children fell above this score as fell below this score. The final row is the ASQ:SE cutoffs. Because the scores on this questionnaire were unequally distributed, the median provides a more helpful comparison than the mean, which is an average of all of the scores. The �N� refers to the number of children in the sample. The Median is the score where an equal number of children fell above this score as fell below this score. The final row is the ASQ:SE cutoffs. Because the scores on this questionnaire were unequally distributed, the median provides a more helpful comparison than the mean, which is an average of all of the scores.

26. Range, means, standard deviations and cutoffs Range Means SD�s Cutoff 6 0-115 22.5 22.5 45 12 0-145 27.7 21.7 48 18 0-255 34.6 33.5 50 24 0-220 35.4 30.0 50 30 0-300 48.6 45 57 36 0-220 49.9 45.9 59 48 0-280 55.7 55.2 70 60 0-275 47.5 49.1 70 You can see from this slide the enormous range of scores. The range shows us the lowest scores recorded to the highest scores that a child received. In general, a large number of the questionnaires we received had quite low scores. Parents, in general, were comfortable with their child�s behaviors and felt like they were age appropriate. However, we do see scores rise as risk factors rise (which makes sense, since these families have additional stress in their lives). We see scores rise if a child has a disability. And occasionally we see some very high scores where a family is really struggling with their child�s behavior. This slide shows you the means and the standard deviations, to illustrate that the cutoff scores were not created in the same way as the ASQ. Ask participants: Can anyone tell me where the ASQ cutoffs fall? Answer: 2 Standard Deviations below the mean. If the ASQ:SE were created in a similar way (I.e., 2 standard deviations above the mean), you can see how high the cutoffs would be. Instead we used a statistical procedure called a ROC (Receiver Operating Curve) to create the cutoffs. This will be discussed further in a bit.You can see from this slide the enormous range of scores. The range shows us the lowest scores recorded to the highest scores that a child received. In general, a large number of the questionnaires we received had quite low scores. Parents, in general, were comfortable with their child�s behaviors and felt like they were age appropriate. However, we do see scores rise as risk factors rise (which makes sense, since these families have additional stress in their lives). We see scores rise if a child has a disability. And occasionally we see some very high scores where a family is really struggling with their child�s behavior. This slide shows you the means and the standard deviations, to illustrate that the cutoff scores were not created in the same way as the ASQ. Ask participants: Can anyone tell me where the ASQ cutoffs fall? Answer: 2 Standard Deviations below the mean. If the ASQ:SE were created in a similar way (I.e., 2 standard deviations above the mean), you can see how high the cutoffs would be. Instead we used a statistical procedure called a ROC (Receiver Operating Curve) to create the cutoffs. This will be discussed further in a bit.

27. This slide shows what the ASQ:SE �curve� looks like. It is not a bell curve. You can see the there are many children who fall on the left side of this curve, with low total scores, and than fewer and fewer children with high scores. This slide shows what the ASQ:SE �curve� looks like. It is not a bell curve. You can see the there are many children who fall on the left side of this curve, with low total scores, and than fewer and fewer children with high scores.

28. Concurrent Validity Comparison of ASQ:SE classification with standardized tools Achenbach Child Behavior Checklist Vineland Social Emotional Early Childhood (SEEC) Comparison of ASQ:SE classification with social-emotional diagnosis DSM-IV DC:0-3 EI/ECSE Behavioral Diagnosis We used these different diagnostic tools and professional diagnosis to compare ASQ:SE scores. We would look at a child�s total score on the ASQ:SE and than the total score on an Achenbach, or the SEEC, or if they had a diagnosis from the DSM-IV, the Zero to Three classification system or were eligible for services. The ROC analysis than compares scores and finds the best cutoffs for the ASQ:SE that balances: identifying children who do have a social-emotional delay (this is called Sensitivity) with identifying children who do not have a social-emotional delay (this is called Specificity). We used these different diagnostic tools and professional diagnosis to compare ASQ:SE scores. We would look at a child�s total score on the ASQ:SE and than the total score on an Achenbach, or the SEEC, or if they had a diagnosis from the DSM-IV, the Zero to Three classification system or were eligible for services. The ROC analysis than compares scores and finds the best cutoffs for the ASQ:SE that balances: identifying children who do have a social-emotional delay (this is called Sensitivity) with identifying children who do not have a social-emotional delay (this is called Specificity).

29. ASQ:SE Cutoffs Based on ROC (N = 1043) N Cutoff Sens Spec % Agree 6 71 45 78.6 98.2 94.0 12 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 The N indicates how many children were involved in the validity studies. There is a balance between sensitivity and specificity that is similar to over-referring children and under-referring children. Overall, 78% of the time the tool accurately identified children who were experiencing a social-emotional delay (according to these other tools or a diagnosis), and 94% of the time accurately identified children who were looking okay in the social-emotional area. Keep in mind, that we were comparing the ASQ:SE, in many cases, with other parent-completed tools (both the Achenbach and the SEEC were primarily parent-completed). They are more in-depth tools, and are well validated tools, but they are also a parent�s perspective). The N indicates how many children were involved in the validity studies. There is a balance between sensitivity and specificity that is similar to over-referring children and under-referring children. Overall, 78% of the time the tool accurately identified children who were experiencing a social-emotional delay (according to these other tools or a diagnosis), and 94% of the time accurately identified children who were looking okay in the social-emotional area. Keep in mind, that we were comparing the ASQ:SE, in many cases, with other parent-completed tools (both the Achenbach and the SEEC were primarily parent-completed). They are more in-depth tools, and are well validated tools, but they are also a parent�s perspective).

30. ASQ:SE Reliability Test-retest Parent at time 1 and 2 N = 367 94% agreement Test-Retest Reliability Reliability refers to the consistency of an assessment tool. Test-Retest Reliability tools at consistency �over time�. So, we administered the ASQ:SE once, and than administered the tool at a second time, 2-3 weeks later, and compared the results. 94% of the time the results (whether the total scores fell above or below the cutoffs) agreed. Inter-rater Reliability Another type of Reliability is called Inter-rater. This involves looking at two different caregivers filling out an assessment and comparing results. At this time, we are collecting information on Inter-rater reliability with the ASQ:SE. In general, with these types of tools, inter-rater reliability is not very high. Ask Participants: Why do you think Inter-rater reliability may not be so high with social-emotional assessments (as with developmental)? How should we use that knowledge during our assessment and decision -making?Test-Retest Reliability Reliability refers to the consistency of an assessment tool. Test-Retest Reliability tools at consistency �over time�. So, we administered the ASQ:SE once, and than administered the tool at a second time, 2-3 weeks later, and compared the results. 94% of the time the results (whether the total scores fell above or below the cutoffs) agreed. Inter-rater Reliability Another type of Reliability is called Inter-rater. This involves looking at two different caregivers filling out an assessment and comparing results. At this time, we are collecting information on Inter-rater reliability with the ASQ:SE. In general, with these types of tools, inter-rater reliability is not very high. Ask Participants: Why do you think Inter-rater reliability may not be so high with social-emotional assessments (as with developmental)? How should we use that knowledge during our assessment and decision -making?

31. UtilityParent satisfaction survey (N=731) How long did it take to complete the questionnaire? 70% Less than 10 minutes 28% 10-20 minutes 2% More than 20 minutes It was easy to understand the questions? 97% Easy 3% Sometimes 0% Not easy

32. Utility The questions were appropriate for child�s age 96% Yes 3% Sometimes 1% No The questionnaire was...... (check all that apply) 57% helped me think about my child�s behavior 56% was interesting 27% was fun to do 19% didn�t tell me much 1% was a waste of my time 1% took too long

33. Administering ASQ:SE Method(s) mail-out, home visit, interview Setting(s) child care setting pediatric waiting room Intervals all selected

34. Administering ASQ:SE Have parents complete as independently as possible. Some questions may require some clarification: (All intervals) Eating problems (18 months and older) Perseverative behaviors Review answers to questions Staff should not provide their opinion about how to answer the questionnaire. Staff should encourage the parent to provide his or her �best answer� based on their feelings about their child�s behavior. Staff should provide as little interpretation as possible, other than to help the parent understand what is being asked. There is guidance in the User�s Guide (see page 40 of the User�s Guide, the section titled �Parent Comments) related to these questions-in terms of what types of behaviors would be of concern. Sometimes parents will indicate the presence of a behavior, but it actually is a typical behavior given the age of the child. For example, the question; �Does your child do things over and over and can�t seem to stop?� Examples are�(parent�s can write in an answer). Parent�s have written in things such as �wants to read the same book�. After questioning the parent, you may realize this is just a typical 24 month old need to repeat an activity over and over, rather than a perseverative, or compulsive type behavior. Staff need to use their professional judgment in these cases. After a parent has completed filling out the questionnaire, the staff member can review items marked as concerns, or problem behaviors that are happening too often or too infrequently. Staff can note comments a parent makes during these conversations, and if the item was clearly misunderstood, changes can be made to the scoring.Staff should not provide their opinion about how to answer the questionnaire. Staff should encourage the parent to provide his or her �best answer� based on their feelings about their child�s behavior. Staff should provide as little interpretation as possible, other than to help the parent understand what is being asked. There is guidance in the User�s Guide (see page 40 of the User�s Guide, the section titled �Parent Comments) related to these questions-in terms of what types of behaviors would be of concern. Sometimes parents will indicate the presence of a behavior, but it actually is a typical behavior given the age of the child. For example, the question; �Does your child do things over and over and can�t seem to stop?� Examples are�(parent�s can write in an answer). Parent�s have written in things such as �wants to read the same book�. After questioning the parent, you may realize this is just a typical 24 month old need to repeat an activity over and over, rather than a perseverative, or compulsive type behavior. Staff need to use their professional judgment in these cases. After a parent has completed filling out the questionnaire, the staff member can review items marked as concerns, or problem behaviors that are happening too often or too infrequently. Staff can note comments a parent makes during these conversations, and if the item was clearly misunderstood, changes can be made to the scoring.

35. Scoring the ASQ:SE Determine child�s total score # of questions with x ___ x 10 = ____ # of questions with v ___ x 5 = ____ # Concerns ___ x 5 = ____ Total points on each page = ____ Go through and complete Louis Questionnaire together with participants. Direct participants to the ASQ:SE Information Summary Page for Scoring Instructions. X (similar to Roman numeral X) for 10 points V (similar to Roman numeral V) for 5 points Z (for zero) Remember: Open-ended Questions are not scored. Tip: I scan each page, going down the �sometimes� column (which are all 5 points), going down the concern column (5 points each) and finally scanning back and forth between the Most of the Time and the Never or Rarely columns (10 points each). Total each page at the bottom. Transfer page totals to back page. Go through and complete Louis Questionnaire together with participants. Direct participants to the ASQ:SE Information Summary Page for Scoring Instructions. X (similar to Roman numeral X) for 10 points V (similar to Roman numeral V) for 5 points Z (for zero) Remember: Open-ended Questions are not scored. Tip: I scan each page, going down the �sometimes� column (which are all 5 points), going down the concern column (5 points each) and finally scanning back and forth between the Most of the Time and the Never or Rarely columns (10 points each). Total each page at the bottom. Transfer page totals to back page.

36. Review questionnaires with parent Discuss items that individually score 10 or 15 points. Discuss answers to open-ended questions Discuss referral considerations Review score and compare to cutoffs Remember that cutoffs on ASQ:SE are very different from ASQ!

37. Referral Considerations Time/Setting Factors Developmental Factors Health Factors Culture/Family Factors Have participants get in groups and brainstorm additional information they would like to gather about Louis in order to make a referral decision. See Table 10 on page 49 for a list of possible information to gather in these categories. After small groups have generated a list of questions, discuss in large group format. Examples of questions: Are his behaviors due to a developmental issue? Are behaviors setting specific? Is the child reacting to a traumatic event or stressful life situations? Are behaviors due to medical or health related issues? Is the child currently on medication? Are behaviors related to individual characteristics or are they appropriate given the child�s cultural context?Have participants get in groups and brainstorm additional information they would like to gather about Louis in order to make a referral decision. See Table 10 on page 49 for a list of possible information to gather in these categories. After small groups have generated a list of questions, discuss in large group format. Examples of questions: Are his behaviors due to a developmental issue? Are behaviors setting specific? Is the child reacting to a traumatic event or stressful life situations? Are behaviors due to medical or health related issues? Is the child currently on medication? Are behaviors related to individual characteristics or are they appropriate given the child�s cultural context?

38. Interpreting Scores The �Sometimes�Issue The Subjectivity Issue Validity of Report Teen parents Parents involved in protective services First time parents/isolated parents Parents actively involved with drugs and alcohol Parents with mental illness Sometimes parents overuse the �sometimes� column and this results in an inflated score. These types of tools do have some subjectivity inherent in their design. It is important to get input from other caregivers. Ask Participants, When the child is a concern for only one caregiver, but not another-what might be going on? Or-if a child is a concern for everyone, what does that tell you? It is important to consider the validity of report and what might be impacting their ability to report accurately. If you have a concern about validity, have another caregiver complete the ASQ:SE or use another type of assessment to compare results (e.g., a professionally completed tool, or a parent/child interaction scale). Sometimes parents overuse the �sometimes� column and this results in an inflated score. These types of tools do have some subjectivity inherent in their design. It is important to get input from other caregivers. Ask Participants, When the child is a concern for only one caregiver, but not another-what might be going on? Or-if a child is a concern for everyone, what does that tell you? It is important to consider the validity of report and what might be impacting their ability to report accurately. If you have a concern about validity, have another caregiver complete the ASQ:SE or use another type of assessment to compare results (e.g., a professionally completed tool, or a parent/child interaction scale).

39. Possible Follow-up Below Cutoff Provide ASQ:SE activities & monitor. Close to Cutoff Follow up on concerns Provide information, education and support. Re-administer ASQ:SE. Make referrals as appropriate.

40. Possible Follow-up Above Cutoffs Refer to EI/ECSE Refer to local community agencies Feeding clinic Church groups Community groups (e.g., YMCA, Birth to Three) Parenting groups Early Head Start Refer to primary health care provider Refer for mental health evaluation

41. Culture-Specific Awareness & Understanding  Consider diversity within cultural groups as well as between cultural groups Gather culture-specific Information Study, read, use cultural guides, participate in daily life, learn the language, learn parenting & caregiving practices Culture specific issues and intervention Make no assumptions about concerns, priorities & resources!

42. Cross-Cultural Communication Adapt to style that is comfortable for the family Consider nonverbal behavior eye contact facial expressions proximity and touching body language, gestures Sensitive use of translators, interpreters

43. ASQ:SE User�s Guide Excellent resource Covers all topics in depth ASQ:SE User�s Guide 2nd Edition Review slide. Explain the ASQ:SE Users Guide is an excellent resource. Trainees may be assigned specific pages to read. ASQ:SE User�s Guide 2nd Edition Review slide. Explain the ASQ:SE Users Guide is an excellent resource. Trainees may be assigned specific pages to read.

44. To order ASQ:SE ASQ User�s Guide and Questionnaires: $125 for set Paul Brookes Publishing Company www.brookespublishing .com Great website Case studies, examples of questionnaires available Technical Report on-line 1-800-638-3775 Show User�s Guide and Box of Questionnaires to participants. The User�s Guide is an important resource. All sites should have a copy of the User�s Guide on hand. The questionnaires come in a photo-ready set, and can be copied by programs. This increases the cost-effectiveness of the system (rather than having to by protocols for each child separately).Show User�s Guide and Box of Questionnaires to participants. The User�s Guide is an important resource. All sites should have a copy of the User�s Guide on hand. The questionnaires come in a photo-ready set, and can be copied by programs. This increases the cost-effectiveness of the system (rather than having to by protocols for each child separately).

45. In Summary Early Identification is critical for improving developmental outcomes. ASQ:SE can assist in making referrals to community agencies. Social emotional issues are very complicated. Interdisciplinary, community-based teams can assist in decision-making. No one should feel as though they should have all the answers. In Summary Review slide.In Summary Review slide.

46. For more information please contact: University of Oregon Early Intervention Program/ASQ:SE Project 5253 University of Oregon Eugene, OR 97403-5253 541-346-0807 Project Staff: Jane Squires,Liz Twombly, Sue Yockelson, Jantina Clifford