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An Evidence Based Proposal to Implement the Use of the Ages and Stages Questionnaire (ASQ) to assess the components of development within the 0-4 year old population in XXX









Erinn L. V. Smith

10 December 2020











MSc Practice Development: Public Health



Word Count:








This dissertation proposed the introduction of Squires and Briggs’ Ages & Stages Questionnaire (ASQ) to assess the components of development in the 0-4-year-old population in XXX using an evidence-based change.  A literature review of five key pieces of research was utilized to underpin this change.  The research analysis indicated a strong correlation in the benefits of routine developmental screenings in childhood using the ASQ tool. This dissertation supported the ASQ implementation within the health visiting service in XXX in promoting and enhancing community collaborations, reducing healthcare costs over time, strengthening the family unit, and empowering the child (Bian, Xie, Squires & Chen, 2017). Three theories of change, namely Lewin’s Change Model (1951) (Bartunek& Woodman, 2015), Kotter’s Change Theory (1996) (Henry et al., 2017), and the National Health System Change Model (2018) (Donnelly & Kirk (2015), were reviewed in this dissertation. Out of the three models, Kotter’s Change Theory was selected for the proposed change due to its flexibility of use. Kotter’s Change Theory is characterized by creating urgency, forming a guiding coalition, developing a vision, communicating the vision, removing obstacles, creating short-term wins, consolidating gains and anchoring change in corporate culture (Henry et al., 2017). The anticipated barriers were expected from health staff, parents, and community leaders (Galli, 2018). The transformational style of leadership was adopted and aligned with the implementation of Kotter’s Change Theory. The choice of transformational leadership ensured that stakeholders were motivated to achieve more than the organization’s expectations (Trevino & Nelson, 2014). A pilot study was conducted to measure the success factors and detect possible challenges when rolling out the proposed change on a large scale (Cassaret al., 2018). A parallel technique was adopted in the pilot phase with a frontline staff and the design team (Wunderlich et al., 2019). This evidence based proposal for change aims to broaden the current HV service in XXXthrough the implementation of the ASQ developmental tool.




Table of Contents





Chapter 1: Introduction                                                                   Page 5



Chapter 2: Change Plan                                                                Page 17



Chapter 3: Implementing Change                                                            Page 26



Chapter 4: Evaluation                                                                     Page 36



Chapter 5: Conclusion                                                                   Page 43



Reference List












The primary role of the Health Visitor (HV) as a Specialist Community Public Health Nurse (SCPHN) is to respond to key health promotion priorities bysearching forand stimulating an awareness of health needs, influencing health policy and facilitating health-promoting activities (Cowley & Frost, 2006). XXX, a 22-square mile island located within the Atlantic Ocean, is a British Overseas Territory and has been since 1612. Locally, the health visiting service has been established for almost forty-years (L. Jackson, personal communication, November 4, 2019) and is offered through the Department of Health’s Child Health Section.Essentially theservice consists of home visits, facilitation of HV led baby clinics, management of buildings, supervision of school nurses, involvement on various stakeholder committees, inspection of foster care homesand routine communicable diseasesurveillance of preschools and nurseries.  All of these services align with Cowley & Frost’s (2006) four core principles and underpin the service deliveryfor the null-to-four year-old population, their families and the wider community in XXX. Within local practice, an adapted version of the United Kingdom’s Healthy Child Programme (Department of Health & Social Care, 2009) is adhered to(L. Jackson, personal communication, November 4, 2019); with two universallymandated visits:a primary home visit within 14 days of discharge from hospital and a follow-up home visit at six weeks post-birth.  Plan of care is based on the discretion of the HVwith families categorized into three care (or service)pathways: universal, universal plus or universal partnership plus (Department of Health, 2009) (Appendix 1).  Currently, families who fall under the universal partnership plus pathway are offered a developmental screening by their assigned HVbetween eight and ninemonths using the Schedule of Growing Skills(Bellman, Lingham&Auckett, 1996)developmental tool; however this is not routinely performed amongst team members(L. Jackson, personal communication November 4, 2019).Furthermore, at the age of two, all children island-widecan receive a complimentary developmental screening, an initiative endorsed by the Ministry of Education’s Child Development Programme (CDP). Similar to the HV service, CDPtargets families with children from birth to four years of age.  Despite the many support servicesCDP has to offerin enhancingparental capacity and fostering healthy family units,the service is under-utilized locally with a 51% and 54% participation rate in 2018 and 2019 respectively(A. Daniels, personal communication, January 8 2020).


Developmental Screening:


Routine developmental screening in childhood is one way to ensure the best chances at identifying and detecting delays (Guralnick, 2005; Shonkoff, 2010; Gregoire& Lucky, 2002).  Many studies have acknowledged the long-term negative impact of developmental delays whichcan occur in early childhood, on emotional, behavioral and physical levels(Baker et al., 2003; Emerson &Einfeld, 2010), challenges in child-care, child-rearing and the parent-child relationship (Brown et al., 2011; Blanchard et al., 2006), educational attainment (Blanchard et al., 2006; Boyle et al., 1994), and economic impacts on both families and societies (Chan et al., 2002; Newacheck& Kim, 2005; Quach et al., 2014; Sciberraset al., 2015; Westruppet al., 2014).Positive or negative experiences within the first five years of life profoundly impact brain development and functioning throughout life (Block et. al., 2013; Bruder, 2010).  Timely intervention services can provide support services to children at-risk of developmental delay(Bruder, 2010; Serrano &Boavida, 2011) and can lead to a significant improvement in the functioning of many children (Manning et al., 2010; Anderson et al., 2003; McCormick et al., 2006; Spittle et al., 2007).  Thus, universal screening, detection and referral of children- especially those whom are likely to benefit from early childhood intervention services- is of paramount importance (Zirakashaviliet. al., 2018).


Ages & Stages Questionnaire:


The psychometric properties of the Ages and Stages Questionnaire (ASQ) have been examined based on over 18,000 completed questionnaires globally (Squires et. al., 2009); the evidence also validates this questionnaire as a cost-effective and parent-friendly instrument that can be used to screen and monitor developmental capacities in children (Singh, Jung Yeh& Blanchard, 2017).The tool is easy-to-use, fun in its delivery and in the event of challenges, decision-making instructions are detailed in the User’s Guide for referencing (Squires 2009; Squires et. al., 2009).  The ASQ(Squires et. al., 2009) is a set of twenty-one age-specific questionnaires adapted for use from 1 month to 5 ½ years of age.  Each questionnaire appraises five domains of development: communication, gross motor skills, fine motor skills, problem solving and personal-social skills with six scored items each. This dissertation will examine the literature surrounding global childhood development practices (specifically from a screening perspective), discuss current management protocols and propose an evidence-based change to practice through the implementation of the ASQ to assess the components of development within the 0-4 year old population in XXX.


Literature Review:


The following literature review highlights five key pieces of research from around the worldand features variable age groups, ethnicities and cultures from null-to-four years; some of the selected pieced of evidence utilize a HV service comparable to XXX.  All of these studies corroborate the latest edition of the ASQ, ASQ-3, as a sound and reliable tool to assess the components of development within the null-to-four- year old population (Velikonja et. al, 2016; van Heerdenet. al, 2017;Nozadi et. al, 2019; Schonhautet. al, 2013;Kendall et. al, 2019)).


A literature search was conducted utilizing the following databases: CINAHL, MedLine and ProQuest,within the University of Cumbria’s search engine OneSearch.Articles were found using keywords:childhooddevelopment AND screening AND ages and stages questionnaire; this generated over 2,100 articles.  The search was further refinedusing the keywords: childhood AND/OR development AND screening AND ages and stages questionnaire-3 and produced 84 articles.  Through title/abstract screening, the total of articles was substantially reduced, resulting in five studies that applied the Ages and Stages- 3 questionnaire, to support the change proposed within this dissertation.  Search parametersincluded peer-reviewed articles published in English between a ten-year span – 2009 and 2019 – andfull-text format. Subsequent searches for research were obtained through tracking of references from identified papers. In order to gauge a sound evidence-base,no restriction was placed on the location of neither the study nor the research-study type as this embodies best practice when considering a change supported by a solid evidence base (Craig and Stevens, 2012).The official Ages and Stages website (agesandstages.com) was explored as a supplemental informational resource.


In 2012, the Department of Health (DH) in England commissioned an audit of existing early developmental measures with the intent to implement public health outcomes for all children aged between 2 and 2.5 years across the country (Velikonja et. al, 2016).Velikonja and colleagues (2016) through a systematic review, examined global evidence discussing the psychometric properties of the latest editions of the Ages and Stages questionnaires – third edition and social-emotional- for ages 2-2.5.  This study followed the two-phased review conducted in 2013 and 2014 (Bedford et. al., 2013;Kendallet. al., 2014), which acknowledged the ASQ as the best tool meeting many of the prerequisites set out by the DH. As an added benefit, the questionnaireevaluated several domains of child development: physical, emotional, social, cognitive and speech and language (Velikonja et. al., 2016); making it a superior tool to use as an outcome measure.  Twenty studies were identified and analyzed for validity and reliability in their efforts to tailor results for a British audience.  The study concluded that both versions of the ASQ were in fact favorable; with ‘positive’ reliability values and‘positive’ sensitivity values well over 60%; all of the studies demonstrated more than 70%‘positive’ specificity values.  The authors did note that heterogeneity due to language and variations in age was a factor to be aware of when scrutinizing the evidence; thus reminding research appraisers to be mindful of cultural and societal influencers.


vanHeerdenet. al., (2017) examined the practicality of the ASQ questionnaire as a developmental screening tool via a cross-sectional study of children aged 2-60 months in Africa, namely South Africa and Zambia.  It compared the results of 853 children – with approximately 40 children in each questionnaire cohort– to those from the United States, Norway, Korea and Spain and determined that the ASQ-3 tool is applicable. In fact, children residing in the southern region of Africa performed significantly better than those residing in other parts.  In order to be a part of the study, participants had to have no history of impairment or disability;could not have been born prior to 37 weeks gestationor have a low-birth weight with no concerns expressed from parent of developmental concern; this can be noted as a limitation as this dissertation proposes this questionnaire to be used universally within the null–to-four yearpopulation.While the sample size was considerably smaller to those of the comparing jurisdictions, the age-specific variance was similar (van Heerdenet. al., 2017).  Overall study results found that children in South Africa and Zambia performed better across the studies’ ages in the gross motor domain, especially at 4, 8, 48 AND 60 months; performed significantly lower than children from other countries especially after 12 months; performed lower in problem solving at 2, 3, 36 and 46 months; but did just as well as the other countries in the personal-social domain in all ages. vanHeerdenet. al (2017) attribute mean differences of these results to interpretation based on cultural understanding and expectation, cultural practices and social context. Despite these variances the team conclude that ASQ-3 is a developmental screening tool that is feasible within the studies’ population, particularly within the first twenty-four months of life(van Heerdenet. al., 2017).  A noted strength of this study is that it examined all twenty-one questionnaires the ASQ-3 entails and supports the importance of early interventions in order to promote positive life-long trajectories.


A similar study conducted by Nozadiet. al (2019) aimed to compare ASQ-3 results from a sample of Navajo infants to those from a representative sample of infants in the United States.  Their aim was to gauge the specificity and sensitivity of the tool within the Navajo population (Nozadiet. al, 2019).  It studied 530 infants between 1 and 13 months during several home visits between 2 and 12-month assessment windows. This study ascertained that while Navajo children displayed lower mean scores after 6 months with higher percentages of children at-risk for developmental delays—sensitivities and specificities suggested a comparable validity performance to that of other ASQ-3 studies.  This piece of literature was chosen due to its procedure in delivering the questionnaire as the local HV team will be the key driver in administering this tool and home visits will be one delivery pathway in which this questionnaire will be conducted.  This study also speaks to the diversification and versatility of the tool through its ability to be applied within different cultural and ethnic contexts.


The validity of the ASQ-3 is further supported in an unprecedentedrepresentative sample study of 306 children age 8, 18 and 30 months (corrected gestational age, if born prior to 37 weeks) in Santiago, Chile (Schonhautet. al., 2013) in which researchers sought to examine the psychometric properties of the tool across different testing ages and prematurity conditions.  Parents completed the ASQ-3 in their homes and then trained professionals administered the Bayley-III (Bayley, 2005) in a clinical setting.  Sensitivity, specificity and predictive factors were calculated for the ASQ-3 against another developmental tool: the Bayley-III (Bayley, 2005) as a gold standard reference.  Psychometric properties were confirmed with 75% sensitivity, 81% specificity, positive predictive value close to 50% and negative predictive value less than 10%; which demonstrated synchronistic features when comparedto the Bayley-III developmental assessment within the studied population. The study found that psychometric measures improved with testing ages of children born extremely pre-term.  A highlighted strength of this study related to twins; again psychometric properties of the ASQ-3 were similar.  Mothers of twins were able to individualize and identify the capabilities of each child separately; this further demonstrates the reliability of the ASQ-3 tool.  However, limitations include bias as it relates to study subjects being recruited from private medical clinics within Chile and effects related to small sample size.  Overall, this study supports the use of the ASQ-3 for routine pediatric development screening.


Bedford and colleagues (2013) conducted a review of 32 existing developmental measures and determined the ASQ-3 was most suitable in providing data needed for public health outcome measures in the United Kingdom.  The tool had been usedsporadically within sections of England, prior to policy changes in 2011. A consideration was made before introduction throughout the country to explore the extent in which parents and healthcare providers would be receptive and compliant with its use (Bedford, et. al., 2013). Kendall et al., (2019) used an exploratory, mixed-methods (interviews, focus groups, surveys) approach across four study sites within England to evaluate how parents and healthcare providers understand, use and acceptthe ASQ-3tool, during the 2-year old health review.  The study was two-fold and wanted to obtain information pertaining to the parents whose children had received a 2-year review and health providers who had used the tool within practice.  It consisted of 40 mothers (10 per site) participating in one-to-one interviews that discussed the parents’ opinion of the ASQ-3 comprehensively – its use, their understanding and their expectations.  Similarly, semi-structured interviews guided 12 focus group sessions; which explored healthcare providers experience with the process of administering the ASQ-3 tool.  Strengths of this study include it being the first of its kind and acceptance for guiding policy at the macro-level to facilitate wider uptake of the 2-year old review.  The data was analyzed using applied thematic analysis (Guest, MacQueen&Namey, 2012) and coding structure was devised to address themes of compliance, ease of use and purpose of the ASQ-3.  Overall, most study subjects accepted the ASQ-3 as a sound measure that provides insighton a child’s development at age 2.  Feedback from parents was mostly positive; they found both the process and tool easy-to-use, enjoyable and valuable to assess their child; although some parents reported anxiety after perceiving the ASQ-3 as a test.  Several concerns were raised relating to safety and culture and most parents felt a disclaimer should be included on the tool to re-assure parents if their child was not mastering certain items on the questionnaire; healthcare providers supported this concern.  The focus groups discovered that there had been inconsistency in the use of the tool; this presented a challenge in practice. This study improved awareness of the partnership between parents and healthcare providers in identifying potential problems at the 2-year development review.


Scope of Change:


Of the 324 homes visited by HVs in XXX during 2019, 268 were classified as universal, 45 as universal plus and 11 as universal partnership plus (L. Jackson, personal communication November 4, 2019).  As aforementioned, there are only two mandated home visits conducted by HVs in XXX; the first is primarily focused on gauging parental capacity and assessing the home environment and the second visit is centered onevaluating maternal mental wellbeing for postpartum depression. As it stands in current practice, there is no separate/formal visitdedicated to the child’s development (although bothhome visits encompass components of the child’s development, such as weight), unless the assigned HV schedules one based on professional discretion.  Therefore, this paper will propose the introduction of the routineadministration and implementation of the ASQ tool in practice by the HV team to strengthen efforts in identifying developmental delays within the null-to-four-year-old population.  This would be carried out by aligning the distribution of the ASQ within the local adapted version of the Healthy Child Programme (DH, 2009); by offering screenings between 8 and 12 months and again at 4 years locally, as the 2 year old developmental screening is already offered by CDP.


The Department of Health and Social Care published national policy, The Healthy Child Programme (2009), which speaks to thepreventive services offered to families by way of health education and promotion in the United Kingdom.  Within this document, there is mention of universal developmental screenings throughout the first four years of life (see appendix for current UK HV service plan), carried out by the HV.Additionally, the National Institute of Clinical Excellence (NICE) provides guidancefor several conditions that can present within the first four years of childhood and affect development: pre-term birth (NICE, 2017), challenging behaviors and learning disabilities (NICE, 2015), autism (NICE, 2013; NICE, 2011).


Rationale for proposed change:


There is neither consistency nor policy locally within the health visiting service regarding routine developmental screenings, hence this proposed change in practice.  An attempt to rectify this was made in 2013, however this was never approved.In addition, the Civil Service (CS) in XXX is undergoing reform and much of this processwill draw from existing resources within the CSin order to decease expenditure and become future-forward(D. Binns, email communication, August 12, 2019).(Appendix mention the 11 values; folder at WHC from in-service). Another significant factor to consider with this change is the birth rate, which has steadily declined since 2016 (Department of Statistics, 2019).  In 2018, the island recorded 530 births – just two births under the number of deaths recorded; this is the first time in almost 60 years there has been a population decline (Department of Statistics, 2019).  As a result, the entire child health programme is being challenged with the task of creatively re-purposing services to meet and sustain the needs of our clients. One such idea could be to offer developmental screeningsin conjunction with baby clinics; this will allow parents to bring in their child(ren) for developmental assessment and also present an opportunity for the healthcare professional i.e. HV, School Nurse or Medical Officer to provide anticipatory guidance, preventive health services (immunizations, weight checks, etc) and health education.  Data from 2019indicates that 15% of children attended the government-run clinics, for the primary immunization series (first 3 doses of DTap/IPV/ Hib) , with the remaining percentage accessing services (well checks and immunizations) from a private pediatric office (L. Jackson, personal communication, November 4, 2020). With the successful implementation of this proposed change, community collaborations with private healthcare providers, community resources and stakeholders will be enhanced whilstbenefiting the family unit and empowering the child due to the evidence-based framework provided by the Healthy Child Programme (DH, 2009).







Systematic understandings of organizational change and processes of organizational change are crucial for the development and success of health promotion initiatives (Batras, Duff & Smith, 2014) and as such, several frameworks were considered to guide and plan this evidence-based change.  This chapter will consider the implementation and management of the change plan and discuss the planning process.  The literature identifies numerous complexities associated with transforming plans into action, and likens failed attempts to change agents taking an unstructured approach to application (Wright, 1998 cited in Mitchell, 2013).As such, Lewin’s change theory (1951, cited in Mitchell, 2013), Kotter’s change management theory (1996) and the National Health System (NHS) Change Model (NHS England, 2018) will be examined and critiqued. Policy design and delivery pathway for the implementation of the ASQ in practice will occur over time and include short and long term goals (Appendix 2).


Lewin’s Change Theory (1951)

As per Bartunek& Woodman (2015), Lewin’s change model, originated in 1951, can be categorized into three change-step processes: unfreeze, change, re-freeze. To Kurt Lewin, an individual’s behavior is influenced by the dynamic balance of opposing forces: driving and restraining forces. Hussain et al. (2018) affirm that driving forces motivate individuals to achieve their desired goal, while restraining forces demotivate the individual by diverting attention and interest away from desired goal. To alter a behavior pattern, Connelly (2016) suggests that the current condition should be unfrozen. Through unfreezing, the strains of individual resistance and unity of a group can be ensured. The unfreezing process can be initiated by increasing the driving force aimed at directing the behavior from the current situation, in this case introducing routine administration of the ASQ tool to the HV service.The next step is to minimize the restraining force that adversely influences the motion from the current situation. Individuals are encouraged to accept this new state through reinforcement, following the change.

According to Wojciechowski, Pearsall, Murphy & French (2016), movement can be made effective by persuading the target population (HV team, medical stakeholders, families of 0-4 year olds) to have a different perspective about their achievement target (implementing ASQ for routine developmental screenings). Through teamwork, a new source of relevant information is sought, the views of the group connect, and action-driven leaders facilitate the needed change.  Refreezing is the last step of Lewin’s model; this is achieved after implementation of the change for sustainability. Without refreezing, the probability that the target population will revert to their previous behavior, which has been altered, is very high. At this stage, integration of the new behavior pattern to the organizational culture is ensured through reinforcement (Huarng& Mas-Tur, 2016).

In terms of strength, Lewin’s model is very simple to use and easy to comprehend. It is heavily concentrated on the workforce category that opposes the change as a result of fear.  This model appears be the most basic in bringing about a change in an organization due to its flexibility in organizations that are not used to the science of change management (Wojciechowski, Pearsall, Murphy & French, 2016). Oppositions to change are easily identified and addressed with the use of this model.Huarng& Mas-Tur (2016) agree that its implementation requires a few steps to be executed in an efficient and timely manner.

Alternatively, the model is not holistic in its approach to effecting change. It usually sets the foundation for the development of other models or requires assistance from other models to bring about the expected change.Burnes&Bargal (2017) assert that the model is mostly viewed and utilized as a template to create an innovative contemporary model rather than alone. Hussain et al. (2018) believed that Lewin’s change model creates insecurity among the workforce of an organization. Naturally, it is difficult to accept change, the HV teammay becomeanxiousabout shifts inworkloads with the proposed change. The refreezing stage is time demanding since much time is needed to settle down after freezing in a challenging environment where the organization needs to adjustto the newly implemented change.


Kotter’s Change Management Theory (1996)

Kotter’s change theory was proposed in 1996 by John Kotter with eight steps to change the state of an individual. The first step in Kotter’s change theory is to increase urgency. This step draws attention to tentative challenges and the need to mitigate these challenges through exploration of available opportunities and resources (Henry et al., 2017).  Stakeholders must be kept informed and convinced about the change

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