HEALTHY FAMILIES MASSACHUSETTS POLICIES AND PROCEDURES PROMOTING HEALTHY CHILD DEVELOPMENT A major goal of HEALTHY FAMILIES MASSACHUSETTS

(HFM) is to achieve optimal health, growth, and development of children in infancy and early childhood as this is critical to positive parentchild interaction and ensuring the childs maximum potential for the future. To accomplish this goal, HFM assesses the developmental milestones of all participant children to promote healthy growth and development. This policy is divided into the following sections: Rationale; Promoting on-target child development; Tracking child development and using the Ages and Stages Questionnaire (ASQ); and Promoting healthy development for children with identified developmental delays. Attached to this policy is the following appendix: Appendix A: Practice Recommendations For ASQ Implementation Appendix B: Practice Recommendations for ASQ-SE Implementation Rationale Two primary foci of home visits are the delivery of child development information and proactive support of healthy child development; therefore, programs work to: ensure that parents have the correct information on appropriate child developmental milestones; help parents develop appropriate expectations in order to reduce parenting stress and normalize parenting challenges; and reinforce the concept of variations in achievement of developmental milestones in order to support positive, consistent parent-child attachment. HFM recognizes that delays in child development can be detrimental to both the childs wellbeing and the parent-child relationship. The early identification of potential delays provides the family with knowledge of the delay(s) and the opportunity to access specialized services to support the childs growth and development, which maximizes the childs chances of overcoming the delay(s). Therefore, HFM programs systematically screen all children for delays in growth and development, consistently follow up on areas of concern, support parents in their understanding of their childs needs and relevant community resources, and collaborate with community service providers to ensure coordinated services. In all cases, including those where developmental delays are present, HFM continues to support healthy child development
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and parent-child interaction. These activities foster home environments that encourage learning and children who have the ability to enjoy and explore their world. I. PROMOTING ON-TARGET CHILD DEVELOPMENT Home visitors promote healthy growth and development by giving participants information about child development , such as milestones and appropriate expectations. Additionally, home visitors talk with participants about their child(ren), the experience of being a parent, and discovering together the childs abilities and their skills as parents. HFM programs must have protocols in place that outline how the program will deliver this content (please see the HFM HOME VISITNG POLICY for more information). During home visits, home visitors support participants in promoting their childs development by: A. Providing Age-appropriate Child Development Information Home visitors should discuss child development at every possible home visit. These discussions should take place with participants who are pregnant as well as with participants who have already given birth. Information discussed should include developmental milestones, typical age-related challenges, the impact of parent-child interaction on development, and guidance on appropriate expectations for upcoming developmental stages. This information should be delivered in ways best-suited to the participants learning style. B. Providing Information and Materials on Activities to Promote Child Development Home visitors may use curriculum or other materials to identify age-appropriate activities to do with children and participants during home visits. Home visitors should bring materials to home visits (e.g. wooden beads to string and board books) to ensure that the planned activity can be completed. Home visitors may initiate the activity with the child, but should partner with the participant as much as possible and encourage the participants efforts. In particular, home visits should include activities that promote literacy and pre-literacy, such as reading to the child, identifying colors and numbers, naming objects, etc. C. Modeling Parent-Child Interaction Styles That Support Healthy Development Home visitors should actively model optimal parent-child interactions to demonstrate techniques that support development and healthy attachment. This includes responding positively to the childs cues, holding the baby, as appropriate, and including the child in home visiting activities. Active role modeling is more likely to positively impact parenting choices and therefore, home visitors should discuss with participants what they are doing and why they are doing it. D. Providing Opportunities to Support Development Home visitors should encourage participation in activities that promote development, such as referring participants to the HFM Parenting Education group series and the HFM parent-child interaction group, and encourage trips to the local library or playground. This fosters participant access to resources in the community, strengthening healthy development.
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E. Observing Parent-Child Interaction and Encouraging Interactions That Support Development Home visitors are uniquely positioned to see how participants interact with their children and should use these observations to promote child development and strengthen the attachment between parent and child. Home visitors should discuss the interactions, and actively model optimal interactions. Home visitors should appropriately document observations in the CHEEERS section of the Participant Datea System (PDS) and always discuss their observations regarding parent child interaction during supervision. F. Raising the Topic of Child Development During Crisis When participants are in crisis, it may be difficult to focus the discussion on how the situation could affect a childs development. Home visitors should pivot the conversation to the child during a crisis, actively modeling that it is always important to consider the childs developmental stage and the impact of the crisis. G. Reviewing Child Development in Case Review Home visitors and supervisors must review child growth and development, including related home visit content.. Discussion should also include potential community resources and the follow-up and/or outcome of any referrals made. Supervision is an ideal time to explore and plan strategies for supporting optimal child development and parent-child interaction. II. TRACKING CHILD DEVELOPMENT AND USING THE AGES AND STAGES QUESTIONNAIRE (ASQ) HFM programs track and follow up on child development of all children in the HFM program as follows: A. Tracking Healthy Child Development Using Ages and Stages Questionnaire (ASQ) The ASQ is intended to screen for potential development delays and is not a diagnostic tool. The ASQ is the only tool that can be used with a participating child to meet service delivery standards. HFM programs must screen all children in HFM, using the ASQ, at age 2 months, 4 months, 8 months, 12 months, 16 months, 20 months, 24 months, 30 months and 36 months. The ASQ is administered in the course of a home visit, or in the course of a center-based visit, in collaboration with participants. Programs must complete ASQs with every child who is eligible to be screened (i.e. appropriate age) according to the timeframe regardless of the participants service level (e.g. Engagement and Re-Engagement, etc.). Additionally: 1. HFM programs must train HFM staff members in a timely way to administer the ASQ. No HFM staff member may administer the ASQ until s/he has been trained in its use. New HFM staff should observe an ASQ being administered prior to completing ASQ training. (Please see the HFM TRAINING POLICY for further information)
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2. HFM staff must administer the ASQ during the timeframes in which the tool is valid. All ASQs must be administered between one month before and one month after the child reaches each screening age. For premature infants, age for the ASQ may be adjusted by the weeks of prematurity in order to provide a more accurate screen, until the child reaches 24 months. . 3. Home Visitors document the ASQ within the valid timeframes. ASQs administered outside of these timeframes have not met program requirements and must not be entered in the PDS. ASQs that have been completed outside of the timeframe may still be included in the participant paper record and the results should be reviewed within supervision as this information may be relevant to healthy child development. Incomplete ASQs should have all available scores recorded in PDS with the reasons the ASQ was not completed (e.g. no further home visits made, baby sick or sleeping) noted in the appropriate home visit records. Home visitors must document the reasons for missed ASQs in the home visit record. 4. HFM staff must be prepared to administer the ASQ to all HFM children who are eligible for screening (i.e., are of the appropriate age). Participants may decline to have their child screened; however, staff must note the reason in home visit records, as well as all discussions with the participant regarding the implications of this choice. During case review the home visitor and supervisor should discuss strategies to encourage the participant to reconsider this decision. Each child must have his /her own ASQ; twins must have individual ASQs. 5. ASQs done with ineligible siblings are not documented in the PDS. At participants request, the ASQ may be completed with other children in the family. These results must not be documented in the PDS, although the paper copies may be placed in the participant record. 6. HFM staff administer the ASQ as part of service delivery. Home visitors should complete the ASQ with the participant(s). The ASQ need not be completed in a single home visit; however, all visits at which the ASQ is done must be made within the ASQ time window. Home visitors must collaborate with the parent(s) during the home visit to complete the ASQ and: a. Discuss the ASQ with participants. Prior to any home visit at which the ASQ will be administered, home visitors must discuss with the participant what the ASQ is, its utility as a screening tool to anticipate development issues, the types of activities included, the purpose of scoring the tool, and for what purpose the results will be used. This discussion is critical as some participants may be concerned that the ASQ is a test of their baby or a test of their parenting. Supervisors and home visitors should review in supervision how the ASQ will be introduced to participants and any challenges the home visitor anticipates.

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b. Include the participant in the activities of the ASQ. This means offering the participant the opportunity first to see if the child can complete a specific task, and/or asking if the participant has noticed the childs skill, to be confirmed by the ASQ. The ASQ includes many tasks that can or should be routine parts of the interaction between parent and child (e.g., observing smiles, drawing, playing with block or mirrors), and as such, it can be relatively simple to draw the participant into demonstrating the childs skills. Additionally, if there are tasks that are not already a part of the routine, the ASQ gives home visitors the opportunity to introduce and model the activity to participants, and discuss ways to include the task in everyday life. c. Review the ASQ with the participant. The home visitor must review with the participant his/her experience of the ASQ. Areas of focus for this review should include the participants perspective on the ASQ, what he or she learned from the ASQ, what he or she observed in his/her child, any places of pride or areas of concern the participant has, and any way in which the home visitor can improve the experience. Additionally, the home visitor must review the ASQ scores once the tool is completed; however, the home visitor, if desired, may seek supervisory consultation before sharing the ASQ scores with the family. The home visitor must review scores with the participant no later than the home visit following the visit at which the ASQ was completed to ensure timely necessary referrals. 7. The ASQ is scored when completed and HFM staff interpret and share the score with the participant. This ensures that the participant knows in which developmental domains his/her child is strong, and any domains in which there are challenges. The home visitor can also plan activities for future home visits that will enhance the strengths and support the challenges noted. Other activities can flow from the results of the ASQ including: a. When ASQ scores are in the high range and no delays are suspected, home visitors should plan activities to identify the childs strengths and support the childs development between ASQs using curriculum-based activities or teachings. Home visitors can use the Activities Pages in the ASQ manual as curriculum between ASQ administrations as a way to strengthen parent-child interaction and parent knowledge about child development. . b. When ASQ scores are in the middle range, where a referral for further evaluation is not indicated but there are some emerging concerns, the home visitor should discuss areas for activities that may need to be more of a focus in future visits. Home visitors can use the Activities Pages in the ASQ manual as curriculum between ASQ administrations and may also consider completing non-required ASQs. These ASQs can be added to the participant paper record; however, these scores must not be entered into PDS.

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c. When ASQ scores fall in the low range, home visitors must discuss with the parent any score that is below the cut off in any domain of the ASQ. This discussion must include a recommendation for a referral for further evaluation. Ultimately, the participant must give consent for the referral. Home visitors must give clear information to the participant regarding the impact of this decision including the need for Early Intervention (EI) screening and potential exacerbation of the delay if no consent is given. If the participant gives consent for the referral, the home visitor must make the referral as soon as possible. Home visitors must follow up with EI and the participant regarding the results of any evaluation as well as any EI plans to monitor the family. 8. Home visitors must document results of ASQs completed both with the family and documentation in the PDS WITHIN the valid timeframe. The PDS will only accept scores during the timeframes when the tool is valid and PDS will not accept scores for optional ASQs. a. When all sections of the ASQ have been completed the scores must be recorded in the PDS. Do not enter partially completed ASQs scores in the PDS. b. All original copies of ASQs must be placed in participant paper records. When an optional ASQ is completed, this should also be placed in the paper record c. For required ASQs, scores must be documented in the ASQ section of the PDS. d. Home visitors are encouraged to make copies of completed ASQs and provide each parent, or with participant permission other extended family members, with a copy. 9. If an ASQ is completed OUTSIDE of the timeframe (i.e. outside the timeframe stipulated by the ASQ tool or outside of the PDS window of opportunity for documentation) home visitors must document the results of the ASQs completed with the family both in the home visit section of the participant record in PDS and the paper record on file. The PDS will only accept scores during the timeframes when the tool is valid and PDS will not accept scores for optional ASQs. a. All original copies of ASQs must be placed in participant paper records. When an optional ASQ is completed, this may also be placed in the paper record as well. b. Incomplete ASQs and ASQs that are completed outside of the valid window should be placed in paper records; however, there should be a note on the tool indicating that it is late or incomplete. These scores should be documented in the Notes field of the home visit record at which the ASQ was started.

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**IMPORTANT NOTE** If the program does not complete the ASQ tool with a family for any reason (child is involved in EI services, ASQ was started but not completed or missed all visits within the ASQ window), the program MUST CREATE THE ASQ RECORD in the PDS as a place holder. Leave all scores at 0 and note the reason why the tool was missed in the notes field. Please see the PDS manual section Creating an ASQ Record for more information. 10. Supervisors should routinely discuss with home visitors timeframes for ASQ administration and documentation, and plans for completion in the home visit. As a part of case review, supervisors must discuss all ASQ results and follow up as needed on referrals for additional services and parental response to referrals. Supervisors should document attention to these areas in case notes in the supervision log. Supervisors should take into consideration those participants who are on the Engagement service level to plan for the administration of the ASQ for these participants according to the timeframe. B. Children with ASQ Results Indicating a Need for Further Evaluation. As stated previously, participants always make the decision whether to accept a referral to EI. If the participant accepts the referral(s), home visitors must seek consent from the participant to exchange information with EI in order to ensure coordinated service delivery. Again, the participant may decline to give this consent; in that case, home visitors should follow up with participants during home visits regarding the results of the EI evaluation and further plans. If the participant gives consent, home visitors must coordinate with EI to share follow up planning, activities to support the childs development, goal plans, as appropriate, and results of further evaluation. Additionally: 1. Home visitors are not required to complete the ASQ with children who are enrolled in EI. Participants may choose to have the ASQ administered as a child development activity. (See Appendix A for more information.) 2. Missed ASQs due to EI enrollment must be documented in the PDS as follows: First, the ASQ form must be opened and saved during the timeframe for which the ASQ will be valid as PDS will not accept these notes during any other time frames. Select Yes to the question Was a Screening Completed by EI? to indicate the reason the ASQ was not completed. C. Documenting Growth and Development in the PDS Child Status Report. Home visitors should thoroughly complete as many of the fields as possible. In addition to completing the questions regarding developmental delays and EI results, home visitors must complete the questions regarding the childs height and weight curves, whether the child has been diagnosed as failure to thrive, whether the child has been screened for lead levels, and whether the child has been screened for low hemoglobin.
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III. PROMOTING HEALTHY DEVELOPMENT FOR CHILDREN WITH IDENTIFIED DEVELOPMENTAL DELAYS Once a child has been identified as having a developmental delay and begins to receive EI services, work within HFM to support this childs ongoing development will shift slightly. Home visitors will still partner with participants regarding milestones, parent-child interaction, play activities, etc., that foster growth and development, however, this will also be done in collaboration, as much as possible, with other care providers involved with the child. Promising practice for working with participants whose children have identified developmental delays includes: A. Asking the Participant to Consent to Information Exchange between the Early Intervention and/or other Practitioners Working With the Child and the Home Visitor This may require in-depth, sensitive discussion with the participant regarding concerns, fear, and implications for supporting the childs progress within HFM. Participants always have the option to decline this exchange. If the participant does not agree to the exchange, home visitors must discuss this within supervision in order to assess if there are appropriate other ways to raise this with the participant and secure consent and/or how the program can support the family in the absence of direct communication with practitioners. If the participant agrees to the exchange, home visitors must contact these practitioners as soon as possible to get information on how HFM can integrate plans and activities to support the childs growth. The aim of collaboration with the practitioner is to help the HFM home visitors and/or supervisors understand the implications of the childs delay and appropriate activities/curriculum to use. If appropriate and in order to facilitate smooth collaboration, home visitors should request copies of EI paperwork, such as EI IFSPs and developmental assessments. These copies must be kept in the participants paper record file. B. Checking On the Childs Progress and Plans Regularly and Respectfully Even though child development topics are a routine part of home visits, dedicated time should be given to discussing how the family is addressing issues and how the child is progressing towards identified goals. C. Checking On How the Participant Is Managing the Childs Development Plan Participants should be asked if there are any barriers arising that are interfering with the childs ability to access services, e.g. transportation, schedule conflicts. Home visitors should also discuss the participants satisfaction with the services received and report back on any communication with practitioners. Finally, home visitors should explore what, if any, impacts this is having on the participant, e.g. increased stress, feeling frustrated with self or partner, etc. and provide support and referrals as appropriate.

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D. Continuing To Discuss Child Development at Home Visits It is important for the home visitor to address the overall health and growth of the participating child, even with the presence of a specific or multiple developmental delays. This will serve to normalize the childs growth in other domains. It will also underscore both the unique parenting joys and challenges the participant is experiencing and those s/he shares with all parents. As other services the family receives may be child-focused, HFM home visitors should discuss development questions, achievements, and concerns from the participants viewpoint, using the relationship-based approach to services to support the parents engagement in all community services. E. Administering the ASQ, At the Participants Request As stated previously, home visitors are not required to administer the ASQ if a child is receiving services with EI. Some participants may still enjoy, however, the opportunity to do the ASQ with their child to see growth in other areas, to have the opportunity for parent-child interaction in a strengths-based, supportive context, or to have full access to HFM services and resources. . Home visitors may fulfill the participants request; there should be some prior discussion with the participant regarding domains in the ASQ where the child may not perform well in order to ensure realistic expectations. These ASQs must not be recorded in PDS; the paper copies may be placed in the participant paper record with a notation that the ASQ was optional. F. Reviewing the Childs Progress and Support To the Participant During Supervision Supervisors and home visitors must discuss child development as part of case review, and as such, the goals, plans and progress of a child with developmental delays should also be a topic for review.

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Practice Recommendations For ASQ Implementation

Use the calendar function in PDS to schedule ASQ timelines. This can help ensure that the ASQs are completed in the given timeframes. Take out the ASQ tool and material at each home visit once the administration window is open and until the window is closed. This can be helpful in ensuring that the every opportunity to begin and/or complete the ASQ is used. Have kits of materials to be used in each ASQ time point so that these can be easily gathered when planning home visits. Ideally, there is one kit for each ASQ time point for each home visitor. Videotape the ASQ as the child and participant complete the tasks. Use this video as a teaching tool to show the participant the effects of his/her interaction with the child. If possible, use the same tape to record the ASQ, the participant will then have a historical record of his/her childs development. Before administering the ASQ, consider some common pitfalls, such as: o Parents experience the ASQ as a test of their childs normalcy or of their parenting skills; o Home visitors focus on the paperwork or the score of the ASQ while overlooking its role in building parental knowledge of child development or strengthening the parent-child bond; o Parents may overstate their childs abilities for many reasons, including they want their child to be successful. It is important, therefore, that home visitors complete the ASQ with the parent and child and to base scores on observed accomplishment of ASQ tasks, not just parental report; and o Discussing general child development can be a delicate issue if a delay has been identified or if a relevant condition (i.e. prematurity, physical disability, etc) exists. It is important for home visitors to grow their knowledge and comfort level in this area. These and other pitfalls are important topics for discussion during reflective supervision. Use the Activities Pages in the ASQ manual as curriculum between ASQ administrations as a way to strengthen parent-child interaction and parent knowledge about child development.

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Practice Recommendations for ASQ-SE Implementation:

Currently, the Ages and Stages Questionnaire-Social Emotional screening tool (ASQ-SE) is not a required part of the HFM program. The implementation of the required use of the ASQ-SE is planned for FY 2013. In order to become familiar with the ASQ-SE now, programs are encouraged to use the tool with families at six month intervals (i.e. 6, 12, 18, 24, 30, & 36 months) as a supplement to the required ASQ intervals. Please note that the ASQ-SE has a larger window than the ASQ and can be administered in between the administration of the ASQ required intervals. In practice, the ASQ-SE can be more easily integrated when it is not done on the same visit with the ASQ. Programs may find that using the ASQ-SE is an additional way to stay connected with families,
support the development of positive Parent Child Interactions (PCI), and connect families to resources as necessary. The tool is also helpful to focus home visiting content during transitions from babyhood to toddlerhood as it provides opportunities to discuss age appropriate behavior, expectations, and discipline. Programs should utilize their connection with their local EI programs or other community Mental Health agencies for training. Additionally, programs should take the time to identify in advance resources for parents whose childs scores indicate the need for further screening. Some examples of these programs include local Head Start programs, EI, and local mental health resources, including Childrens Behavioral Health Initiative providers. Programs may find that in order to make the most effective use of the tool, they should consider the childs age when planning referrals and activities. For example, some programs find that they make referrals to EI for younger children and connect with other local mental health agencies for those children who are 30-36 months of age. Supervision is an opportunity to review the ASQ-SE results, discuss the home visitors observations of PCI and the childs social interactions, review the parents concerns, discuss discipline and the childs behavior in the home, as well as make plans for follow up including activities and anticipatory guidance related to the childs stage of development. The activities and information in the ASQ-SE can be used as a resource to support positive PCI and social interactions. Additionally, programs should review their program curriculum library and plan additions to include resources and activities to support social emotional development and behavior challenges. At this time, hard copy ASQ-SE forms can be placed in participant paper records.
HEALTHY FAMILIES MASSACHUSETTS Appendix B: Promoting Healthy Child Development Policy Practice Recommendations for ASQ-SE Implementation September 2011