As previously indicated, the standardization sample of the Greenspan Social-Emotional Growth Chart was used to calculate norms for the Social-Emotional Scale. This sample consisted of 456 children ages 15 days to 42 months, and representative of the US population consistent with the October 2000 US Census data (Bayley, 2006a). The sample was stratified at each age band according to parent education level, race/ethnicity, and geographic region.
When developing item sets, items from the Greenspan Social-Emotional Growth Chart were analyzed to determine their age-appropriateness; an item was considered appro- priate for inclusion at a particular age when the most frequent response for that item was 4 (‘‘most of the time’’) or 5 (‘‘all of the time’’) (Bayley, 2006a). These norms were used to calculate scaled scores and composite scores for the scale.
Reliability
Evidence of reliability for the Social-Emotional Scale is derived from the Greenspan Social-Emotional Growth Chart.
Coefficient alpha was used to calculate internal consistency reliability for both the Social-Emotional Scale and the Sensory Processing items. Coefficients ranged from 0.83 to 0.94 for the Social-Emotional Scale and from 0.76 to 0.91 for the Sensory Processing items, thus reflecting suitable internal consistency (Bayley, 2006a). Preliminary data were collected on test–retest reliability with a sample size ofn¼35 (Briggs, 2008). The total growth chart scores and growth chart screening categories showed strong correlations between first and second test administrations on the Social Emotional Growth Chartamong the participants, with interclass correlations of 0.96 and 0.94 (P<0.01). The total Sensory Processing scores and Sensory Processing screening categories were found to be reliable measures, with interclass correlations of 0.73 and 0.75 (P<0.01).
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Validity
Validity for the Social-Emotional Scale is seen, in part, in the discussion of item development for the Greenspan Social- Emotional Growth Chart. Evidence of content validity (i.e., evidence that the items seemingly reflect the trait being measured) is provided in two forms: (1) the items composing the scale are based on three or more decades of research and clinical expertise; and (2) the social-emotional constructs included in the Social-Emotional Scale reflect assessment and intervention guidelines provided by the Interdisciplinary Council on Developmental and Learning Disorders (2000) (Bayley, 2006a).
Empirical evidence of validity, based on estimates of its internal structure, is also provided by the Bayley-III. Intercor- relations between the Social-Emotional Scale and other subtests on the Bayley-III range between 0.18 and 0.25. Intercorrelations between the Language Scale and others are the highest, espe- cially as age increases (Bayley, 2006a). The latter reflects the increasing importance of language on social-emotional devel- opment as children become older.
Empirical validity also is seen in the relationships between the Bayley-III and the following external measures: the Bayley Scales of Infant Development, Second Edition (BSID-II), the Wechsler Preschool and Primary Scale of Intelligence, Third Edition (WPPSI-III), the Preschool Language Scale, Fourth Edition (PLS-4), the Peabody Developmental Motor Scales, Second Edition (PDMS-2), and the Adaptive Behavior Assess- ment System, Second Edition (ABAS-II). Correlations between the Social-Emotional Scale and the BSID-II ranged from 0.24 to 0.38, with a moderate correlation between the scale and the BSID-II Behavior Rating Scale (Bayley, 2006b). Correlations between the scale and the WPPSI-III ranged from 0.27 to 0.53, with a moderate correlation between the scale and the verbal IQ, further indicating the interconnectedness between inter- personal communication skills and social-emotional func- tioning (Bayley, 2006a). Correlations between the scale and the PLS-4 ranged from 0.20 to 0.23, whereas correlations between the scale and the PDMS-II ranged from 0.06 to 0.33. Correlations between the scale and the ABAS-II ranged from 0.02 to 0.15.
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Clinical Validity and Utility
Studies involving special needs children also were included in the validation of the Bayley-III Social-Emotional Scale. These included young children deemed at risk, premature, and small for gestational age, and those with pervasive developmental disorder (PDD), Down syndrome, language impairment, asphyxia, cerebral palsy, or fetal alcohol syndrome/fetal alcohol effects. Data from these special group studies provide evidence of the scale’s clinical utility. In other words, such special group studies provide evidence that the Bayley-III Social-Emotional Scale can be used to differentiate the development of infants and young children who do and do not display special needs (e.g., the scale can adequately differentiate typically developing and non-typically developing children). For example, approxi- mately 67 percent of children diagnosed as displaying pervasive developmental disorders obtained scaled scores of 4 (i.e., 2 or more standard deviations below the mean) on the Social-Emotional Scale, and 0 percent of children in the matched control group had comparable score values (Bayley, 2006a). Thus, the Social-Emotional Scale scores for children with special needs tend to be lower than those of the matched control groups. As such, the Social-Emotional Scale demon- strates clinical utility in that data support its ability to discriminate across various clinical populations when studied in relation to matched control groups. Analysis of these data indicated that, with the scaled score of 6 or less, the Social- Emotional Scale has a sensitivity of 86.6 percent, correctly identifying about 87 percent of children with special needs, and a specificity of 90.2 percent, correctly identifying about 90 percent of all typically developing children (Breinbauer &
Casenhiser, 2008).
STRENGTHS AND CONCERNS
The Social-Emotional Scale’s ease of administration may be its most notable strength. It provides a straightforward and quick assessment of qualities generally relevant to clinicians,
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childcare specialists, and parents of infants and toddlers. The scale’s built-in interpretation aids are helpful, including its Social-Emotional Growth Chart. Persons new to the scale are likely to find its administration, scoring, and interpretation features can be acquired somewhat quickly and thereafter used efficiently.
The scale’s focus on birth to 42 months of age constitutes another strength, thus enabling professionals and caregivers to assess and monitor growth in social-emotional development and functioning from very young ages. Therefore, the Social- Emotional Growth Chart can be an excellent surveillance instrument because it helps clinicians move from observing just one domain of development at a time to observing the inter- action and engagement between the child and caregiver, allowing for observation of child development over a short time period (Breinbauer & Casenhiser, 2008). Other measures of social-emotional functioning generally do not provide assess- ments for such young ages.
The availability of the Sensory Processing score underscores the importance of the reciprocal relationship between sensory processing and social-emotional skills. The inclusion of a sensory processing component within the Social-Emotional Scale is a strength by enabling administrators to more clearly define areas of concern and potential interventions for children who experience problems related to social-emotional func- tioning. Thus, professionals working with a child who displays delayed social-emotional functioning and sensory processing limitations are likely to consider tailoring interventions that address the overlay between social-emotional functioning and sensory processing, noting that a sensory processing disorder may interfere with his or her social-emotional functioning.
As such, the impact of the child’s sensory processing on the child’s social-emotional functioning may be addressed more appropriately.
The scale also has reasonable reliability for a measure that targets an area of development that historically has been diffi- cult to measure objectively at such young ages. As previously indicated, internal consistency reliability coefficients range from 0.83 to 0.94 for the Social-Emotional Scale, and 0.76 to 0.91 for the Sensory Processing score.
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USE IN CLINICAL POPULATIONS
The American Academy of Pediatrics (AAP) recommends developmental surveillance at every well-child preventative care visit (Council on Children with Disabilities, 2006; Johnson et al., 2007). The Bayley-III Social-Emotional Scale, also known as the Social-Emotional Growth Chart, can be used as an autism screening instrument as well as a surveillance tool within the clinical population of infants and young children. Develop- mental surveillance includes ‘‘eliciting and attending to the parents’ concerns; maintaining a developmental history;
making accurate and informed observations of the child;
identifying the presence of risk and protective factors; and documenting the process and findings’’ (Council on Children with Disabilities, 2006: 408). However, according to Edward Schor (2004: 212), ‘‘.pediatricians cannot squeeze more into the limited time they have available for each well-child visit.’’
A review of recent brain development research, evidence, and child development expert consensus can help us identify how pediatricians can use the well-child visit time more effi- ciently by focusing on the essential developmental processes that are vital for healthy functioning. New findings show that language and cognition emerge from, and are inextricably tied to, increasingly complex affect gesturing between a child and his or her caregiver (Shanker & Greenspan, 2007). There is consensus among child development experts that self- regulation and attention, engagement and attachment, social interaction, reciprocity, social problem-solving, and meaningful use of language and ideas are vital for healthy functioning, and often are impaired in children with various types of challenges (CDC-ICDL Collaboration Report, 2006).
Unlike other child development assessments that include items on each domain measured (e.g., language, fine motor, gross motor, cognition), this developmental scale uses items to assess the six functional emotional milestones consistent with the DIR/
Floortime model (see ‘‘Content’’) as the theoretical framework.
Each of these milestones or stages can be progressively evaluated at each well-child visit.Table 5.1shows the functional milestones evaluated at each of the six developmental stages, and the
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months at which well-baby check-ups are recommended. In this sense, the scale involves a paradigm shift from observing the individual child’s skills within the classical domains to observing the child’s interaction and engagement with the caregiver through a developmental approach (Breinbauer & Casenhiser, 2008). Furthermore, this scale allows pediatricians to conduct a developmental surveillance within 20 minutes during the well- child visit, including ‘‘eliciting and attending to parent concerns, making accurate and informed observations of the child, TABLE 5.1 Social-Emotional Growth Chart Conceptual Framework, Domains and Number of Items
Functional emotional milestones Age Well child
visit Number of
questions Stage 1 Self regulation and
interest in the world
0 3 months 1þ2 months 11
Stage 2 Engages in relationships 4 5 months 4 months 13 Stage 3 Uses emotions in
interactive, purposeful manner
6 9 months 6þ9 months 15
Stage 4a Uses series of interactive emotional signals or gestures to communicate
10 14 months 12 months 17
Stage 4b Uses series of interactive emotional signals or gestures to solve problems
15 18 months 15þ18 months 21
Stage 5a Uses symbols or ideas to convey intentions or feelings
19 24 months 18 24 months 24
Stage 5b Uses symbols or ideas to express more than basic needs
25 30 months 30 months 28
Stage 6 Creates logical bridges between emotions and ideas
31 24 3þ4 years 35
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maintaining a developmental history, identifying the presence of risk and protective factors, and documenting the process and findings’’ (Council on Children with Disabilities, 2006: 408).
The brief developmental questionnaire can be easily completed by parents or caregivers within 5–10 minutes while they are waiting to be seen by the pediatrician. Administration time depends on the number of items to be completed accord- ing to the child’s age.Table 5.1also shows the number of items administered at each age and stage. The process of completing the questionnaire also serves to prompt parents/caregivers to ask the pediatrician other questions they may have about their child’s development. A nurse or other trained personnel can score the results of the questionnaire. If the questionnaire was completed at a previous well-baby check, the nurse can also chart the child’s developmental progress on the growth chart compared to the normative growth line (seeFigure 5.1above).
The completed growth chart showing the child’s scores then can be viewed by the pediatrician, who can contrast the parent report with his or her own observations of the child’s interac- tions with the parent. This observation can be done while the parent gets the child ready for the examination. At this time, the pediatrician can elicit any parent concerns about the child’s development, and provide recommendations according to the scale results and his or her observations. If the scores show the child has ‘‘emerging mastery’’ of the items for his or her age range, then the pediatrician can reassure the parent/caregiver that the child is on track developmentally. The pediatrician can also encourage the parent/caregiver to spend at least 1 hour a day playing interactively with the child while helping him or her to continue to master the age-expected milestones. If the child’s scores show possible challenges, the pediatrician can provide a handout with suggestions for a home program that could include more intensive Floortime sessions (Greenspan &
Wieder, 1998, 2008), as well as possibly a referral to a specialist for further evaluation.
The use of the scale as a surveillance instrument allows clinicians and caregivers to follow the child’s social emotional measures of growth from an early age and continue through time, allowing the monitoring of the child’s rate of progress or any developmental growth changes while using interventions.
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Figure 5.2shows examples of three different types of outcomes;
quicker progress than expected, slower progress than expected, and problems increasing with age. In the case of Autism Spectrum Disorders (ASDs), the growth chart may also assist in identifying some children who show regression or early onset of developmental disorders. Figure 5.3 shows an example of regression in functioning, and an example of early onset of symptoms, which are patterns sometimes observed in ASD.
Thus, the scale in combination with the growth chart is a very effective surveillance instrument for the monitoring of a child’s social and emotional development (Breinbauer & Casenhiser, 2008).
The scale also can be used as a valid and reliable screening instrument at the ages recommended by the AAP (ages 9, 18, 24, and 30 months). As shown inTable 5.2, the original 2004 version of the scale identifies children as having possible develop- mental challenges in social and emotional functioning when they obtain scaled scores under 4. However, further research by Breinbauer & Casenhiser (2008) has determined that when
Developmental Stages
Age in Months Logical bridges Ideas beyond basic needs Ideas (words/symbols) 4b. Complex problem-solving 4a. Simple problem-solving 3. Purposeful interaction 2. Engagement 1. Attention/focus
0–3
The Social-Emotional Growth Chart
4–5 6–9 10–14 15–18 19–24 25–30 31–42 Slower progress
Problems increase with age Quicker progress
FIGURE 5.2 Quicker Progress, Slower Progress, and Problems increase with age growth lines (Greenspan, 1999).
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Developmental Stages
Age in Months 6. Logical bridges 5b. Ideas beyond basic needs 5a. Ideas (words/symbols) 4b. Complex problem-solving 4a. Simple problem-solving 3. Purposeful interaction 2. Engagement 1. Attention/focus
The Social-Emotional Growth Chart
0–3 4–5 6–9 10–14 15–18 19–24 25–30 31–42 Norm
Regression
Early Onset
FIGURE 5.3 Norm, Regression and Early Onset growth lines (Greenspan, 1999).
TABLE 5.2 Corresponding Categories when using Scaled Score of 4 as Cut-off Score between Emerging Mastery and Challenges
Age bands Possible
challenges Emerging
mastery Full mastery
0 3 months 0 14 15 33 34 55
4 5 months 0 33 34 50 51 65
6 9 months 0 44 45 61 62 75
10 14 months 0 52 53 66 67 85
15 18 months 0 60 61 84 85 105
19 24 months 0 68 69 93 94 120
25 30 months 0 84 85 119 120 140
31 42 months 0 96 97 141 142 175
Scaled scores 1 3 4 7 8 18
Corresponding
categories Possible
challenges Emerging
mastery Full mastery 5. THE BAYLEY-III SOCIAL-EMOTIONAL SCALE
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using the total growth chart scaled score of 6 or less as the cut- off, the Bayley-III Social-Emotional Scale yields a specificity of 90.2 percent and a sensitivity of 86.6 percent in correctly identifying children with ASDs when used as a screening tool.
Table 5.3 shows the newly recommended categories that emerge when using a scaled score 6 as a cut-off score to differentiate different levels of functioning and risk for ASD.