Versão em português da apresentação de Jane Squires, uma das autoras do ASQ-3 (sigla para Ages and Stages Questionnaires), método de avaliação infantil desenvolvido nos Estados Unidos e utilizado em mais de 18 países, apresentado pela Secretaria de Assuntos Estratégicos (SAE) promoveu no dia 05 de dezembro de 2011.

1.  Jane Squires, Ph.D.
 University of Oregon
 Early Intervention
Program
 jsquires@uoregon.edu
 Brazilia, Brazil
 December, 2011
1

2.  Define and discuss benefits of
developmental screening.
 Describe Ages & Stages
Questionnaires.
 Describe Ages and Stages: Social-
Emotional.
 Discuss and compare screening
approaches.
2

3. Poor environments during early
childhood can be like shifting the
course of an ocean liner two degrees at
the beginning of a voyage. Over a
thousand mile trip (or a 70 year life
span) you wind up in a different port.
Or you may crash into rocky shores.
 Myers, 2006, American Project
3

4. 2.53% 5.74% 11.36 %
Incidence of children identified as having disability (2009)
http://www.ideadata.org
4

6. Benefits of early, universal screening
 Earlier age for receiving
services and supports
 Improved child and family
outcomes
 Reduced stress
 Cost effective
6

7. Early childhood programs save money
 3 to 1 benefit-cost ratio
 Better health and academic outcomes
 $3-9 for every dollar invested
 16% annual return
• http://epinet.org
• http://brookings.edu
• http://minneapolisfed.org/
7

8. Nonrandom Distribution of Childhood
Morbidities
Biomedical/Psychiatric
Morbidities
& Health Care Utilization
1 in 5 children are responsible for over ½ W. T. Boyce
health cost, morbidity University of British Columbia

10.  Cost effective to intervene earlier
 Less use of community resources
Health/mental health
Social service
School
Legal system
 Large pay off for services for each dollar
spent

12. Participants in programs
• Have higher scores on reading and math
achievement tests
• Better language and cognitive abilities
• Improved social emotional development
• Better prepared to succeed in
elementary school
• More likely to pursue secondary
education

13.  Participants in programs
• Have less need for special education and other
remedial services
• Have lower dropout rates and higher graduation
rates
• Have better health and
• Experience less child abuse and neglect
 These children are less likely to become teenage
parents, more likely to be employed as adults,
have less rates of drug use, lower rates of
delinquency and adult crime, and lower
incarceration rates.

14.  A brief assessment
procedure designed to
identify children who
should receive more
intensive diagnosis or
evaluation from local early
intervention, early
childhood special
education, health, mental
health agencies.
Similar in theory to health screenings such as a quick hearing or
vision screen. 14

15. Below Cutoff Near Cutoff Not near cutoff
Professional Continue to monitor
(re-screen) & use
Assessment curriculum-based
assessment to
Eligible Not Eligible
develop learning plans
15

16.  Informal checklists or tests without
psychometric data
 Expensive professionally administered tests
 “Islands” of screening
 No system for referral, follow up
16

17. Without With Screening
Screening Tools Tools
Developmental 30% identified 70-80%
Palfrey et al, 1994
Disabilities identified
Squires et al, 1996
Mental Health 20% identified 80-90%
Lavigne et al, 1993
Problems identified
Sturner, 1991
Courtesy of START
17

18. Effective screening tests
 Parent or caregiver completed
 Quick and easy to administer
 Low cost
 Valid and reliable
 Able to be used in a
variety of ways
18

20.  Validity
 Reliability
 Adequate normative
population
 Cultural sensitivity
 Comprehensiveness
 Attractiveness to children

21. Professionally-administered
Parent-completed
Information on screening tools
 http://www.dbpeds.org/
 http://www.fpnotebook.com
 http://www.cimh.org
 Individual publishers

22.  Battelle Developmental Inventory Screen, 2nd
(http://www.assess.nelson.com)
 Bayley Scales of Infant Development Screen, 3rd
(http://harcourtassessment.com)
 Brigance Screens
(http://www.curriculumassociates.com)
 Denver II
(http://www.denverii.com/DenverII.html)
 Early Screening Inventory
(www.pearsonearlylearning.com)

23.  Pediatric Evaluation of Developmental
Status PEDS--Glascoe
• www.pedstest.com
 MacArthur Communicative Development
Inventory--Fenson et al.
 Minnesota Child Development Inventories
• http://www.childdevrev.com/cdi.html
 Ages & Stages Questionnaires
• http://www.brookespublishing.com
• http://agesandstages.com

24. “the science of examining the strange
behaviors of children in a strange
situation with strange adults for the
briefest possible periods of time”
(Bronfenbrenner, 1979)

26. Parents are reservoirs of rich
information about their
children
Parental involvement reduces
cost
Screening structures
observations, reports and
communications about child
development

27. Screening may become a teaching tool for
parents and teaching staff
Information/communication can be useful
for primary health care providers and
communication based rehabilitation center
Effective and efficient method of early
identification

28.  As accurate as formal measures for identifying cognitive delay
(Glascoe, 1989, 1990; Pulsifer, 1994)
 As accurate as formal measures for identifying language delay
(Tomblin, 1987)
 As accurate as formal measures for identifying symptoms of ADHD
and school related problems (Mulhern, 1994)
 More accurate than Denver for predicting school-age learning
problems (Diamond, 1987)

29. Accuracy of parent report
 Dinnebeil & Rule (1994)
 23 studies
 High reliability in parent report
 Area specific studies
 Cognitive (Glascoe, 1999)
 Communication (Ring and Fenson, 2000)
 Attention deficit and school related problems
(Mulhern, 1994)
 Gross motor (Bodnarchuk & Eaton, 2004)
29

30. Parent, caregiver report
 Low cost, economical
 Often know child best
 Natural environment for child
 Accurate, if based on
current, observable behavior
30

31. Agreement between parent-completed ASQ and
professionally administered standardized assessment:
Low income parents .85 (N = 54)
(below federal poverty level)
Middle income parents .89 (N = 42)
No statistical significance between groups
Squires, Potter, & Bricker, (1998) Early Childhood Research Quarterly,13, 2, 345-
354.

32.  Parents/caregiverscan provide rich
information about child across settings
 Parent involvement reduces cost
• 3-10 times less
 Screening structures
observations, reports, communications
about child development

33. Cost Effective
Parent-completed assessments
range between $1.25-10 per
assessment (U.S. interview/mail
models)
Professionally-administered cost 3-
10 times more
(Chan & Taylor, 1998; Dobrez Lo Sasso, Holl et al., 2001;
Glascoe, Foster, & Wolraich, 1997)

34.  24 month olds, 52 infants/mothers
 Bayley administered by psychologist
 Communication and personal social—
moderately correlated .55
 Gross motor & motor .46
 Sensitivity = 100%
 Specificity = 87%
 Recommended, as cost effective
 Gollenberg, Lynch et al., 2010
34

35.  Identify children at risk for developmental
delays
 Series of questionnaires for
children ages 1 month to 5 ½
 Parent- or caregiver-completed
screening tool that encourages parental/
caregiver involvement
35

36.  ASQ initiated in 1980 at University of Oregon by
Diane Bricker and colleagues.
 Authors reviewed standardized tests, literature.
 ASQ skills selected were:
 Easily observed or elicited by parents in home.
 Adopted by pediatric, child care, early
intervention, child welfare programs for early
identification
 Most widely tool by pediatricians (70%)
36

37.  Follow-up of medically
at risk infants
 Developmental
screening for
infants/toddlers living
in poverty, other risk
conditions
 Universal screening
 Translated, used
internationally
37

38. ASQ
 Communication
 Gross motor
 Fine motor
 Problem solving
 Personal-social
38

39. 39

40. 40

41. 21 Questionnaire intervals:
• 2*, 4, 6, 8, 9*, 10, 12, 14, 16, 18, 20, 22, 24
• 27, 30, 33, 36 (spaced 3 months apart)
• 42, 48, 54, 60 (spaced 6 months apart)
*New intervals included in ASQ-3 system
41

42.  5 developmental areas (e.g., Communication)
 6 questions in each area
 Questions are in hierarchical order
 Questions #5 and #6 are average skills for
children of that age interval
 (i.e., a 12 month skill for a 12 month child).
 Response options: Yes, Sometimes, Not
Yet
 Written at 4th to 5th grade reading level
42

43.  Un-Scored Section
 Looks at quality of skills (e.g., speech)
 Example: “Does your baby use both hand
equally well?”
 “No” response indicates possible cerebral palsy.
Important to follow up.
 Parent concerns very predictive.
 Any concerns or questionable responses
require follow-up
43

44.  Not yet = 0 points
 Sometimes = 5 points
 Yes = 10 points
 Domain scores are totaled and compared to
cutoff points
44

45. 45

46.  Alternative administration methods for
individuals from different cultural backgrounds.
 Alternative materials for individuals from
different cultural backgrounds.
 Normative sample includes diverse populations.
 Scoring permits omission of inappropriate items.
46

48.  ASQ companion tool
 Focused on social
emotional, behavioral,
self regulation
competencies
48

49.  6, 12, 18, 24, 30, 36, 48 & 60 month intervals
 3-6 month administration window on either side
 4th to 5th grade reading level
 Competence and problem behaviors targeted
 From 19 items (6-month interval) to 33 items
(60-month interval)

50. Behavioral Definition
Areas
Ability/willingness to calm, settle, or adjust to
Self-Regulation
physiological or environmental conditions
Compliance Ability/willingness to conform to the direction
of others and follow rules
Communication Verbal/nonverbal signals that indicate
feelings, affect, internal states
Adaptive Ability/success in coping with physiological
needs
Autonomy Ability/willingness to establish independence
Affect Ability/willingness to demonstrate feelings
and empathy for others
Interaction with Ability/willingness to respond or initiate
People social responses with caregivers, adults,peers.

51. 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)?

52.  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

53.  Does your baby laugh or smile at you and
other family members?
 (z)Most of the time (v) Sometimes (x) Rarely or
never
 Does your baby like to be picked up and held?
(z)Most of the time (v) Sometimes (x) Rarely
or never

54.  Does your child destroy or damage things on
purpose?
 Does your child hurt himself on purpose?
 Does your child play alongside other
children?
 Most of time Sometimes Rarely/Never

55. ASQ-3 N Sens.% Spec.%
2-12 mo. 108 84.6 91.3
14-24 mo. 78 89.2 77.9
27-36 mo. 90 85.9 85.7
42-60 mo. 103 82.5 92.1
Normative sample = 18,572

56.  Overall (2-60 months)
 Sensitivity: 86.1%
 Specificity: 85.6%
 Percent agreement: 85.8%
 Under-identified: 6.0%
 Over-identified: 8.1%
 Test retest reliability: 92%
56

57.  Validity
 Reliability
 Utility
 Conducted
between 1995-
2001
 Sample of 3014

58. 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
Test-retest reliability = 94%
Utility = parents said easy to understand, appropriate,
helped think about child’s behavior

59.  Developmental screening
 Monitoring course of development
 Caregiver/teacher tool
 Prevention—target low areas
 General overview of development of
classroom
 Research
59

60.  Identify children with potential delays in
development
 5-18% may have scores below cutoff points
 Monitoring
 Follow-along screening
 9, 18, 24, 36, 48 months (pediatric guidelines)
 Make sure development on course
60

61.  334 children
 12-60 months
 ASQ and PEDS and Bayley, Wechsler, or
Vineland
 PEDS = .74 sensitivity, .64 specificity
 ASQ = .82 sensitivity, .78 specificity
 Limbos & Joyce, 2011, Dev & Behavioral Peds
61

62.  Flower growing region
 ASQ administered to children as well as
growth measurement, blood test
 Children 24-61 months residing in high-
exposure communities scored significantly
lower on gross motor skills compared to low
exposure group
 Handal, Lozoff, Breilh, & Harlow, 2007
62

63. 50
45
40
35
Percent delay
30
25
20
15 Community C
10 Communities A and B
5
0

64.  Minnesota--statewide
 Large Hmong and Somali populations
 ASQ:SE on small PDAs, paper
www.patienttools.org
 Screened 10,000 children
 Extremely low cost—start up was most
 High satisfaction by programs and parents
 Identified between 5-28% of children
 Foundationforsuccess.org

65.  Currently on line and paper versions
 Over 10,000 on-line questionnaires
completed.
 http://asq.uoregon.edu
 Initial “DIF” Analysis conducted
 Few differences found between on-line
versus paper completed ASQ’s.
 Differential item functioning = 45/500
items
65

66.  Provides feedback on general development
of individual children
 Allows monitoring of classroom, school
 Can target skills or areas that are in need of
practice
 Prevent further delays
 Can compare curriculum with needs in
classroom
66

67.  Prevention
 Intervention
 ASQ User’s Guide activities
 ASQ Learning Activities (available in Spanish)
 Beautiful Beginnings (Raikes & Whitmer)
67

68.  Put toys on a sofa or sturdy table so that your
baby can practice standing while playing with
the toys.
 Find a big box that your baby can crawl in and
out of. Stay close by and talk to your baby
about what she is doing. “You went in! Now
you are out!”
 Read baby books or colorful magazines by
pointing and telling your baby what is in the
picture. Let baby pat pictures. (8-12 months)
68

69.  Galicia, Spain
 2-step process
 Parents complete PEDS
 Preschool teachers complete ASQ
 Focus curriculum on children’s needs
 Provide follow-up to individual children with
low scores
 Refer children with very low scores to
specialist
 Monitor through ASQ 69

70.  Retrospective study on children diagnosed
with ASD who had ASQ data
 N = 58; 81% < 3 years
 100% identified
 96.6% failed communication
 86.2% failed personal-social
 81.0% failed problem solving
 100% of parents identified concerns
 High sensitivity in identifying ASD
70

71. Follow-up study (magnesium sulfate)
Latin American, Africa, India (125 centers in 19
countries)
Completed ASQ interview in homes and
community based health and rehabilitation
centers
2600 children screened by ASQ
78% sensitivity, 79% specificity
Children whose mothers received magnesium
sulfate during birth had improved outcomes
(Duley at al., under review)

72.  12 and 24 months
 20 pediatric practitioners
 76% agreement between ASQ and
pediatrician estimate of development
(OK, at risk)
 Pediatricians referred mostly for
communication, gross motor delays
 Referrals for further assessment increased
224% in one year
72

73.  ASQ in the office or mail it from home
 30 minutes of training for staff
 Resource staff scored the ASQ forms
 Itemized cost = $1.61 - $2.43 per patient.
 Cost varied on the mail-back option and
practitioner f/u decisions
 Reception, Nurse, Doctor all said:
 “The ASQ is a fun and very important part of this well-
child visit. Please fill it out. If you don’t have time, take
it home and mail it in.”

74. Control and screening year
referrals

75. 75

76. ASQ-3 and ASQ:SE
 Parent, caregiver-completed tools
 Low cost, effective
 Flexible administration
 Provides common platform for multiple
agencies serving young children and
families
 Follow up activities on “not yet” skills
using activity based intervention
76

77.  Kiosk in office with toy kit
 Mail to home and bring in at visit (or
email back)
 Complete first one at office, mail
remainder to home
 Home visiting--nurses, social workers,
child welfare
 Child care settings

78. Universal screening systems
 Identification of delays
 Better outcomes for children/families
 Requirements of system
 Valid, reliable, culturally relevant measures
 Low cost methods
 Coordinated systems
for follow-up and referral
78

79. Universal screening systems
 Effective systems identify children at risk for
developmental delays
 Benefits in terms of economic savings and
investment in future
 Technology offers creative and unique
solutions
 Use of videoconferencing, embedded
video, web-based screening involving
multiple agencies
79

80. 80