prevention research center for family and child health d a...

Prevention Research Center for Family and Child Health

Dyadic Assessment of Naturalistic Caregiver-Child Experiences:

DANCE

Manual (Version 4.0)

DANCE Coding Manual i

© 2016 The Regents of the University of Colorado, a body corporate. All rights reserved. Dyadic Assessment of Naturalistic Caregiver-child Experiences (DANCE) Coding Manual – Version 4.0 (08/2016)

Acknowledgements

We would like to thank several individuals for their help and support in the development of the Dyadic Assessment of Naturalistic Caregiver-child Experiences (DANCE), the associated training program, and the Strategies To Enhance Parenting Skills (STEPS). We want to thank Dr. Nancy Donelan-McCall for her leadership, expertise, and dedication in guiding the development of the DANCE tool, training methodology, and DANCE STEPS. We are indebted to Kim Weber Yorga for her exemplary and creative work in the development of the DANCE training methodology and associated training materials. We are grateful for the support of our dedicated project team including Pilar Baca, Mariarosa Gasbarro, Francesca Pinto, and Kim Weber Yorga whose expertise in supporting parents and other caregivers to learn to DANCE with their children and whose countless hours reviewing videotaped interactions of caregivers and children has made a remarkable contribution to the development of the measure and training program. We thank Dr. David Olds for his support, leadership, and commitment to continue to improve the Nurse-Family Partnership (NFP) in community-based practice and to identify innovative methods and interventions to support the growth of at-risk families. We would also like to acknowledge the support, guidance, and valuable contributions provided by our colleagues from the Family Nurse Partnership (FNP) programme in the United Kingdom including the leadership and support of Kate Billingham and Ann Rowe; expert guidance and clinical support from Dr. PO Svanberg, Ruth Rothman, and Emma Cooke; and valuable insight on practice-based and training considerations from Alison Oxley, Mary Clarke, Rebecca O’Doran, Terry Fulton, Michelle Ackroyd, Lynda Dawson, Marie Livesley, and Irma Shepheard. We are also grateful to the FNP and NFP sites and NFP National Service Office Nurse Consultants who participated in the DANCE feasibility test. We also extend our appreciation to our Project Advisory Committee including Joan Barrett, Joan Loch, Brenda Mensink, Michelle Neal, Gina Veloni, Mary Beth Wenger, Dr. Paula Zeanah, and Quen Zorrah for their on-going review and revision of the DANCE measure, training methodology, and guidance on ensuring clinical utility of the DANCE in NFP practice.

Finally, we are very grateful for the generous financial support provided to this project by John and Marci Fox, the JPB Foundation, and the Colorado Clinical and Translational Sciences Institute. Without their generosity we would not have been able to conduct this very important work. Sincerely, The DANCE Development Team: Nancy Donelan-McCall, Pilar Baca, Mariarosa Gasbarro, Francesca Pinto, and Kim Weber Yorga.

DANCE Coding Manual ii


Confidentiality Statement for DANCE Training and Use in Practice

The Dyadic Assessment of Naturalistic Caregiver-child Experiences (DANCE) is a caregiver-child interaction measure developed by the Prevention Research Center for Family and Child Health (PRC) at the University of Colorado Denver. All DANCE related materials, procedures, and methods are protected under copyright to The Regents of the University of Colorado Denver, a body corporate. All rights reserved.

DANCE Coding Manual iii


Table of Contents Section 1 – Introduction Key Characteristics of the DANCE ....................................................................................... 1.1 DANCE Theoretical Overview .............................................................................................. 1.3 The Dimensions of the DANCE ............................................................................................ 1.5 Emotion and Affect in Caregiver-Child Interactions ............................................................ 1.11 Preparing to Use the DANCE ................................................................................................ 1.14 Observation and Coding Guidelines for the DANCE ............................................................ 1.16 DANCE Education................................................................................................................. 1.22 DANCE Scale – All Dimensions ........................................................................................... 1.25 Sample DANCE Coding Sheet .............................................................................................. 1.26 DANCE Coding Sheet: All Dimensions .............................................................................. 1.27

Section 2 – Emotional Quality Dimension Theoretical Importance ......................................................................................................... 2.1 DANCE Scale: Emotional Quality Dimension ...................................................................... 2.3 Expressed Positive Affect ..................................................................................................... 2.5 Caregiver’s Affect Complements Child’s Affect ................................................................. 2.9 Verbal Quality ....................................................................................................................... 2.13 Response to Distress ............................................................................................................. 2.17 Negative Comments About the Child ................................................................................... 2.21

Section 3 – Sensitivity and Responsivity Dimension Theoretical Importance .......................................................................................................... 3.1 DANCE Scale: Sensitivity and Responsivity Dimension ...................................................... 3.2 Positioning ............................................................................................................................ 3.3 Visual Engagement ............................................................................................................... 3.7 Negative Touch ..................................................................................................................... 3.11 Pacing .................................................................................................................................... 3.13 Non-Intrusiveness ................................................................................................................. 3.17 Responsiveness ...................................................................................................................... 3.21

DANCE Coding Manual iv


Section 4 – Support of Behavioral and Emotional Regulation Dimension Theoretical Importance .......................................................................................................... 4.1 DANCE Scale: Support of Behavioral and Emotional Regulation Dimension ..................... 4.2 Limit Setting .......................................................................................................................... 4.3 Completes Interactions .......................................................................................................... 4.7

Section 5 – Promotion of Developmental Growth Dimension Theoretical Importance ......................................................................................................... 5.1 DANCE Scale: Promotion of Developmental Growth Dimension........................................ 5.2 Supports Exploration ............................................................................................................ 5.3 Scaffolding ............................................................................................................................ 5.7 Verbal Connectedness ........................................................................................................... 5.11 Praise ..................................................................................................................................... 5.15 Negative Verbal Content ....................................................................................................... 5.17

Section 6 – Getting Started with DANCE Transition to Using the Dance During a Home Visit ............................................................. 6.1 Recommended Schedule for Completing the Dance ............................................................. 6.3 Facilitating Caregiver-Child Interaction ................................................................................ 6.4 Challenges to Completing a Dance Observation ................................................................... 6.5 Documenting a Dance Observation ....................................................................................... 6.6 Dance Integration ................................................................................................................... 6.7

References DANCE Glossary of Terms ................................................................................................... R.1 References .............................................................................................................................. R.3

Introduction 1.1


INTRODUCTION As a nurse home visitor (NHV), you engage in observations of caregiver-child interactions every time you meet with your client and her child during a visit. You notice how your client is feeling as well as the new developmental milestones her child is accomplishing. You note when your client seems tired, or that her child has learned to roll over. You might notice that your client seems frustrated with her child or she is beaming because her child can smile and she wants to share this with you. You are aware when caregivers develop in their parenting role and you are aware when caregivers experience challenges or seek support. Although you are already observing important aspects of caregiver-child interactions, the Dyadic Assessment of Naturalistic Caregiver-child Experiences (DANCE) will help to organize your observations and your thinking about caregiver-child interactions in ways that will help you identify both strengths within the caregiver-child relationship as well as areas for growth for your clients’ caregiving behaviors. DANCE is a framework to facilitate nurses’ work with families on important aspects of the caregiver-child relationship that are a core part of the NFP program model. DANCE provides a common language for describing caregiver-child interactions that nurse home visitors are observing during home visits. The DANCE tool outlines 18 caregiving behaviors that support children’s healthy growth and development. The DANCE STEPS (Strategies To Enhance Parenting Skills) then utilize findings from DANCE observations to provide parenting pathways that guide interventions in the maternal role domain of the program. They help identify the most appropriate NFP program materials to reinforce areas of strength and support areas for growth for client’s caregiving behaviors. The NFP DANCE STEPS serve to build caregiver’s reflective capacity, knowledge, and skill around caregiving interactions. The DANCE STEPS provide a language to support guided conversations between the nurse and the client (or other caregiver) around how the child communicates, learns and grows, and the child’s unique characteristics (e.g., temperament), as well as supporting the nurse to understand the caregiver’s beliefs about care giving and what is important to the caregiver. The DANCE STEPS are designed to be a starting point for nurse home visitors to identify NFP materials that support sharing information about each DANCE behavior. They provide a link to the NFP materials, highlighting the concepts that can be used to strengthen caregivers’ knowledge and skills about caregiving. The DANCE STEPS provide essential information for presenting each topic and content area as they relate to the DANCE behaviors. KEY CHARACTERISTICS OF THE DANCE Successful promotion of competent caregiving requires that nurses have feasible, clinically useful, and valid tools to assess qualities of caregiver-child interactions so that such information can be used to target intervention. Through extensive review of the literature on caregiver-child interactions (including cross-cultural literature), existing caregiver-child interaction measures, reviews of papers and reports from the original Nurse-Family Partnership (NFP) trials to identify the parenting dimensions that the program intends to address, expert input, and guidance from the project’s Advisory

Introduction 1.2


Committee (composed of NFP nurses, supervisors, and NFP state and national nurse consultants), and colleagues in the UK implementing the Family Nurse Partnership (as NFP is known in the UK), the DANCE was created to:

• Focus on core NFP caregiving competencies and behaviors,

• Guide developmentally appropriate observation of caregiving behaviors,

• Capitalize on the unique opportunity that NHVs have to view the caregiver-child relationship in natural settings over the course of a family’s participation in the program, and

• Provide NHVs with information and resources that will readily support their work with families around the promotion of competent caregiving.

The DANCE has been developed to be a valid and reliable tool, feasible to use in the context of home visitation, and clinically useful for nurses working with families to support caregiving. Reliability and validity testing with over 100 families observed using the DANCE assessment at child age 6, 12, and 21 months demonstrates that the DANCE is a reliable tool that predicts children’s outcomes across a range of developmental domains (language development, cognitive development, academic achievement, executive functioning, and emotional and behavioral regulation) through child age 9.

What is the clinical value of using a reliable measure?

The term "reliability" refers to the degree to which the DANCE measures a given attribute consistently across observers. For example, if the DANCE behaviors are reliable, two nurse home visitors observing a caregiver and child interacting together at the same point in time should score the interaction very similarly. Reliability of the DANCE assessment holds great value clinically. For nurses, a reliable DANCE instrument ensures that when a nurse completes a DANCE observation s/he will have accurate information to help guide his/her work with the client. A reliable assessment tool allows the nurse to provide the most appropriate support for the client given the client’s specific circumstances and needs. Support provided based on client’s specific circumstances and needs is more likely to support the client’s growth in caregiving behaviors. A tool (or user) that is not reliable may result in differences in assessment that are not related to caregiving behaviors but to the user’s own experience, beliefs, interpretations, and biases. This type of assessment can result in a misperception of the client’s strengths and areas for growth and the possibility of not supporting the client in the most appropriate and effective manner. Additionally, a reliable DANCE tool allows the nurse to complete the DANCE assessment at different points in time and have confidence that changes in caregiving behavior are more likely to be true differences and not an artifact of scoring. Finally, a reliable assessment tool holds significant clinical value to the larger team of practitioners. A reliable tool ensures that nurses and supervisors discussing DANCE behaviors hold a common understanding of what a specific behavior and score for that behavior represent. This type of common understanding allows nurses and supervisors to support each other during supervision, case conferences, visit planning, and covering caseloads when a nurse is out of the office.

Introduction 1.3


What is the clinical value of using a valid measure?

The term “validity” refers to the degree to which the DANCE measures a set of constructs and that these constructs relate to healthy outcomes for caregivers and their children. Clinically, this means that the DANCE measures aspects of caregiving that are related to the outcomes the program is targeted at impacting (e.g., children’s language development, positive peer relationships, pro-social behavior, and academic achievement). Therefore, as a DANCE user you can have some assurance that the information from the DANCE will help you to target aspects of caregiving that are likely to have a positive impact on children’s growth and development.

What does the DANCE provide to users?

The DANCE is a strengths-based assessment tool that has been developed to help nurses identify areas of strength and areas for growth in their clients’ caregiving behaviors. The DANCE provides users with a rigorously developed tool and education model designed to enhance nurses’ delivery of the NFP program. The DANCE 1) deepens nurses’ understanding of dyadic interaction; 2) serves as a framework to guide intervention in the maternal role domain of the program; and 3) offers opportunities for ongoing assessment over the course of the program to determine how the caregiver is developing his/her caregiving skills and supporting developmental shifts in the child. The DANCE was developed in consultation with NFP/FNP nurse home visitors, supervisors, educators, and nurse consultants in the US and UK to ensure that the tool meets the needs of nurse home visitors and is feasible to use in the context of home visitation.

DANCE THEORETICAL OVERVIEW One of the most important processes that shape the lives of very young children is the interaction they have with their primary caregivers. Over several decades, hundreds of studies have substantiated the relationship between qualities of early parenting behaviors and children’s emotional development (Spinrad et al., 2004; Kochanska, Aksan, & Carlson, 2005; Little & Carter, 2005), cognitive development (Feldman, Greenbaum, Yirmiya, & Mayes, 1996), social development (Brown, Donelan-McCall, & Dunn, 1996; Dunn et al., 1991; Kochanska et al., 2005), and the development of aggression, conduct disorder, antisocial behavior, and depression/anxiety in children (Kaufman, 1991; Warren et al., 1997). Evidence in support of the relationship between early parental care and child outcomes has made a significant contribution to our understanding of adaptive (and maladaptive) child development. Recent evidence supports an enduring effects model for the role maternal sensitivity plays in subsequent social and academic competence through childhood, adolescence, and early adulthood (Fraley, Roisman et al., 2013; Raby, Roisman et al., 2015). The promotion of caregivers’ competence in providing care that is sensitive, responsive, and supports developmental growth is at the core of the NFP model. The DANCE has been developed to help nurses support their clients’ desires to support their children’s healthy development by identifying areas of strength and opportunities for growth in caregiver’s behaviors with the goal to enhance competent caregiving. As described in Figure 1, like a dance,

Introduction 1.4


the interactions between a caregiver and child are comprised of a combination of steps: Step 1) children come into the world with physiological and psychological needs; Step 2) children have the ability to communicate these needs through signals or cues; Step 3) caregivers learn to read the signals or cues; Step 4) caregivers learn to respond to their children’s signals or cues in ways that meet their children’s needs; and Step 5) children respond to their caregivers' responses. When all five steps are performed regularly, a graceful dance between the caregiver and child is achieved. When there are repeated missteps, the dance is awkward and disruptive.

FIGURE 1: Caregiver-Child Interaction Dance.

It is important to note that the dance between the caregiver and child is not based on any individual step but how all the steps combine across interactions to create synchrony in the relationship. Despite the developmental significance of dancing in synchrony, caregivers and children are not perfect and are expected to misstep. According to Tronick (1989), about 30 percent of the time exchanges between mothers and their babies are perfectly “in sync” with one another. The remaining 70 percent of the time, interaction errors occur. However, Tronick believes that warm, sensitive caregivers become especially skilled at repairing these errors and returning to a synchronous state, or in our terms a graceful dance. The DANCE has been developed to help nurses work with caregivers to enhance the quality and maintenance of positive caregiver-child interactions. When caregiver-child interactions are positive and synchronous, caregivers spend more time with their children. They develop a sense that they are effective caregivers and discover that when they support their children’s growth and development, their children respond positively. Children who experience positive caregiver-child interactions will engage more with their caregivers, will reinforce caregivers’ behaviors, and will develop a sense of trust in their relationships with their caregivers and others.

Introduction 1.5


THE DIMENSIONS OF THE DANCE The DANCE consists of a set of parenting behaviors that were selected after an extensive review of the literature and deep consideration of the NFP model. After developing a list of over 50 candidate behaviors, caregiving behaviors were chosen based on the following criteria:

1. The behavior is likely to be observed during routine home visits,

2. The behavior is amenable to change through the NFP program,

3. The behavior is reflective of a dyad’s communication and interaction styles, and

4. The behavior supports children’s healthy development. In total, 18 caregiving behaviors have been selected for inclusion in the DANCE. The 18 behaviors have been grouped into four caregiving dimensions: Emotional Quality, Sensitivity and Responsivity, Support of Behavioral and Emotional Regulation, and Promotion of Developmental Growth. The boxes in Figure 2 provide an overview of how the DANCE can be incorporated into the NFP program model; specifically, how the DANCE can be used to help NHVs work with families to promote responsive and competent caregiving and in turn receive positive outcomes for child health and development. Nurse home visitors have the opportunity to work with families using the information obtained from the DANCE to influence the pathways illustrated in Figure 2. The NFP program has been developed to help NHVs work with families around the promotion of competent caregiving with the goal of reducing child maltreatment and injuries and fostering children’s cognitive development and emotional and behavioral regulation. Such impacts on children’s growth and development have lasting effects on their later functioning, including prosocial behavior, positive peer relationships, academic achievement, and executive functioning (e.g., sustained attention, decision-making, impulsivity). The unshaded boxes represent the pathways through which the DANCE can be used to help NHVs promote competent caregiving. The shaded boxes represent the two other primary goals of the NFP program, 1) improving pregnancy outcomes (through improved prenatal health behaviors) and 2) improving economic self-sufficiency. These goals are included in this model because all three NFP goals are inter-related.

Introduction 1.6


FIGURE 2: Conceptual Model of the Influence of DANCE Dimensions on Child Development.

Birth Outcomes

● Preterm Delivery ● Low Birth weight ● Complications

Prenatal Health

Behaviors

Responsive and Competent Caregiving

Child Neurodevelopment

Outcomes

Child

Characteristics

Emotional &

Behavioral Regulation

Child/Adolescent Outcomes

Attachment ● Prosocial Behavior

● Positive Peer Relationships

● Academic Achievement

● Executive Functioning

DANCE Dimensions

● Emotional Quality

● Sensitivity & Responsivity

● Regulation ● Promotion of

Developmental Growth

Cognition/Language Social Cognition

Economic Self-

sufficiency ● Subsequent

Pregnancies ● Education ● Work ● Father

Involvement

Later Economic Self-sufficiency

● Economic Self Sufficiency

● Welfare Dependence

● Substance Abuse

The DANCE dimensions are embedded in the “Responsive and Competent Caregiving” box on the far left of Figure 2. Within this box we see a vertical bidirectional (two-way) arrow between child characteristics (shaded) and DANCE dimensions indicating that a child’s characteristics influence his or her caregiver’s behaviors, and the caregiver’s behaviors influence the characteristics of the child. For example, children who are characterized by greater reactivity may have caregivers who become more disregulated in response to their children’s distress. Alternatively, caregivers whose responses are characterized by inconsistency to their children’s distress may have children who become increasing reactive to their environments. Moving from the “Caregiving” box on the far left to the middle “Attachment” box we see a unidirectional (one-way) arrow indicating the relationship between caregivers’ behaviors (classified into one of four dimensions) and the quality of children’s attachment relationships.

NFP Program

Introduction 1.7


Caregivers who read their children’s cues accurately provide care that is sensitive and responsive to their children’s needs, support their children’s emotional states by helping their children to regulate their affect during distress, share positive affect with their children during interactions, demonstrate reflective functioning, and foster a sense of safety and security in their children. According to Bowlby (1988), children organize their experiences with their primary caregivers in the form of working models, which consist of inner representations of the attachment figure(s), the self, and the environment. Children with secure attachment classifications develop an internal working model that the world is predictable and reliable and that they can trust and rely on their caregiver. To the right of the “Attachment” box we see an arrow leading to children’s neurodevelopment outcomes including emotional and behavioral regulation and cognitive, language, and social cognitive competence (understanding others’ thoughts, feelings, and beliefs). Theoretically, children whose primary caregivers are sensitive, responsive, affectively supportive, and understand their children’s thoughts, beliefs, emotions, and perspectives as separate from their own, have children who develop internal working models that the world is a safe place to explore, that their primary caregiver will be available if needed, and that they are valued and loved. The development of emotion regulation has been related consistently to sensitive caregiving and attachment security (Bell & Ainsworth, 1972; Braungart-Rieker et al., 1998; Bridges & Grolnick, 1995; Cassidy, 1994; Fish, Stifter, & Belskey, 1991). It is hypothesized that within the context of a secure relationship with a primary caregiver, children learn how to experience and regulate their emotional and behavioral responses. Children who develop an internal working model of the world as safe and believe that their primary caregiver will be available when needed are more likely to explore their world and gain experiences that foster cognitive growth and development. We also see a single directional arrow that directly links DANCE caregiving dimensions to children’s neurodevelopment. This arrow represents both the theoretical and empirical relationships that exist independent of children’s attachment relationships between caregiving behavior and children’s emotional and behavior regulation and cognitive and social-cognitive competence. For example, several researchers have found that aspects of families’ conversations about emotions, beliefs, and intentions are predictive of children’s emotion regulation and social cognitive competencies, even if you take in to account the children’s attachment classification. Similarly, children who develop secure attachment relationships with their primary caregiver are less likely to experience high levels of anxiety when exploring their environments. High levels of anxiety can interfere both in a neurologic and experiential way to inhibit exploration that fosters cognitive development. In general, poor parenting is correlated with low child serotonin levels (Pine 2001, Pine 2003) which, in turn, are implicated in stress-induced delays in neurodevelopment (Bremner and Vermetten 2004). Although attachment may mediate the relationship between parenting behavior and cognitive outcomes, there are direct influences of caregivers’ behavior on children’s cognitive development. For example, research has indicated that a parent’s deliberate action to develop child language is a significant predictor of language acquisition; availability of age appropriate toys and books and opportunities to explore the environment in a developmentally appropriate, supportive manner are predictive of children’s language development and school readiness (Hart and Risley, 1995). Therefore, Figure 2

Introduction 1.8


represents how parenting behaviors and child characteristics, through their bi-directional effects on each other, serve to foster attachment relationships that in turn predict children’s emotional, behavioral, cognitive, language, and social cognitive competence. The final arrow in Figure 2 represents the relationship between children’s emotional, behavioral, cognitive, language, and social-cognitive competencies and a range of child and adolescent outcomes. The capacity to regulate emotion is believed to play a major role in the development of children’s social competence, peer relationships, and problem behaviors. Positive associations have been reported between children's ability to understand others' emotions and positive peer relationships, and children’s early language abilities are predictive of their school adjustments and academic achievement. The ways in which the NFP program influences the life course of clients and their children are many. One of the most important aspects presented in Figure 2 is that there are specific parenting behaviors (competencies) that predict children’s healthy development. The DANCE helps you to observe these behaviors and support your work with families around strengthening these behaviors to improve the development and life course of children. Following is a review of each of the DANCE dimensions and an in-depth discussion of how the behaviors in each dimension support the relationship between the caregiver and child, as well as the child’s development. Although each of the behaviors in the DANCE have been listed in a single dimension, it is important to note that many of the behaviors are not mutually exclusive of other behaviors and often are aspects of other caregiving dimensions. For example, Response to Distress is a behavior that Supports Behavioral and Emotional Regulation but also is indicative of Sensitive and Responsive caregiving and the Emotional Quality of the relationship. Each behavior has been assigned to a dimension where there was the greatest conceptual connection to other behaviors; however, all caregiver behaviors help to support the interactive dance that supports children’s optimal development.

Emotional Quality

The Emotional Quality dimension is comprised of five caregiver behaviors including Expressed Positive Affect, Caregivers’ Affect Complements Child’s Affect, Verbal Quality, Response to Distress, and Negative Comments About the Child to Others. The behaviors in the Emotional Quality dimension are predominately observed through the caregivers’ affect or the verbal, facial, and behavioral (posture, eye contact) displays caregivers use to express their feelings and emotions. The emotional quality of the dyad is critical for development of a trusting, secure relationship (Kochanska, 1998), for the development of children’s emotional and behavioral regulation (Eisenburg, Spinrad, & Eggum, 2010), and development of emotional understanding (Dunn and Brown, 1992). According to Kochanska (1998), when mothers respond to infants’ cues and dyads share more pleasant emotions and experiences together, the development of the infant’s attachment security is supported. Similarly, Isabella and Belsky (1991) have described the term

Introduction 1.9


interactional synchrony as a sensitively tuned “emotional dance” in which the caregiver responds to the infant’s signals in a well-timed, appropriate fashion and, in addition, both partners match emotional states, especially the positive ones. Interactional synchrony distinguishes children with regard to their attachment classification. These studies suggest that it is the combination of responsiveness and affective quality that supports the development of attachment security. During the first two years of life children are rapidly learning how to be social partners with their caregivers. Caregivers play a significant role in this learning by supporting their children’s development of emotional and behavioral understanding and regulation. According to Dodge (1989), emotional self-regulation refers to the strategies we use to adjust our emotional state to a comfortable level of intensity so we can accomplish our goals. Behavior regulation can be thought of as the strategies we use to express our thoughts, feelings, beliefs, wants, desires, and states in ways that are acceptable to our society and facilitate goal attainment. As caregivers help infants regulate their emotional states, they also provide lessons on the social rules around expressions of emotions and behaviors. Parents support this learning in three ways: modeling affective responses that are predominately positive, helping children regulate their emotional and behavioral responses, and talking about emotional states (Eisenberg, Spinrad, and Eggum, 2010). Maternal interactions characterized by warmth (or positivity), sensitivity, and supportive responses with emotional coaching during distress are related to the development of children’s emotion regulation and effortful control (Eisenberg et al., 2005; Gaertner et al., 2008; Lengua, 2008; Spinrad et al., 2007). Additionally, caregivers’ responses to children’s emotional disregulation (particularly negative disregulation) provide children with valuable information about expressions of emotion, strategies for regulating negative arousal, and social expectations for the display of negative emotions. Caregivers who are able to support their children’s distress by responding in a supportive manner are more likely to have children who demonstrate higher levels of emotional understanding and behavioral regulation as preschoolers than caregivers who do not support their children’s distress (Denham & Couchoud, 1991; Spinrad et al., 2004). The caregiver-child relationship offers the first opportunity for children to learn the rules and expectations for emotional expression and effortful control and it is the starting point for developing strategies for managing their emotions and behaviors.

Sensitivity and Responsivity

The Sensitivity and Responsivity dimension contains six behaviors including: Positioning, Visual Engagement, Negative Touch, Pacing, Non-Intrusiveness, and Responsiveness. Caregiving sensitivity has been defined as the ability to accurately perceive the child’s signals and to respond to these signals in prompt and adequate ways (Ainsworth et al., 1978). Sensitive and responsive parenting during infancy is associated with the development of trust and a secure attachment (Ainsworth, Bell, & Stanton, 1971; Bowlby, 1988). Caregivers who are sensitive and responsive to their children’s needs foster a sense of security and safety in their children. This sense of security and safety allows children to explore their world and learn from their experiences.

Introduction 1.10


The development of emotion regulation has been related consistently to sensitive caregiving and attachment security (Bell & Ainsworth, 1972; Braungart-Rieker et al., 1998; Bridges & Grolnick, 1995; Cassidy, 1994; Fish, Stifter, & Belskey, 1991). Sensitive responsive caregiving is caregiving that involves mothers’ responsivity to their infants’ cues and emotional reactions. This has been linked with lower negativity and more regulatory behavior (Kochanska et al., 2000; Spinrad et al., 2007). Furthermore, individual differences in maternal sensitivity and responsiveness have been associated with differential outcomes in children's self esteem (Cassidy, 1988), peer interactions (Jacobson & Wille, 1986; Rydell, Bohlin, & Thorell, 2005) and dependency (Sroufe, Fox, & Pancake, 1983). Caregivers who accurately read their babies’ cues, empathize with their infants, and respond sensitively to their babies’ signals are less likely to abuse or neglect their children and are more likely to read their children’s developmental competencies accurately, leading to fewer unintentional injuries (Peterson & Gable, 1998) and more sensitive parenting. Support for Behavioral and Emotional Regulation The capacity to regulate emotion and behavior is believed to play a major role in the development of children’s social competence (Cassidy et al., 1992; Eisenberg & Fabes, 1992; Saarni, Mumme, & Campos, 1998) and problem behaviors (Eisenberg et al., 2001). Therefore, observing the role caregivers play in supporting their children’s behavioral and emotional regulation is an important aspect of competent caregiving. The Support for Behavioral and Emotional Regulation dimension captures this aspect of caregiving through the observation of two behaviors: Limit Setting and Completes Interactions. Maternal limit setting has been related to higher effortful control in children (Lengua et al., 2007) and caregivers who complete interactions with their children create predictability and routines for their children and foster security and trust. Completing interactions also enhances children’s ability to transition from one activity or experience to the next with less disruptive behaviors.

Promotion of Developmental Growth

Vygotsky (1978) believed that developmental phenomena such as voluntary attention, memory, and problem solving have their origins in social interactions. Through joint activities with more mature and experienced partners, children master activities and learn the social rules of their society. Caregivers who provide support for their children’s development through their use of language, scaffolding, and supportive environments have children who demonstrate more sophisticated problem solving abilities, superior language scores, higher scores on measures of executive functioning, and better academic achievement (Bradley, 1999; Evans & Kantrowitz, 2002; Feldman et al., 1996; Tamis-LeMonda et al., 2005; Tamis-LeMonda et al., 2004). Executive functioning involves cognitive processes such as planning, working memory, attention, problem solving, verbal reasoning, inhibition, multi-tasking, initiation, and monitoring of actions and are essential to successfully handling novel situations. Additionally, children enjoy listening to caregivers and will orient themselves toward their caregiver when they hear their caregivers’ voice. Children’s marked interest in speech (including orienting toward the caregiver) encourages parents to engage with and talk to their children, fostering more opportunities for interaction. The Promotion of Developmental Growth

Introduction 1.11


domain captures five behaviors related to caregivers support for children’s developmental growth including: Supports Exploration, Scaffolding, Verbal Connectedness, Praise, and Negative Verbal Content. In the most basic sense, caregiver’s behaviors serve to either support or inhibit children’s interactions with their caregivers and their subsequent development. At its best, the interaction is coordinated and has the grace of a dance in which each partner’s movements influence the other, helping both dance partners grow and flourish. It is important to keep in mind that both the caregiver and the child are actively contributing to how the dance unfolds. EMOTION AND AFFECT IN CAREGIVER-CHILD INTERACTIONS As human beings, emotional communications underlie all of our social encounters, including those between caregivers and children. In fact, the emotional relationship between parents and their children lays the foundation for infants to learn healthy emotional communication, a necessary skill for engaging in the social world. Through their emotional communications caregivers provide opportunities for infants to see and learn about emotions, express emotions in healthful ways, and learn to talk about and discuss their emotions. As infants grow older, they use emotional cues from their caregivers to help guide their exploration and to learn which behaviors and actions are valued and which are not. Because the emotional relationship between caregivers and infants is so critical for healthy development, the DANCE includes several behaviors that represent the emotional aspects of the relationship and therefore the observer will observe the affect of both the child and caregiver. Before using the DANCE it is important to understand the DANCE definition of emotions and how emotions can be seen and heard through affect displays (or affect). What are Emotions? Emotions are states of consciousness in which feelings are experienced as responses to stimuli. We can think about emotions along two continuums: 1) pleasure - displeasure and 2) low intensity – high intensity (Bullock and Russell, 1986). Pleasure is the state or feeling of being happy or gratified and creates a positive feeling (positive emotions) that one is motivated to recreate in the future. Displeasure is a state of being dissatisfied or annoyed and is an experience that creates negative feelings (negative emotions) that one is motivated to avoid in the future. The intensity of an emotion describes the arousal level of the emotion, the degree of pleasure or displeasure. What is an Affect Display (Affect)? The expression of emotion is known as an affect display or affect. Affect can be observed by others and is expressed or displayed by facial expressions, body language, and tone of voice. As displayed in Figure 3, we can conceptualize affect displays considering both pleasure and intensity. Surprise is an example of an emotion that is considered to be high intensity pleasure whereas interest is considered to be low intensity pleasure. Flatness is an example of an emotion that is considered to be low intensity displeasure, whereas anger is considered to be high

Introduction 1.12


intensity displeasure. When using the DANCE to observe caregiver-child interactions, the nurse home visitor will observe the affect of both the child and caregiver.

Figure 3: Intensity and Pleasure of Various Affect Displays1

How Can I See and Hear Affect?

Affect can be observed by examining facial expressions, body language, and tone of voice. Through facial expressions we can recognize positive affect through wide, bright eyes; raised brow; and an up-turned mouth. These characteristics are evident in a joyful smile but also are present when we think about contentment or interest (albeit at a lower intensity including focused-eye contact, slightly up-turned mouth). Negative affect is characterized by such facial expressions as a furrowed brow, down-turned mouth, narrowed or dropping eyes. Affect can also be seen in one’s body language including posture (sitting up and learning toward someone as signs of positive affect versus slouching and leaning away as signs of negative affect) and arm movements (slow and fluid movements for positive affect versus quick and sudden movements for negative affect). In addition to seeing affect displays, you can hear affect through one’s tone of voice. Tone of voice includes the pitch, volume, speed/rhythm, and emphasis of communication. Positive tone is often reflected in tone characterized by variable pitch; lower volume; and relaxed, variable, but predictable rhythm. Negative tone is often reflected in tone that is loud, tense, monotone, harsh, not rhythmic, and very high or very low pitch. Table 1 presents characteristics of facial expressions, body language, and tone of voice for positive and negative affect displays. Understanding these characteristics and looking for them at various levels of intensity will help aid your DANCE observations of many of the behaviors that involve the emotional quality of the relationship.

1 Adapted from: Bullock, M. & Russell, J.A. (1986). Concepts of emotion in developmental psychology. In C. Izard and P. Read (eds.) Measuring Emotions in Infants and Children (203-237). Cambridge, UK: Cambridge University Press.

Mid Intensity

Introduction 1.13


Table 1: Positive & Negative Characteristics of Facial Expressions, Body Language, and Tone.

Affect Facial

Expression Body

Language (including gestures)

Tone of

Voice

Pleasure (Positive)

• Wide, bright eyes • Open eyelids: the upper lid is

raised and the lower lid is drawn down

• Eyebrows that are raised so they become curved and high.

• Horizontal wrinkles across the forehead.

• Upturned mouth, often into a smile or with laughter

• Dropped jaw so that the lips and teeth are parted, with no tension around the mouth.

• Slow, fluid movements • Open body and arms • Relaxed muscles • Attentive posture

• Soft, but easily heard volume • Warm, welcoming • Variable tone, sing-song • Relaxed tone • Moderate pitch • Variable, but predictable

rhythm

Displeasure (negative)

• Furrowed brow • Down-turned mouth, pursed

lips • Narrowed-eyes, down-

turned lids, lost focus, poor eye contact

• Abrupt, quick movements • Tense muscles • Yawning • Tilted head, slouched

posture, oriented away from others

• Loud • Tense • Flat • Lacking in energy • Very high or very low pitch • Monotone, non-rhythmic

Variations in Affect Display

Across all cultures, human beings benefit from displays of pleasure. However the intensity with which pleasure is displayed varies by society, cultural group, neighborhoods, families, etc. DANCE considers these cultural and individual differences in affect intensity as described in the Emotional Quality dimension.

What if I See One Thing and Hear Another?

While affect displays are typically consistent across the various display modalities (facial expressions, gestures, tone) there are occasions when you may see conflicting information. One might see a caregiver whose facial display presents low intensity, negative affect (e.g., flat) but has a low-intensity, positive tone of voice (e.g., interest). Determining the caregiver’s emotional state can be challenging when mixed affect is displayed. For mixed affect display, determine the predominant affect displayed.

Introduction 1.14


PREPARING TO USE THE DANCE The DANCE has been developed to be completed based on naturalistic observations that occur during routine home visits. Naturalistic Observations Naturalistic observation is a method of observation that involves observing caregivers and children interacting together in settings familiar to the dyad (Connors & Glenn, 1996; Pett et al., 1992). The nurse is able to carefully observe the relationship between the caregiver and child in the setting where the caregiver and child most often interact (Gardner, 2000). This method gives nurses important insight into the relationship experiences that each individual child has with their mother or other caregivers. This observation approach is invaluable for planning interventions and evaluating outcomes that are specific to each dyad’s strengths and areas for growth. As mentioned previously, this observation approach is part of nursing assessment and involves collecting and organizing data (Timby, 2009). There are many approaches to observing caregivers and their children that vary in terms of the presence of an observer, type of task observed, and location of interaction. Often observations of caregivers and their children are conducted in the context of standardized, brief interactions designed to illicit the variability and quality of naturally occurring behaviors (Gardner, 2000; Pett et al., 1992). Reviews of the few studies that have examined the presence of an observer, type of observation task, and location of observation found that the presence of an observer does not necessarily affect the generalizability of the observations to behavior in the home; however, observations in structured tasks or in laboratory/clinic settings do not necessarily represent the types of interactions that are naturally occurring in the home (Gardner, 2000). Naturalistic observation has the advantage of imposing little burden on the dyad. The caregiver and child have little interference and the natural flow of behaviors is allowed to occur (Gardner, 2000). The NFP visit schedule is an advantage for nurse home visitors’ ability to engage in naturalistic observation, and creates regular and frequent opportunities to view dyads. This provides information on patterns of behaviors and allows progress towards enhanced caregiving as determined by the observation. Although naturalistic observations have many advantages in the context of interventions, they also create challenges that warrant caution. In naturalistic observations, caregivers and children may be affected by the presence of the observer, known as observer reactivity (Connors & Glenn, 1996). The presence of the observer may cause the caregiver or child’s behavior to be altered. Individuals who know they are being observed may alter their behavior to try to gain approval from the nurse, but reactivity tends to diminish after the first 10 minutes of the observation period. A benefit to using naturalistic observation for completing the DANCE is that clients are already accustomed to having a nurse present in their home given the nature of the NFP program. An additional concern of naturalistic observation is that certain behaviors may not be observed during the defined observation period. Observational parameters for using the DANCE, which will be discussed later in this section of the DANCE manual, have been structured to minimize this concern. One final concern for using naturalistic observation is that it

Introduction 1.15


can be a time consuming endeavor. However, the DANCE has been structured so that it can be completed within the normal context of a home visit and does not require longer observation or more frequent observation periods than the NFP home visit schedule. Utilizing the DANCE in nursing practice requires that the nurse home visitor plan to observe, and subsequently record, caregiver-child interactions that occur during a home visit. Nurse home visitors already have experience observing dyads during PIPE and caregiving interactions and later documenting their observations on their clinical records. Becoming familiar with using the DANCE during home visits will require some practice to be able to conduct a home visit, observe the specific DANCE behaviors, and complete the DANCE coding sheet immediately after the visit. These activities build upon observation and documentation skills nurses’ regularly use in practice. Preparing to Observe As individuals prepare to use the DANCE in practice, there are several activities that can help increase observation skills. Individuals can reflect on how they currently observe dyads and what has been learned through observation. Furthermore, one may want to consider what has facilitated or hindered observation in the past or in a certain context. In addition to reflecting on observation approaches, being well prepared for the visit enhances the ability to observe dyadic interaction. The ability to fully engage in observation may be reduced if the client or child is ill, if distractions or disruptions occur during the visit, or if the observer is experiencing her own stressors. Consider which of these factors can be controlled and what can be done to structure the home visit and environment for focusing attention and maximizing observation. Specific observation parameters for the DANCE will be addressed in the next section. These parameters provide further considerations for ensuring observation opportunities can be maximized. It is important to be aware of any biases one may carry into an observation. Therefore, observers are encouraged to reflect on thoughts and feelings about individual clients, their children, and caregiving behaviors that may influence observation. Are there certain behaviors that may influence observations of a caregiver or child? For example, if a caregiver uses a form of discipline that does not align with the observer’s approach to discipline, will this cause an observer to bias coding of the caregiver-child interaction? Recognizing and acknowledging personal judgments and biases, and talking with colleagues and supervisors about one’s reflections, will increase the likelihood of remaining objective as possible when completing the DANCE.

Objective Observation

An essential tenet of naturalistic observation is that the observer should remain neutral, and not influence a change in the environment beyond the inevitable change that accompanies the presence of an observer. The nurse role is to observe the DANCE behaviors in the home without attempting to influence or control the caregiver-child interactions. Remaining neutral also requires the nurse home visitor to remain as objective as possible. This is sometimes challenging given the fact that the nurse home visitor and client are engaged in a relationship with each other. Additionally, NHVs are trained to work with clients in a strengths-based model. A focus on

Introduction 1.16


identifying client strengths may create a tendency for the nurse to want to “up-code” clients on the DANCE. Being mindful of this natural inclination will enhance one’s objective observation skills, and better support the promotion of positive caregiver-child relationships by capturing a true picture of where the dyad is at on any given day, and identifying next steps for building stronger parenting competencies.

The most realistic and useful assessments of the dyad will be completed when the nurse home visitor can observe the dyad with “Fresh Eyes.” Developing curiosity and enthusiasm to view the dyad as if it were for the first time allows the nurse home visitor to see exactly what is happening between the caregiver and child at this exact moment in time. The DANCE is created from a strengths based perspective recognizing that all caregivers have areas of strength and areas for growth. Objective observation provides information about where this dyad is currently at and facilitates planning of follow-up interventions that will be the most relevant and helpful to the dyad. Documentation of Objective Observation Part of objective observation using the DANCE is to document, objectively, what you observe. Using the DANCE behaviors and observational parameters as your framework for viewing the dyadic interaction, your documentation should include the following:

• Examples of when you see the behavior occurring (based on the DANCE definition and developmental consideration),

• Examples of when you did not see the behavior occurring (based on the DANCE definition and developmental consideration), and

• Wording to indicate the frequency and duration of the behavior you are observing o Frequency: rarely, few, on occasion, infrequently, frequently, often, usually,

consistently, constantly, once, twice, many, always, never o Duration: brief, short, fleeting, quick, prolonged, 10 seconds (any indicator of

time), extended, lengthy, extensive A DANCE coding sheet has been developed to support your observation and documentation for each DANCE behavior. This documentation will support your learning of the tool during training and when using the tool in practice. OBSERVATION AND CODING GUIDELINES FOR THE DANCE Using the DANCE During a Home Visit The DANCE has been designed to support observation of caregiving behaviors and child characteristics that occur when caregivers and children are engaged in everyday activities in environments that are familiar to them. Therefore, when completing the DANCE in the context of a home visit, the visit must meet certain requirements. The requirements include:

Introduction 1.17


• Child Available for Interaction: The child must be present, awake, and available to interact with the caregiver for at least half the visit.

• Caregiver is Active Caregiver: The caregiver is acting as the caregiver during the interaction period. For example, the grandmother or father of the child is not taking primary care of the child during the observation period.

• Familiar Location: The visit should take place where the caregiver and child are currently living (preferred) or in a familiar location.

• Routine Visit: Neither caregiver or child should be experiencing any unusual acute social or medical issues. If the client experiences chronic social or medical issues, then dealing with these issues during the visit does not disqualify the visit for DANCE coding.

• Caregiving Activity: A caregiving activity, lasting at least 5 minutes, must occur during the visit (e.g., diaper changing, feeding, play, reading, putting the child to sleep, holding or cuddling, PIPE demonstration).

If any of these conditions cannot be met, then DANCE coding should be conducted during a future visit. In order to ensure accuracy in use of the DANCE, it is an expectation that the DANCE coding sheet be completed immediately following the visit. Home visits should be scheduled with this consideration in mind. Guiding Principles for DANCE Coding

1) The DANCE has been developed as a strengths-based tool that will help nurses identify caregiver strengths and areas for growth.

2) The DANCE has been developed to be clinically useful and feasible to use in the context

of a home visit. Most behaviors are scored as a proportion of time that they occur and a few are based on the frequency of occurrence. These proportions and frequencies are categorized to support translation to the DANCE STEPS as follows:

a. Area of Strength – The behavior “Usually” occurred (75-100% of the observation period). These behaviors can be reinforced and are skills to support the caregiver through difficult times or child development transitions. These behaviors may also offer an entry point to other behaviors that may be areas for enhancement or growth.

b. Area for Enhancement –The behavior occurred “At times” (between 25 – 74% of the observation period). These are behaviors that the caregiver demonstrates occasionally but may need support to consistently demonstrate, or may need guidance to understand the context in which the caregiver does and does not exhibit the behavior.

Introduction 1.18


c. Area for Growth – The behavior occurred “Rarely” (0-24% of the observation period). These are behaviors that are infrequently observed and can be targeted for support in strengthening.

3) The DANCE was developed with the understanding that caregivers are not perfect. Even

the most sensitive caregiver can miss a cue, tune out for a moment or two, or respond (on occasion) in an intrusive manner. The DANCE examines the caregiver’s behaviors over the course of a home visit and looks for caregiving behaviors that represent “good enough” caregiving (e.g., for the behavior to be considered an Area of Strength, it needs to be present at least 75% of the time).

4) Most behaviors are rated on how the caregiver responds to or reacts to the child and not on the success of a response. A mother may respond in a very sensitive and responsive way to her child’s distress but may not successfully calm the child.

5) The actions (or inactions) that caregivers and children engage in during the course of an

interaction do not necessarily influence a single DANCE behavior or characteristic. Rather, a behavior may influence a score across several behaviors. For example, a caregiver who uses a very directive communication style to guide her child’s exploration may influence the rating of Verbal Quality, Responsiveness, Limit Setting, Verbal Connectedness, and Supports Exploration behaviors.

Special Coding Considerations

1. Coding When a Child was Born Premature

DANCE assessments are not adjusted for prematurity because the observation and coding is based on caregiving behavior relative to children’s developmental needs (not birth age). The observer indicates the degree to which the caregiver responds based on each child’s unique developmental needs.

2. Coding When There are Multiple Children or Caregivers

If there is more than one child present in the home (e.g. multiples), code only one child per observation period. If there are multiple caregivers present (e.g., mother, father, grandparent), code only one caregiver per observation period.

3. Coding When Impairments Exist

When caregivers or children have visual, speech, or hearing impairments there will be some behaviors that you cannot code during a DANCE observation. For example, for a caregiver who is unable to communicate verbally, you would not code Verbal Quality, Verbal Connectedness, and Negative Verbal Content. If a caregiver has a visual impairment, behaviors such as Visual Engagement cannot be coded. Complete DANCE observations according to the recommended schedule, coding the behaviors that can be observed. Note on the coding sheet that the behaviors were not observed due to

Introduction 1.19


impairment and use the information that could be observed to guide clinical intervention planning.

4. Coding When the Child or Caregiver has Developmental Disabilities

The DANCE inherently accommodates observation of caregiver-child interactions with children who have developmental disability or delay. Some DANCE behaviors do not have developmental considerations (e.g., Expressed Positive Affect, Negative Comments about the Child to Others) and apply across all developmental abilities up to two years. However, most DANCE behaviors have developmental considerations that require the NHV to be aware of a child’s development level and to use that knowledge to inform the observation of the behavior (e.g., Positioning – closer for children with limited mobility and/or ability to communicate, greater spacing for children with increased mobility and ability to communicate). Therefore, a NHV must always recognize a child’s developmental skill and use the developmental considerations described in the DANCE coding manual to accurately complete a DANCE observation. If a child is developmentally delayed, then the NHV will conduct the DANCE observation looking to see the extent to which the caregiver’s behaviors are appropriate based on the child’s developmental ability and as defined by the DANCE developmental considerations.

When conducting a DANCE observation with clients with developmental delays or disabilities, there may be certain DANCE behaviors that cannot be coded. For example, if a client is non-verbal, Verbal Quality or Verbal Connectedness cannot be code; similarly, if a client is blind, Visual Engagement cannot be coded and considerations should be made for how the caregiver’s inability to see her child impacts the quality of her positioning. Use clinical judgment to determine how the developmental disability impacts the ability to code the interaction, and document accordingly to explain any behaviors that could not be observed and provide a reason explaining why.

5. Coding When the Caregiver Speaks a Language Different than the NHV

There are a few considerations for when a caregiver speaks a language that the NHV does not. If the caregiver speaks just a few words that the NHV does not understand, complete the DANCE observation. When appropriate, ask the caregiver what was said. If the caregiver speaks to the child throughout in a language that the NHV does not, then you cannot complete behaviors based on verbal communication such as Verbal Quality, Verbal Connectedness, and Negative Verbal Content. Other behaviors can be observed if you have sufficient information from behavioral information such as Praise, Responsiveness and Pacing. Positioning, Visual Engagement, and Negative Touch can be coded. Note on the coding form why those behaviors were not observable, and use the information that could be observed to guide clinical intervention planning.

6. Coding When a Translator is Present During the Observation

Similar to observing a client who speaks a language that the NHV does not, there are a few considerations when a translator is present at the visit. If the translator provides

Introduction 1.20


translation for conversations between the caregiver and child you are likely to be able to complete the entire DANCE observation. If the translator does not provide translation for the communications between the caregiver and child, code those behaviors that are not dependent solely on verbal communications as described in #5 above.

You may be able to observe DANCE behaviors when conducting home visits with interpreters if you are not able to understand the client’s communication to her child through the interpreter. If there is any concern that communications are not accurately conveyed by the translator, you may only be able to code behaviors that do not require observers to understand the content of what is communicated (e.g., positioning, visual engagement, negative touch).

The DANCE Scales and Operational Definitions The DANCE scales and operational definitions are organized by dimension, as indicated previously. For each DANCE behavior, an operational definition has been developed to provide the following information: Scale: The scale label, definition, and qualifiers for coding the behavior.

Theoretical Importance: A brief paragraph or two on the theoretical and empirical support for the behavior or characteristic. The theoretical importance of each behavior has been structured based on how the behavior supports two aspects of children’s development:

i. Enhancing the quality and maintenance of positive caregiver child interactions, and

ii. Supporting children’s physical, cognitive, social, and emotional development. Definition: The scale definition of the behavior or characteristics (this definition may be more detailed than the definition presented in the scale).

Terms to Define: Specific terms used in the definition of the measure or rating categories that are defined to ensure a common understanding by all raters.

Observational Parameters: Instructions on when and how the behavior or characteristic should be measured. Clients assume dual roles during home visits, that of a client and that of a caregiver. In the client role, focus is on interaction with the home visitor and the visit content. However, the caregiver role is the client’s primary role, even within the context of a home visit. It is expected that the caregiver attend to the child as needed. The client-nurse relationship requires multitasking between competing roles, and represents a proxy for how the client manages competing responsibilities in her daily life. DANCE coding is completed during the parts of the visit that the client is in the caregiver role. Most behaviors are coded while the caregiver and child are interacting with each other, while a subset are coded during the time the child is present, but not necessarily

Introduction 1.21


interacting with the caregiver. The standard statements for these observational parameters are:

P = Item is coded for the portion of the visit that the child is present, but not necessarily interacting with the caregiver. The caregiver is serving as the primary caregiver to the child during this time. CA = Item is coded for the portion of the visit (at least 5 and not longer than 8 minutes) that the caregiver and child are engaged in a caregiving activity. This can include a PIPE demonstration, diaper changing, feeding, playing, putting the child to sleep, holding or cuddling, etc. Play can include playing with toys, reading, singing, nursery rhymes, playing hand clapping games, etc. The activity can come about spontaneously but the nurse home visitor must consciously decide that this is the caregiving activity that will be observed for DANCE purposes. D = Item is coded only for those periods of interaction where the child exhibits distress.

Developmental/Child Considerations: Information on how the demonstration of the parenting behavior or child characteristic may differ as a function of children’s developmental stage or child characteristics.

Exceptions for Coding: Instructions on exceptions to rating guidelines.

Examples: This section includes written examples that serve to illustrate each behavior, including examples that highlight good and poor caregiving behaviors across developmental time points.

Introducing DANCE to Clients Typically, DANCE will be introduced to clients early in the program (during pregnancy) as part of the Maternal Role domain information. NHVs will discuss how they will partner with clients to help them understand how their babies communicate and how the clients responses to their children lay the foundation for the children’s growth and development. In this discussion nurse home visitors will share that they use a number of resources to do this, one of which is the DANCE. During pregnancy, the DANCE serves as a foundation for discussing the 18 “things” [or 4 “groups of things” (the four dimensions)] caregivers can do to support their children’s healthy growth and development. Following the birth of the child, the DANCE behaviors provide a framework and common language to discuss how the clients support their children’s growth and development. Other tools for promoting positive parenting include conversations with the caregivers, the use of parenting facilitators, Keys to Caregiving, PIPE, and Ages and Stages Questionnaires.

Introduction 1.22


From the beginning of the program, NHVs should share that part of their job is to record what is happening during visits and that some of the tools are filled out during the visit and some are completed after the visit. NHVs will use all of these tools to guide their observation, assist in their reflection, inform their practice, and in collaboration with the client, set agendas around aspects of child care and caregiving that are of greatest interest and importance to the client. DANCE EDUCATION Arc of Learning in DANCE Education Based on feedback from nurse home visitors, the DANCE Education program is a very intensive and rewarding experience. Learning a tool that is reliable, valid, and clinically meaningful and captures so many critical aspects of caregiving takes dedication and persistence. The DANCE Education model is designed to support development of knowledge and skill to successfully integrate the DANCE into nursing practice. The DANCE Education model consists of three components as outlined in the Table 2 below. Table 2: DANCE Education Model.

DANCE Preparation DANCE Fundamentals DANCE Integration • Four hours • Individual and team-based • Designed to prepare new

DANCE users for DANCE Fundamentals

• 24 hours (three days) • Face-to-face education • Designed to support learning

and implementation of the DANCE, develop DANCE observation and documentation skills, and support translation of DANCE observations into intervention strategies (DANCE STEPS)

• Six months • Individual and team-based • Designed to support mastery of

the DANCE and integration into practice

DANCE Preparation consists of individual and team-based learning activities completed up to 8 weeks before DANCE Fundamentals. Keys to Caregiving and DANCE Preparation are pre-requisites for attending DANCE Fundamentals. DANCE Fundamentals is an interactive face-to-face program with a fast-paced agenda designed to support learning and implementation of the DANCE tool as well as introduce the translation of DANCE observations into intervention strategies during home visits using the DANCE STEPS. The knowledge and skills gained during DANCE Fundamentals lay the foundation for using the DANCE in practice and creates a deeper understanding of caregiver-child interactions. However, DANCE Fundamentals is just a beginning for learning to incorporate this new dyadic observation and intervention framework into practice. DANCE Integration is a six month period following DANCE Fundamentals consisting of team and individual based learning activities to support nurses to incorporate the DANCE and DANCE STEPS into practice. The recommended DANCE Integration activities support mastery of the DANCE and integration into practice. Nurses who have previously learned the DANCE recommend utilizing the tool as soon as possible after DANCE

Introduction 1.23


Fundamentals and as often as possible in practice. This enables nurses to feel comfortable and confident using the tool with clients who have a wide range of parenting styles and skills. Strategies to support learning and adoption of DANCE into practice are woven throughout the entire DANCE Education program. General concepts and theories are introduced during DANCE Preparation and later built upon during DANCE Fundamentals and Integration. During DANCE Fundamentals, behaviors are introduced one dimension at a time, with the goal to practice observing using all 18 behaviors at the end of the three day training. There are frequent opportunities for discussion and questions while learning the details of the DANCE behaviors along with many practice opportunities for using the tool to observe caregiver child interactions. Regular breaks, along with learning activities and demonstrations, are dispersed throughout the training days to break the information learned into small, manageable chunks. DANCE Integration activities support review of the behaviors along with practice opportunities to begin to utilize the observation tool during home visits. Your supervisor and/or a Nurse Consultant will offer integration support for six months following the completion of DANCE Fundamentals. Videos Clips for DANCE Education The video clips we will be using throughout the education session were obtained from several sources. Most of the video clips shown during the education session were selected to highlight very specific behaviors. These specific clips are not meant to represent a caregiver’s overall caregiving qualities, but specific instances within the interaction when DANCE behaviors are present or absent at each measurement level. Coding tapes are longer in duration and are intended to represent the strengths and areas for growth of a caregiver. Denver Trial Videos Selected families from the Denver trial of the NFP graciously agreed to have their videos used for education of professionals working with at-risk families. The videos were obtained as part of the research component of the trial and therefore contain structured interactions in the home and lab settings. Most of the video clips are excerpts from a free play interaction in which mothers were provided with a standardized set of toys and asked to play with their child as they normally would at home. Mothers were encouraged to have themselves and their children facing the camera at all times. Dr. P.O. Svanberg Videos We are thankful to Dr. Svanberg and the families he has worked with for sharing their videos of caregiver-child interactions. The families in Dr. Svanberg’s sample are predominately younger than 6 months of age and a nice complement to the videos that reflect interactions with older children from the Denver trial. Most of the interactions were obtained in the families’ homes and the mothers were asked to interact with their children in a typical manner.

Introduction 1.24


Other Videos Clients from Colorado NFP sites agreed to have their NHVs videotape them interacting with their children during routine home visits. In addition, some video has been collected from non-NFP families who also have agreed to have their interactions recorded for use in the DANCE video training library. We are grateful to all of these families for letting us into their homes and sharing these interactions with us. Videos from the World Wide Web have periodically been used when our video sample did not provide examples needed to illustrate some DANCE behaviors. Selection of Example Clips for each DANCE Behavior During the DANCE training, trainees will view video examples (1-5 examples for each DANCE behavior) that help to define the behavior(s) they will observe. These video examples were selected by consensus agreement with 2-3 of the DANCE developers/educators and were endorsed by up to three additional members of the DANCE Development Team. Only those clips with consensus support and endorsement are presented as training examples. Scoring of Video Clips for Practice Coding and Proficiency During DANCE Fundamentals, learners will have several opportunities to practice using the DANCE based on their observations of videotaped interactions (practice coding). After viewing and coding the practice videotaped interactions, the DANCE Educators will review and discuss the “Gold-Standard” codes for each behavior. To obtain “Gold Standard” codes, each video-taped interaction was coded independently by 3-4 DANCE coders. The coders met to review and discuss discrepancies and to reconcile differences using consensus agreement. Obtaining DANCE Proficiency DANCE proficiency ensures that learners are prepared to use the tool in practice. One of the learning objectives of DANCE education is to establish proficiency in using the DANCE in observations of caregiver/child interactions. DANCE proficiency is determined by comparing trainee codes to the gold-standard codes. Percentages within 15% of the Gold Standard (or exact frequencies) are considered accurate. For dyadic observation, there is a level of acceptable variability across observers that does not impact the validity of the tool. For the DANCE, given the scale 0-100, a range of 15% around the Gold Standard is considered to fall within the range of acceptable validity. Following completion of DANCE Fundamentals, copies of learners’ coding sheets are submitted to the Prevention Research Center (PRC) for calculation of trainee proficiency. Proficiency results are provided to learners within four weeks following completion of DANCE Fundamentals. NHVs who are determined to be proficient are encouraged to immediately begin using the DANCE in NFP practice. NHVs who are not proficient following the completion of DANCE Fundamentals will be provided with specific behaviors that could benefit from review, will be offered support from a DANCE Educator, and will have up to three months to further demonstrate proficiency.

Introduction 1.25 © 2016 The Regents of the University of Colorado, a body corporate. All rights reserved.

Dyadic Assessment of Naturalistic Caregiver-child Experiences (DANCE) Coding Manual – Version 4.0 (08/2016)

DANCE Scale Behavior Definition Code

Em

otional Quality

Expressed Positive Affect CA Observable display (facial expression, verbal tone, body language, and gestures) that reflects low, mid, or high intensity pleasure.

• Qualifier: If the caregiver’s affect is not positive, note if it is angry, sad, flat, irritable/agitated, or bored %

Caregiver’s Affect Complements Child’s Affect CA The caregiver’s affect facilitates the maintenance of child’s positive to neutral affective state, and as needed, a return to child’s positive

to neutral affective state. %

Verbal Quality CA Caregiver’s verbal communication to child is kind, respectful, cheerful. If the caregiver does not vocalize during the caregiving activity, note N/A on the coding sheet. • Qualifier: If the caregiver’s verbal quality is not kind, respectful, cheerful, note if it is angry, flat, tense, annoyed, or disrespectful.

% or

N/A

Response to Distress D

Caregiver regulates her affect in response to child’s distress in a complementary manner. If no distress occurs, note N/A on the coding sheet. • Qualifier: If caregiver’s response to the child’s distress is not complementary, note if it is an over-, under-, or inappropriate

response.

% or

N/A

Negative Comments About the Child to Others P Caregiver’s use of overt criticism, accusations, threats, name-calling, and unrealistic developmental expectations of the child to others. #

Sensitivity and R

esponsivity

Positioning P Caregiver is positioned to be able to read child’s communications. %

Visual Engagement CA Caregiver’s visual attention is directed toward the child or a shared focus of interest. %

Negative Touch P Caregiver’s touch of the child is rough. #

Pacing CA The tempo of caregiver-child interactions is complementary to child’s behavior, activity level, & needs. • Qualifier: If the caregiver’s pace is not complementary, note if it is fast or slow. %

Non-Intrusiveness CA Caregiver does not intrude upon child’s activity, emotional, and physical space. %

Responsiveness P Caregiver response to child’s state, affect, communication is supportive of child’s needs. %

Regulation

Limit Setting P

Caregiver establishes and maintains limits for the child that address damage to property, harm to others, and safety of the child. If there was no opportunity for limit setting within the three categories (damage to property, harm to others, and safety of the child) note N/A on the coding sheet.

% or

N/A Completes Interactions P Caregiver provides closure to interactions. %

Promotion of

Developm

ental G

rowth

Supports Exploration P Caregiver facilitates exploration that meets the child’s needs. %

Scaffolding CA Caregiver attempts to provide support to promote success beyond what the child is able to do on his or her own. • Qualifier: Note if the caregiver provides developmentally inappropriate support (starts below or above where the child is

developmentally). #

Verbal Connectedness CA The caregiver's verbal communication creates a connection that facilitates interaction. % Praise CA Caregiver genuinely compliments the child. #

Negative Verbal Content P Caregiver use of overt criticism, accusations, threats, name-calling, and unrealistic developmental expectations of the child conveyed to the child. #

Observational Parameters: P= when child is present CA= when CG and child are engaged in a caregiving activity D=when distress occurs Codes: % = the proportion of time that the behavior occurred (0-100%) # = frequency or number of times that the behavior occurred (0, 1, 2, or 3)

Introduction 1.26


Sample DANCE Coding Sheet (Child’s age: 12 months)

Behavior Comments

Em

otional Quality

Expressed Positive Affect

CA Caregiver’s tone was positive throughout. Her facial affect was usually positive and she had a brief period in the middle of the interaction where she was flat.

Caregiver’s Affect Complements Child’s Affect

CA The child and caregiver demonstrated positive affect during most of the interaction. The caregiver was below the child’s affect a couple of times when the child was vocalizing and the caregiver responded with a low energy “Uh Hmm.”

Verbal Quality CA The caregivers’ verbalizations were always positive in tone and content.

Response to Distress D The child cried when the toys were being put away at the end of the interaction. The caregiver remained calm the entire time the child was crying.

Negative Comments About the Child to Others

P None heard


Positioning

P The child’s back was to the caregiver and the caregiver leaned around a lot of the time. There were a few brief times when the caregiver and child were sitting beside each other. This positioning was appropriate for the task and age of child.

Visual Engagement CA The caregiver’s gaze was often on the child and/or shared focus of interest. The caregiver was looking at her own book for a moderate period one time.

Negative Touch CA None

Pacing

CA The caregiver did let the child explore toys a lot of the time. She was slow in her pacing for a moderate time when she was looking at her own book and not engaging with the child and the book the child was interested in. The caregiver was briefly fast in the introduction of the ball and then the child joined in quickly.

Non-Intrusiveness CA The caregiver was briefly intrusive with a book in the middle of the interaction and briefly while introducing the ball. Both times the child was interested in other objects.

Responsiveness

P Most of the time the caregiver was usually responsive to the child’s need to engage with the toys. Her few brief intrusions limited her responsiveness. The caregiver was also unresponsive for two fleeting times during the interaction. There was some support of language and a few missed opportunities for praise.

Regulation

Limit Setting

P No opportunity to observe.

Completes Interactions P The caregiver said “all done” when she started picking up toys.

Promotion of

Developm

ental Grow

th Supports Exploration

P The play area was safe. A few toys were accessible to the child. The bag of toys was over by the caregiver and the caregiver always was the one to get toys out of the bag, limiting the child’s exploration occasionally. The child’s exploration was also limited by brief periods of intrusiveness.

Scaffolding CA No attempts to scaffold were noted.

Verbal Connectedness CA The caregiver did not talk a lot throughout the interaction with extended periods of silence. She spoke the most to the child when he was distressed. The quality of what she said to the child when she did speak was kind and respectful throughout.

Praise CA No praise heard. Negative Verbal Content P None heard.

P= when child is present CA= when CG and child are engaged in a planned caregiving activity D=when distress occurs

Introduction 1.27


DANCE CODING SHEET: ALL DIMENSIONS Behavior Comments Code

Em

otional Quality

Expressed Positive Affect CA

%


CA

%

Verbal Quality CA %

or NA

Response to Distress D %

or NA

Negative Comments About the Child to Others P #


Positioning P

%

Visual Engagement CA

%

Negative Touch P

#

Pacing CA

%

Non-Intrusiveness CA

%

Responsiveness P

%

Regulation

Limit Setting P %

or NA

Completes Interactions P

% Prom

otion of D

evelopmental G

rowth

Supports Exploration P

%

Scaffolding CA

#

Verbal Connectedness CA

%

Praise CA

#

Negative Verbal Content P

#

Observational Parameters: P= when child is present CA= when caregiver and child are engaged in a caregiving activity D=when distress occurs

Emotional Quality 2.1


EMOTIONAL QUALITY

Theoretical Importance

The Emotional Quality dimension is comprised of five caregiver behaviors including Expressed Positive Affect, Caregivers’ Affect Complements Child’s Affect, Verbal Quality, Response to Distress, and Negative Comments About the Child to Others. The behaviors in the Emotional Quality dimension are predominately observed through the caregivers’ affect or the verbal, facial, and behavioral (posture, eye contact) displays caregivers use to express their feelings and emotions.

The emotional quality of the dyad is critical for development of a trusting, secure relationship (Kochanska, 1998), for the development of children’s emotional and behavioral regulation (Eisenburg, Spinrad, & Eggum, 2010), and development of emotional understanding (Dunn and Brown, 1992). According to Kochanska (1998), when mothers respond to infants’ cues and dyads share more pleasant emotions and experiences together, the development of the infant’s attachment security is supported. Similarly, Isabella and Belsky (1991) have described the term interactional synchrony as a sensitively tuned “emotional dance” in which the caregiver responds to the infant’s signals in a well-timed, appropriate fashion and, in addition, both partners match emotional states, especially the positive ones. Interactional synchrony distinguishes children with regard to their attachment classification. These studies suggest that it is the combination of responsiveness and affective quality that supports the development of attachment security.

During the first two years of life children are rapidly learning how to be social partners with their caregivers. Caregivers play a significant role in this learning by supporting their children’s development of emotional and behavioral understanding and regulation. According to Dodge (1989), emotional self-regulation refers to the strategies we use to adjust our emotional state to a comfortable level of intensity so we can accomplish our goals. Behavior regulation can be thought of as the strategies we use to express our thoughts, feelings, beliefs, wants, desires, and states in ways that are acceptable to our society and facilitate goal attainment. As caregivers help infants regulate their emotional states, they also provide lessons on the social rules around expressions of emotions and behaviors. Parents support this learning in three ways: modeling affective responses that are predominately positive, helping children regulate their emotional and behavioral responses, and talking about emotional states (Eisenberg, Spinrad, and Eggum, 2010). Maternal interactions characterized by warmth (or positivity), sensitivity, and supportive responses with emotional coaching during distress are related to the development of children’s emotion regulation and effortful control (Eisenberg et al., 2005; Gaertner et al., 2008; Lengua, 2008; Spinrad et al., 2007).



Additionally, caregivers’ responses to children’s emotional disregulation (particularly negative disregulation) provide children with valuable information about expressions of emotion, strategies for regulating negative arousal, and social expectations for the display of negative emotions. Caregivers who are able to support their children’s distress by responding in a supportive manner are more likely to have children who demonstrate higher levels of emotional understanding and behavioral regulation as preschoolers than caregivers who do not support their children’s distress (Denham & Couchoud, 1991; Spinrad et al., 2004). The caregiver-child relationship offers the first opportunity for children to learn the rules and expectations for emotional expression and effortful control and it is the starting point for developing strategies for managing their emotions and behaviors.

Emotional Q

uality 2.3

© 2016 The R

egents of the University of C

olorado, a body corporate. All rights reserved.

Dyadic A

ssessment of N

aturalistic Caregiver-child Experiences (D

AN

CE) C

oding Manual – V

ersion 4.0 (08/2016)

Emotional Quality Dimension

Behavior Definition Code

Em

otional Quality


CA

Observable display (facial expression, verbal tone, body language, and gestures) that reflects low, mid, or high intensity pleasure. • Qualifier: If the caregiver’s affect is not positive, note if it is angry, sad, flat,

irritable/agitated, or bored

%


CA The caregiver’s affect facilitates the maintenance of child’s positive to neutral affective state, and as needed, a return to child’s positive to neutral affective state. %

Verbal Quality CA

Caregiver’s verbal communication to child is kind, respectful, cheerful. If the caregiver does not vocalize during the caregiving activity, note N/A on the coding sheet. • Qualifier: If the caregiver’s verbal quality is not kind, respectful, cheerful, then note if it is

angry, flat, tense, annoyed, or disrespectful.

% or

N/A


Caregiver regulates her affect in response to child’s distress in a complementary manner. If no distress occurs, note N/A on the coding sheet. • Qualifier: If the caregiver’s response to the child’s distress is not complementary, note if it

is an over-, under-, or inappropriate response

% or

N/A


P Caregiver’s use of overt criticism, accusations, threats, name-calling, and unrealistic developmental expectations of the child to others. #

Observational Parameters: P=when child is present CA=when CG and child are engaged in a caregiving activity D=when the child is distressed

Notes:



This Page Left Blank

Notes:



Emotional Quality Dimension EXPRESSED POSITIVE AFFECT Behavior Definition Code


CA

Observable display (facial expression, verbal tone, body language, and gestures) that reflects low, mid, or high intensity pleasure. • Qualifier: If the caregiver’s affect is not positive, note if it is

angry, sad, flat, irritable/agitated, or bored

%

CA=when CG and child are engaged in a caregiving activity Theoretical Importance:

Caregiver affect and non-verbal communications are a powerful means for caregivers to communicate with their children. Securely attached infants have mothers who express positive emotions (Ainsworth et al., 1978) and the expression of positive emotions by caregivers provides a strong foundation for development of healthful cognitive, social, and emotional growth in children. Caregivers who display positive affect while interacting with their children are more likely to have children who mirror their caregiver’s use of positive affect. The result is a mutually enjoyable experience for both caregiver and child. Caregiver positive affect also opens the opportunity for the child to interact with the caregiver, by offering positive cues that signal to the child that the caregiver invites further interactions. Positive affect facilitates feelings of being valued and accepted, leading to safety and contentment, the development of a positive worldview, and self-confidence.

Observation Parameters:

Item is to be coded for the portion of the home visit (at least 5 and not longer than 8 minutes) that the caregiver and child are engaged in a caregiving activity.

Terms to define:

Affect Display: The observable, physical representation of one’s emotional state. Affect is expressed verbally through tone of voice and nonverbally through facial expressions, gestures, and body movements.

Low Intensity Affect: Contentment, interest High Intensity Affect: Joy, excitement, surprise Pleasure: The state or feeling of being happy or gratified; an experience that creates a

positive feeling that one is motivated to re-create in the future.

Notes:



Angry: Characterized by displeasure, rage, irateness. The affect display may include a loud harsh tone, tense body posture, and tense verbal tone with short/brief communications (commands).

Sad: Overall caregiver affect is down, blue, easily prone to crying. This may include a slumped body posture, head down, low volume of voice, monotone or broken tone, teary, and downturned mouth.

Flat: Characterized by no emotional expression. Flat is not neutral, it is displeasure. For the purpose of DANCE, adults do not have neutral affect. Irritable/Agitated: Caregiver affect reflects frustration, impatience, annoyance. Body movements are jerky or fidgety, brow is furrowed, and tone is tense. Bored: Caregiver affect is characterized by the caregiver having down-turned eyes, glazed over expression, slumped posture and yawning.

Developmental Considerations: None for this item.

Exceptions for Coding: When the caregiver presents with flat facial affect and positive tone, the overall affective state for the caregiver should be coded as the predominant affect.

Written Examples: Expressed Positive Affect: (Pleasure) No Expressed Positive Affect: (Displeasure)

Example 1: A caregiver is bathing her 3-month old infant.

Caregiver frequently smiles and uses an upbeat and positive voice when bathing the child.

Caregiver frequently yawns, directs gaze away from the infant, and has flat affect and verbal tone during bath time.

Notes:



Expressed Positive Affect: (Pleasure) No Expressed Positive Affect: (Displeasure)

Example 2: A caregiver and her 14-month old child are playing with a foam puzzle.

Caregiver’s tone is animated and positive when the child struggles with putting a puzzle piece in the correct place. The mother looks on with interest (characterized by bright eyes, slightly upturned mouth), smiles and says, “Oh! So close! Let’s turn the puzzle.”

Caregiver seems irritated as she watches the child attempt to put a puzzle piece in the correct place, saying in an annoyed tone, “No, that’s wrong, it’s not supposed to go in that way. Do it this way.”

Example 3: A caregiver and her 22-month old child are engaged in a book reading activity (i.e., child is “reading” the story to the caregiver using pictures as cues).

Caregiver looks at the book pages with interest and pride as her child sits on her lap “reading” and identifying illustrations in the book.

Caregiver occasionally looks at the book pages with boredom, yawns several times, and frequently looks to the TV as the child sits on her lap interested in the book.

Notes:



Emotional Quality Dimension

CAREGIVER’S AFFECT COMPLEMENTS CHILD’S AFFECT Behavior Definition Code Caregiver’s Affect Complements Child’s Affect

CA The caregiver’s affect facilitates the maintenance of child’s positive to neutral affective state, and as needed, a return to child’s positive to neutral affective state.

%

CA=when CG and child are engaged in a caregiving activity

Theoretical Importance:

Infants become sensitized to emotional states through a natural process of social biofeedback (Gergely & Watson, 1996). This process occurs early in the infant’s life through repeated interaction with their caregiver(s). Caregivers model affect for the child and children mirror affect they are exposed to. A caregiver’s positive affect, especially when the child displays extreme affect, can help a child regulate his or her own affect. Furthermore, caregiver’s positive affective responses help to create mutually enjoyable experiences. Positive emotions create openness for the tendency to approach rather than to avoid (Lyubomirsky, King, & Diener, 2005). Affect regulation influences emotional, cognitive, and social development. Learning these skills helps the child understand and display appropriate responses when encountering a range of social situations.

Observation Parameters: Item is to be coded for the portion of the home visit (at least 5 and not longer than 8 minutes) that the caregiver and child are engaged in a caregiving activity.

Terms to Define:

Affect: Affect is an expressed or observed emotional response. Positive Affect: Observable display (facial expression, verbal tone, body language, and

gestures) that reflects low to high intensity pleasure. Complements: To act in a manner that is supportive, harmonizing, balancing (in a

manner that supports the child affectively). Child’s Neutral Affect: This definition applies to the child’s affect and represents

affective states such as content, drowsy, calm. The caregiver’s affect will be displayed along the continuum of displeasure to pleasure and is not categorized as neutral. Neutral affect is baseline affect; characterized by absence of extremes of

Notes:



emotional valence, but reflects contentment, engagement, interest (e.g., not disengaged, not flat).

Maintenance: The caregiver’s affect supports the child’s positive affective state. Typically, during interactions when the child is positively engaged, the caregiver’s affect “matches” the child’s in pleasure and intensity. If a child’s affect is flat, the caregiver should not be flat; caregiver should use positive affect to increase the child’s positive affect.

Returns to: The caregiver’s affect supports the child to move from a state of disregulation (negative affect, high intense positive affect) to a positive or neutral state.

Developmental/Child Considerations:

Young infants have limited capacity to regulate their own emotional states. They require sensitive, frequent, and prompt responses and support from parents. By 4 months of age, infants develop some capacity for self-regulation. Caregivers can maintain infants’ positive to neutral affect by displaying a range of affective responses including positive and empathic responses. Starting around 10 months, children begin social referencing, applying meaning to facial expressions and relying on the meaning to make decisions of whether to approach or withdraw from a social interaction. For example, if a child looks over at his mother and notices she is displaying fear as he climbs high up on the ladder, he will notice his mother’s negative affect and want to withdraw from the situation. If the child notices his mother’s happiness and excitement when greeting new people, the child is likely to reference his mother and approach the individuals. If the child notices his mother’s boredom or flat affect when playing with him, the child is likely to mirror his mother’s affect, withdraw from interaction with his mother, or become emotionally dysregulated. In the second year of life, children’s affect is more labile. Children are expressing a wider range of emotions and these are expressed verbally and non-verbally. Toddlers’ capacity to regulate their emotions increases toward the end of the second year. Their attention can be redirected or they can be distracted when experiencing distress. They also may require caregiver support for emotional regulation. This support may be empathic, positive, or a non-responsive affective response. At times, a caregiver who responds with little or no affect (e.g., ignoring a child during a temper tantrum) is an effective way to regulate a child’s emotions.

Exceptions for Coding:

None for this item.

Notes:



Written Examples: Caregiver’s Affect Complementing Child’s Affect

Caregiver’s Affect Not Complementing Child’s Affect

Example 1: A 5-month old infant is having a fussy morning after being up several times the previous night.

The caregiver soothes child, maintaining calm affect, in turn helping to calm the child and facilitate the child’s ability to nap.

The caregiver abruptly picks up the fussing child, with her brow furrowed, and tells the infant that if she had slept the night before she would not be so fussy now.

Example 2: A caregiver and 12-month old child are playing during a floortime activity.

The child is engaged with a cup stacking activity, and squeals with delight each time she places a smaller cup inside a larger cup. The caregiver mirrors the child’s happiness, smiling brightly and clapping in response to the child’s joyful vocalizations.

The child is engaged with a cup stacking activity and squeals with delight each time she places a smaller cup inside a larger cup. The caregiver provides the child with another cup to stack; her affect remains flat and matter of fact, with no reciprocation of the child’s happiness.

Example 3: A 19-month old toddler has a tantrum.

The toddler is upset after being asked to clean-up the toys he has finished playing with. The caregiver shows disengaged affect in response to the child’s tantrum, thereby not encouraging the tantrum and helping the child return to a neutral state.

The toddler is upset after being asked to clean-up the toys he has finished playing with. The caregiver responds to the child’s tantrum by tensing her face, narrowing her eyes, and becoming visibly irritated that the child is not listening to her request.

Notes:



Emotional Quality Dimension VERBAL QUALITY Behavior Definition Code

Verbal Quality CA

Caregiver’s verbal communication to child is kind, respectful, cheerful. • Qualifier: If the caregiver’s verbal quality is not kind,

respectful, cheerful, then note if it is angry, flat, tense, annoyed, or disrespectful.

% or

N/A


Infants and young children are attuned to the emotional tone of verbal communications. The use of positive verbal quality and tone provides children with a warm, nurturing environmental context and frame of reference for interpersonal interaction. Positive verbal quality, therefore, facilitates positive caregiver-child attachment and a sound foundation for social, emotional, and cognitive development. Additionally, caregiver use of cheerful, sing-song verbal communication styles with young children supports verbal development by presenting language in discrete phonemic components that children can more readily differentiate between, in turn facilitating child aptitude for learning language.



Terms to define:

Communication: The manner in which the caregiver expresses herself through words and sounds and includes both tone and content.

Kind: Content and tone is warm and loving. Respectful: Content and tone recognizes child’s needs and contribution to the

interaction. Cheerful: Content and tone is characterized by happiness, may be presented in a sing-

song fashion.

Notes:



Angry: Content and tone reflects displeasure, rage, and irateness. Flat: Content and tone lacks any emotional tone and is not positive. Tense: Caregiver content and tone is on-edge; characterized by anxiety, over-concern,

unease. Annoyed: Content and tone is characterized by frustration, impatience, irritability. Disrespectful: Being rude, impolite, discourteous, or mean-spirited in tone and/or

content.

Developmental Considerations: None for this item


If caregiver does not offer verbal communication to the child, a response of no verbal communication (N/A) is recorded.

Written Examples: Positive Verbal Quality Not Positive Verbal Quality

Example 1: A caregiver and her 4-month old infant are engaged in feeding.

The caregiver speaks to child with affection and warmth, saying, “Mmm, you like your bottle, don’t you!”

The caregiver speaks to child in a flat tone without emotional intonation, saying, “Go on, drink.”

Example 2: A caregiver and her 13-month old child are cleaning up toys before leaving for a doctor’s appointment at the end of the home visit. The child wants to continue playing with his favorite ball, but is told it is time to clean up. The child becomes upset and bites the caregiver out of frustration.

Caregiver uses a calm and respectful voice, telling the child, “Ow! That hurts Mommy. We need to be gentle and not bite. It is time to clean up now. We can play with your ball when we get back from the doctor.”

Caregiver uses an annoyed and irritated tone, and threatens the child, stating, “If you bite me, I bite back.”

Notes:



Positive Verbal Quality Not Positive Verbal Quality

Example 3: A caregiver and her 20-month old child are playing tea party.

Caregiver describes the child’s actions in a happy, positive, upbeat tone, “Thank you for the plate! Are you giving me the blue cup? Oh, you have put tea in it for me, thank you! This is delicious!”

Caregiver provides directive comments using an irritated tone, “No, the plate doesn’t go on the cup, it needs to be on the table. Don’t put the spoon in the cup; it belongs next to the plate.”

Notes:



Emotional Quality Dimension RESPONSE TO DISTRESS Behavior Definition Code


Caregiver regulates her affect in response to child’s distress in a complementary manner. • Qualifier: If the caregiver’s response to the child’s distress is

not complementary, note if it is an over-, under-, or inappropriate response.

% or

N/A

D=only when the child exhibits distress Theoretical Importance:

During distress the caregiver provides a secure base for the child to explore their feelings. This exploration allows children to begin to understand and deal with the various emotions they can experience. Caregiver’s regulated responses to children’s distress helps children to learn that they are supported when they are experiencing distress. Sharing a child’s negative feelings does not require a caregiver to join with the child. Children respond better to caregivers who express calm confidence as compared to expressing frustration or anger. Soothing of children’s distress is important for the immediate regulation of infant affect and is thought to be an important contributor to children’s development of emotion regulation (Jahromi, Putnam, and Stifter, 2004). Caregivers who are unable to regulate their own affective state in response to their children’s distress are at increased risk for child maltreatment/abuse. Caregiver’s use of calm guidance, distraction, or ignoring distress demonstrates regulated caregiver affect. Caregivers also are models of affect for children. Children will copy the behaviors they observe. They are more likely to express positive affect when they observe it frequently, even when they are distressed.


This item is coded only for those periods of interaction where the child exhibits distress. The rating is based on caregiver responses during the times the child is experiencing distress. If child does not experience distress during the home visit then a response of no distress observed is recorded.

Notes:



Terms to define: Regulate: Addresses caregiver’s ability to manage her own affect during distress. If the

caregiver remains calm during the distress period she is coded as regulating her affect regardless of her success in calming the child’s distress as long as her affect does not exacerbate the child’s distress. Caregiver’s regulation during the child’s distress requires the caregiver to understand and accept her emotional experience, to engage in healthy strategies to manage uncomfortable emotions when necessary, and to engage in appropriate behavior (e.g., soothing child when child is upset) when distressed. In this behavior, regulate is defined as adjusting or maintaining affect.

Affect: The observable, physical representation of one’s emotional state. Distress: Crying, screaming, and demonstrated anger are distress regardless of duration.

Prolonged fussiness is distress when it is sustained for at least 15 seconds. Prolonged fussiness is an episode of distress that may include a series of fussy utterances or a single prolonged utterance, either one lasting for at least 15 seconds. A child is considered calm and the distress ends when there are no negative vocalizations or negative actions for at least 15 seconds.

Complementary: Providing an emotional response that meets the child’s need or offsets the child’s distress in a sensitive manner (remaining calm when child is upset). The caregiver’s responses do not have to be successful in soothing the child.

Over-response: Caregiver’s response to child’s distress is characterized by frustration, anger, anxious/nervous behavior.

Under-response: Caregiver’s response to child’s distress is characterized by detachment, avoidance, minimal acknowledgement, lack of awareness. This does not include intentional ignoring which is sometimes used as a strategy for toddlers to help them calm down when acting out in challenging ways.

Inappropriate Response: Caregiver response to child’s distress is characterized by smiles, laughter, teasing, mocking, fear. These responses represent the caregiver internally being anxious or frustrated and not knowing how to handle their child’s distress.


At eight months, children begin to express more emotions. What was expressed as general distress in early months is now displayed as anger, distress, fear, and disgust. At this age, children rely on their caregivers to help them recover from strong emotions. Most children under 12 months have developed some self-regulation skills but often need caregivers to help with regulation of emotional extremes. This mutual regulation requires the caregiver to hold, comfort, or soothe the child to quiet their emotions.

Notes:



A caregiver’s non-response to toddler behavior that is disruptive (e.g., temper tantrums, oppositional behavior) may be a complementary response and not an under-response if the caregiver is intentionally not responding in order to avoid reinforcing the toddler’s disregulated behavior. Expectations for a child’s ability to self-regulate increase as the child becomes older. Ignoring a 21-month old child who is having a temper tantrum is acceptable. However, ignoring crying from a 6-month old child is unacceptable because the child requires additional support from the caregiver in regulating his/her distress.


If no distress occurs, note N/A on the coding sheet and move to the next behavior. Written Examples: Complementary Response to Distress Non-Complementary Response to Distress

Example 1: A 3-month old infant is crying in his crib.

The caregiver picks up the infant from the crib and gently cradles the baby, holding him close to her body and making soft, calm, soothing sounds.

Caregiver approaches the crib and gently pokes at the baby’s stomach, saying “Boo” several times in an upbeat, cheery tone, laughing and smiling.

Example 2: A caregiver and her 8-month old child are engaged in floor time play. The infant crawls and stumbles over a toy, bumping her nose and forehead on the floor. The child begins to cry.

The caregiver moves to child and gently picks her up, rubbing her back and saying in a soothing voice, “Oh, you’re OK. That block got in your way, didn’t it? I’ll kiss your nose to make it feel better.”

The caregiver remains seated and points and laughs at the child after she falls on her face and cries.

Notes:



Complementary Response to Distress Non-Complementary Response to Distress

Example 3: A caregiver is putting away groceries. Her 24-month old child sees her putting candy in the pantry and begins reaching and repeating “can-dy, can-dy!” The caregiver tells the child he may have candy later, after dinner. The child throws himself on the floor in a tantrum.

Caregiver calmly repeats once more, “We’ll have a piece of candy after dinner” and ignores the child’s tantrum, continuing to put away groceries.

Caregiver says, “Oh, come on! Stop it! No candy now. You need to calm down or you won’t get anything!” in an irritated tone.

Notes:



Emotional Quality Dimension NEGATIVE COMMENTS ABOUT THE CHILD TO OTHERS Behavior Definition Code Negative Comments About the Child to Others

P Caregiver’s use of overt criticism, accusations, threats, name-calling, and unrealistic developmental expectations of the child to others.

#

P= when child is present Theoretical Importance:

Caregiver’s comments about the child are reflective of the emotional climate offered to the child via the caregiver’s communications. Children are highly attuned to the emotional tone of language in their environments, an important contribution to child social, emotional, and cognitive development. Caregivers who share positive verbal comments about their children with others in the environment (e.g., partners, parents, visitors) facilitate positive dyadic interactions by providing children with positive emotional context. Conversely, caregivers who express negative comments about their children are more likely to experience less healthful caregiver-child interactions, with children being exposed to a less positive emotional environment. In addition, comments about the child also may illustrate the caregiver’s experience of being a caregiver. Caregivers’ expressions of positive comments about their children may suggest that the caregiver feels content with parenting; whereas caregivers’ use of negative comments about their children may reflect caregiver feelings of frustration or displeasure with their role as a parent.

Observation Parameters: This item is to be coded for the portion of the home visit that the child is present, but not necessarily interacting with the caregiver.

Terms to define:

Overt: Open and readily perceived; apparent, not ambiguous. Criticism: Statements that suggest fault; censure, disapproving comments including

judgments and negative statements. Accusation: A statement of blame.

Notes:



Threat: A statement of intent to inflict negatively inappropriate consequences; a warning of probable trouble.

Name-calling: The use of a name that carries a negative meaning with a purpose to belittle or humiliate. You can determine if the name is said with the intent to belittle or humiliate by considering the following:

o Caregiver’s tone (irritated, frustrated, annoyed, disappointment, anger), o Caregiver’s facial expressions (tense, annoyed, irritated), o Content of the rest of the caregiver’s communications around this comment, o History that you know this is something that frustrates the caregiver, o By asking the caregiver what the name means to her or her family.

Unrealistic Developmental Expectations: Verbalizations to others that communicate inappropriate beliefs or misattributions about the child’s ability given the child’s developmental capabilities.

Comments: Expressed verbalizations they may be offered in passing through dialogue or in direct response to questions posed by the professional or other people present in the home. Comments also may be offered in response to the child’s behavior.

Developmental Considerations:

None for this item.

Exceptions for Coding: None for this item.

Written Examples: Non-Negative Comments About the Child to Others


Example 1: A caregiver and health care professional are talking about how things are going with the caregiver and her 6-month old infant.

The caregiver shares, “I really love him a lot, and he really loves me, too. He gets fussy when I leave him at daycare, but his baby-sitter says he calms down right after I leave. And he’s always so happy to see me when I pick him up!”

The caregiver shares, “I really love him a lot, but am getting annoyed with him crying every time I leave him at daycare. I think he cries on purpose (accusation) so I cannot leave him with anyone else. He’s only happy if he’s with me, it’s getting to be a hassle.”

Notes:



Non-Negative Comments About the Child to Others


Example 2: A caregiver and health care professional are discussing strategies for an upcoming interview the client is preparing for, when the caregiver’s 11-month old child starts to vocalize frustration and points under the couch after her bottle rolls out of reach.

The caregiver states, “Oh, Jane is fussing, let me get her bottle. She’s so good at letting me know when she needs my help.”

The caregiver states “Oh, Jane is fussing, let me get her bottle. She’s such a cry baby (name-calling or criticism) when she does not get what she wants!”

Example 3: A caregiver gives her 15-month old son a small bowl full of dry cereal for a snack during the home visit. She asks the child to sit down and keep his cereal in the bowl and not make a mess. While the caregiver is talking with the health care professional, the child spills his cereal all over the kitchen floor.

The caregiver states, “Uh oh, the Cheerios spilled! He must have tipped the bowl over when he was reaching for juice. I must have put the cup too far out of reach.”

The caregiver states, “Ugh! I told him to sit down and not spill his Cheerios! (unrealistic developmental expectations) He’s so naughty. (criticism) He never does what I tell him to.” (unrealistic developmental expectations or accusation)

Example 4: A caregiver is visiting with her health care professional while sitting beside her 21-month old who is playing contently with cars on the floor.

The caregiver states, “He had a bad day at school today. It is hard to believe because he seems fine now.”

The caregiver states, “He had a bad day at school today. I bet he’s going to be a terror and so difficult to deal with after you leave.” (criticism)

Sensitivity and Responsivity 3.1


SENSITIVITY AND RESPONSIVITY


The Sensitivity and Responsivity dimension contains six behaviors including: Positioning, Visual Engagement, Negative Touch, Pacing, Non-Intrusiveness, and Responsiveness. Caregiving sensitivity has been defined as the ability to accurately perceive the child’s signals and to respond to these signals in prompt and adequate ways (Ainsworth et al., 1978). Sensitive and responsive parenting during infancy is associated with the development of trust and a secure attachment (e.g., Ainsworth, Bell, & Stanton, 1971; Bowlby, 1988). Caregivers who are sensitive and responsive to their children’s needs foster a sense of security and safety in their children. This sense of security and safety allows children to explore their world and learn from their experiences. The development of emotion regulation has been related consistently to sensitive caregiving and attachment security (Bell & Ainsworth, 1972; Braungart-Rieker et al., 1998; Bridges & Grolnick, 1995; Cassidy, 1994; Fish, Stifter, & Belskey, 1991). Sensitive responsive caregiving is caregiving that involves mothers’ responsivity to their infants’ cues and emotional reactions. This has been linked with lower negativity and more regulatory behavior (Kochanska et al., 2000; Spinrad et al., 2007). Furthermore, individual differences in maternal sensitivity and responsiveness have been associated with differential outcomes in children's self esteem (Cassidy, 1988), peer interactions (Jacobson & Wille, 1986; Rydell, Bohlin, & Thorell, 2005), and dependency (Sroufe, Fox, & Pancake, 1983). Caregivers who accurately read their babies’ cues, empathize with their infants, and respond sensitively to their babies’ signals are less likely to abuse or neglect their children and are more likely to read their children’s developmental competencies accurately, leading to fewer unintentional injuries (Peterson & Gable, 1998) and greater sensitivity.


3.2

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Sensitivity and Responsivity Dimension




Visual Engagement CA Caregiver’s visual attention is directed toward the child or a shared focus of interest. %


Pacing CA The tempo of caregiver-child interactions is complementary to child’s behavior, activity level & needs.

• Qualifier: If the caregiver’s pace is not complementary, note if it is fast or slow. %

Non-Intrusiveness CA Caregiver does not intrude upon child’s activity, emotional, and physical space. %


Observational Parameters: P=when child is present CA=when CG and child are engaged in a caregiving activity

Notes:



Sensitivity and Responsivity Dimension POSITIONING Behavior Definition Code



Responsive and sensitive caregiving begins with the caregiver positioning him or herself to be able to read and respond to the child’s communications and developmental needs. Good positioning communicates to the child that the caregiver is open and available to the child. An open position provides the opportunity for the interaction to be initiated and extended. An open position facilitates feelings of safety and security and supports the child’s capacity for interaction.

Observation Parameters: This item is to be coded for the portion of the home visit that the child is present (but not necessarily interacting) with the caregiver.

Terms to Define:

Positioned: A caregiver’s physical location or orientation in relation to the child; caregiver orients self or child so the child’s verbal and nonverbal communications can be read.

Read: Caregiver is able to see (and as the child is older) hear the child. Communication: A process by which a child conveys information to engage others and

convey meaning. Communication provides information about the child’s wants, needs, and desires. Communication is expressed verbally through voice and sounds, and non-verbally through wordless messages that include facial expressions, posture, gestures, motor movements, and eye contact.


The position of the caregiver is dependent on: • The developmental abilities of the child, • The context of the interaction (task and situation), and • Environmental (safety) considerations.

Notes:



A very young child needs close positioning (caregiver is facing the front or side of the child’s body) during caregiving activities for the caregiver to be able to see verbal and non-verbal cues. Older children are more independent and, as they acquire increased mobility and language abilities, greater distances between the caregiver and child are appropriate. For example, as children engage in exploration or independent play, caregivers may position themselves to hear their child’s cues and see large motor cues but may not be positioned to read subtle facial cues. Caregivers of older children must maintain the ability to hear or observe child communications. Positioning also may be dependent on the interaction context and environment. For example, older children learning a new task or reading books with their caregiver are likely to benefit from closer positioning that allows the caregiver to read the child’s facial cues. Similarly, closer positioning may be necessary when environmental safety considerations warrant.


Written Examples: Supportive Positioning Non-Supportive Positioning

Example 1: A 3-month old is bottle feeding.

The caregiver is cradling the child in his/her arms while sitting on the sofa during the bottle feeding.

The child is in a swing without the safety belt on. The back of the swing is facing mom, mom is talking with the home visitor. The bottle is propped up with a blanket.

Example 2: A caregiver and her 6-month old child are sitting on the floor playing.

The caregiver is sitting to the side of the child, in close proximity, during floortime. The caregiver is able to see the child’s face.

The caregiver sits to the side, and slightly behind the child. The caregiver is unable to see the child’s face without leaning in, which she rarely does during the floortime interaction.

Notes:



Supportive Positioning Non-Supportive Positioning

Example 3: A 20-month old toddler is playing with toys in the caregiver’s bedroom.

The child is sitting across the room from the caregiver. The room has been child-proofed and there is nothing that poses a safety risk to the child. The caregiver is able to see the child’s body and hear the child’s communications.

A toddler took a couple of toys and is playing in the caregiver’s bedroom with the door closed. There are some breakable items and personal electrical appliances (computer, flat iron, curling iron) that are within reach of the child. The caregiver and health care professional are in another room.

Notes:




VISUAL ENGAGEMENT Behavior Definition Code

Visual Engagement CA Caregiver’s visual attention is directed toward the child or a

shared focus of interest. %

CA= when CG and child are engaged in a caregiving activity Theoretical Importance:

Visual engagement includes gaze or eye contact with the child and joint attention on a shared focus of interest. Gaze communicates where an individual’s attention is focused. Visual engagement is fundamental to maintaining the child-caregiver interaction, and almost all communication emerges from this mutual reference point. Gaze directed toward the child, particularly to the child’s face, facilitates a sense of safety and comfort, and communicates to the child that his or her caregiver is aware and available. Visual engagement also supports cue reading and the caregiver’s ability to sustain interaction by identifying and focusing on activities the child finds interesting and engaging. Additionally, face-to-face contact provides the opportunity to teach the child about patterns of expression and communication. Joint attention on a shared focus of interest allows the dyad to foster a shared perspective and focus for the interaction, facilitating coordination and synchrony. Joint attention moves the infant’s exploration of the environment into a social context. Joint attention enriches the child’s exploration by moving this experience from a child-object experience to a child-object-caregiver experience (Schaffer, 1989).



Terms to Define:

Visual Attention: Visual attention refers to the caregiver actively looking at the child’s face, the child (which includes any part of the child’s body), or at the object the child is engaged with.

Shared Focus of Interest: An observation that the child and caregiver jointly experience (e.g., another person, book, toy, activity, looking out the window together, etc.).

Notes:



Developmental/Child Considerations: Visual engagement is dependent on the child’s age, fine and gross motor capabilities, and cognitive abilities. Around 4 months of age infants start to gaze in the same direction that the caregiver is looking, and caregivers begin to follow the child’s gaze as well. As the caregiver follows the child’s gaze, they often begin to comment on what the child is seeing, labeling the child’s world. For younger children (less than 4 months old), interactions that involve predominately face-to-face orientation between the caregiver and child is appropriate. As a child’s activity level and mobility increases, less face-to-face interactions occur as the child moves out to explore the world. For older children (> 4 months), increased shared focus of interest with shared objects helps to maintain a connection between caregiver and child during interactions while allowing the child to explore his or her world.


None for this item. Written Examples: Visual Engagement No Visual Engagement

Example 1: A caregiver is sitting beside her 4-month old who is lying on his back on the floor reaching for and holding toys.

The caregiver and child are in very close proximity and sharing face-to-face gaze. The caregiver is shifting focus between the child and toy during the interaction.

The caregiver is sitting at the child’s feet. The caregiver’s visual engagement is focused on the television while the child is holding and shaking a rattle.

Example 2: A caregiver and child are sitting together with a children’s book.

The 21-month old child is very interested in the book. The caregiver positions the child on his/her lap, with the child’s back against the caregiver’s chest. They sit together reading the book, both with their visual engagement focused on the pages of the book.

The caregiver has a 5-month old child positioned on his/her lap, with the child’s back against the caregiver’s chest. The caregiver sits and looks at the book and the back of the child’s head, while the child occasionally looks at the book as well as the toys in front of him.

Notes:



Visual Engagement No Visual Engagement

Example 3: A caregiver and 21-month old child are sitting on the floor playing with toys.

The toddler becomes significantly distressed but does not want to be held. Mom orients her visual engagement toward the child to be able to read the child’s cues.

The toddler becomes significantly distressed but does not want to be held. The caregiver walks away and goes to another room, unable to see the child.

Notes:



Sensitivity and Responsivity Dimension NEGATIVE TOUCH Behavior Definition Code


P=when child is present Theoretical Importance:

Negative touch can feel unsafe and unsupportive to children. It can be frightening or painful (Butterfield, Dolezal, & Knox, 2002). Negative touch can result in physical and emotional danger to the child, and leads to feelings of distrust in the caregiver-child relationship. A child who experiences negative touch may have low self-esteem and often has difficulty expressing or regulating emotions. Frequent negative touch can create increased levels of cortisol in children which impedes development and brain growth.

Observation Parameters: This item is to be coded for the portion of the home visit that the child is present, but not necessarily interacting with the caregiver.

Terms to Define: Touch: Physical contact through the caregiver’s body to the child.

Rough: Touch that has the potential for physical pain or harm (e.g., too firm of a grip, jolting movements, slap, forceful push away). It includes touch that is abrupt or awkward provided the awkward and abrupt touch has the potential for pain or harm.


None for this item.


Notes:



Written Examples: Non-Negative Touch Negative Touch

Example 1: A caregiver is changing the diaper of a 2-month old.

The caregiver gently lays the child on her back. Using smooth and slow movements she removes the child’s diaper.

The caregiver lays the child on her back and then abruptly lifts her legs by the ankles so that the child’s neck is bent. The caregiver removes the diaper and abruptly drops the child legs without any support.

Example 2: A caregiver and 17-month old are playing with puzzles on the floor.

The caregiver gently places her hand on the child’s to guide the placing of a puzzle piece. She lets go of the child’s hand when the child attempts to place the puzzle piece in the wrong spot.

The caregiver tightly grabs the child’s arm and pulls it back (rough) as the child attempts to place the puzzle piece in the wrong spot. The child responds with an “ouch.”

Example 3: The caregiver is helping a 9-month old stand.

The caregiver is beside the child, initially supporting the child’s upper trunk. The caregiver loosens her hold for a second to see if the child can balance, keeping her hands very close to the child’s body while doing so. The child loses balance and the caregiver replaces her hands under the child’s arms to support the child’s upper body.

The caregiver is beside the child, initially not holding the child. The child loses balance and the caregiver grabs the child by one wrist and lifts the child a couple of feet off the ground using a swinging motion and saying “Wee, you can fly.”

Notes:



Sensitivity and Responsivity Dimension PACING Behavior Definition Code

Pacing CA

The tempo of caregiver-child interactions is complementary to child’s behavior, activity level, & needs.

• Qualifier: If the caregiver’s pace is not complementary, indicate if it is fast or slow.

%


Pacing is a core component of maternal sensitivity. Appropriate pacing allows the child to anticipate the timing and predictability of the caregiver’s responses and develop trust in the interaction. Appropriate pacing also facilitates the development of children’s behavior regulation, self-efficacy, and maintenance of engagement in an interaction. Pacing may require the caregiver to down- or up-regulate a child’s emotions, behaviors, and/or activity level based on the child’s needs. Caregiver-child pacing in an interaction should match or be complementary, with the caregiver setting a pace that meets the child’s temperamental and state-based needs. Pacing experiences influence the formation of the child’s understanding of the turn-taking nature of human social interactions, and provides the child with the opportunity to be an active contributor to the caregiver-child interaction.



Terms to Define:

Tempo: The speed or rate of the caregiver response relative to the child’s expressed need. This includes the caregiver supporting turn-taking between herself and the child during the interaction.

Interaction: Initiation and maintenance of engagement with each other. Complementary: To act in a manner that is supportive, harmonizing, balancing,

matching (in a manner that supports the child). Behavior: Child’s actions, conduct. Activity Level: Child’s physical energy.

Notes:



Needs: Children’s needs are physical (food, shelter, human contact, safety) and psychological (self-esteem, exploration) in nature and are necessary to live a healthy life. Children express needs through verbal and non-verbal communication. Needs are distinguished from wants in that an unmet need would cause a clear negative outcome.

Fast: Taking a turn too early, before the child cues. Slow: Taking a turn too late or not at all.


The pacing of a caregiver’s responses to the child should be considered within the context of the child’s needs, behavior, and activity level. Consider the following: What is the child’s pace? Is caregiver’s pace helping the child move along with the activity or his/her play? Is the caregiver moving along with the child? Does the task warrant a different pace?

For example, caregivers of infants who are low reactive may attempt to pace the interaction more quickly in order to help the child engage more actively. Caregivers of children who are more active may attempt to slow the pace of the interaction to help the child focus and engage in the interaction. Pace also considers the length of the child’s and caregiver’s turn taking, the caregiver’s length of turn should match the child’s. For example, if a child “coos,” a caregiver’s response should be equally brief using a similar vocalization or single word. If the child provides lengthier or more elaborate vocalizations, the caregiver’s response should match this. The pace of the interaction is established by a series of initiations, pauses, and responses. Pausing is an important component of pacing regardless of who initiates the interaction. If the caregiver initiates, then the caregiver must pause to let the child respond. If the child initiates, then the caregiver must pause to let child complete their interaction. Caregiver responses also should match the complexity of the child’s behaviors. If the child claps once, a caregiver may clap once or twice but should not introduce a complex clapping sequence. Caregivers can create slightly lengthier or complex responses to scaffold growth, but the response to the child’s turn must be taken in the context of the child’s contribution to the interaction and his or her attention span for the activity. Caregiver responses should complement the content of the play along with the child’s interests. Good pacing does not require extension or expansion of play. It requires the caregiver to move along at a pace that complements the child’s pace or change the pace

Notes:



when the task or child’s needs warrant. Extension and expansion of play are considered in the behaviors Responsiveness and Scaffolding.


None for this item

Written Examples: Complementary Pacing Non-Complementary Pacing (Fast or Slow)

Example 1: A caregiver is feeding a 7-month old.

The caregiver offers the food from the spoon at a pace that allows the child to remain engaged in the feeding while at the same time pausing to allow the child to swallow and make cooing sounds.

The caregiver is feeding the child with little pausing. Caregiver offers the child a bite of food every time the child opens his mouth, even if it is an attempt to vocalize.

Example 2: A caregiver and 4-month old are playing peek-a-boo.

The child looks at the caregiver as the caregiver starts covering her own face with her hands and then moves to covering her head with a blanket. The child continues to show interest. The caregiver then begins to partially cover the child’s face with the blanket and pulls it off, pacing the interaction a little more quickly to help the child engage more actively in the interaction. The child reaches for the blanket, pulls it off his face, and shares a smile with the caregiver.

The child looks at the caregiver as the caregiver starts covering her own face with her hands and then moves to covering her head with a blanket. The caregiver pauses a long time before appearing and the child begins to lose interest by turning his head away. The caregiver then begins to partially cover the child’s face with the blanket and pulls it off several times in a row, going very quickly. The child becomes overwhelmed and attempts to roll over.

Notes:



Example 3: A caregiver and 18-month old are singing songs together.

The child is engaged in singing with the caregiver, vocalizing and adding hand and body actions. The caregiver pauses, allowing a child the turn to vocalize. When the child has taken her turn, the caregiver takes a short turn, repeating what the child says and adding some actions. The caregiver then says “it’s your turn” and pauses, waiting for the child’s response.

The child is engaged in singing with the caregiver, vocalizing and adding hand and body actions. The caregiver joins in, often singing over the child, with very little or no pausing. The caregiver is excited about the child joining in and adds new actions showing the child at the same time that the child is doing her own actions, which are different from the caregiver’s.

Notes:




NON-INTRUSIVENESS Behavior Definition Code

Non-Intrusiveness CA Caregiver does not intrude upon child’s activity, emotional and

physical space. %


Intrusive responses are a type of insensitive caregiving behavior. A caregiver who is intrusive is not being responsive to the child’s needs and imposes his or her own agenda. Caregivers who respect children’s interests, including their emotional and physical space, help children foster autonomy in their interactions with others and a sense of trust and security in relationships. Non-intrusive caregivers also create a sense of self-efficacy for their children as children learn that they are not passive recipients of their environments but can actively influence their caregivers and the environment. Intrusive caregiving behaviors are related to poor cognitive and academic achievement outcomes for children.



Terms to Define:

Intrude: Caregiver imposes own agenda regardless of the child’s cues, activity level, and needs. Caregiver responding to child’s needs for safety, health, and regulation are not considered intrusive.

Emotional space: Space needed to express a range of emotions and to seek autonomy. Physical space: The personal space each person needs to feel they are not being intruded

upon. A caregiver who looms, positioned so that his/her face is close to the child’s (closer than 8 inches), even if the child does not appear to be bothered by this, is violating the child’s physical space and would be considered to be intrusive.

Notes:



Developmental/Child Considerations: Non-intrusiveness considers the child’s mobility, understanding of cause and effect, and the need for autonomy. A non-intrusive caregiver of a younger child respects the child’s space and paces well. As children become mobile, violations of the child’s ability to explore and be autonomous also are considered intrusiveness. Parent non-intrusiveness refers to the parent’s ability to give structure to the interaction without over-controlling and diminishing the child’s autonomy. The caregiver’s agenda may override respect for the child’s interests as well as their physical and emotional space. Also, a caregiver’s expectation may exceed or under-estimate the child’s developmental ability, causing the caregiver to respond to the child in an intrusive manner.

Exceptions for Coding: None for this item. Written Examples: Non-Intrusiveness Intrusiveness

Example 1: A 14-month old child is playing with a shape shorting toy.

The caregiver hands a shape to the child with the opportunity to explore it independently and experiment placing it in the different holes.

The caregiver holds the top of the child’s hand, guiding the child to the hole that matches the shape the child is holding. The caregiver continuously provides directive statements to the child such as “No, not there, it goes here” and “Put it in this one.” When the child is unsuccessful in placing the shape in the hole, the caregiver takes the shape out of the child’s hand and places it in the correct hole herself.

Example 2: A caregiver is bottle feeding a 3-month old infant.

The caregiver holds the child in her arms, keeping her face at least 8 inches away from the child’s face.

The caregiver holds the child in her arms and leans in several times to kiss the child and blow on the child’s face, causing the child to choke and stop drinking from the bottle several times.

Notes:



Non-Intrusiveness Intrusiveness

Example 3: A 22-month old and his mother are playing pat-a-cake.

The caregiver says the words of the rhyme while at the same time demonstrating the actions. When the child is displaying different hand actions, the caregiver says “Look, try it like this,” gets the child’s attention, and demonstrates the actions again.

The caregiver says the words of the rhyme while at the same time demonstrating the actions. When the child is displaying different hand actions, the caregiver says, “Look, try it like this,” grabbing the child’s hands, clapping them together.

Notes:



Sensitivity and Responsivity Dimension RESPONSIVENESS Behavior Definition Code



Responsivity is an essential characteristic of the overall parenting role. Prompt, contingent, and appropriate responsivity is based on the child’s needs. Responsive caregiving is predictable, consistent, non-intrusive, and demonstrates awareness of the child’s needs. A component of responsive caregiving is reflected by the caregiver anticipating the child’s needs (e.g., hunger, safety, sleepiness) and offering responses before the needs are strongly expressed. Caregiver responsiveness demonstrates attunement to the child’s experience and strengthens the affective bond between caregiver and child. Responsiveness also increases the child’s sense of security and creates a willingness to engage in exploratory behavior. High levels of caregiver responsivity are associated with better development of a child’s social, cognitive, and language skills. Responsiveness helps to develop a child’s sense of competence and self-worth, enhances communication abilities, and leads to greater assertiveness and competence interacting with peers.


This item is to be coded for the portion of the home visit that the child is present, but not necessarily interacting with the caregiver.

Terms to Define:

Response: The caregiver’s behavioral and emotional reply or reaction to the child. State: Refers to the child’s state of consciousness or awareness. State describes a child’s

level of arousal: light and deep sleep, drowsiness, quiet and active alert, fussiness and crying.

Needs: Children’s needs are physical (food, shelter, human contact, safety) and psychological (self-esteem, exploration) in nature and are necessary to live a healthy life. Children express needs through verbal and non-verbal communication. Needs are distinguished from wants in that an unmet need would cause a clear negative outcome.

Affect: Affect is an expressed or observed emotional response.

Notes:



Communication: Communication is the process by which a child imparts information to engage others and convey meaning. In the context of this tool, the information considered describes the child’s state, wants, needs, and desires. Communication is expressed verbally through voice and sounds, and non-verbally through wordless messages that include facial expressions, posture, gestures, and eye contact.


As children become increasingly competent in their abilities to regulate their own behaviors, develop an understanding of cause and effect, and become increasingly competent in understanding and producing language, children’s expressions of their needs and caregivers’ responses will change. Children become increasingly competent in their communicative abilities and their self-regulatory skills during the first two years of life. In addition, short-term memory capacities increase drastically between birth and 8 months as children’s brains develop and they learn to organize their world. Therefore, the timing of parental responses changes during the course of the first two years. Infants under the age of 12 months will benefit from caregiver responses that occur with immediacy, where little time (within 5 seconds) has lapsed between the child’s expressed state, affect, communication, and the caregiver’s response. As children get older, timing of caregiver responses can be extended with consideration to the child’s needs and situation. Caregiver responses should still occur within a relatively brief period of time (10-20 seconds) unless there are extenuating circumstances (e.g., child is throwing a temper tantrum and caregiver is intentionally ignoring).


None for this item.

Notes:



Written Examples: Responsiveness (timely and sensitive)

Poor Responsiveness (not sensitive and/or not timely)

Non-Responsiveness (not timely)

Example 1: A caregiver and a 9 month child are sitting on the floor reading a book.

The child turns her attention from the book, looks at the caregiver, and smiles. The caregiver gazes at the child and smiles back immediately.

The caregiver glances at the child and says “Don’t look at me, focus on the book.”

The child turns her attention from the book, looks at the caregiver, and smiles. The caregiver continues looking at and reading the book.

Example 2: A 4-month old child is showing hunger cues.

The caregiver comments, “Oh, you must be getting hungry. Let me get your bottle ready so I can feed you.”

The caregiver comments, “It is not time to eat yet. You only ate an hour ago.” The caregiver then offers the child a pacifier, which the child refuses.

The caregiver continues playing with the child and the child’s fussing escalates.

Example 3: A caregiver and 17-month old child are sitting on the floor, surrounded by six different toys.

The caregiver pauses, letting the child choose a toy and then engages with the child and the selected toy.

The caregiver introduces a new toy while the child is engaged with another toy.

The caregiver does not offer any verbal or physical responses to the child’s selection and engagement with a toy. The caregiver sits by the child, looking off in the opposite direction from where the child is.

Support of Behavioral and Emotional Regulation 4.1


SUPPORT OF BEHAVIORAL AND EMOTIONAL REGULATION


The capacity to regulate emotion and behavior is believed to play a major role in the development of children’s social competence (Cassidy et al., 1992; Eisenberg & Fabes, 1992; Saarni, Mumme, & Campos, 1998) and problem behaviors (Eisenberg et al., 2001). Therefore, observing the role caregivers play in supporting their children’s behavioral and emotional regulation is an important aspect of competent caregiving. The Support for Behavioral and Emotional Regulation dimension captures this aspect of caregiving through the observation of two behaviors: Limit Setting and Completes Interactions. Maternal limit setting has been related to higher effortful control in children (Lengua et al, 2007) and caregivers who complete interactions with their children create predictability and routines for their children and foster security and trust. Completing interactions also enhances children’s ability to transition from one activity or experience to the next with less disruptive behaviors.

Support of Behavioral and Em

otional Regulation 4.2

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ssessment of N


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Support of Behavioral and Emotional Regulation Dimension


Regulation

Limit Setting

P

Caregiver establishes and maintains limits for the child that address damage to property, harm to others, and safety of the child. If there was no opportunity for limit setting within the three categories (damage to property, harm to others, and safety of the child) note N/A on the coding sheet.

% or

N/A

Completes Interactions P Caregiver provides closure to interactions. %


Notes:



Support of Behavioral and Emotional Regulation Dimension LIMIT SETTING Behavior Definition Code

Limit Setting

P Caregiver establishes and maintains limits for the child that address damage to property, harm to others, and safety of the child.

% or

N/A


The development of self-regulation is one of the primary goals of early childhood, beginning in infancy. Through social interactions with caregivers who establish clear, reasonable, and consistent limits on children’s behaviors, children begin to internalize rules, norms, and standards of behavior that will facilitate the development of self-initiated monitoring and self-evaluation necessary for self-regulation (LeCuyer-Maus and Houch, 2002). When limits become internalized they make children feel safe and allow the child to begin to anticipate events. Limit setting helps children understand that there are rules, and how the child can regulate his/her behavior to meet the expectations of the rules. Development of self-concept during toddlerhood also contributes to the capacity for self-regulation, including self-awareness and emotional awareness of wrongdoing; development of self-concept appears to be influenced by interactions during limit-setting as well (Houck & LeCuyer-Maus, 2002; LeCuyer & Houch, 2006; Stipek, Gralinski, & Kopp, 1990).


This item is to be rated for the portion of the home visit that the child is present (but not necessarily interacting) with the caregiver.

Terms to define:

Establishes: To initiate, start. Maintains: To continue, retain, keep in existence regardless of the child’s compliance to

the limit. Limits: Limits are stated or unstated rules, developed in response to a child’s action, that

facilitate safety of child and others and demonstrate respect for property.

Notes:



Damage to property: Child behaviors that cause or are likely to cause damage to property.

Harm to others: Child behaviors that cause or are likely to cause physical harm to others, which includes humans and pets.

Safety of the child: Child behaviors that are or are likely to be unsafe to the child. Developmental/Child Considerations:

None for this behavior Exceptions for Ratings:

If no limit setting opportunities occurred during the observation, note No opportunity to observe limit setting (N/A) on the scoring sheet.

Written Examples: Limit Setting No Limit Setting

Example 1: A 5-month old child rolls on the floor close to the floor lamp. The child reaches out, grabbing and pulling on the cord. The floor lamp wobbles a little.

The caregiver sees the child pulling on the cord, going over to the child saying, “No, that’s dangerous. It could hurt you.” The caregiver picks up the child, placing him back in the middle of the floor and provides a few toys that are within reach.

The caregiver looks at the child and then turns to the health care professional stating, “He is busy now that he is moving around the room.” The caregiver then shifts gaze away from the child to the health care professional.

Example 2: A 16-month old child becomes upset when her caregiver tells her it’s time to put away her toys and take a nap. The child hits the caregiver out of frustration.

After being hit, the caregiver tells the child, “Ouch! That hurts mommy! You need to be gentle. We don’t hurt people. It’s time to clean up now; we’ll play again after your nap.”

After being hit, the caregiver says nothing to the child and continues cleaning up the toys by herself.

Notes:



Limit Setting No Limit Setting

Example 3: A caregiver and her 23-month old child are cleaning up blocks after floortime play. The child throws blocks overhand, and with surprising force, at the wall. The caregiver says, “Joey, we don’t throw blocks, we take care of our toys. Put them in the box please.” The child throws the blocks again.

After the second time the child throws the blocks, the caregiver uses a calm voice and says, “Joey, we don’t throw blocks, we take care of our toys. It’s time to clean up. Do you want to hold the box while I put blocks away, or should I hold the box while you put blocks away?”

After the second time the child throws the blocks, the caregiver says, “Oh well, I guess I’ll just put them away.”

Support for Behavioral and Emotional Regulation 4.6





Support of Behavioral and Emotional Regulation Dimension COMPLETES INTERACTIONS Behavior Definition Code

Completes Interactions P Caregiver provides closure to interactions. %


Caregivers who complete interactions with their children create predictability and routines for their children and foster security and trust. This sense of security facilitates emotional and behavioral regulation. Furthermore, infants and toddlers learn best when they feel safe and can trust the adults who care for them (Zero To Three, 2008). Completing interactions also enhances children’s ability to transition from one activity or experience to the next with less disruptive behaviors.

Observation Parameters: This item is to be rated for the portion of the home visit that the child is present (but not necessarily interacting) with the caregiver.

Terms to Define: Closure: Bringing an interaction to an end, actively supporting transition to a new interaction. There are two times when a caregiver needs to provide closure. The first is when an activity ends. For example, if a caregiver and child are playing and it’s time for a bath, the caregiver needs to provide closure so the child knows they are done with play and moving onto something else rather than just picking the child up and moving to the bathtub. The second is when the caregiver or child leaves the activity. An example is when a caregiver and child are playing and the doorbell rings. Play is still going on but the caregiver is leaving and needs to let the child know she is going to get the door.

Closure doesn’t have to be grand; it can be simple such as saying “All done.” It just needs to communicate to the child that the activity is over.

Interaction: Occurs when either the caregiver or child initiates an interaction or there is an assumption that an interaction is taking place such as a diaper change even if the caregiver does not acknowledge the child. In this context, interaction is not defined by a single exchange that occurs between the caregiver and child but is characterized by big picture events which include all the exchanges that occur in a caregiving activity such as play, feeding, soothing, bathing, and others.



We do not observe Completes Interactions within an activity. For example, we are not observing during a feeding that the caregiver provide closure to peas, and then provided closure when moving to cereal, and then when moving to milk. We are observing the end of the feeding to see if the caregiver provided closure or not. Similarly for play, a caregiver and child may play with blocks, then move onto a ball, and then shift to playing with the cat. For this behavior, we are not looking for closure between each play activity but the entire play interaction when they are done. It’s not the mini transitions but the major ones at the end of feeding or play.

Developmental/Child Considerations: For young infants, verbal strategies are likely to be used to complete the interaction. The caregiver would tell the young child “All done” or “It is time to move on,” along with moving the child or task object. As children become older, can comprehend language, and are emotionally labile, adding physical and/or distraction strategies to verbal and physical strategies are expected. The use of games as well as shifting attention and focus are examples of distraction strategies.

Exceptions for Ratings: None for this item. Written Examples: Completion of Interactions No Completion of Interactions

Example 1: The phone rings just as a caregiver is finishing up changing her 2-month old infant’s diaper.

The caregiver says, “Oh, the phone is ringing! Let’s snap this last button – snap – all done with your change, now you’re all clean! Let’s go answer the phone!”

The caregiver snaps the last button on the outfit closed, and goes to answer the phone without providing any verbal explanation of what’s happening to the child.

Example 2: A caregiver and her 12-month old child are cleaning up toys after playtime.

The caregiver states, “It is time to clean up” and begins singing a song about clean up, asking the child to join in.

The caregiver puts away the toys, physically taking away ones that the child is holding, without verbal cues.



Completion of Interactions No Completion of Interactions

Example 3: A 24-month old child is engaged in art activity, the caregiver and child have plans to meet friends at the park for a play date in 15 minutes.

The caregiver offers the child a verbal transition, “Two more minutes to finish your picture, Jane.” After two minutes pass, the caregiver says, “Okay, time is up. Let’s put on our coats and go see our friends at the park!”

The caregiver doesn’t provide the child with a verbal transition. When it’s time to leave for the park, the caregiver puts away the child’s picture and dresses the child in a coat without verbal explanation of what’s happening.

Example 4: A caregiver is planning to bathe her 14-month old child who is engaged in play.

The caregiver holds up a plastic animal that the child always plays with during bath time and smiles. The caregiver runs toward the bathroom.

The caregiver picks up the child from the middle of the room and walks her down to the bathroom.

Promotion of Developmental Growth 5.1


PROMOTION OF DEVELOPMENTAL GROWTH


Vygotsky (1978) believed that developmental phenomena such as voluntary attention, memory, and problem solving have their origins in social interactions. Through joint activities with more mature and experienced partners, children master activities and learn the social rules of their society. Caregivers who provide support for their children’s development through their use of language, scaffolding, and supportive environments have children who demonstrate more sophisticated problem solving abilities, superior language scores, higher scores on measures of executive functioning, and better academic achievement (Bradley, 1999; Evans & Kantrowitz, 2002; Feldman et al., 1996; Tamis-LeMonda et al., 2005; Tamis-LeMonda et al., 2004). The Promotion of Developmental Growth domain captures five behaviors related to caregivers support for children’s developmental growth including: Supports Exploration, Scaffolding, Verbal Connectedness, Praise, and Negative Verbal Content.

Promotion of D

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Promotion of Developmental Growth Dimension


Promotion of D

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Scaffolding CA

Caregiver attempts to provide support to promote success beyond what the child is able to do on his or her own.

• Qualifier: Note if the caregiver provides developmentally inappropriate support (starts below or above where the child is developmentally)

#

Verbal Connectedness CA The caregiver's verbal communication creates a connection that facilitates interaction. %

Praise CA Caregiver genuinely compliments the child. #

Negative Verbal Content P Caregiver use of overt criticism, accusations, threats, name-calling, and unrealistic

developmental expectations of the child to the child. #


Notes:



Promotion of Developmental Growth Dimension SUPPORTS EXPLORATION Behavior Definition Code



A child’s exploration, in the context of the caregiver’s supportive actions, provides a setting for cognitive and social development. Infants whose mothers gently direct their attention and encourage them to manipulate the environment demonstrated greater sophistication in their play, language, and problem-solving skills during their second year (Tamis-LaMonda & Bronstein, 1989). Caregivers who provide environments with equipment and materials that are developmentally appropriate allow the child to explore the materials and equipment in ways that foster physical, cognitive, and social development. Materials that are accessible to children encourage child autonomy and self-efficacy.

Observation Parameters: This item is to be rated for the portion of the home visit that the child is present, but not necessarily interacting with the caregiver.

Terms to define:

Facilitates: Caregiver provides assistance, supporting when needed, and not inhibiting. Needs: Children’s needs are physical (food, shelter, human contact, safety) and

psychological (self-esteem, exploration) in nature and are necessary to live a healthy life. Children express needs through verbal and non-verbal communication. Needs are distinguished from wants in that an unmet need would cause a clear negative outcome.

Notes:



Developmental/Child Considerations: This behavior takes in to consideration the following:

• Does the child have a safe place to explore? • Are there developmentally appropriate materials and resources available to the

child? • Does the caregiver avoid interfering or preventing the child from exploring? • Does the caregiver provide support for exploration when needed?

For younger children, who are not yet mobile, exploration is focused on more immediate surroundings including self, toys, and other people. For older children, who are mobile, exploration is focused on the broader environment. Consideration of support of exploration should take into account areas accessible to the child and the quality (safe, developmentally appropriate) and quantity of toys or resources the child has available to explore.

Exceptions for Coding: None for this item. Written Examples: Supports Exploration Does Not Support Exploration

Example 1: A caregiver and 3-month old child are playing with toys.

The child is lying on his back. The caregiver offers the child a rattle that the child is able to grasp and manipulate (e.g., toy is not too large) and caregiver allows the child to hold and mouth the toy. The caregiver returns the toy to the child when it is dropped and falls out of the child’s reach.

The child is lying on his back. The caregiver places several toys off to the side out of reach of the child. The child rolls to his side and is unable to roll all the way over to be able to get the toys.

Notes:



Supports Exploration Does Not Support Exploration

Example 2: A caregiver and her 21-month old are reading books.

The caregiver lets the child explore a book. The child holds the book upside down and turns the pages independently, sometimes two or three pages at a time. The caregiver comments about what she sees on each page.

The caregiver does not let the child explore a book. The caregiver turns the book right side up when the child was holding the book upside down. The child begins turning pages, sometimes two or three pages at a time. The caregiver says, “You missed some” and turns back to the pages that were skipped.

Example 3: A 15-month old child is playing in the room while the caregiver and health care professional visit.

The caregiver has placed developmentally appropriate toys in a basket on a low shelf that is accessible to the child. The caregiver allows the child to remove and explore the toys as desired.

The caregiver has placed several toys on a shelf that is out of reach to the child. The child points and fusses, pointing at the toys on the shelf. The caregiver continues visiting with the health care professional, ignoring the child’s request. The child becomes increasingly distressed and throws himself down on the floor.

Notes:



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Notes:



Promotion of Developmental Growth Dimension SCAFFOLDING Behavior Definition Code

Scaffolding CA

Caregiver attempts to provide support to promote success beyond what the child is able to do on his or her own.

• Qualifier: Note if the caregiver provides developmentally inappropriate support (starts below or above where the child is developmentally).

#


Through the practice of scaffolding, caregivers support children’s development by extending children’s learning in ways that are consistent with children’s current level of development. Scaffolding often allows children to participate in activities or tasks that they would not typically be able to do on their own (at least initially), but could accomplish with the help of their caregiver. Infants whose mothers gently direct their attention and encourage them to manipulate the environment demonstrated greater sophistication in their play, language, and problem-solving skills during their second year (Tamis-LaMonda & Bronstein, 1989). From an emotional and behavior regulation perspective, scaffolding children’s emotional experiences by providing support and structure that is well matched to the child’s needs may result in the development of internalized strategies for dealing with challenge and distress. These internalized strategies support increasingly independent regulatory strategies on the part of the child. Children who have not received this scaffolding may be more likely to develop maladaptive regulatory patterns (Cole et al., 1994).


Item is to be rated for the portion of the home visit (at least 5 and not longer than 8 minutes) that the caregiver and child are engaged in a caregiving activity.

Notes:



Terms to define: Attempts: Caregiver offers developmentally appropriate support that builds on the

child’s demonstrated interests. The child may or may not follow. When coding, you count each attempt that the caregiver teaches or supports the child to go one step further.

Support: Caregiver provides assistance that is developmentally appropriate, meeting the child’s specific circumstance or needs.

Promote Success: To provide structure and support to start where the child is developmentally and using incremental expansion to not jump too far ahead.

Developmentally Inappropriate Support: Caregiver offers support that starts below or above where the child is developmentally. For example, it would be considered developmentally inappropriate for a caregiver to continuously make requests to a child to complete a task the child has already demonstrated. It is also developmentally inappropriate for a caregiver to make requests of the child that are far below the child’s developmental abilities or to start where the child is and expand far above the child’s developmental abilities.


With very young infants, you may not see many instances of scaffolding. However, caregiver responses to the child’s needs constitute the foundations for scaffolding. Examples of this type of scaffolding may include the caregiver supporting (scaffolding) the child’s ability to soothe by helping the child to transition from supported-soothing to self-soothing (introducing child’s thumb, distraction). Scaffolding for very young infants may also include visual tracking, imitation of facial expressions, cooing or babbling to work on new sounds, tummy time that includes offering a strategy to encourage the child to raise her head, reaching for an object, and grasping and releasing. For infants starting around 7 months of age, scaffolding also may include the presentation of an object followed by caregiver verbalizations that expand the child’s exploration and understanding of the object. This is known as labeling.


This item is scored based on the frequency of occurrence, not on the percentage of time the behavior occurred.

Notes:



Written Examples: Supportive Scaffolding Non–Scaffolding

Example 1: A caregiver and her 18-month old child are looking at a book about farm animals.

The child comments on a picture saying “Cow.” The caregiver replies, “Yes, that’s a cow, that’s a brown cow. Cows say ‘moo’. Can you say ‘moo’?”

The child comments on a picture saying “Cow.” The caregiver replies, “Yes, that’s a cow” and turns the page.

Example 2: A caregiver and her 21-month old child are playing with a shape sorting toy.

The child tries to put a shape in the wrong hole. The caregiver points to a hole in the shape sorter and says, “Why don’t you try this hole?” The child picks up a different shape and the caregiver moves the shape sorter so that the correct hole is in front of the child. Caregiver says, “That’s the circle. Can you put it in the hole?” The child attempts to place the circle into the hole. Caregiver says, “Try turning it a bit” and motions with her hand.

The child tries to put a shape in the wrong hole. The caregiver takes the shape from the child and puts it in the correct hole. Then the caregiver picks up three shapes and quickly drops them all in their correct holes and says, “See, now you put these five in.” Child picks up one of the shapes and tries to put it in the wrong hole. Caregiver says, “No,” takes the shape and drops it in.

Example 3: A 4-month old child is in a bouncy seat and is beginning to fuss. A caregiver is trying to complete some paperwork during the visit.

The caregiver talks to the child in a gentle voice while completing the form saying, “Just one more minute and I am going to come pick you up. Here’s your favorite blanket to hold onto while you are waiting. Caregiver continues talking until the form is completed and then she immediately picks up the child and says, “There you go.”

The caregiver talks to the child in a matter-of-fact tone saying, “You’re fine, now hush your fussing.” The caregiver then continues to fill out form.

Notes:



Supportive Scaffolding Non–Scaffolding

Example 4: A caregiver and a 5-month old child are sitting on the floor together. The child is learning how to sit on his own and has not yet mastered this skill.

The caregiver is sitting to the side and slightly behind the child. The caregiver’s leg is extended behind the child for support and to prevent the child from falling over. The caregiver places her hand gently on the child’s back, helping to stabilize the child’s upper body.

The caregiver is sitting directly beside the child. The child keeps falling over on his side, landing on a cushion. Every time this happens the caregiver reaches over to return the child to a sitting position and then removes her hands from the child’s body. Each time the caregiver does this, the child leans over and then eventually topples all the way over on his side.

Notes:



Promotion of Developmental Growth Dimension VERBAL CONNECTEDNESS Behavior Definition Code

Verbal Connectedness CA The caregiver's verbal communication creates a connection

that facilitates interaction. %


From birth, children are prepared for the task of acquiring language. Newborns are especially sensitive to the sounds of human speech and are able to recognize and respond to their own caregiver’s voice. Children enjoy listening to caregivers and will orient themselves toward their caregiver when they hear their caregiver’s voice. Children’s marked interest in speech (including orienting toward the caregiver) encourages parents to talk to them. Caregiver’s verbal communication strengthens children’s readiness to acquire language, strengthens the bond between the child and caregiver, encourages sharing, and helps to initiate and maintain engagement in interactions. The number of words children hear during their first few years of life are related to their language acquisition, school readiness, and academic achievement (Hart and Risley, 1995).

Observation Parameters: Item is to be rated for the portion of the home visit (at least 5 and not longer than 8 minutes) that the caregiver and child are engaged in a caregiving activity.

Terms to define:

Verbal: The use of audibly expressed spoken words, language, and sounds. Communication: Communication is the process by which a caregiver sends messages to

the child. Communication for this item is expressed verbally. Connection: Communication is used to establish a sense of joint involvement and

engagement that supports continuing interaction. Verbal connection is determined by both the quality and quantity of the caregiver’s communications.

Interaction: Initiation and maintenance of engagement between a caregiver and child.

Notes:



Communications that Do Not Create

Verbal Connectedness Communications that Create

Verbal Connectedness • Communications to the child that have

poor verbal quality (commanding, harsh, punitive, mean, etc.)

• Communications to the child that have positive verbal quality (respectful, kind, cheerful)

• Communications that are not child centered

• Communications that are child centered

• Too many or too few communications to the child

• Regular communications to the child that include pauses

Developmental Considerations:

Children are born with a capacity that supports their interest and engagement in caregiver’s communications. For newborns, verbal communications between the infant and caregiver provides comfort and security to the infant and supports the foundation for the development of self-efficacy. In interactions with newborns, caregivers support a verbal connection by talking and singing to the baby and responding verbally to babies’ cues. Around 2 months of age children begin to “coo” and around 6 months of age they begin to babble. During this time, caregivers begin to listen and take turns with their young children through verbal exchanges. A verbal connection is supported when caregivers allow the child their “turn” in the interaction. Additionally, caregivers continue to talk and sing to their children and respond verbally to cues. Around 12 months, children become capable of intentional behavior, and they start to use gestures and words to communicate with their caregivers. When caregivers respond, the child learns that using language can result in a desired outcome. The transition from babbling to language is facilitated largely by verbal connections with children’s caregivers. Verbal connections are established with children when caregivers allow conversational turn-taking; when caregivers respond to children’s verbal and non-verbal communications in simple, clear, descriptive, supportive statements; and when caregivers expose children to a range of language and language-based experiences (singing, book reading, and conversations with others). As the child’s language expands, the caregiver’s use of words and sentence structure becomes increasingly complex.


Notes:



Written Examples: Good Verbal Connectedness Poor Verbal Connectedness

Example 1: A caregiver sings to her 3-month old.

The caregiver sings two lines of a song and then pauses, providing the opportunity for the child to respond. The child makes a cooing sound. After the child’s response, the caregiver offers a verbal comment, “That’s right” and continues to sing a few more lines of the song.

The caregiver begins singing a song and the child vocalizes. The caregiver keeps singing, over-talking her young child, and not facilitating the connection.

Example 2: A caregiver sings a song with her 18-month old.

After the caregiver finishes the first song, she asks, “Do you want to hear more?” The child shakes his head and says “No!” The caregiver stops singing.

After the caregiver finishes the first song, she asks, “Do you want to hear more?” The child shakes his head and says “No!” The caregiver starts another song.

Example 3: A caregiver is sitting with her 12-month old during mealtime.

Between bites of food, the caregiver talks to the child about the trip they had to the zoo earlier that day. The caregiver pauses frequently, waiting for the child’s response.

Between bites of food, the caregiver uses discouraging or overly directive language such as “Don’t put your cup there,” “You need to use your spoon.”

Notes:



Promotion of Developmental Growth Dimension PRAISE Behavior Definition Code

Praise CA Caregiver genuinely compliments the child. #


Praise, in the form of compliments, offered by the caregiver to the child creates a sense of warmth in the relationship. Through compliments children develop a sense of self-esteem. Praise can help to guide children’s emotional and behavioral responses by reinforcing those behaviors that are valued in the social environment. This process facilitates the development of emotional and behavioral regulation. Praise supports children’s learning of cause and effect relationships and helps to maintain involvement in interactions with objects and people.


Item is to be rated for the portion of the home visit (at least 5 and not longer than 8 minutes) that the caregiver and child are engaged in a caregiving activity.

Terms to define:

Genuinely: Authentically, sincerely, heart-felt. Compliments: Expressions of praise, admiration, or congratulations. Includes clapping

or gestures (e.g., thumbs-up, high-five, clapping) in response to child’s attempt or achievement of a task or activity. Includes general expressions of praise (“What a good boy,” “You are such a pretty baby”) as well as specific expressions (“Nice work putting the shape in the hole”).

Expression: An expression is a single sentence or action. When there is a pause between expressions, this would be counted as two instances of praise. For example, when a caregiver says “All right, way to go” without pausing, this would be counted as one expression of praise. When a caregiver says, “All right,” pauses, and then later adds “You did it,” this would be counted as two expressions of praise.

Developmental/Child Considerations: None for this item.

Notes:



Exceptions for Coding: This item is scored based on the frequency of occurrence, not on the percentage of time the behavior occurred. Thank You is coded as praise when the caregiver offers it in response to a request she has made to the child. For example, if the caregiver asks the child to hand her the block, the child does it, and then the caregiver says “Thank You,” this is counted as one expression of praise. In contrast, if the child walks over to the caregiver and hands her the block without any request made from the caregiver and the caregiver says “Thank You”, this is not praise; it is considered a social convention.

Written Examples: Praise Non-Praise

Example 1: A 15-month old is learning to feed himself with a spoon.

As the child brings the spoon to his mouth, getting some food in his mouth and some dropping on his bib, the caregiver says, “Nice try. You are getting so good at using the spoon.”

As the child brings the spoon to his mouth, getting some food in his mouth and some dropping on his bib, the caregiver says, “You’re messy.”

Example 2: A caregiver asks a 23-month old to put his dirty diaper in the trash.

The child walks over to the trashcan and puts in the diaper. The caregiver looks at the child, claps, and says “Great job." You are such a good helper.”

The child walks over to the trashcan and puts in the diaper. The caregiver looks at the child and says, “All done.”

Example 3: A caregiver and 18-month old are playing with a shape sorter toy.

The caregiver asks the child to put the circle shape in the circle hole. The child is successful in meeting the caregiver’s request and the caregiver says, “Thank you.”

The child attempts to put the circle shape in the circle hole and is unsuccessful. The child hands the shape to the caregiver, nonverbally asking the caregiver for assistance. The caregiver takes the shape and says, “Thank you.”

Notes:



Promotion of Developmental Growth Dimension NEGATIVE VERBAL CONTENT Behavior Definition Code

Negative Verbal Content P

Caregiver use of overt criticism, accusations, threats, and name-calling and unrealistic developmental expectations of the child conveyed to the child

#


Negative verbal content increases a child’s production of stress-related hormones, inhibiting brain development (Barish, 2009). Criticism misattributes characteristics of behavior to child intentions and motivations. Parental criticism is significantly related to emotional, behavioral, and social problems (Baker, Heller, & Henker, 2000; Peris & Baker, 2000; St. John-Seed & Weiss, 2002). Maternal criticism is related to maternal stress and the quality of the caregiver-child relationship. Threats create fear and children withdraw socially and emotionally. Persistent negative verbal content contributes to demoralization, resentment, and defiance, decreasing child’s self-confidence and initiative (Barish, 2009).


This item is to be rated for the portion of the home visit that the child is present (but not necessarily interacting) with the caregiver.

Terms to define:

Overt: Open and readily perceived; apparent; not ambiguous. Criticism: Statements that suggest fault; censure; disapproving comments including

judgments and negative statements. Accusation: A statement of blame. Threat: A statement of intent to inflict negatively inappropriate consequences; a warning

of probable trouble. Name-calling: The use of a name that carries a negative meaning with a purpose to

belittle or humiliate. Name-calling when considered an objective term of endearment (e.g., “my little potato”), will not be considered name-calling. You can determine if the name is said with the intent to belittle or humiliate by considering the following: o Caregiver’s tone (irritated, frustrated, annoyed, disappointment, anger),

Notes:



o Caregiver’s facial expressions (tense, annoyed, irritated), o Content of the rest of the caregiver’s communications around this comment, o History that you know this is something that frustrates the caregiver, o By asking the caregiver what the name means to her or her family.

Unrealistic Developmental Expectations: Verbalizations to the child that communicate inappropriate beliefs or misattributions about the child’s ability given the child’s developmental capabilities.

Developmental/Child Considerations: None for this item. Exceptions for Coding:

This item is scored based on the frequency of occurrence, not on the percentage of time the behavior occurred.

Written Examples: Non-Negative Verbal Content Negative Verbal Content

Example 1: A 17-month old is having a temper tantrum.

The caregiver says, “You better calm down” in an irritated voice.

The caregiver states, “You better calm down or I will spank you.” (threat)

Example 2: A 12-month old crawled over to a shelf and pulled down a trinket. The trinket hit the floor and broke.

The caregiver looks at the child and says in a singsong voice, “Uh oh. We had better clean that up. Let’s not play with those any more.”

The caregiver looks at the child and says, “You’re so clumsy – you broke it.” (accusation)

Example 3: A 4-month old child is fussy during most of the home visit.

The caregiver says to the child, “I’m not sure what is wrong with you today.”

The caregiver says to the child, “Stop being such a cry baby.” (name-calling)

Getting Started with DANCE 6.1 © 2016 The Regents of the University of Colorado, a body corporate. All rights reserved.


GETTING STARTED WITH DANCE The knowledge and skills you have gained from DANCE Fundamentals is a great start to using the DANCE in practice and to a deeper understanding of caregiver-child interactions. However, DANCE Fundamentals is just the beginning to supporting your incorporation of this new dyadic observation and intervention framework into your practice. There are several things that can facilitate this transition. This section provides information and recommended activities to support mastery of the DANCE and integration into practice. TRANSITION TO USING THE DANCE DURING A HOME VISIT During DANCE Fundamentals training, you practiced using the DANCE to code dyadic interactions from videotaped interactions. This helped you to become familiar with the tool and develop skills and confidence to be able to objectively observe and record your observations. As you complete training and transition to using the DANCE during home visits, the following considerations should be kept in mind.

• Ensure DANCE Observational Requirements are Met • Utilize DANCE Observational Parameters • Prepare for Variable Duration of Caregiver-Child Interactions • Manage the Dual role of DANCE Observer and Nurse Home Visitor • Recognize and Assess Distractions

Ensure DANCE Observational Requirements During DANCE Fundamentals you did not have to consider the DANCE observational requirements when coding a videotaped interaction as all observations coded during training are considered codeable. However, during a home visit you will need to determine if all observational requirements are met and the visit is codeable. These requirements include:

• Child Available for Interaction: The child must be present, awake, and available to interact with the caregiver for at least half the visit.

• Caregiver is Active Caregiver: The caregiver is acting as the caregiver during the interaction period. For example, the grandmother or father of the child is not taking primary care of the child during the observation period.

• Familiar Location: The visit should take place where the caregiver and child are currently living (preferred) or in a familiar location.

• Routine Visit: Neither caregiver or child should be experiencing any unusual acute social or medical issues. If the client experiences chronic social or medical issues, then dealing with these issues during the visit does not disqualify the visit for DANCE coding.

• Caregiving Activity: A caregiving activity, lasting at least 5 minutes, must occur during the visit (e.g., diapering, feeding, play, reading, putting the child to sleep, holding or cuddling, PIPE demonstration).

Ensuring that these requirements are met to complete a DANCE observation may require advanced planning to ensure the child is present, awake, and available to the caregiver during the visit. Your plans to complete a DANCE observation need to be flexible to ensure all of



the observational requirements can be met. If they are not met, prepare to complete a DANCE observation at a future visit. Utilize DANCE Observational Parameters When coding from video, only the caregiving activity is shown. In the home, most behaviors are observed during the caregiving activity (noted as “CA” on the DANCE coding sheet), however some are observed during the entire time the child is present (noted as “P” on the DANCE coding sheet), and one behavior is observed when the child is distressed at anytime during the visit (noted as “D” on the DANCE coding sheet). Preparing to observe DANCE behaviors requires you to review the DANCE Coding Manual and DANCE Coding Sheet to familiarize yourself with the observational parameters assigned to each behavior. Prepare for Variable Duration of Caregiver Child Interactions When coding videotaped interactions during DANCE Fundamentals you were told, before viewing, the exact duration of the interaction. The duration of the caregiving activity and the time the child is present will vary across home visits. Guidance for the length of the caregiving activity is at least 5 and not longer than 8 minutes. If the caregiving activity continues beyond 8 minutes, stop observing the DANCE behaviors assigned with the observational parameter of “CA” (when CG and child are engaged in a caregiving activity) and continue observing the behaviors assigned with the observational parameter of “P” (when child is present) and “D” (when distress occurs). The caregiving activity does not need to end after 8 minutes but the remainder of the time will not be considered in the code for behaviors observed during the caregiving activity. The skills you gained during DANCE fundamentals will support your transition from observation based on videotaped interactions to observation in the home. Some helpful strategies to support observation during home visits are to note the total length of time of the caregiving activity as well as the length of time that the child was present during the home visit. As opportunity permits, take brief notes throughout the visit using frequency, intensity, and duration words for consideration when determining DANCE codes for each behavior. Be aware of any personal biases you may have that might increase or decrease your perception of the actual duration of time a behavior occurred. Manage the Dual role of DANCE Observer and Nurse Home Visitor During DANCE Fundamentals, your role when viewing videotaped interactions was as a silent observer, fully attending to the video. During a home visit you have a dual role. You are both a DANCE observer and a nurse home visitor. This may require you to talk with the client during the interaction in a way that facilitates the clients’ comfort to engage with her child as you observe. Be mindful that your level of engagement with the client does not detract from or interfere with her interaction with her child.



Recognize and Assess Distractions The practice videos you coded in DANCE Fundamentals usually portrayed the caregiver and child interacting with few distractions (noise, involvement of others, etc.). In the home you can expect other individuals to be present and many other distractions to occur during a routine home visit. Other adults or children may join and participate in the home visit, there may be background noise occurring (e.g., televisions, conversations, phones), and other distractions (e.g., pets). Determine if these factors influence the caregiver-child interaction in a manner that would be consider atypical for this dyad. If so, attempt a DANCE observation on a different day. If these distractions are typical for this client and child then complete the DANCE observation. The DANCE has been developed for observation of one child and one caregiver. If a second caregiver is present and regularly involved in the care of the child, you may choose to complete a DANCE observation with the second caregiver and child on a subsequent visit. If there are multiple children, complete a DANCE observation for each child and caregiver during different home visits. RECOMMENDED SCHEDULE FOR COMPLETING THE DANCE Recurring assessment of caregiver-child interactions in the NFP is recommended to provide information about the dyad that can be used to target ongoing intervention within the maternal role domain of the program. Recommendations for ongoing use of the DANCE in practice have been developed with consideration of: 1) feedback from nurses participating in the DANCE feasibility studies; 2) other NFP data collection requirements; and 3) children’s development. Child age serves as the basis for the recommended schedule of use and you are encouraged to complete DANCE observations within one month of the recommended times. A range is provided with consideration to the visit schedule and the DANCE coding parameters (child is available for interaction, caregiver is the active caregiver, visit occurs in a familiar location, it is a routine visit, a caregiving activity of 5-8 minutes occurs). The schedule for completing the DANCE is listed in the table below, along with the corresponding NFP visit number.

Child’s Age Recommended Time to Complete

DANCE Observations (Child’s Age) NFP Visit Number

2 months 1-3 months Infancy #4-9

9 months 8-10 months Infancy #19-23

16 months 15-17 months Toddler #7-11

22 months 21-23 months Toddler #19-21

The DANCE Observation Client Tracking Form (Attachment A, p. 6.8) facilitates planning for and record keeping of DANCE observations. Use this form for planning of DANCE observations to ensure consistent use of the DANCE within the NFP program.



FACILITATING CAREGIVER-CHILD INTERACTION One of the DANCE observational requirements is that a caregiving activity, lasting at least 5 minutes, occurs during the home visit. Caregivers have a dual role during the course of the home visit, to care for their child as well as visit with their nurse. Caregiving activities are likely to occur naturally during a home visit as the caregiver spends time caring for the child in addition to visiting with the nurse. When these activities occur and you are conducting a DANCE observation, you are encouraged to sit back, allowing the DANCE observation to be the focus of the home visit plan for the next several minutes as the caregiver-child interaction occurs. If necessary, interact with the client at a level that would facilitate the client’s comfort, ensuring that you do not disrupt the interaction or distract the client and/or child. At other times, you may need to offer support for a caregiving activity to occur. If the client rarely interacts with her child during home visits, consider age-appropriate caregiving activities that you can support during a visit. Offer the client a choice of activities in preparation for DANCE observation to be completed at the subsequent visit. Come prepared with materials that may facilitate a caregiving activity during the current visit (e.g., age appropriate toy, book, caregiving facilitators/handouts, Ages and Stages Questionnaires). Ideally at the time of enrolment, discuss with your client that one of your roles in the program involves helping the client understand how her child communicates, what her child needs, and how she can support her child in her responses to her child’s communications and needs. Share that you do this by talking with the client as well as watching the client and her baby together during home visits. Other opportune times to have a conversation about your role in supporting the client in her role as a mother are during late pregnancy and early infancy. As you prepare for and discuss the baby’s arrival, provide information on recognizing and responding to infant communication. These conversations provide a foundation for observing dyads during home visits and offering supportive feedback and guidance using the DANCE STEPS. Some clients may be resistant and/or refuse to interact with their children when you suggest a caregiving activity. Ensure you are offering caregiving choices rather than making the client feel that you are telling her to do something. Here are a few options for things the nurse could say to the client:

• “It would be great to see how Johnny is communicating and responds to you. Do you think Johnny would enjoy eating, playing, or being held right now?”

• “It would be great to see how Johnny is communicating and responds to you now that he is ___ months old. Do you think Johnny would enjoy eating, playing, or being read to? Which of these would you like to do at the next visit?”

• “I brought a few new toys for you to try with Johnny. Which of these do you think he would enjoy? Let’s take a few moments right now to find out.”

Also, placing focus on the child, rather than the caregiver, may decrease the client’s resistance. For example:

• “I would really like to see what new things Johnny is able to do. Let’s take a few moments and you can show me some of these things.”

Nurses sometimes feel challenged to facilitate caregiving activities between caregivers and young infants (<3 months of age). Very young infants do not have the capacity to grasp,



hold, and play with toys. However, they do have the capacity to interact with their caregivers. These interactions may occur during feeding, cuddle time, reading, and as they are going to sleep. It may help to extend the interaction if you talk to your client, asking her to comment on how things are going with her infant. Access the DANCE website for video examples of caregivers interacting with young infants. CHALLENGES TO COMPLETING A DANCE OBSERVATION There are several factors that can make DANCE observations challenging including infrequent visitation, availability of the child, stressful life circumstances, chaotic home environments, and the client’s caregiving abilities. You should be aware of these challenges so that when they do arise you can identify strategies for addressing them, facilitating DANCE observation. Support and guidance from the team, supervisor, and DANCE Educators should be sought as necessary. It can be challenging when a client misses many of your scheduled home visits, as this reduces opportunities for completing DANCE observations. Plan to complete a DANCE observation at every scheduled visit with clients who miss frequently until a DANCE observation is completed. Some children may be sleeping during every home visit or clients may make arrangements for the child to be cared for by others during home visits so that the nurse and client can visit together uninterrupted. One of the DANCE observational requirements is that the child needs to be available for interaction. To facilitate the child’s involvement during a home visit request an activity that would involve the child such as a physical exam, bring a play activity for the caregiver and child, observe a feeding, or complete an Ages and Stages Questionnaire. Make arrangements for these activities ahead of time to increase the likelihood that the child will be awake and present during your home visit. Remind the client of your arrangements the day before your scheduled visit. Some clients regularly experience stress or crises and focus the home visit on these events/issues. One of the observational requirements for completing a DANCE is that the caregiver or child should not be experiencing unusual acute social or medical issues. If the client experiences chronic social or medical issues, then you should work to establish an expectation with the client that you will spend a specific amount of time talking about her current experiences and then move on to other items in your home visit plan, increasing the likelihood a DANCE observation could occur. Noisy and chaotic homes can make DANCE observations challenging. If the noise and chaos are not typical for this dyad, then assess if there is a quieter area in the home where the visit may take place. If this is a regular occurrence, complete the DANCE observation as this is the dyad’s typical environment. Your informal observations may lead you to feel that a client has many caregiving challenges. The thought of completing a DANCE observation may be overwhelming. Be open and curious to see what can be discovered by completing a DANCE observation. The DANCE is a strengths-based measure. Often when caregivers have areas for growth or enhancement, they also will have areas of strength. Identifying what the specific caregiving



challenges are for a client allows you to develop a clinical plan to offer targeted support to enhance caregiving behaviors. DOCUMENTING A DANCE OBSERVATION DANCE documentation provides a record of your observations of the interaction between the client and child during the home visit. It allows you to identify changes in caregiving behavior over the course of the program. DANCE documentation provides an outline for you to reflect on and identify caregiving strengths as well as areas for growth. This serves as a foundation on which to develop an intervention plan that is individualized to clients’ needs. When documenting DANCE observations, you should remain as objective as possible. Be mindful of the natural inclination to want to “up-code” clients. Document what you observed during the current observation, setting aside what you have seen on previous home visits. Be aware of, and set aside any biases you may have while documenting. These considerations enhance objective observation and documentation, providing information about where this caregiver is currently at. This facilitates planning follow-up interventions that will be the most relevant and helpful to the caregiver and child. Nurses are the most accurate in their recall of the observation when they can document as soon as possible after the home visit. However, home visit demands and schedules can make immediate documentation challenging. Having a DANCE Coding Sheet or paper for note-taking available during the home visit will help to identify and note key events important to consider when coding. Adjusting your home visit schedule to allow a little extra time following a home visit facilitates immediate documentation of the DANCE observation. Concise documentation will minimize the burden of DANCE documentation. Plan to document 1-2 sentences for each behavior. Your documentation should include examples of when you see the behavior occurring (based on the DANCE definition and developmental consideration) as well as examples of when you did not see the behavior occurring (based on the DANCE definition and developmental consideration). When the code for the behavior is 100%, or when coding behaviors that are frequencies, use your Intensity, Duration, and Frequency words to develop one sentence that justifies your code. When the code is less than 100% (e.g., Expressed Positive Affect was 70%), add a second sentence to explain why the code is less than 100%. A third sentence may be necessary as circumstances warrant. Sample DANCE coding sheets for all the DANCE Fundamentals coding videos are available on the DANCE website. The DANCE coding sheet has been developed to support your observation and documentation for each DANCE behavior. DANCE documentation becomes part of the client’s medical record. You may choose to record DANCE observations using an electronic or hard copy coding sheet. Have your DANCE Coding Manual and the DANCE Behavior Guide available to reference as you complete the DANCE coding sheet, especially when you are first coding and are not as familiar with the specifics of the DANCE behaviors (e.g., observational parameters, developmental consideration, definitions,).



DANCE INTEGRATION DANCE Fundamentals training was developed to introduce you to DANCE concepts and behaviors at a novice level. DANCE Integration is a six-month, individual and team-based learning and support program designed to support mastery of the DANCE and integration into practice. The information you will gain and activities you will complete during DANCE Integration are designed to deepen your understanding of the DANCE, support your use of the DANCE in practice, support your use of the DANCE STEPS, and move you toward an expert level as a DANCE user. Supervisors have been provided with the complete DANCE Integration packet. It can feel overwhelming to integrate a new tool and practice method into an already busy practice. However, delaying the review and utilization of the DANCE causes increased difficulties in recalling the knowledge and skills gained in DANCE Fundamentals training. Also, motivation and confidence to incorporate the use of the DANCE into practice decreases as time between the start of use and DANCE Fundamentals training lengthens. Getting started as quickly as possible with DANCE Integration activities, taking small and consistent steps toward integration, is the best way to ensure long-term success in using DANCE in practice. There are two primary goals of DANCE Integration. The first is to support your skill and confidence to complete DANCE observations with all clients in accord with the data collection schedule within three months from the start of Integration. The second goal is to use DANCE and DANCE STEPS to assist with visiting planning that supports each client’s unique caregiving strengths and areas for growth and enhancement. The DANCE Integration activities during the first month provide opportunities to review the DANCE while enhancing confidence, knowledge, and skills required for implementing the DANCE in practice. It is recommended that you review your DANCE manual and DANCE coding form on your own. Share your questions about the DANCE behaviors and observation requirements with your peers or supervisor. Have your manual accessible as you may need to refer to it quite often, especially in the beginning, while you are coding.

In addition to reviewing your DANCE manual and coding sheets we recommend the following activities during Month 1:

• Introduce DANCE to a few clients. Use guidance from the Month One Learning Activity – Preparing for DANCE Observations. This activity extends discussions from DANCE Fundamentals training to develop and practice strategies for setting up a planned caregiver activity during a home visit. Nurses complete this activity individually and then share the outcomes with their supervisor after they have implemented their strategies in the home. Refer to the Month 1 tab for detailed instructions to complete this activity.

• Observe for opportunities to support caregiver-child interactions during routine home visits. You might ask the following questions after each visit, when do activities occur, what might I do to extend the duration of the interaction, how involved was I during the activity, what might I do differently next time.

• Code a single dimension or select behaviors during a home visit. Following Fundamentals the goal of integration is to support your on-going skill to complete



DANCE observations in the home. Start by selecting a few behaviors to code and build each week or two by adding new behaviors.

• Discuss DANCE with your supervisor during one-to-one supervision each week. Set one or two small goals for the coming week that will support your DANCE Integration. Goals would include introducing DANCE to a few clients, supporting caregiving activities to occur between client and child, coding a single dimension, etc. Each week with your supervisor reflect for a couple minutes on your experience in carrying out your goals and set new goals for the following week.

Review of the DANCE may also include accessing the DANCE website to code and review practice clips either individually or together as a team. A login and password to access the website will be sent to you shortly following the completion of DANCE Fundamentals training. Video clips from the DANCE Fundamentals training are posted on the website along with a Gold Standard Code Sheet and a clinical version of the DANCE coding sheet for each DANCE observation. This provides opportunity to clarify and refine thinking about behaviors, as well as to gain a sense with regard to the expectations for documenting DANCE observations in the field. Your supervisor, site DANCE Champion (when applicable), Nurse Consultant and DANCE Team ([email protected]) are available to provide support and to answer any questions you may have during the six month DANCE Integration period. Using the tool on a regular basis helps to sustain your competence as a DANCE observer and helps to promote competent caregiving for your clients in the NFP program. Complete DANCE observations during home visits according to the recommended schedule. Use findings from the DANCE to target intervention within the maternal role domain of the program with each of your clients. Reflect on DANCE observations with your peers and supervisor as you go along.

Thanks for “DANCE”ing: Your dedication and persistence for learning new “STEPS” is appreciated!

mailto:[email protected]

References R.1


DANCE GLOSSARY OF TERMS

These terms are used throughout DANCE education (often in the theoretical importance sections) and provide additional context related to the DANCE measure. Additional terms are defined specifically in each behavior operation definition in the DANCE Coding Manual. Affective: Referring to moods and feelings. Disregulation: Emotional and behavioral responses are out of control. Effortful Control: The ability to regulate one's responses to external stimuli. Empathic Response: Responding in a manner that demonstrates understanding and

sharing of another person’s emotions and experiences. Executive Functioning: A set of mental processes and skills that include sustained

attention, decision-making, and impulse control enabling the ability to plan, focus attention, remember instructions, and juggle multiple tasks successfully.

Interactional Synchrony: Involves a caregiver responding to the child’s signals in a well-

timed, appropriate fashion with both partners match emotional states, especially the positive ones. This creates mutuality, reciprocity, rhythmicity and harmonious interactions between a caregiver and child.

Naturalistic Observation: Method of observation that involves observing caregivers and children interacting together in settings familiar to the dyad.

Objective Observation: Recall and describe exactly what is happening without making

assumptions about why they are occurring. Prosocial Behavior: Social actions that benefit other people or society such as helping,

sharing, donating, co-operating, and volunteering. Regulation: Person’s ability to provide adequate control over his/her emotional and behavior responses.

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References R.3


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