Transcript Team Approaches to Assessment Cindy Oser, R.N., M.S. Evelyn Shaw, M.Ed.

Team Approaches to
Assessment
Cindy Oser, R.N., M.S.
ZERO TO THREE
Washington, DC
Evelyn Shaw, M.Ed.
NECTAC
Chapel Hill, NC
Overview
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What is screening, assessment, and
informed clinical opinion
Principles and purpose of assessment
Examples of assessment approaches
(autism, DC:0-3)
Partnering with teams and team models
Putting it all together
Screening
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A brief assessment procedure
designed to identify children who
should receive more intensive
diagnosis or evaluation
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.
Early intervention (EI)
Early childhood special education (ECSE)
Mental health/social service
Health systems
Diagnostic Assessment
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An in-depth assessment of one or
more developmental areas to
determine the nature and extent of a
physical or developmental problem
and determine if the child is eligible
for early intervention or mental health
services.
Curriculum-Based Assessment
(Programmatic, On-going Assessment)
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An in-depth assessment that helps to
determines a child’s current level of
functioning. This type of assessment
can:
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Provide a useful child profile
Help with program planning
Identify targeted goals and objectives
Be used to evaluate child progress over
time
Monitoring
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Developmental surveillance
(screening at frequent intervals) of at-
risk infants and toddlers not known to
be eligible for special health,educational
or mental health services
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Similar in theory to a person with diabetes monitoring blood
sugar
Informed Clinical Opinion
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What does informed clinical opinion
mean?
What is the role of informed clinical
opinion in assessment?
Why is it necessary to document
informed clinical opinion?
Shackelford, J. (2002) Informed Clinical Opinion.
NECTAC Notes, Issue No. 10.
Defining Informed Clinical
Opinion
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“Informed clinical opinion makes use of
qualitative and quantitative information to
assist in forming a determination regarding
difficult-to-measure aspects of current
developmental status.”
Appropriate training, previous experience with
evaluation and assessment, sensitivity to
cultural needs and the ability to elicit and
include family perceptions are all important
elements of informed clinical opinion.
Role of Informed Clinical
Opinion in Assessment
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“Informed clinical opinion is especially
important if there are no standardized
measures, or if the standardized
procedures are not appropriate for a
given age or development area.”
Informed clinical opinion is used at the
individual team member level and at
the team level.
Role of Informed Clinical
Opinion in Assessment
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Individual team member level:
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Clinical interviews with parents
Evaluation of the child at play
Observation of parent-child interaction
Information from teachers or child care
providers; and
Neurodevelopmental or other physical
examinations
Role of Informed Clinical
Opinion in Assessment
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Team Level:
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Multidisciplinary team, including the family,
synthesizes and interprets all available
information.
This opportunity to integrate observations,
impressions, and evaluation findings facilitates a
“whole child” approach.
The functional impact and implications of noted
delays or differences in development can be
discussed and considered by the team in
determining eligibility and developing a plan for
services (such as the IFSP).
Documenting Informed Clinical
Opinion
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Provides a baseline against which to measure
the progress and changing needs of the child
and family over time. Assessment is an ongoing process. Perceptions and impressions of
team members may change over time.
Facilitates communication during transitions
when families move, changes service
providers or enter additional or new service
deliver systems.
Principles of Assessment
1.
2.
3.
Assessment must be based on an integrated
developmental model.
Assessment involves multiple sources of
information and multiple components.
An assessment should follow a certain sequence.
Principles of Assessment (con’t.)
4.
5.
6.
The child’s relationship and interactions with his or
her most trusted caregiver should form the
cornerstone of an assessment.
An understanding of sequences and timetables in
typical development is essential for understanding
developmental differences.
Assessment should emphasize attention to the
child’s level and pattern of organizing experience
and to functional capacities.
Principles of Assessment (con’t.)
7.
8.
9.
10.
The assessment process should identify the child’s
current competencies and strengths, as well as the
competencies.
Assessment is a collaborative process between
clinicians and parents.
The process of assessment should always be
viewed as the first step in a potential intervention
process.
Reassessment of a child’s developmental status
should occur in the context of day-to-day family
and/or early intervention activities.
Practices to Avoid in Assessment
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Child is separated from parents or familiar
caregivers during the assessment.
Assessment by a strange examiner.
Assessments that are limited to areas that are
easily measurable, such as certain motor or
cognitive skills.
Formal tests or tools as the cornerstone of the
assessment.
Assessment Approaches
Barriers to Assessing SocialEmotional Development
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Lack of screening tools
Lack of knowledge
Variety of terminology
Complexity of issues
Lack of services
Types of Behavioral/Social Emotional
Assessment
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Parent (e.g, ASQ:SE) or professional
report of child’s behavior (e.g., PKBS)
Parent stress assessments (e.g, PSI)
Parent/child interaction scales (e.g., NCAST)
Combination tools (e.g., FEAS)
Structured environmental scales (e.g.,
HOME)
Examples of Child-focused
Screening Tools (Infant/Toddler)
Infant Toddler Symptom Checklist
 Temperament and Atypical
Behavior Scale (TABS)
 Ages and Stages Questionnaire:
Social Emotional (ASQ:SE)

Assessment of Autism
Spectrum Disorders
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Practice Parameter: Screening and Diagnosis of
Autism – Report of the Quality Standards
Subcommittee of the American Academy of
Neurology and the Child Neurology Society
www.aan.com/professionals/practice/pdfs/gl0063.pdf
Reviews the empirical evidence and establishes
recommendations for an approach to screening and
diagnosis of autism spectrum disorders (ASD)
Autism Spectrum Disorders
•Autism or Autistic Spectrum Disorders (ASD) and
Pervasive Developmental Disorders (PDD) (term
used in the Diagnostic and Statistical Manual IV) are
often used synonymously.
•ASD refers to a “wide continuum of associated
cognitive and neuro-behavioral disorders, including,
but not limited to, three core-defining features:
impairments in socialization, impairments in verbal
and nonverbal communication, and restricted and
repetitive patterns of behaviors.” (Filipek, et al, 1999)
Autism Spectrum Disorders
•
It is particularly appropriate to use ASD to
describe younger children because diagnoses
within the spectrum have been found to be
quite stable over time, but distinctions within
the spectrum are not very reliable at these
young ages.
Variability of children with ASD
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Wide range of
symptoms from
severe to mild.
Individual variability
(e.g. child may have
some characteristics
but not all that have
been identified as
part of syndrome).
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It is a developmental
diagnosis; the
symptoms vary with
the age of the child.
It is a lifelong
disability even
though symptoms
may fluctuate or
vary.
Variability of Children with
ASD
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Autism co-occurs with other syndromes (i.e.
mental retardation, epilepsy, tuberous sclerosis,
Fragile X)
Approximately 50% of all autistic persons
function in the retarded range. (Freeman,
Ritvo, Needleman, and Yokota, 1985)
Approximately 25% of the children have
normal intelligence (Ritvo, Freeman, MasonBrothers, Ritvo, 1994).
Variability of Children with
ASD
•
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While cognition may
be impaired, many of
these children have
strengths in certain
areas (for example,
visual spatial skills,
long term memory).
Children with autism
can progress in all
areas.
•
While children with
ASD may have a slow
rate of learning,
appropriate
educational
strategies and
practices are needed
in order to maximize
their potential.
(Rogers, S., 1999)
Age of Diagnosis and Early
Identification
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Reliability of the diagnosis is unknown prior to the
age of two; autism can be reliably diagnosed
between the ages of two and three.
Currently, children are typically identified
between the ages of 2 and 3.
Children with Asperger Syndrome may not be
identified until they reach elementary school.
Many children are not identified as early as they
could be.
Age of Diagnosis and Early
Identification
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Why is there a reluctance to diagnose?
 Concerns regarding emotional impact on the
family; belief that ASD carries a poor prognosis
 Lack of confidence in the accuracy and stability
of the diagnosis
 Lack of awareness of warning signs of ASD.
 Lack of knowledge regarding the availability of
early intervention and preschool services to
which to refer the child and family.
Age of Diagnosis and Early
Identification
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Research in early identification is evolving
Observations of videotapes of first birthday
parties (children later identified as having autism
and children that had typical development) has
confirmed that there are behavioral warning
signs for autism spectrum disorders that are
present before the age of two.
Experienced and trained clinicians have been
able to identify children with ASD as young as 18
months.
Age of Diagnosis and Early
Identification
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The Quality Standards Subcommittee of the
American Academy of Neurology and the Child
Neurology Society has issued a report titled
“Practice parameter: Screening and diagnosis
of autism”. (Endorsed by national professional
groups as well as parent/advocacy groups.)
It calls for a multi-level approach to identifying
children at risk for developmental delays,
including ASD with step-by-step procedures
screening and diagnosing children with ASD.
Early Warning Signs of ASD
Filipek, P.A, et. al., 2000)
 These warning signs would indicate a need for the child
to have an immediate evaluation:
• No babbling or pointing or other gesture by 12
months
• No single words by 16 months
• No 2-word spontaneous (not echolalic) phrases by 24
months
• Any loss of any language or social skills at any age
Assessment of Autism
Spectrum Disorders
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Level 1 – Routine developmental
surveillance and screening specifically
for autism
Level 2 – Diagnosis and evaluation of
autism
Assessment of Autism
Spectrum Disorders
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Level 1
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Developmental surveillance at all well-child visits
(infancy through school-age) or at any age when
concerns are raised about social acceptance,
learning or behavior.
Recommended developmental screening tools:
Ages and Stages, BRIGANCE Screens, Child
Development Inventories and Parents Evaluation
of Developmental Status.
Assessment of Autism
Spectrum Disorders
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Level 1 (continued)
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Further developmental evaluation is required
whenever a child fails to meet the following:
Babbling by 12 months
Gesturing (e.g. pointing, waving bye-bye) by 12
months
Single words by 16 months
Two-word, spontaneous phrases by 24 months
Loss of any language or social skills at any age
Assessment of Autism
Spectrum Disorders
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Level 1 (continued)
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Siblings of children with autism should be carefully
monitored for acquisition of social, communication
and play skills, along with “maladaptive”
behaviors.
Screening for autism should be performed on all
children failing routine developmental screening
using one of the validated instruments (CHAT or
Autism Screening Questionnaire)
Assessment of Autism
Spectrum Disorders
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Level 2 Recommendations
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Although educators, parents, and other health
care professionals identify signs and
characteristics of autism, a clinician experienced in
the diagnosis and treatment of autism is
necessary for accurate and appropriate diagnosis.
Clinicians rely on their clinical judgment, aided by
guides to diagnosis, as well as the results of
various assessment instruments, rating scales and
checklists.
Assessment of Autism
Spectrum Disorders
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Level 2 (continued)
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Diagnostic Parental Interviews
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The Gilliam Autism Rating Scale
The Parent Interview for Autism
The Pervasive Developmental Disorders Screening Test –
Stage 3
The Autism Diagnostic Interview – Revised
Diagnostic Observation Instruments
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Childhood Autism Rating Scale (CARS)
The Screening Tool for Autism in Two-Year Olds
The Autism Diagnostic Observation Schedule-Generic
(ADOS)
Assessment of Autism
Spectrum Disorders
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Level 2 (continued)
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Medical and neurologic evaluations
Evaluation and monitoring of autism diagnosis
Speech, language and communication evaluation
Cognitive and adaptive behavioral evaluations
Sensorimotor and occupational therapy
evaluations
Neuropsychological, behavioral and academic
assessments
Challenges for States
From Oser,C. and Shaw,E. in press
 Developing specific public awareness campaigns
to alert health care providers, parents and other
professionals of the warning signs for ASD
 Training professionals to utilize screening tools
with greater sensitivity to detect ASD, including
milder forms of ASD (e.g. Asperger Disorder)
• Developing a cadre of trained professionals with
expertise in evaluating and diagnosing children
with ASD.
Challenges for States
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Children are identified close to the age when they
transition from Part C to Part B. Flexible policies
that would enable children to transition more
smoothly are needed.
Developing awareness of Asperger Disorder in
preschool and public school programs.
Developing sufficient and appropriate early
intervention/special education services to meet the
needs of these children and their families.
National Center for Infants, Toddlers and
Families
A Language That Works:
Diagnosing Disorders of
Infancy and Early Childhood
Using DC:0-3
Why diagnostic
classification?
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A common vocabulary for
professionals and families
Development of clearly articulated
assessment and treatment plans
Why diagnostic
classification? (cont’d)
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Accumulation and refinement of
clinical and research knowledge
Securing resources for
assessment and treatment of
very young children
DC: 0-3 as a tool in prevention
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Builds on the young child’s drive toward
healthy development
Reframes symptoms as coping mechanisms
Recognizes the protective, buffering power of
the child’s relationships
Understands timing – help before symptoms
are internalized or generalized
DC: 0-3 encourages us to:
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Recognize individual differences in
the ways infants and young children
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process sensation
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organize experience
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implement action
DC: 0-3 encourages
us to (cont’d):
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Observe and understand the
child’s behavior -- especially in
the context of interaction with
important caregivers
DC: 0-3 encourages
us to (cont’d) :
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Explore the impact on the child’s
development of
family patterns
cultural patterns
community patterns
DC: 0-3 encourages
us to (cont’d):
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Identify the child’s
adaptive processes
developmental challenges
How does DC: 0-3 organize
clinical observations into
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a diagnostic profile?
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recommendations for intervention?
The DC: 0-3 multiaxial
framework
Axis I:
Primary diagnosis
Axis II:
Relationship classification
Axis III: Medical and developmental
disorders
Axis IV:
Psychosocial stressors
Axis V:
Functional Emotional
Developmental Level
Guidelines to selecting
appropriate diagnosis
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Infants and young children have
limited ways of responding to
stress
Primary diagnosis should
reflect
most prominent features
The reward -Axis I systematically
addresses specific risk factors:
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Environmental (traumatic stress, adjustment)
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Interactional (disorders of affect)
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Constitutional and interactional (regulatory)
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Constitutional (relating and communicating)
Jean Thomas and Roseanne
Clark
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Hyperactive, aggressive and defiant
behaviors as a final common pathway
for expression of internal distress
DC: 0-3 identifies specific risk factors
that guide intervention strategies
DC: 0-3 Axis II:
Relationship Classification
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Used only to diagnose
significant relationship
difficulties
When a disorder exists, it is
specific to a relationship
Axis III
Medical and
developmental
diagnoses
Axis IV
Psychosocial stressors
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Severity
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Duration
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Overall impact
Identify all sources of stress
Axis IV: Psychosocial
stressors
Ultimate impact depends on:
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Severity of stressor
Developmental level of child (age,
endowment, ego strength)
Adults as protective buffers
Source of Stress
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Abduction
Abuse - physical
Abuse - sexual
Abuse - emotional
Adoption
Birth of sibling
Foster placement
Hospitalization
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Loss of parent
Two-year TANF limit
Loss of significant other
Medical illness
Move
Neglect
Parent illness - medical
Source of Stress (cont’d)
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Parent illness -psychiatric
School/child care entry
Separation from parent
- work
Separation from parent
- other
Sudden loss of home
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Sudden injury
Trauma to significant
other
Violence in environment
Other
Number of stressors
Axis V: Functional Emotional
Developmental Level (FEDL)
The way in which the infant or
young child organizes experience,
reflected in his or her functioning.
Essential Capacities
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Becoming calm,
attentive and
interested in the world
Falling in love
Becoming a two-way
communicator
Essential Capacities (con’t.)
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Solving problems and forming a
sense of self
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Discovering a world of ideas
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Building bridges between ideas
DC: 0-3
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Developmentally informed
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Emphasizes relationships
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Identifies strengths to build
on
DC:0-3 Applications:
DIAGNOSTIC TOOL
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“Bridge” between DSM-IV and the
infant-toddler field
Common language
Diagnostic thinking
Social-emotional development
DC:0-3 Applications:
SYSTEMS CHANGE
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Reflective supervision
Financing
Training
Infuse and integrate IMH concepts
Create MH partnerships
DC:0-3 Applications
INTERVENTION STRATEGIES
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Legitimize IMH work
Plan appropriate interventions
Develop family-centered IFSP’s
Partnering with a Team
Putting It All Together
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Assessment Planning
Pre-Assessment Team Meeting
Team Report Writing Process
Looking Back – What Worked? What
Didn’t?
Models of Team Interaction
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Multidisciplinary
Interdisciplinary
Transdisciplinary
Cross-agency
Inclusive
Guidelines for Instruments
Used in Team Assessment
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Flexible enough for different disciplines;
Understood by families;
Comprehensive, from variety of domains and
sources;
Able to measure quality and quantity of performance;
Linked to intervention and curriculum;
Functional – help to identify strengths and needs;
and
Consistent with the next learning and caregiving
environment.
Team Report Writing Process
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Report is based on information generated at
the post-assessment meeting.
Written document is draft until reviewed by
the family.
All team members participate in development
of the report.
The family is not typically involved in writing
the report.
Report Writing: Interdisciplinary
vs. Transdisciplinary
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Interdisciplinary:
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Assessment results written by each team member
according to developmental area;
Writing done individually;
One team member has responsibility for
addressing concerns and questions raised by the
family and other team members;
One team member writes final report, including
changes and obtaining signatures.
Report Writing: Interdisciplinary
vs. Transdisciplinary
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Transdiscipinary:
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Draft written by team, usually right after the
assessment. Entire team participates; one member
serves as scribe.
Report broken down into narrative areas that
address child strengths and needs; written across
disciplinary boundaries.
Team members teach and learn across disciplinary
boundaries as they write integrated narratives and
outcomes.
Responsibility for obtaining family review, making
changes and obtaining signatures rotates among
members.
Using Assessment Results
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What do these findings mean for the child’s
functioning in the various settings where she lives her
life?
What are some ways in which this child can be
misunderstood, given his capacities and deficits?
What are some mismatches between this child’s
abilities and environmental demands?
How do these findings help us understand this child’s
experiences of the world and the parents’
experiences of the child?
Putting It All Together
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Assessment Planning
Pre-Assessment Team Meeting
Team Report Writing Process
Looking Back – What Worked? What
Didn’t?
Resources
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www.nectac.org
www.zerotothree.org
“New Visions for the Developmental Assessment of Infants and
Young Children” (ZERO TO THREE Press)
http://www.nectac.org/pubs/pubs.asp
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NECTAC Early ID/Autism webpages
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http://www.nectac.org/topics/earlyid/idspecpops.asp#asd
http://www.nectac.org/topics/autism/autism.asp
First Words – demonstration and research project at Florida
State University http://firstwords.fsu.edu/
First Signs – public awareness website designed for families,
caregivers and primary referral sources, especially physicians
http://firstsigns.org/