AGES AND STAGES: THE TWO
YEAR REVIEW
WELCOME
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Thank you for coming
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You’ve all passed….there is no exams
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Promise from me…not confusing, not hard, not
rocket science.
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Easier life
A BIT OF A PLAN:
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Look at the need for a development tool
What we do
What knowledge of child development we need
How to complete a holistic development assessment
How to use the ASQ -3
Briefly look at ASQ- social and emotional questionaire
IF THERE IS SOMETHING YOU WISH TO ASK
PLEASE SHOUT OUT!
GOALS
That we improve our service, and ultimately provide
better outcome for children and families
 The you are equipped and armed with a new tool
that will make your work easier, more thorough and
comprehensive.
 That families will learn and feel supported by this
new intervention.
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BECOMING A HV EARLY IMPLEMENTER
SITE
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As part of becoming a Health Visitor Early Implementer
Site key areas of the Healthy Child Programme were
identified and plans put in place to develop these areas.
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1. Increasing antenatal contacts
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2. Developing the two year review.
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ASQ-3 was trialled in other counties as their identified
areas for improvement and we have learnt from them,
and have chosen to role out ASQ-3 and ASQ-SE within
Norfolk.
BELIEFS
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Early detection of developmental delay is essential to
timely and effective interventions.
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Constant findings that biological and medical indicators
i.e. low birth weight are not liable predictors of
subsequent infant outcomes (only 30%).
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Socio-economic rather than biological factors are best
indicators to future problems, seen in longitudinal
reports.
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Problems can arise at any point in the infants life.
HISTORICALLY
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Developmental reviews were based on professional
judgement and informing parents.
Usually performed by skill mix team rather than HV
Parents who were expected to contribute little or no
understanding
Need for affordable, effective, easy predictors that are
accurate and timely
HEALTHY CHILD PROGRAMME
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How Health Visiting should be….. given the time and
resources.
Making best use of skills within a team.
Empowering, flexibility, partnership working
Need to empower people to take responsibility for their
child's health and well being.
To enable parents to provide an environment which
fosters their children's development (physical, social,
emotional and cognitive).
INTENTIONS?
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Standardized approach across the county.
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Effective, economical tool.
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Parents to become genuinely involved in the
assessment, intervention and evaluation of activities
surrounding their infant.
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To test and monitor development of those infants
thought to be at risk as a result of medical, biological,
environmental factors.
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Training to empower and support all.
INTENTIONS CLINICALLY?
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To provide a parent education process
To not provide a tick box approach
Support you in assessing, planning, empower, help teach
families, evaluating and referencing.
Detection Rates:
NO TOOL
WITH A TOOL
30% developmental disabilities
identified (Palfrey et al. JPEDS.
70-80% developmental
disabilities are identified (Squires et al.
1994:111:651-655)
JDBP 1996:17:420-427)
20% Mental Health problems
identified (Lavigne et. al. Podiatry 1993: 91:
80-90% Mental health problems
identified (Sturner JDBP 19:51-64)
649-655)
WHAT WE DO NOW?
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With the person next to you can you in 2 minutes just
discuss what you have seen in practice?
What have you seen good, bad and ugly?
What tools do you use?
Who undertakes 2 year checks?
What toys do your team use?
What is in development bags?
WHAT IS ASQ-3? PACKS: ONE PER BASE
WHAT ARE THE AGES AND STAGES
QUESTIONNAIRES (ASQ-3)
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Not just another tool it will be the tool for developmental
reviews in Norfolk, already used in East Coast, FNP use tool
at regular intervals.
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Based on 30 years of research, five major revisions and on 3rd
edition (ASQ-3)
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Started in 1979 first edition in 1995, referenced in the HCP.
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Similar in theory to health screening such as a quick hearing
or vision screen
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Identifies a family that needs further support, more intensive
assessment or referral for a more specialist service.
INSIDE:
21 PAPER QUESTIONNAIRES FOR AGES:
2, 4, 6, 8, 9, 10, 12, 14, 16, 18, 20, 22, 24, 27, 30, 33, 36, 42, 48,
54, 60 MONTHS (PAPER COPIES)
CD ROM (DIGITAL VERSION)
USER GUIDE
CHILDREN DEVELOP QUICKLY, ASQ PROVIDES FREQUENT MONITORING.
FOCUS ON 2 YEAR DEVELOPMENTS: 24
MONTH QUESTIONNAIRE
(HAND OUT)
ADJUSTING FOR PREMATURITY
ASQ-3 : Calculate a corrected date of birth for a
child born more than 3 weeks premature, until the
child is 2 years old.
 Just like the red book
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ASQ AS A PARENT EDUCATION TOOL
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30 developmental items/ behaviours that discusses
developmental activities tied to the age of the child
being screened
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5 section:
1.
Communication,
Gross motor (Arm and body movements),
Fine motor (hand and finger movements),
Problem solving (learning and playing with toys)
Personal-social (Solitary and social play with toys and others) .
2.
3.
4.
5.
Now is your chance to show off….
Tell us all about 2 year olds
What is normal developmentally?
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Each section has 6 questions in order of difficulty for an
average child.
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Then an overall section for elaboration on 9 different areas
including behaviour
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Illustrations and for a reading level of a 10 year old
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Should be a positive experience that the parent shares with
the child.
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Answer yes, sometimes, not yet
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Emphasis on what they can do and not what they can not do.
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Space to fill in examples of the child behaviour, and for
comments.
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Designed to be used at home, and completed by the person
that is central to that child's life.
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Completed by the primary care giver and allows them to gain
valuable information about developmental milestones, their
child's strengths and appropriate interventions.
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The questionnaire completion should be fun and a game for
the whole family to enjoy to encourage interaction.
STEP ONE: SCORING
Total the points in each area
“yes”=10, “sometimes” =5, “not yet”=0.
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Review items marked not yet or sometimes if the more
advanced items are answered as yes.
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A child often regressed with development when learning a
new skills. They may have once been able to complete a
behaviour but not currently able to. This would still be marked
as yes.
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If no omitted answers go to step two.
OMITTED ITEMS
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Total score in that section
Divide that score by how many questions are answered
Add that score to the original answer.
Example
A child scores 35 but only answers 5 questions.
35/ 5 = 7 ……then add the 7 to the original 35 making an overall
score of 42.
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If there are 3+ omitted then do not complete this section as
score will be inaccurate.
STEP TWO: Summary sheet in parts
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Transfer the area totals
LOW scores indicate concern
Black: Referral
Grey: Referral and /or activity
White: Routine developmental review and or activity.
STEP THREE: INDIVIDUAL ITEM RESPONSE
Read the answers in the overall section carefully and
responds appropriately and discuss to identify problems.
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BEING MINDFUL
A child may pass the expressive items within the
communication areas however a parent may feel that
others do not understand what the child is saying,
answering yes to having concerns.
A child may put words together however has poor
articulation which interferes with their ability to
communicate with others.
This may still warrant a referral
ACTIVITY SHEETS
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Include games and fun events for parents and their children to
encourage development.
Different sheets corresponding to the ASQ-3 intervals
1-4, 4-8, 8-12, 12-16, 16-20, 20-24, 24-30, 30-36, 36-48, 48-60,
60-66
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Parents find it helpful to receive suggested learning activities.
Pick certain activities to guide developmental areas.
Let the parent decide on activity, timescale,
All should include materials that most people have.
PLAN:
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On system one: Tick the indicator box for the development.
Scan on summary sheet and document please see scanned
item, with regards to the developmental review.
Record weight and height measurements and other holistic
assessments as per usual.
TAKE INTO ACCOUNT
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1.
2.
3.
4.
5.
6.
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A child’s environment and lifestyle will always plays a role in
how they score
Biological and health factors
Family and child care environment
Social supports
Developmental history
Family and cultural context
Parental concerns
Consider outside factors before making a referral.
Review the purpose, avoid pass test or fail, emphasize
strengths along with guided activities.
RECAP
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Primary care giver completes the questionnaire
Review the questions
Total each section
Record on the summary sheet
Review the over all section and record on the summary sheet
Plan activities and outcome
If all white scores leave questionnaire with the family
KPI :- Scan summary sheet onto system one, ensuring you
tick the indicator box.
SCENARIO: ASQ-3
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Now your turn ……..
Jenny is the mother of five Brad aged 8, Angelina aged 6, Victoria
aged four, David aged 2, and baby Leo 6 months.
David comes to the Health Visitor at the children’s centre today
for his two year review. Jenny is running very late as Victoria was
refusing to walk to the centre and Leo needed feeding. Brad and
Angelina are at school. Dad has been away in the forces now for
three months and there is no family support. On entering the
clinic room David is quiet sucking his dummy and hiding behind
mum. Victoria is crying as it is nap time and demanding
attention.
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Jenny gets very upset by this and start to cry.
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YOU ARE THE HEALTH VISITOR – WHAT WOULD YOU DO?
ASQ- 3
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Now meet Matilda…..
Tim is a father to Matilda age 2, his partner Tasha is at
work when you go to the home for a review. The family live
with Tim’s Mum who present as well.
Matilda is a lively girl and the family say she enjoys going
to nursery a few hours a week, funded by the children’s
centre. Tim tells you the nursery say she doesn’t talk much.
Matilda weighs 16.60 kg and is wearing 4-5 year old
clothes. Tim’s mum says she has a sweet tooth and her
Granddad likes to walk her to the corner shop each day for
a packet of sweets when he buys his tobacco.
You are the health visitor what would you do?
What next for your practice?
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Go to your base and have a good rummage through the box,
you’ll find a book and CD- ROM.
Take time to watch your mentors and team. Learn how to
use ASQ– 3 to best advantage within your practice area. To
reassure anxious parents or to assess harm?
Get to see as many 2 year olds as you can? They can be
very diverse but all within “Normal Range”
Use your team clinical supervision (car chatter) time to
learn from each other how to make this tool work as part of
your developmental assessment.
ASQ-SOCIAL AND EMOTIONAL
QUESTIONNAIRES
DEFINITIONS
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Social competence: An array of behaviours that
permits one to develop and engage in positive
interactions with peers, siblings, parents, and other
adults
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Emotional competence: The ability to effectively
regulate emotions to accomplish ones goals.
ASQ-SE: THE INTENTION
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1995, responding to an increased demand for a tool to screen
the socio-emotional delays and concerns in young children.
To expand ASQ-3: A Parallel patient completed tool to
measure social and emotional behaviours.
Tested all over the USA between 1996-2001.
The ages and Stages Questionnaires for Social-Emotional
growth and behaviours was then published in 2002.
ASQ and ASQ:SE can be used concurrently
INTENTION: Assessing a complex area
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Critical to the well being of children is their ability to
successfully regulate their emotions and manage social
interactions in ways that are accepted by others.
Habituated and ingrained social/ emotional problems are
highly resistant to change and may intensify over time.
While most developmental skills can be reliably assessed a
typical social-emotional behaviour can often be more difficult
to assess.
The intention of this tool is to successfully assess this area of
development.
WHAT IS ACCEPTABLE
BEHAVIOUR?
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OR
TOLERABLE
Ok to run around and scream in a play area but not in a shop
Some encourage children to be naturally inquisitive (get their
hands dirty) where as others do not
When are they crossing the line?
Serious social and emotional problems suggest a gradual
acceleration in frequency or troubling behaviour, or both until
the child crosses the line.
This tool is based on Social learning models, and
developmental psychology.
PACK INCLUDES:
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Total possibility of 8 Questionnaires and covers three months
through to five and half years of age
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Questionnaires can be at any or all of the following intervals:
6,12,18,24,30,36,48,60 months of age.
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Age range of each questionnaire is around two months each
side unlike ASQ-3 which is around 4 weeks each side.
QUESTIONNAIRES
ASQ-SOCIAL AND EMOTIONAL
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7 behavioural areas that are not grouped
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1. Self regulation (Ability and willingness to calm and settle down to physiological
or environmental; conditions)
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2. Compliance (Ability or willingness to conform to the direction of others and
follow rules)
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3. Communication (Ability or willingness to response to or initiate verbal or non
verbal signals to indicate feelings, affective or internal states)
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4. Adaptive behaviours (Success and ability to cope with physiological needs
such as sleeping, eating, safety)
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5. Autonomy ( Ability and willingness to self initiate or respond without guidance for
example moving to independence)
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6. Affect (Ability or willingness to demonstrate own feelings and empathy for others)
7. Interactions with people (Ability and willingness to respond or initiate social
responses to parents, other adults and peers).
ASQ-SE
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1.
2.
3.
4.
29 Questions in the two year ASQ-SE questionnaire
Ends with the same 4 questions and asks for
explanation
Has anyone expressed concerns about your baby’s
behaviour?
Do you have any concerns about your baby’s eating or
sleeping behaviours?
Is there anything that worries you about your baby?
What things do you enjoy most about your baby?
Different questionnaire have different amounts of
questions p14
THE QUESTIONS
ASQ-SE
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Developmental areas are not grouped, they are shuffled
Primary care giver fills in the questions answering most of the
time, sometimes, rarely or never.
The items are coded Z, V, X, so responses are also shuffled,
unlike the ASQ-3
Z=0 points
V=5 points
X=10 points (Roman Numerals)
5 points if they have a concern
SCORING THE ASQ-SE
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ONE Score
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Unlike the ASQ-3 HIGH Scores in the ASQ-SE
are an indication of concern
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ASQ-SE is not corrected for prematurity
OMITTED ANSWERS
Maximum of three omitted
 Divide total score by number of questions answered
 i.e. 105/29 questions= 3.6 points
 Add this number to the total score to get a new total
score
 i.e. 105+3.6= 108.6
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ACTION
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Discuss strengths and reinforce positive parent child
interaction
Discuss individual items that score 10-15 points
Discuss open ended questions (End four questions)
Review score and cut off point
Discuss referral pathways if needed and activity sheets with
all.
Use teams to discuss score outcomes and activities and
actions.
Take these to supervision and continue this learning, compare
clients with similar scores!
Scenarios
ASQ-SE
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Thomas
William is a 57 year old parent of Thomas. He took early
retirement when Thomas was born, his wife is at work as a
Headteacher. Bill enthusiastically attends the nursery nurse’s
music group and told everyone he had sung in many choirs.
Bill has been invited to visit you, his Health Visitor today to
complete an ASQ-SE and have a chat because Thomas cries
throughout all of the music sessions. Bill has told your team that
Thomas is very intelligent and he likes to tidy away his toys he
even categorises and colour sorts them. Bill and his wife do not
really understand why the nursery nurse thinks ASQ-SE is a
good idea but go anyway because it is an excellent service.
You are the Health Visitor – How do you tell Bill you have
concerns?
CONCLUDE
Goal is to have an effective standardised approach
across towards developments in Norfolk to support
better outcomes for children.
 We now have a quick and easy parent led tool
recommended in the HCP, that makes effective
ongoing monitoring of development possible.
 Intention: Support professionals.
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BENEFITS
Empowering, can help bridge communication
between families, by looking at development in a
strength based way.
 Will help when referring onto other agencies,
professionals
 Able to reference in child protection reports and
court reports.
 Quicker documentation
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Thank you very much for listening
If you have 2 minutes for evaluation
form to help me with my practice
teacher portfolio I would be very
grateful.