4/2/2015 early brain development, toxic stress, and resiliency · early brain development, toxic...
TRANSCRIPT
4/2/2015
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Early Brain Development, Early Brain Development, Early Brain Development, Early Brain Development, Toxic Stress, and Resiliency Toxic Stress, and Resiliency Toxic Stress, and Resiliency Toxic Stress, and Resiliency
Gerri Mattson, MD, FAAP
Children and Youth Branch
Photo credit: Cade Martin, 2009
ID# 11344 CDC Public Health Image Library
ObjectivesObjectivesObjectivesObjectives
• Explain the potential impact of toxic stress on lifelong health
• Describe examples of two red flags in infants and young children
• Name two new strategies to use with young children andtheir families to assess for toxic stress
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Risks and Stressors and Brain Risks and Stressors and Brain Risks and Stressors and Brain Risks and Stressors and Brain DevelopmentDevelopmentDevelopmentDevelopment
• Ability to manage stress is controlled by brain circuits and hormone systemsactivated early on starting prenatally
• Stress causes increased levels of stress hormones and other chemicals in the mother which affects the fetus and infant
• Areas of the child’s brain may become less sensitive to negative feedback andmore sensitive to positive feedback
• Results in infants, children and adolescents who may have a tougher time learning in school and who experience more anxiety and fear
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http://developingchild.harvard.edu/resources/multimedia/videos/three_core_concepts/toxic_stress/
Potential Impact on Development and Potential Impact on Development and Potential Impact on Development and Potential Impact on Development and Lifelong HealthLifelong HealthLifelong HealthLifelong Health• Development is a function of “nature dancing with nurture over time”
• Brain circuits and neurons are vulnerable to toxic stress as they are developing and growing over time
• If development is disrupted by toxic stressors, an infant or child can have a lower threshold for reacting to external stresses in the future
• Different exposures to stressors at critical times in a child’s life can affect behavior and cause a variety of physical and mental health conditions over time
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Providers can share this information with mothers and other caregivers.
Adverse Childhood Adverse Childhood Adverse Childhood Adverse Childhood Experiences Experiences Experiences Experiences (ACE) Study(ACE) Study(ACE) Study(ACE) Study
• Largest scientific research study of its kind- 17,000 adults; collaboration between Kaiser and CDC
• 50 scientific articles published
• Over 100 conference and workshop presentations
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Adverse Childhood ExperiencesAdverse Childhood ExperiencesAdverse Childhood ExperiencesAdverse Childhood Experiences
• Recurrent and severe physical abuse
• Recurrent and severe emotional abuse
• Sexual abuse
• Neglect (physical and/or emotional)
• Alcoholic or substance abuse in household family member
• Imprisoned household family member
• Mentally ill, depressed, or institutionalized household family member
• Mother treated violently
• Parental separation or divorce
ACE Study Results ACE Study Results ACE Study Results ACE Study Results • ACE’s are common but often unrecognized and
concealed
• As the number of ACE’s a person experiences increase, the risk for many health and behavioral problems also increases
• The number of co-occurring health conditions increases as ACE’s increase
• Transforms psychosocial experience into organic disease, social malfunction, and mental illness
• Linked to heart disease, obesity, chronic lung disease, diabetes, depression, anxiety, substance addiction and poor quality of life
Increased Risks for Certain Poor Increased Risks for Certain Poor Increased Risks for Certain Poor Increased Risks for Certain Poor Psychosocial Outcomes Psychosocial Outcomes Psychosocial Outcomes Psychosocial Outcomes
• School failure
• Gang membership
• Unemployment
• Homelessness
• Incarceration
• Poverty
• Lack of supportive social relationships
• Single parents
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Adoption of
Health-risk Behaviors
Social, Emotional,
and Cognitive Impairment
Early
Death
Adverse Childhood Experiences
Death
Disease, Disability
and Social Problems
Conception
Scientific
gaps
Source: ACE Study, The ACE Pyramid, Centers for Disease Control
Source:
Effects of Toxic Effects of Toxic Effects of Toxic Effects of Toxic StressStressStressStress
• Persistent elevation of hormones like cortisol, can disrupt the developing brain in the areas of the amygdala, hippocampus, and prefrontal cortex (PFC)
• Ultimately can impact learning, memory, and behavioral and emotional adaptation
• Suppresses the immune response, affects other organ systems and makes an infant, child or adult more vulnerable to infections and chronic health problems
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Stressed vs. Stressed OutStressed vs. Stressed OutStressed vs. Stressed OutStressed vs. Stressed Out• Stressed
• Increased cardiac output
• Increased available glucose
• Enhanced immune functions
• Growth of neurons in hippocampus & prefrontal cortex
• Stressed Out
• Hypertension & cardiovascular diseases
• Glucose intolerance & insulin resistance
• Infection & inflammation
• Atrophy & death of neurons in hippocampus & prefrontal cortex
Slide borrowed from Dr. Lu
Additional Manifestations Additional Manifestations Additional Manifestations Additional Manifestations of ACE’sof ACE’sof ACE’sof ACE’s• A traumatic event can affect the way infants and children view
themselves, the world around them, and their future
• An infant, child or adolescent who is traumatized may not be able to trust others, may not feel safe, and may have difficulty handling transitions and other life changes and exhibit certain behaviors or red flags across all ages
Providers can have a role in looking for and teaching parents about red flags.
Red FlagsRed FlagsRed FlagsRed FlagsAn infant, child or adolescent may show certain early symptoms and behaviors which may mean that he or she is not coping well
and indicates concerns with social emotional development or mental health…..and a need to assess further…
Providers can learn what these are and teach mothers to let them know if red flags occur.
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Examples of Red FlagsExamples of Red FlagsExamples of Red FlagsExamples of Red Flags
• Difficulty acquiring developmental milestones in infants
• Toileting issues (i.e., constipation, encopresis, enuresis, regression of toileting skills even in teens)
• Self-abuse (i.e., biting, hitting self, cutting)
• Feeding and eating issues
• Defiance/arguing
Source: Best Practices for CCNC and CC4C and AAP’s Helping Foster and
Adoptive Families Cope with Trauma
Red Flags (cont.)Red Flags (cont.)Red Flags (cont.)Red Flags (cont.)
• Hypervigilance, anxiety, or exaggerated response
• Flat affect, withdrawn, not smiling, resists cuddling (problems with attachment)
• Dissociation (i.e., detachment, numbing, compliance, fantasy)
• Sleep problems
• Frequent severe temper tantrums
• Losing details can lead to confabulation, viewed by others as lying
Red Red Red Red Flags (cont.)Flags (cont.)Flags (cont.)Flags (cont.)
• Self-regulation issues (inability to console or soothe orcalm self even in teens)
• Frequently in trouble at child care and school and with peers for fighting/disrupting
• Aggressive with other children
• Excessive crying
• Inappropriate sexual behaviors or gestures
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Assessing Children for Red Flags Assessing Children for Red Flags Assessing Children for Red Flags Assessing Children for Red Flags
• Help caregivers learn about trauma and the variety of red flags as a result of trauma and other toxic stressors
• Help caregivers learn that children may perceive and respond to the world in ways the parent does not expect or understand based on that infant’s or child’s experiences of trauma, past relationships, triggers, and growth and development
• Help prevent or reduce the lack of knowledge and support by mothers from re-traumatizing children by reframing behavioral concerns for mothers
• Discuss need for visit with primary care provider/medical home or referral to a mental health provider if child has one or more red flag(s)
Assessing Children for TriggersAssessing Children for TriggersAssessing Children for TriggersAssessing Children for Triggers
• Triggers can be smells, sounds, places, postures, tones of voice, or emotions that affect the way an infant or child sees and responds to the world around him/her
• Try to figure out what things or situations may cause an infant or child behave a certain way such as being inconsolable, resisting cuddling or being anxious (i.e., red flags)
• Try to help the mother learn to notice and to avoid (or lessen) some of these triggers
Providers can look for and teach parents to look for these triggers.
Good News: Life Trajectories are NOT Good News: Life Trajectories are NOT Good News: Life Trajectories are NOT Good News: Life Trajectories are NOT Set in StoneSet in StoneSet in StoneSet in Stone
• Interactive processes
• The development of health over a lifetime is an interactive process, combining genes, environment and behaviors
• Infants and families have varying abilities and strengths that can be developed to increase their protective factors
• Lifelong development/lifelong intervention
• At all stages of life, even for those whose trajectories seem limited, risk factors can be reduced and protective factors enhanced, to improve current and subsequent health and well-being
Slide adapted from slide from Dr. Verbiest
Providers can have a positive impact on reducing risk factors and increasing
protective factors!
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The The The The Life Course ModelLife Course ModelLife Course ModelLife Course Model
• Health trajectories are particularly affected during critical or sensitive periods (timing)
• Today’s experiences and exposures determine tomorrow’s health (timeline)
• The broader environment –biologic, physical, and social –strongly affects the capacity to be healthy (environment)
• Inequality in health reflects more than genetics and personal choice (health equity)
Amy Fine, Milt Kotelchuck, 2009
Life Course ModelLife Course ModelLife Course ModelLife Course Model
Hea
lth p
oten
tial
Optimal Life Trajectory
Life Trajectory Impacted by Inequity
Cumulative PathwaysEarly Programming
Slide borrowed from Dr. Sarah Verbiest, UNC Center for Maternal and Infant Health
Examples of Social Determinants Examples of Social Determinants Examples of Social Determinants Examples of Social Determinants TTTThat hat hat hat Protect Health Protect Health Protect Health Protect Health • Safe and good housing
• Stable/secure home life
• High school education level or higher for parents/caregivers
• Opportunities for stable income/employment for household
• Food security for household
• Safe neighborhood with no violence
• Community resources for fresh produce, exercise, social interactions
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Promote Healthy Brains With the Family Promote Healthy Brains With the Family Promote Healthy Brains With the Family Promote Healthy Brains With the Family and Medical Homeand Medical Homeand Medical Homeand Medical Home• Nutrition
• Nurturance
• Optimal environment
• Parent/caregiver health & mental health
• General developmental screening and surveillance in the medical home
• Social-emotional and mental health screening in the medical home
• Anticipatory Guidance
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Assess Ways to Make Stress Less ToxicAssess Ways to Make Stress Less ToxicAssess Ways to Make Stress Less ToxicAssess Ways to Make Stress Less Toxic
• Negative effects of toxic stress may be lessened with support of caring adults who understand and support child development
• Need to mitigate effects of toxic stress before irrevocable damage to the brain and other organ and metabolic systems is done
• Additional support and interventions (including evidence-based therapies) are needed to help return the stress response system to baseline
• Need to look for risk factors and red flags while providing services
Assess for Ways to Promote ResilienceAssess for Ways to Promote ResilienceAssess for Ways to Promote ResilienceAssess for Ways to Promote Resilience
• Children and families have varying abilities and strengths that can be used to increase their social and emotional competence
• Consistent and loving caregivers can help infants and children learn to trust others, develop confidence, and develop connections
• These efforts add to other efforts to help a child recover from trauma
• Providers can affirm and support the family to recognize, use and increase the current strengths and abilities of the family and the child
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The SEARCH Institute’s Family The SEARCH Institute’s Family The SEARCH Institute’s Family The SEARCH Institute’s Family Assets ModelAssets ModelAssets ModelAssets Model
• Nurturing RELATIONSHIPS
• Establishing ROUTINES
• Maintaining EXPECTATIONS
• ADAPTING to challenges
• Connecting to COMMUNITY
http://www.search-institute.org/research/family-strengths
Photo credit: Cade Martin, 2009
ID# 11344 CDC Public Health Image Library
Strengthening Families’ Five Protective Strengthening Families’ Five Protective Strengthening Families’ Five Protective Strengthening Families’ Five Protective Factors Model Factors Model Factors Model Factors Model
1. Parental resilience
2. Social connections
3. Knowledge of parenting and child development
4. Concrete support in times of need
5. Social and emotional competence of children
http://www.cssp.org/reform/strengtheningfamilies
Source:
Domain Definition
Competence Abilities/skills as well as a positive view of one’s abilities/skills in domain specific
areas, including social, academic, cognitive, and vocational.
Confidence An internal sense of overall positive self-worth and self-efficacy
Connection Positive bonds with people and institutions that are reflected in bidirectional
exchanges between the individual and peers, family, school, and community, in
which both parties contribute to the relationship.
Character Respect for societal and cultural rules, possession of standards for correct
behaviors, morality, and integrity
Caring A sense of sympathy and empathy for others.
The Five C’s The Five C’s The Five C’s The Five C’s of Positive Youth of Positive Youth of Positive Youth of Positive Youth Development (PYD)Development (PYD)Development (PYD)Development (PYD)
Slide borrowed from Dr. Gary Maslow
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Interventions to Increase Infant and Child Interventions to Increase Infant and Child Interventions to Increase Infant and Child Interventions to Increase Infant and Child Protective FactorsProtective FactorsProtective FactorsProtective Factors• Use of strengths-based communication among parents, families and
primary care providers to deliver family-centered care (e.g. use of motivational interviewing, Reach Out and Read, Motheread)
• Identification of concerns, risks, stressors, strengths and assets with early screening/assessment and ongoing surveillance (e.g., tools)
• Model quality interactions with the parents and child to build healthy relationships and supports
• Education and provision of anticipatory guidance and parenting strategies for infants and children
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Interventions to Increase Infant and Child Interventions to Increase Infant and Child Interventions to Increase Infant and Child Interventions to Increase Infant and Child Protective Protective Protective Protective Factors (cont.)Factors (cont.)Factors (cont.)Factors (cont.)
• Be aware of red flags and triggers
• Identify and increase child and family protective factors to build trust, attachment, and mental health
• Support the home environment
• Include an assessment of social-emotional concerns of children in foster care and with exposure to ACE’s
Share Anticipatory Guidance From the Share Anticipatory Guidance From the Share Anticipatory Guidance From the Share Anticipatory Guidance From the AAP on the Fostering Health NC SiteAAP on the Fostering Health NC SiteAAP on the Fostering Health NC SiteAAP on the Fostering Health NC SiteThe Medical Home Approach to Identifying and Responding to
Exposure to Trauma on pages 5-7 or go to the link at (which may take a second try as you do not have to log on):
http://www.aap.org/en-us/Documents/ttb_medicalhomeapproach.pdf
Parenting After Trauma: Understanding Your Child’s Needs (available in English and Spanish on the Fostering Health NC site)
http://www.ncpeds.org/health-care-providers-online-library
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Interventions to Increase Self Interventions to Increase Self Interventions to Increase Self Interventions to Increase Self Management and Care for YouthManagement and Care for YouthManagement and Care for YouthManagement and Care for Youth• Youth can have unique experiences and journeys related to health
care transition and are focused on priorities other than health (social, educational, vocational)
• Providers can work as or with medical homes to try to use simple, plain language in their communication with youth (address health literacy)
• Providers can work with youth to write down important questions the youth can ask about their health before the visit and how to ask questions about the information being shared with them
Interventions to Increase SelfInterventions to Increase SelfInterventions to Increase SelfInterventions to Increase Self----Management and Care (cont.)Management and Care (cont.)Management and Care (cont.)Management and Care (cont.)
• Providers can work with young mothers to update and understand their current medical summaries and emergency action plans (i.e., passport or portable medical summary)
• This includes information current and past medical problems, family history, medications, allergies, and emergency contacts
Additional Interventions Additional Interventions Additional Interventions Additional Interventions
• Collaborate with families to assure linkage and ongoing care of children with a medical and dental home
• Consider more frequent visits during transitions and when red flags are found or a referral for other services
• Identify local evidence-based community services if available that could assist the child and parents with needs (i.e. CC4C, Early Intervention, mental health, Triple P, home visiting programs, Early Head Start)
• Triple P or Positive Parenting Program : http://www.triplep-parenting.net/nc-en/get-help/find-a-triple-p-provider/
• NC Child Treatment Program for mental health resources for children: http://www.ncchildtreatmentprogram.org/
• Mother-infant dyad resources: http://www.ncpeds.org/ccnc-network-staff-online-library
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Additional Interventions (cont.)Additional Interventions (cont.)Additional Interventions (cont.)Additional Interventions (cont.)
• Identify additional local supports for parents available through friends, neighbors, quality child care, faith-based and other community support groups
• Identify and link families to local community agencies/services to address domestic violence, food insecurity, parental substance abuse, unstable or unsafe home, parental mental health, homelessness, or social services
• Develop reliable, standardized communication systems with medical homes, mental health providers, child care, and other local community services and programs
Ages and Stages Ages and Stages Ages and Stages Ages and Stages Questionnaire: SocialQuestionnaire: SocialQuestionnaire: SocialQuestionnaire: Social----
Emotional (ASQ:SE)Emotional (ASQ:SE)Emotional (ASQ:SE)Emotional (ASQ:SE)A Parent-Completed Child-Monitoring System for Social-Emotional Behaviors
Gerri Mattson, MD, MSPH, FAAP
Children and Youth Branch
Source: Many slides are based on information from the ASQ:SE
User’s Guide by Dr. Jane Squires, Dr. Diane Bricker, and Elizabeth
Twombly; Several Slides borrowed and/or adapted from Dr. Marian
Earls, Dr. Jane Foy, and Dr. Andrew Garner
New FamilyNew FamilyNew FamilyNew Family
• You have a first time young mother with a new infant and you see the mother and child for regular well visits
• You complete an ASQ-3 at 6 and 12 months and the child is doing well with no concerns
• You provide anticipatory guidance to the mom to help support optimal development
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After the 12 Month Visit, Lots of Things After the 12 Month Visit, Lots of Things After the 12 Month Visit, Lots of Things After the 12 Month Visit, Lots of Things Happen…Happen…Happen…Happen…
• The father of baby left when the infant was 1 year old and is no longer in the child’s life
• The great grandmother died and mom was very close to her
• Mom began to have very little interaction with the child after the death starting when the child was 13 months
• The child has liked spending time with an aunt who is profoundly intellectually delayed. However, the aunt has had to spend more time in respite care ever since the grandmother died and is not as much a part of the child’s life
18 Month Visit18 Month Visit18 Month Visit18 Month Visit
• Child comes in at 18 months and you notice aggressive behaviors, that the child is not wanting to be held and appears detached from the mom
• You complete the ASQ-3 and see some communication issues, receptive and expressive language issues and social- emotional concerns
What should you do?
Examples of Possible ActionsExamples of Possible ActionsExamples of Possible ActionsExamples of Possible Actions
• Use the ASQ:SE tool with the child to assess for social- emotional concerns
• Refer to DSS due to safety issues and neglect and concerns for possible abuse
• Refer to the Early Intervention Program at the CDSA
• Refer mother for mental health (but she declines and refuses help)
• Mom says she knows what to do, but you can tell she lacks motivation and is not mentally healthy and able to do the things you are suggesting
• Ask the mom if there is support in her church or others she can turn to for support
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Additional Actions and ProgressAdditional Actions and ProgressAdditional Actions and ProgressAdditional Actions and Progress
• Share the developmentally appropriate SE activities
• Get the child into quality child care
• Engage mom in reading with the child
• Help mom become invested over time in her mental health to allow a referral for mental health services for the mother/infant dyad
• See some improvement in the ASQ-SE scores with time especially related to support, modeling and stimulation provided in child care
Challenges and StrengthsChallenges and StrengthsChallenges and StrengthsChallenges and Strengths
• Less than excited mom with many stressors and reluctant to participate
• Building a relationship with the family over time is important
• Mom’s ability to stick with supports and more compliance may increase with an ongoing relationship
• Able to use some of the MI training with refresher sessions (use MI language and reinforce what was learned)
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ObjectivesObjectivesObjectivesObjectives• Explain the importance of assessing the social and emotional
competence of infants and young children
• Learn how to use the ASQ:SE system and tools
• Use two new strategies to improve how you work with families related to screening, anticipatory guidance and building assets using the ASQ:SE tools
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SocialSocialSocialSocial----Emotional DevelopmentEmotional DevelopmentEmotional DevelopmentEmotional Development
“Critical to child well-being is the ability of a child to successfully regulate their emotions and manage their social interactions in ways
that are acceptable to themselves and others.”
Source: ASQ:SE User’s Guide
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Risks for SocialRisks for SocialRisks for SocialRisks for Social----Emotional DelayEmotional DelayEmotional DelayEmotional Delay
The risk for developmental delays especially social-emotional delay in infants and young children, increases with the co-occurrence of adverse experiences, stressors, and certain conditions for infants and children:
• Poverty
• Maternal depression
• Others in household with mental illness
• Household substance abuse
• Divorce/separation of parents
• Death of parent
• Domestic Violence
• Household member incarceration
• Child abuse and neglect (including foster care)
Slide Adapted and Borrowed from Dr. Marian Earls
Importance of SocialImportance of SocialImportance of SocialImportance of Social----Emotional Emotional Emotional Emotional Screening Screening Screening Screening
Identify and elicit concerns and strengths early and offer the potential to intervene early to…
• Prevent or reduce the impact of social emotional developmental delays
• Identify, build and reinforce developmental assets and strengths in the child and family
• Prevent fully developed mental, emotional and behavioral disorders in all ages
• Help to support school readiness and academic success
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Ages and Stages Questionnaires: SocialAges and Stages Questionnaires: SocialAges and Stages Questionnaires: SocialAges and Stages Questionnaires: Social----Emotional (ASQ:SE)Emotional (ASQ:SE)Emotional (ASQ:SE)Emotional (ASQ:SE)
• “Secondary” screening tools completed by parent or primary caregiver to address social and emotional development and behaviors (competence) of young children
• Easy to use and low cost
• Not a diagnostic tool
• Can be completed in 10-15 minutes
• 1-3 minutes to score
• Available in Spanish
• Written at a 5th to 6th grade reading level
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PersonalPersonalPersonalPersonal----Social and Behavioral DomainsSocial and Behavioral DomainsSocial and Behavioral DomainsSocial and Behavioral Domains
• Domains include solitary social play, play with toys and play with other children
• Examples of milestones in these domains include:
social smile, looks at parent, self comfort and calming down, shows pleasure from interactions with parents or others, seeks parents for comfort, cries when you leave, indicates wants, plays peek-a-boo, laughs in response to others, plays with peers, self-care skills
Assessing Social and Emotional Assessing Social and Emotional Assessing Social and Emotional Assessing Social and Emotional CompetenceCompetenceCompetenceCompetence
An array of behaviors* that
permits one to develop and
engage in positive
interactions with peers,
siblings, parents and other
adults
The ability to effectively
regulate emotions to
accomplish one’s goals.
*Seven behavior areas:
Self-regulation, compliance, communication, adaptive functioning, autonomy,
affect and interaction with people
Source: ASQ:SE User’s Guide
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VariablesVariablesVariablesVariables That Influence BehaviorsThat Influence BehaviorsThat Influence BehaviorsThat Influence Behaviors
ASQ:SE questions try to account four variables that affect assessing the appropriateness of social behaviors and emotional responses:
• setting/time
• developmental level of child
• health of the child
• family values and culture
ASQ:SE (cont.)ASQ:SE (cont.)ASQ:SE (cont.)ASQ:SE (cont.)
• Series of 8 questionnaires for 6, 12, 18, 24, 30, 36, 48, and 60 month intervals
• Questionnaires can be used to cover the age range from 3 to 66 months
• The number of items vary, depending upon the age of the child
• Range from 19 scored questions at 6 months to 26 questions at 18 and 24 months, to 33 scored questions at 48 and 60 months
• Additional set of general un-scored questions on each questionnaire
• Can be used to screen at one point in time or can be used to monitor over time
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Questionnaire Items Questionnaire Items Questionnaire Items Questionnaire Items
• Items are representative of critical adaptive and maladaptive or problem behaviors at the targeted age intervals
• Most questionnaire intervals address 7 behavioral areas with scored questions about each area
• There is a section on all questionnaires that asks about general concerns and comments that are un-scored questions:
• anyone has expressed concerns about the child
• has concerns about the child’s eating, sleeping and toileting
• has any worries about the child
• things you enjoy about the child
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Questionnaire Items (cont.)Questionnaire Items (cont.)Questionnaire Items (cont.)Questionnaire Items (cont.)
• Several questions related to sexual interest are included on the 36, 48 and 60 month intervals to help identify concerns related to sexual
abuse and early exposure to domestic violence
• Some questions are considered subjective and parents should be encouraged to use their judgment (i.e., the question, “does your child scream, cry or have tantrums for long periods of time”, may cause a parent to ask about what might be considered a long time)
A Questionnaire Package for Each Age A Questionnaire Package for Each Age A Questionnaire Package for Each Age A Questionnaire Package for Each Age IntervalIntervalIntervalInterval
• Title Page for each age interval
• Indicates the specific ages you can use the questionnaire
• Important points to remember to share with the family if you wish
• Recording Sheet for listing name, data, address and other identifying information (if needed)
• Questionnaire itself for that age interval (multiple pages)
Questionnaire Package (cont.)Questionnaire Package (cont.)Questionnaire Package (cont.)Questionnaire Package (cont.)
• Information Summary page at the end of each interval to summarize assessment information and results and help with the decision-making process by the health care provider
• Contains the same information across all age intervals
• Asks for identifying information about the child and family
• Includes guidance about scoring, a chart indicating cutoff scores for referrals, guidance about interpretation, and a list of considerations that health care providers should be aware of prior to and about making referrals to mental health and other providers
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Steps in Use of the ASQ:SESteps in Use of the ASQ:SESteps in Use of the ASQ:SESteps in Use of the ASQ:SE
• Questionnaire Management
• Introducing the Screening Program
• Questionnaire Completion
• Questionnaire Scoring and Interpretation of Results
• Discussion with Parents
• Follow Up and Referral and Tracking (positive concerns on screens)
• Evaluation of Processes
Questionnaire Management: Choosing Questionnaire Management: Choosing Questionnaire Management: Choosing Questionnaire Management: Choosing the Correct Age Intervalthe Correct Age Intervalthe Correct Age Intervalthe Correct Age Interval• Each questionnaire can be used within 3 months (for the 6 through 30
month intervals) or 6 months (for the 36 through 60 month intervals) of the chronological age targeted by the questionnaire
• For example, the 6 month ASQ:SE can be used with infants from 3-8 months, the 12 month ASQ:SE with infants from 9-14 months, the 48 month questionnaire with children from 42 months through 53 months and the 60 month questionnaire with children from 54 months through 65 months
Questionnaire Management: PrematurityQuestionnaire Management: PrematurityQuestionnaire Management: PrematurityQuestionnaire Management: Prematurity
Questionnaires do not correct for prematurity because of the larger time frame covered by each ASQ:SE interval and the less significant
relationship between social-emotional development and prematurity*
*However, if programs are monitoring the child using the ASQ and have assigned a
corrected date of birth, personnel may use the corrected date of birth for the
ASE:SE as well up until child is 24 months of age
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Introducing the Screening to Introducing the Screening to Introducing the Screening to Introducing the Screening to Parents/Families: Sample ScriptParents/Families: Sample ScriptParents/Families: Sample ScriptParents/Families: Sample Script“The first five years of life are very important to your child because this
time sets the stage for success in school and later life. During infancy and early childhood, many experiences should be gained and many skills learned. It is important to ensure that each child’s development is proceeding without problem during this period; therefore we are interested in helping you follow your child’s social and emotional development… You will be asked to answer questions about some things your child does and does not do.”
Source: ASQ:SE User’s Guide
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Questionnaire CompletionQuestionnaire CompletionQuestionnaire CompletionQuestionnaire Completion
• Nurses can try to determine whether the parents are capable of reading and comprehending the questions
• Nurses an help assist parents with completing the forms if there is a possible literacy problem
• Providers can demonstrate how to elicit required behaviors as needed
• For parents with cognitive or emotional difficulties, another tool administered by another professional may be more appropriate
• OPTIONAL: Decide which toys and other materials that could be available for the parent to be able to assess their child’s social-emotional tasks while completing the questionnaire
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Helping Families Who May Be Unable to Complete Helping Families Who May Be Unable to Complete Helping Families Who May Be Unable to Complete Helping Families Who May Be Unable to Complete the Questionnairethe Questionnairethe Questionnairethe Questionnaire
• Read the items on the questionnaire and use an interview style
• Paraphrase items as needed for parents who need clarification or to account for different family values or cultures
• If an item is not appropriate for the family, it may need to be omitted. If an item is omitted, scoring procedures will need to be adjusted, as specified in Chapter 4 of the User’s Guide
• OPTIONAL: Demonstrate for parents how to elicit the required behaviors required using materials/objects in the clinic
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Questionnaire Completion: Explaining The Questionnaire Completion: Explaining The Questionnaire Completion: Explaining The Questionnaire Completion: Explaining The Columns for Some of the QuestionsColumns for Some of the QuestionsColumns for Some of the QuestionsColumns for Some of the Questions
• The first 19-33 items (varies by age) related to a child’s behavior and are followed by a series of three columns
• Parents can check the appropriate column to indicate whether and how often their child does the behavior Most of the Time,
Sometimes, or Never or Rarely
• A fourth column also permits parents to indicate with a check if the
behavior is of concern to them (more on this later)
Explaining the Fourth Column: Marking Explaining the Fourth Column: Marking Explaining the Fourth Column: Marking Explaining the Fourth Column: Marking ConcernsConcernsConcernsConcerns• The circle in the far right column next to each question should be
checked if the behavior is of concern to the parents (regardless of the frequency of the behavior)
• Encourage parents to check a scoring response first and then indicate if the behavior is a concern
Explaining the OpenExplaining the OpenExplaining the OpenExplaining the Open----Ended QuestionsEnded QuestionsEnded QuestionsEnded Questions
• There are two or three open-ended questions at the end of each questionnaire that are not scored
• Ask about the following:• Overall parental concerns or worries about the child
• Concerns related to the child’s eating, sleeping, and toileting behaviors
• What parents enjoy about their child
• Parents should be encouraged to respond to these questions as appropriate
• A referral may be made solely on a parent’s response to an open-ended question, even if the ASQ:SE score falls within the typical score (below the cutoff score)
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Scoring Guidelines: Point System and Scoring Guidelines: Point System and Scoring Guidelines: Point System and Scoring Guidelines: Point System and Total ScoreTotal ScoreTotal ScoreTotal Score• Items are coded as Z, V, or X next to each checked box to permit
quick and error-free scoring
• Parents’ responses are transferred to point values of 0 (for Z), 5 (for V or Roman numeral V), 10 (for X or Roman numeral X), and 5 for each checked concern respectively
• You then add together the total points on each page to get a combined total score
Scoring Interpretation: Context for Scoring Interpretation: Context for Scoring Interpretation: Context for Scoring Interpretation: Context for Referral and ConsiderationsReferral and ConsiderationsReferral and ConsiderationsReferral and Considerations• Compare the child’s total score with the cutoff in the table for that
age interval.
• The child’s total score will fall above the cutoff (typically has a problem/concern), near or at the cutoff (may have a problem/concern), or below the cutoff (typically does not have a problem/concern): this is opposite to the ASQ-3 scoring
• The child’s total score and parent comments should be used in the context of several (four) factors to decide what are the appropriate interventions (i.e., mental health evaluation)
Context for Referral and Considerations Context for Referral and Considerations Context for Referral and Considerations Context for Referral and Considerations (cont.)(cont.)(cont.)(cont.)• With every child, the User’s Guide and Information Summary Score
Interpretation guidance asks us to look at the information about the score in the context of four main types of factors in the decision about whether the child should have a mental health evaluation
• setting/time (i.e., is the child’s behavior the same at home as at school? Have there been any stressful events in the child’s life recently?)
• Development (i.e., is the child’s behavior related to a developmental stage or a developmental delay?)
• Health (i.e., is the child’s behavior related to health or biological factors?
• Family/cultural factors (i.e., is the child’s behavior acceptable given cultural or family context?)
Refer to pages 44-46 in the ASQ:SE User’s Guide for additional guidance related to
these factors and suggestions for follow up.
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Scoring Above the Cutoff Scoring Above the Cutoff Scoring Above the Cutoff Scoring Above the Cutoff
• Possible decisions include one or more options below:
• refer for diagnostic social-emotional or mental health evaluation (EI and/or mental health provider)
• provide the parent with social-emotional development information and support and monitor the child by repeating the ASQ:SE in 2-3 months
• ask more than one parent or caregiver to fill out the ASQ:SE
• refer to the primary care medical home if you are not the medical home
• assist with referral to additional resources and supports in the community (i.e., CC4C)
Scoring Above the Cutoff: SocialScoring Above the Cutoff: SocialScoring Above the Cutoff: SocialScoring Above the Cutoff: Social----Emotional Concerns Emotional Concerns Emotional Concerns Emotional Concerns • The ASQ:SE can show concerns about infant attachment
• Early Intervention, Part C considers Reactive Attachment Deprivation/Maltreatment Disorder of Infancy in children under three years of age an ESTABLISHED CONDITION
• When you make a referral to EI, indicate your concerns for this condition
Reactive Attachment Deprivation/Maltreatment Disorder Reactive Attachment Deprivation/Maltreatment Disorder Reactive Attachment Deprivation/Maltreatment Disorder Reactive Attachment Deprivation/Maltreatment Disorder of Infancy of Infancy of Infancy of Infancy
• Observed in the context or evidence of deprivation or maltreatment manifested by and established condition for referral to EI:
• Persistent parental neglect or abuse of a physical or psychological nature, of sufficient intensity and duration to undermine the child’ basis sense of security and attachment;
• Frequent changes in, or inconsistent availability of, the primary caregiver, making an attachment to an individual caregiver impossible; or
• Other environmental compromises and situations beyond the control of the parent and child which are prolonged, interfere with the appropriate care of the child, and prevent stable attachments
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Additional Referrals to Consider When Additional Referrals to Consider When Additional Referrals to Consider When Additional Referrals to Consider When Scoring Above the CutoffScoring Above the CutoffScoring Above the CutoffScoring Above the Cutoff• Additional referrals to consider:
• Parenting support and/or home visiting services (Triple P, CC4C, Healthy Families America)
• Mental health services for the mother (especially with concerns for maternal depression)
• Mental health for the infant and mother dyad [i.e., Child Parent Psychotherapy (0-5 yrs), Parent Child Interaction Therapy (3-7 yrs)] and especially when concerns for maternal depression
• With known abuse/neglect [i.e., above plus also consider Attachment Biobehavioral Catch Up (0-36 months), TF-CBT (3-18 yrs)]
Scoring Near the Cutoff Scoring Near the Cutoff Scoring Near the Cutoff Scoring Near the Cutoff
• Possible referral decisions may include one or more options: • refer for diagnostic social-emotional assessment in the clinic or with an outside behavioral
health provider
and/or
• provide the parent with social-emotional development information and support and monitor
and/or
• repeating the ASQ:SE in 2-3 months
and/or
• ask more than one parent or caregiver to fill out the ASQ:SE
and/or
• refer to the primary care medical home if you are not the medical home
and/or
• should assist with referral to additional resources and supports in the community (i.e., CC4C, parenting, family support network)
Scoring Below the CutoffScoring Below the CutoffScoring Below the CutoffScoring Below the Cutoff
• If the score is below the cutoff, this indicates the child typically does not have a problem
• However parental concerns are always important to consider regardless of the score
• referral can still be made for a mental health evaluation
• can still provide close monitoring with repeat of the ASQ:SE
• can still refer to the primary care medical home if you are not the medical home
• should offer to assist with referral to additional resources and supports in the community (i.e., CC4C)
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Discussion With ParentsDiscussion With ParentsDiscussion With ParentsDiscussion With Parents
• Important to discuss all results and what they may mean for the child’s development (not diagnostic) with parents even if scores are below the cutoff and the parent has no concerns
• Gives an opportunity to support and educate about developmentally appropriate interactions and promote social-emotional development
• Allows parents to ask questions and understand the value of developmental screening
• Acknowledges that you appreciate the time the parent took to complete the screening
Plans for Scoring and DocumentationPlans for Scoring and DocumentationPlans for Scoring and DocumentationPlans for Scoring and Documentation
• Assure that the tool is scored by a nurse or the billing health care provider
• Assure that the billing health care provider reviews and documents review of the results and discussion with the parents
• Assure that the results indicate concern or no concerns and actions are documented for concerns in the plan of care
Plans for Follow Up, Referral and Plans for Follow Up, Referral and Plans for Follow Up, Referral and Plans for Follow Up, Referral and TrackingTrackingTrackingTracking• Have a system to follow-up on referrals that is integrated into your
system of care
• Schedule a follow-up visit to monitor referrals and developmental progress sooner than the next scheduled well visit
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Resources for ReferralsResources for ReferralsResources for ReferralsResources for Referrals
• Mental health providers for the mother
• Mental health provider to care for the infant and mother dyad (i.e., Child Parent Psychotherapy (0-5 yrs), Parent Child Interaction Therapy (3-7 yrs)
• Early Intervention (CDSA) www.beearly.nc.gov
• Preschool Early Intervention
• With known abuse/neglect (i.e., also consider Attachment BiobehavioralCatch Up (0-36 mos), Trauma-focused Cognitive Behavioral Therapy (3-18 years)
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Evaluation and Therapy For Social Emotional Evaluation and Therapy For Social Emotional Evaluation and Therapy For Social Emotional Evaluation and Therapy For Social Emotional Concerns in Young ChildrenConcerns in Young ChildrenConcerns in Young ChildrenConcerns in Young Children
Child Parent Psychotherapy (CPP):
• Future rostered provider lists at www.ccfhnc.org or www.ncctp.med.unc.edu
Parent Child Interaction Therapy (PCIT)
Trauma Focused Cognitive Behavioral Therapy (TF-CBT)
http://clipper.med.unc.edu/ctp/Home/Index.rails
Evaluation and Therapy (cont.)Evaluation and Therapy (cont.)Evaluation and Therapy (cont.)Evaluation and Therapy (cont.)
Attachment Biobehavioral Catch Up
Future rostered provider lists at www.ccfhnc.org or www.ncctp.med.unc.edu• Currently: Durham, Guilford, Mecklenburg, Alamance
• Email: Karen Carmody at [email protected]
Circle of Security
National: www.circleofsecurity.net
Future rostered provider lists at www.ccfhnc.org or www.ncctp.med.unc.edu• Email: Karen Carmody at [email protected]
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Additional Infant Mental Health AgenciesAdditional Infant Mental Health AgenciesAdditional Infant Mental Health AgenciesAdditional Infant Mental Health Agencies
• Partnership for Children (www.smartstart.org/Smart-Start-in-your-community-map)
• Infant Mental Health Association
• www.ncimha.org
• Regional Groups:
• Mecklenberg: www.zfive.org
• Alamance: www.alamancesoc.org
Thank You!Thank You!Thank You!Thank You!Questions?Questions?Questions?Questions?