Ages and Stages: The two year review

1. Ages and Stages: The two year review

2. welcome Thank you for coming You’ve all passed….there is no exams Promise from me…not confusing, not hard, not rocket science. Easier life

3. A BIT OF A PLAN: Look at the need for a development tool What we do What knowledge of child development we need How to complete a holistic development assessment How to use the ASQ -3 Briefly look at ASQ- social and emotional questionaire IF THERE IS SOMETHING YOU WISH TO ASK PLEASE SHOUT OUT!

4. GOALS That we improve our service, and ultimately provide better outcome for children and families The you are equipped and armed with a new tool that will make your work easier, more thorough and comprehensive. That families will learn and feel supported by this new intervention.

5. Becoming a HV Early Implementer site As part of becoming a Health Visitor Early Implementer Site key areas of the Healthy Child Programme were identified and plans put in place to develop these areas. 1. Increasing antenatal contacts 2. Developing the two year review. ASQ-3 was trialled in other counties as their identified areas for improvement and we have learnt from them, and have chosen to role out ASQ-3 and ASQ-SE within Norfolk.

6. Beliefs Early detection of developmental delay is essential to timely and effective interventions. Constant findings that biological and medical indicators i.e. low birth weight are not liable predictors of subsequent infant outcomes (only 30%). Socio-economic rather than biological factors are best indicators to future problems, seen in longitudinal reports. Problems can arise at any point in the infants life.

7. Historically Developmental reviews were based on professional judgement and informing parents. Usually performed by skill mix team rather than HV Parents who were expected to contribute little or no understanding Need for affordable, effective, easy predictors that are accurate and timely

8. Healthy Child Programme How Health Visiting should be….. given the time and resources. Making best use of skills within a team. Empowering, flexibility, partnership working Need to empower people to take responsibility for their child's health and well being. To enable parents to provide an environment which fosters their children's development (physical, social, emotional and cognitive).

9. Intentions? Standardized approach across the county. Effective, economical tool. Parents to become genuinely involved in the assessment, intervention and evaluation of activities surrounding their infant. To test and monitor development of those infants thought to be at risk as a result of medical, biological, environmental factors. Training to empower and support all.

10. Intentions clinically? To provide a parent education process To not provide a tick box approach Support you in assessing, planning, empower, help teach families, evaluating and referencing. Detection Rates:

11. WHAT WE DO NOW? With the person next to you can you in 2 minutes just discuss what you have seen in practice? What have you seen good, bad and ugly? What tools do you use? Who undertakes 2 year checks? What toys do your team use? What is in development bags?

12. What is ASQ-3? Packs: one per base

13. What are the ages and stages Questionnaires (ASQ-3) Not just another tool it will be the tool for developmental reviews in Norfolk, already used in East Coast, FNP use tool at regular intervals. Based on 30 years of research, five major revisions and on 3rd edition (ASQ-3) Started in 1979 first edition in 1995, referenced in the HCP. Similar in theory to health screening such as a quick hearing or vision screen Identifies a family that needs further support, more intensive assessment or referral for a more specialist service.

14. Inside:21 paper questionnaires for ages: 2, 4, 6, 8, 9, 10, 12, 14, 16, 18, 20, 22, 24, 27, 30, 33, 36, 42, 48, 54, 60 months (paper copies)CD Rom (digital version)User guideChildren develop quickly, ASQ provides frequent monitoring.

15. FOCUS ON 2 YEAR DEVELOPMENTS: 24 MONTH QUESTIONNAIRE(HAND OUT)

16. Adjusting for prematurity ASQ-3 : Calculate a corrected date of birth for a child born more than 3 weeks premature, until the child is 2 years old. Just like the red book

17. ASQ as a Parent Education tool 30 developmental items/ behaviours that discusses developmental activities tied to the age of the child being screened 5 section: Communication, Gross motor (Arm and body movements), Fine motor (hand and finger movements), Problem solving (learning and playing with toys) Personal-social (Solitary and social play with toys and others) . Now is your chance to show off…. Tell us all about 2 year olds What is normal developmentally?

18. Each section has 6 questions in order of difficulty for an average child. Then an overall section for elaboration on 9 different areas including behaviour Illustrations and for a reading level of a 10 year old Should be a positive experience that the parent shares with the child. Answer yes, sometimes, not yet

19. Emphasis on what they can do and not what they can not do. Space to fill in examples of the child behaviour, and for comments. Designed to be used at home, and completed by the person that is central to that child's life. Completed by the primary care giver and allows them to gain valuable information about developmental milestones, their child's strengths and appropriate interventions. The questionnaire completion should be fun and a game for the whole family to enjoy to encourage interaction.

20. Step One: scoring Total the points in each area “yes”=10, “sometimes” =5, “not yet”=0. Review items marked not yet or sometimes if the more advanced items are answered as yes. A child often regressed with development when learning a new skills. They may have once been able to complete a behaviour but not currently able to. This would still be marked as yes. If no omitted answers go to step two.

21. Omitted items Total score in that section Divide that score by how many questions are answered Add that score to the original answer. Example A child scores 35 but only answers 5 questions. 35/ 5 = 7 ……then add the 7 to the original 35 making an overall score of 42. If there are 3+ omitted then do not complete this section as score will be inaccurate.

23. STEP TWO: Summary sheet in parts Transfer the area totals LOW scores indicate concern Black: Referral Grey: Referral and /or activity White: Routine developmental review and or activity.

24. Step three: Individual item response Read the answers in the overall section carefully and responds appropriately and discuss to identify problems.

25. Being mindful A child may pass the expressive items within the communication areas however a parent may feel that others do not understand what the child is saying, answering yes to having concerns. A child may put words together however has poor articulation which interferes with their ability to communicate with others. This may still warrant a referral

27. Activity sheets Include games and fun events for parents and their children to encourage development. Different sheets corresponding to the ASQ-3 intervals 1-4, 4-8, 8-12, 12-16, 16-20, 20-24, 24-30, 30-36, 36-48, 48-60, 60-66 Parents find it helpful to receive suggested learning activities. Pick certain activities to guide developmental areas. Let the parent decide on activity, timescale, All should include materials that most people have.

28. PLAN: • On system one: Tick the indicator box for the development. • Scan on summary sheet and document please see scanned item, with regards to the developmental review. • Record weight and height measurements and other holistic assessments as per usual.

29. Take into account A child’s environment and lifestyle will always plays a role in how they score Biological and health factors Family and child care environment Social supports Developmental history Family and cultural context Parental concerns Consider outside factors before making a referral. Review the purpose, avoid pass test or fail, emphasize strengths along with guided activities.

30. Recap Primary care giver completes the questionnaire Review the questions Total each section Record on the summary sheet Review the over all section and record on the summary sheet Plan activities and outcome If all white scores leave questionnaire with the family KPI :- Scan summary sheet onto system one, ensuring you tick the indicator box.

31. SCENARIO: ASQ-3 Now your turn …….. Jenny is the mother of five Brad aged 8, Angelina aged 6, Victoria aged four, David aged 2, and baby Leo 6 months. David comes to the Health Visitor at the children’s centre today for his two year review. Jenny is running very late as Victoria was refusing to walk to the centre and Leo needed feeding. Brad and Angelina are at school. Dad has been away in the forces now for three months and there is no family support. On entering the clinic room David is quiet sucking his dummy and hiding behind mum. Victoria is crying as it is nap time and demanding attention. Jenny gets very upset by this and start to cry. YOU ARE THE HEALTH VISITOR – WHAT WOULD YOU DO?

32. ASQ- 3 • Now meet Matilda….. • Tim is a father to Matilda age 2, his partner Tasha is at work when you go to the home for a review. The family live with Tim’s Mum who present as well. • Matilda is a lively girl and the family say she enjoys going to nursery a few hours a week, funded by the children’s centre. Tim tells you the nursery say she doesn’t talk much. Matilda weighs 16.60 kg and is wearing 4-5 year old clothes. Tim’s mum says she has a sweet tooth and her Granddad likes to walk her to the corner shop each day for a packet of sweets when he buys his tobacco. • You are the health visitor what would you do?

33. What next for your practice? • Go to your base and have a good rummage through the box, you’ll find a book and CD- ROM. • Take time to watch your mentors and team. Learn how to use ASQ– 3 to best advantage within your practice area. To reassure anxious parents or to assess harm? • Get to see as many 2 year olds as you can? They can be very diverse but all within “Normal Range” • Use your team clinical supervision (car chatter) time to learn from each other how to make this tool work as part of your developmental assessment.

34. ASQ-Social and Emotional questionnaires

35. definitions Social competence: An array of behaviours that permits one to develop and engage in positive interactions with peers, siblings, parents, and other adults Emotional competence: The ability to effectively regulate emotions to accomplish ones goals.

36. ASQ-SE: The intention 1995, responding to an increased demand for a tool to screen the socio-emotional delays and concerns in young children. To expand ASQ-3: A Parallel patient completed tool to measure social and emotional behaviours. Tested all over the USA between 1996-2001. The ages and Stages Questionnaires for Social-Emotional growth and behaviours was then published in 2002. ASQ and ASQ:SE can be used concurrently

37. INTENTION: Assessing a complex area Critical to the well being of children is their ability to successfully regulate their emotions and manage social interactions in ways that are accepted by others. Habituated and ingrained social/ emotional problems are highly resistant to change and may intensify over time. While most developmental skills can be reliably assessed a typical social-emotional behaviour can often be more difficult to assess. The intention of this tool is to successfully assess this area of development.

38. What is acceptable or Tolerable behaviour? Ok to run around and scream in a play area but not in a shop Some encourage children to be naturally inquisitive (get their hands dirty) where as others do not When are they crossing the line? Serious social and emotional problems suggest a gradual acceleration in frequency or troubling behaviour, or both until the child crosses the line. This tool is based on Social learning models, and developmental psychology.

39. Pack includes: Total possibility of 8 Questionnaires and covers three months through to five and half years of age Questionnaires can be at any or all of the following intervals: 6,12,18,24,30,36,48,60 months of age. Age range of each questionnaire is around two months each side unlike ASQ-3 which is around 4 weeks each side.

40. Questionnaires

41. ASQ-Social and emotional 7 behavioural areas that are not grouped 1. Self regulation (Ability and willingness to calm and settle down to physiological or environmental; conditions) 2. Compliance (Ability or willingness to conform to the direction of others and follow rules) 3. Communication (Ability or willingness to response to or initiate verbal or non verbal signals to indicate feelings, affective or internal states) 4. Adaptive behaviours (Success and ability to cope with physiological needs such as sleeping, eating, safety) 5. Autonomy ( Ability and willingness to self initiate or respond without guidance for example moving to independence) 6. Affect (Ability or willingness to demonstrate own feelings and empathy for others) 7. Interactions with people (Ability and willingness to respond or initiate social responses to parents, other adults and peers).

42. ASQ-SE 29 Questions in the two year ASQ-SE questionnaire Ends with the same 4 questions and asks for explanation Has anyone expressed concerns about your baby’s behaviour? Do you have any concerns about your baby’s eating or sleeping behaviours? Is there anything that worries you about your baby? What things do you enjoy most about your baby? Different questionnaire have different amounts of questions p14

43. The questions

44. ASQ-SE Developmental areas are not grouped, they are shuffled Primary care giver fills in the questions answering most of the time, sometimes, rarely or never. The items are coded Z, V, X, so responses are also shuffled, unlike the ASQ-3 Z=0 points V=5 points X=10 points (Roman Numerals) 5 points if they have a concern

45. Scoring the ASQ-SE ONE Score Unlike the ASQ-3HIGH Scores in the ASQ-SE are an indication of concern ASQ-SE is not corrected for prematurity

46. Omitted answers Maximum of three omitted Divide total score by number of questions answered i.e. 105/29 questions= 3.6 points Add this number to the total score to get a new total score i.e. 105+3.6= 108.6

47. Action Discuss strengths and reinforce positive parent child interaction Discuss individual items that score 10-15 points Discuss open ended questions (End four questions) Review score and cut off point Discuss referral pathways if needed and activity sheets with all. Use teams to discuss score outcomes and activities and actions. Take these to supervision and continue this learning, compare clients with similar scores!

48. Scenarios ASQ-SE Thomas William is a 57 year old parent of Thomas. He took early retirement when Thomas was born, his wife is at work as a Headteacher. Bill enthusiastically attends the nursery nurse’s music group and told everyone he had sung in many choirs. Bill has been invited to visit you, his Health Visitor today to complete an ASQ-SE and have a chat because Thomas cries throughout all of the music sessions. Bill has told your team that Thomas is very intelligent and he likes to tidy away his toys he even categorises and colour sorts them. Bill and his wife do not really understand why the nursery nurse thinks ASQ-SE is a good idea but go anyway because it is an excellent service. You are the Health Visitor – How do you tell Bill you have concerns?

49. Conclude Goal is to have an effective standardised approach across towards developments in Norfolk to support better outcomes for children. We now have a quick and easy parent led tool recommended in the HCP, that makes effective ongoing monitoring of development possible. Intention: Support professionals.

50. Benefits Empowering, can help bridge communication between families, by looking at development in a strength based way. Will help when referring onto other agencies, professionals Able to reference in child protection reports and court reports. Quicker documentation