Challenges on implementing a screening system with ages and stages questionnaires (ASQ-PT) in Portugal

19 N. 2, 2023 CHALLENGES ON IMPLEMENTING A SCREENING SYSTEM WITH AGES AND STAGES QUESTIONNAIRES (ASQ-PT) IN PORTUGAL DESAFIOS NA IMPLEMENTAÇÃO DE UM SISTEMA DE RASTREIO DE DESENVOLVIMENTO COM O AGES AND STAGES QUESTIONNAIRES (ASQ-PT) EM PORTUGAL Rita Laranjeira Research Centre on Education, Institute of Education, University of Minho, Portugal Ana Maria Serrano Research Centre on Child Studies, Institute of Education, University of Minho, Portugal Abstract “Ages and Stages Questionnaires” is a screening instrument that has already been translated, standardised and validated to the Portuguese child population. This study was conducted to understand professionals and parents' perceptions on the use of Ages and Stages Questionnaires (ASQ-PT). Families and professionals (early intervention, health and education) from three geographical areas of Portugal (North, Center and Lisbon and Tagus Valley) used this instrument to screen children previously referenced from community services. After the analysis of the screening system implemented and the collected data, a set of keywords allowed us to reflect on the practical implications of the screening and the ASQ system: Motivation; Collaboration; Trust; Knowledge/empowerment; Coordination; Dissemination; Training. Results of this qualitative study are presented with suggestions on enhancing ASQ-PT usage. Keywords: Ages and Stages Questionnaires, development screening, professionals/families collaboration ____________________________________________________________________________________________ Resumo O “Ages and Stages Questionnaires” é um instrumento de rastreio de desenvolvimento já traduzido, aferido e validado para a população infantil portuguesa. Laranjeira, R., & Serrano, A. M. (2023). Challenges on implementing a screening system with ages and stages questionnaires (ASQ-PT) in Portugal. Child Studies, (2), 19-36. https://doi.org/10.21814/childstudies.4537 20 Este estudo foi realizado para compreender a perceção dos profissionais e dos pais sobre o uso do Ages and Stages Questionnaires (ASQ-PT). Famílias e profissionais (de intervenção precoce, saúde e educação) de três áreas geográficas de Portugal (Norte, Centro e Lisboa e Vale do Tejo) utilizaram este instrumento para rastrear crianças, previamente referenciadas, nos serviços da comunidade. Após a análise do sistema de rastreio de desenvolvimento implementado e os dados recolhidos, um conjunto de palavras-chave permitiu refletir sobre as implicações práticas do rastreio e do sistema ASQ: Motivação; Colaboração; Confiança; Conhecimento/capacitação; Coordenação; Divulgação; Formação. Os resultados deste estudo qualitativo são apresentados com sugestões para melhorar o uso do ASQ-PT. Palavras-chave: Questionários “Ages and Stages”, triagem de desenvolvimento, colaboração profissionais/famílias ____________________________________________________________________________________________ Introduction Early identification of developmental problems in children is essential for achieving their maximum potential and, if necessary, for providing children and their families early intervention as soon as possible. To ensure early identification, it is necessary and fundamental to routinely screen children in child health or pediatric care, as well as in day care centres and kindergartens. It is crucial for each country to have an adequate developmental screening system in place for the early detection of children with special needs or at risk of developmental problems. To implement such a system, a local and regional network must be developed, emphasising the collaboration between services and professionals to promote screening and its importance (Bricker et al., 2013). Developmental screening determines, through the use of brief tests, if children are developing as expected for their age. This procedure is expected to detect and/or identify children with developmental problems, those who are at risk of developmental delays, requiring a formal assessment, and those who have an age-appropriate development (American Academy of Pediatrics, 2001; Glascoe, 2005; Meisels, 1989). The importance of developmental screening relies on the malleability of development and the manifestations of delays over time, which can be detected at specific ages (Glascoe, 2005). Therefore, standardised developmental screening instruments must be used to check a child’s development at specific ages. The screening process must be efficient, using an instrument that: screens a large number of children, is easy to apply and administer quickly, is easy to interpret, has good psychometric qualities (such as sensitivity, specificity, reliability and validity), is cost-effective, and is norm-referenced (American Academy of Pediatrics, 2001; Bricker et al, 2013; Division for Early Childhood, 2007; Meisels & Atkins-Burnett, 2008; Oliveira, 2017; Squires et al., 2009). Screening instruments based on parents’ reports have shown positive results in economically and culturally diverse populations by providing precise information about Laranjeira, R., & Serrano, A. M. (2023). Challenges on implementing a screening system with ages and stages questionnaires (ASQ-PT) in Portugal. Child Studies, (2), 19-36. https://doi.org/10.21814/childstudies.4537 21 child development (American Academy of Pediatrics, 2001). Parental involvement is essential in the screening process, as they are the primary source of information about a child and are those who know their child the best. They can provide valid and essential information that, possibly, may not be otherwise known. Researches have corroborated that the information provided by parents can effectively predict and identify developmental delays (American Academy of Pediatrics, 2001; Bricker et al., 1997; Bricker et al., 2008; Glascoe, 2000). Screening instruments are seldomly used in Portugal and most children are identified through observation, mostly done with professionals in the healthcare and education areas. This leads to a potential failure to identify children with developmental problems. It is considered that a screening network for all children is essential to identify developmental problems as soon as possible and to ensure that all children have the same opportunity to maximise their potential and access to early childhood intervention. Development and adoption of Ages and Stages Questionnaires in the Portuguese population Ages and Stages Questionnaires, 3rd edition (ASQ-3), is a screening tool that meets the requirements for early identification. It promotes family involvement, in collaboration with health and education professionals to identify developmental problems in children. The questionnaire is expected to be filled out by parents and caregivers, and the results are interpreted by professionals. ASQ-3 also creates opportunities for the promotion of new skills. ASQ-3 has been developed since the 1980s by Diane Bricker and Jane Squires, along with their collaborators. It emerged in the United States of America to involve parents and families of children in identification screening and intervention for children with special needs or at risk of developmental delay. ASQ-3 is composed of 21 questionnaires distributed over well-defined age ranges: 2, 4, 6, 8, 9, 10, 12, 14, 16, 18, 20, 22, 24, 27, 30, 33, 36, 42, 48, 54 and 60 months. The questionnaires screen the areas of communication, gross motor, fine motor, problem solving and personal-social. Each questionnaire has 30 items and also has an overall section for general parental concerns. ASQ-3 questionnaires have an information summary sheet to be filled out by professionals who score it. This sheet includes information about the age interval and a brief child identification information, as well as a graphic bar where each development area’s results are placed. The graphic has information about the relation to the cut-off scores for children referral and monitoring. There is also an overall section to write families answers and a guide for score interpretation and follow-up (Squires et al., 2009). Much more than a screening instrument, ASQ-3 is also a screening system. The ASQ research team developed not only the screening instrument but also a flexible system that can be used in different contexts and services and by different professionals. ASQ-3 is used to screen and monitor children who require development assessment to those Laranjeira, R., & Serrano, A. M. (2023). Challenges on implementing a screening system with ages and stages questionnaires (ASQ-PT) in Portugal. Child Studies, (2), 19-36. https://doi.org/10.21814/childstudies.4537 22 who do not. The ASQ-3 system is composed of four phases: planning the screening/monitoring; preparing, organising and managing the screening programme; administering and scoring ASQ-3 and following up; evaluating the screening/monitoring programme (Squires et al., 2009). The questionnaires administering and scoring procedures can include several options previously analysed accordingly with the human resources available, with families’ characteristics and families’ decisions on how they will fill out the questionnaire. Some families might need help from professionals, while others may feel more comfortable filling it out at home and then returning it for scoring and results analysis. The questionnaires are easy to administer and understand, taking about 15 minutes to be filled out. Professionals who present the results to parents can score it in about 5 minutes. The results can be shared with family immediately or at a later moment. The ASQ-3 has been translated, standardised and adapted for the Portuguese child population and is denominated ASQ-PT (Graça, 2013; Lopes, 2013; Teixeira, 2013). Lopes (2013) developed her research with the questionnaires of 2, 4, 6, 8, 9, 10 and 12 months with a sample of 441 children. Teixeira (2013) developed her research with the questionnaires of 14, 16, 18, 20, 22, 24 and 27 months with a sample of 541 children. Graça (2013) developed her research with the questionnaires of 30, 33, 36, 42, 48, 54 and 60 months with a sample of 926 children. These research samples were representative from the Portuguese population from all the Portuguese geographical territory. The calculated psychometric measures, reliability and validity of the translated version of the ASQ, included studies of internal consistency by the values of Cronbach's alpha and Pearson's or Spearman's Rho, test-retest and interobserver agreement (reliability) and factor analysis and comparative studies with a risk sample and a sample undergoing therapeutic follow-up (validity). According to Lopes (2013), Teixeira (2013) and Graça (2013), the results of their standardisation researches demonstrated that the ASQ-PT (2 to 60 months) meets the requirements of a validated screening instrument for the Portuguese population, allowing the early identification of children with development problems. We conducted a qualitative study to understand the perceptions of early intervention, health and education professionals, as well as families, about the use of ASQ-PT, to understand how parents collaborate during the use of ASQ-PT and to raise awareness among practitioners about its use in early identification. We also aimed to understand if the perceptions of professionals and families in our study were similar to those found in other countries where the ASQ instrument is already validated. Methods Our participants were professionals from 3 Local Early Intervention (LEI) teams, health professionals from 4 health centres and one pediatric hospital service, education professionals from 12 kindergartens and day-cares and families. We conducted our Laranjeira, R., & Serrano, A. M. (2023). Challenges on implementing a screening system with ages and stages questionnaires (ASQ-PT) in Portugal. Child Studies, (2), 19-36. https://doi.org/10.21814/childstudies.4537 23 research in three geographical areas of Portugal: North, Centre and Lisbon and Tagus Valley, to get a representation of LEI teams from different regions. All health and education professionals worked in the LEI teams’ geographical areas. Portuguese LEI teams have professionals from different professional areas and from the three coordinated Ministries of National Early Intervention System (SNIPI): Health, Education and Social Security, as established in the Decree-law of Early Childhood Intervention in Portugal (Decreto-Lei n.º 281/2009). The LEI teams have a flexible composition, and have different professionals depending on their specific Ministry. The North LEI team has 12 professionals, the Centre LEI team has 8 professionals and the Lisbon and Tagus Valley LEI team has 12 professionals, as presented in Table 1. Not all the professionals received training in early intervention. Table 1 LEI teams’ constitution LEI team’ constitution Ministry North LEI Centre LEI Lisbon and Tagus Valley LEI Health 1 Physician 4 Nurses 2 Psychologists 2 Social Workers 2 Nurses 1 Nurse Education 3 Early Childhood Educators 2 Early Childhood Educators 3 Early Childhood Educators Social Security 1 Psychologist 1 Social Worker 1 Speech Therapist 1 Physiotherapist 1 Psychologist 2 Social Workers 2 Speech Therapists 1 Occupational Therapist 1 Psychometrician 1 Physiotherapist The participants from the health area were 18 professionals: 4 physicians/pediatricians, 12 nurses, 1 psychologist and 1 social worker. From the education area, 49 professionals participated: 47 early childhood educators, 1 psych pedagogue and 1 director from an education institution. The professionals’ geographical areas are presented in Table 2. We interviewed 14 families that were selected randomly. Interviews were conducted with 13 mothers and 1 tutor of the children screened with ASQ-PT. Each family decided differently how to fill the questionnaire: parents with the child (4 families), parents without the child (3 families), mother with the child (5 families), mother alone (1 family) and mother with the professional (1 family). In order to use ASQ-PT instrument in our study, a permission contract with Paul H. Brookes Publishing was signed. We also got authorisation from the authors of the Portuguese version of Ages and Stages Questionnaires. Laranjeira, R., & Serrano, A. M. (2023). Challenges on implementing a screening system with ages and stages questionnaires (ASQ-PT) in Portugal. Child Studies, (2), 19-36. https://doi.org/10.21814/childstudies.4537 24 Table 2 Geographical area of health and education professionals Health Health Number of institutions Professionals Number of institutions Professionals North 4 2 physicians 10 nurses 1 psychologist 1 social worker 3 13 early childhood educators Centre 0 0 3 8 early childhood educators Lisbon and Tagus Valley 1 2 pediatricians 2 nurses 6 26 early childhood educators 1 psych pedagogue 1 director To carry out our research, we introduced the ASQ-PT instrument and system to professionals whose main goals were to identify developmental problems in children and make referrals for early intervention. Based on the ASQ-3 system (Squires et al., 2009), we defined the phases of screening for the professionals: 1. Planning the screening: determine target population and the resources and administration methods; 2. Organising and managing the screening: identify screening procedures; 3. Administering and scoring ASQ-PT: support parent’s completion of ASQ-PT, communicate results with families; 4. Evaluating the screening process. Early intervention professionals used ASQ-PT to screen children referred to their service. Health and education professionals used the development screening in their services by choosing randomly children to be screened, explaining ASQ-PT screening to families, obtaining families consent for the research and the screening, providing the questionnaires and the results of the screening to families. From a total of 278 questionnaires provided to the different locations of the study, we obtained 91,4% of questionnaires used and scored. After the screening with the ASQ-PT, to collect our data, we conducted semistructured interviews using two different script guides - one for interviewing professionals and the other for interviewing individual families. The interviews were made with sound recording, with the authorisation of the interviewees. One of the health centres did not allowed sound recording so we wrote notes about the information provided. All interviews were transcribed so we could do a descriptive analysis of the data. We carried out exploratory procedures and a content analysis that allowed us to obtain sets of themes and categories to identify the difficulties experienced by professionals during the implementation of the screening, advantages and fragilities to the use of ASQPT, the changes that professionals and families considered that would improve the Laranjeira, R., & Serrano, A. M. (2023). Challenges on implementing a screening system with ages and stages questionnaires (ASQ-PT) in Portugal. Child Studies, (2), 19-36. https://doi.org/10.21814/childstudies.4537 25 screening process and if the interviewees would recommend the ASQ system and the ASQ-PT instrument to other professionals and families. Some challenges were highlighted by professionals and families that can help us to understand the changes that can be taken into consideration when implementing the ASQ system in Portugal. Results Our research aimed to gain knowledge about participant’s perceptions concerning the positive aspects and aspects to improve when using ASQ-PT by professionals and families as well as the changes they would like to implement in the system or if they would recommend ASQ-PT screening to other families and professionals. The analysis of the data allowed us to identify seven categories, presented in Table 3, that helped us to reflect on the practical implications of early identification, screening and, more specifically, the ASQ system. Table 3 Categories and themes Categories Themes Motivation Health professionals: ✓ When more motivated, talk more with families about screening and its importance and gather information about follow up services that can help families with their child’s development. ✓ Service organization and collaborative work. Education professionals: ✓ The need to be actively involved. Families: ✓ More motivated when professional is involved. ✓ Value the opportunity of sharing their knowledge about their children with professionals. Collaboration Key for relations/interactions between professionals and families Professionals: ✓ More involved and active participation in the screening. ✓ Empower their trust on: parents’ answers, the screening result and feel more secure through the process. Education professionals: ✓ Difficulties managing lack of control during the questionnaires filling. Trust Professionals: ✓ Lack of trust in families about development difficulties and filling the questionnaires. Families: ✓ Trust in professionals’ development knowledge. ✓ Increase trust in professionals due to their involvement in the screening. ✓ Felt their development perceptions about their child were valued by professionals. Knowledge/ empowerment Professionals: ✓ Reflected on development. ✓ Increased their attention about children’s skills. ✓ Got more information about children. Laranjeira, R., & Serrano, A. M. (2023). Challenges on implementing a screening system with ages and stages questionnaires (ASQ-PT) in Portugal. Child Studies, (2), 19-36. https://doi.org/10.21814/childstudies.4537 26 ✓ Gain knowledge of families’ perceptions about their children. ✓ Adapted their practice to empower families Families: ✓ Got more knowledge about development. ✓ Reflected, observed and gain more knowledge about their children’s competencies. ✓ Felt empowered to help their children develop more competencies and abilities. Coordination Between professionals ✓ More communication is needed. ✓ More shared information about children’s skills and abilities. ✓ Education professionals’ work needs to be more valued by health professionals. ✓ Need to increase families’ involvement. ✓ Need to increase professionals and families trust. Dissemination Increases the importance of early identification. LEI Teams Professionals: ✓ Early intervention system, methodology and referral process. Health and Education professionals: ✓ Early identification and development screening – for a better acceptance by parents and the community. Families: ✓ Mouth to mouth promotion about screening. Training Health and Education professionals: ✓ Development and red flags; Early identification; Early childhood intervention; Collaboration work with other professionals and with families. Professionals: ✓ ASQ-PT system and instrument. About motivation, we understood that most health professionals from health centres found difficulties in implementing the screening due to a lack of time and human resources. But we did not detect this specific difficulty in one of the health centres or in the hospital, where professionals decided to work together and take advantage of the opportunity to screen children from their community. When professionals are more motivated about early identification, it is easier for them to communicate with families about the children's development, screening, and its importance, as well as to provide information about community services referrals. Education professionals felt they need to be actively involved in the screening process and not just act as intermediaries, as they did in our study. Families felt more motivated to fill out the ASQ-PT questionnaire when professionals were involved in the screening process. Some families believed that they were the ones who should fill out the questionnaire because of their knowledge about their children. At the same time, they felt more secure in this task whenever they could get professional help to clarify their doubts or when, after filling out the questionnaire, families and professionals reviewed the answers together. All interviewees considered fundamental the collaboration between families and professionals. It is very important that professionals have a good knowledge of their Laranjeira, R., & Serrano, A. M. (2023). Challenges on implementing a screening system with ages and stages questionnaires (ASQ-PT) in Portugal. Child Studies, (2), 19-36. https://doi.org/10.21814/childstudies.4537 27 community so they can identify families who can fill out the questionnaires alone or need help from professionals. Some professionals reflected on the importance of being more involved and having an active participation to increase their trust in parents’ answers on the questionnaires, on the results of screening and to feel more secure during the process. Particularly, some early childhood educators had difficulty managing lack of control in the questionnaire filling when handed to families to be filled by them. This may have happened because some professionals chose not to be involved in the screening process and only delivered the questionnaires and the results to parents, believing that this was a way to not influence families. Most professionals need to increase their trust in families when it comes to development knowledge and especially when families have the opportunity to fill out questionnaires about their children’s development. Despite this, we found that some professionals’ motivation is related to a greater sense of trust in families. According to health and education professionals, families, particularly the disadvantaged ones, may devalue screening because they do not know about development, which means they might not value specific competencies acquisitions. Education professionals were the group who most referred lack of trust in a screening process when development questionnaires are filled out by families and in the parents’ abilities to fill out development questionnaires. We considered some hypothesis: this feeling may come from insecurity issues or difficulty in giving families this task because the professionals feel they are the ones, as development specialists, that should present children’s competencies and abilities. Simultaneously, the use of ASQ-PT screening reinforced education professionals’ perception of children’s development through a formal instrument, giving them the tranquillity and security needed to identify children’s developmental problems. Families confirmed in their interviews that they trust professionals’ knowledge about development, and that they contact professionals for information about development, to clear doubts, and to share their concerns. Professionals must be aware of the important role they have in providing families with the necessary development information, guiding them and/or empowering them with newer knowledge to enhance the children’s development opportunities. This role also requires on part of professionals’ sensitiveness and positive communication, respecting culture and unique ways that each family has of educating their child. For most professionals, the ASQ-PT questionnaires provide important knowledge about child development to families. Some health and education professionals found that the ASQ-PT screening made them reflect on child development and focus more on children’s competencies and abilities that may not have been previously detected. 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Repositório Institucional da Universidade do Minho. https://hdl.handle.net/1822/25573 Aknowledgments This work was financially supported by Portuguese national funds through the FCT (Foundation for Science and Technology) within the framework of the CIEC (Research Center on Child Studies of the University of Minho) projects under the references UIDB/00317/2020 and UIDP/00317/2020. Bionotes Rita Laranjeira is an early childhood educator working in Local Early Intervention team in Coimbra/Penacova, SNIPI. As a PhD student, she was a researcher at Research Centre on Education, Institute of Education, University of Minho, Braga, Portugal. Email: [email protected] ORCID: https://orcid.org/0000-0002-5843-5395 Ana Maria Serrano is Associate Professor at the Department of Educational Psychology and Special Education, and Researcher at Research Centre on Child Studies, Institute of Education, University of Minho, Braga, Portugal. She is Chair of the European Association of Early Intervention (EURLYAID) and member of the Board of International Society of Early Intervention. Email: [email protected].pt ORCID: https://orcid.org/0000-0002-6117-4050 Received: February 2023 Published: April 2023 36