Developmental screening in Aboriginal and Torres Strait children

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What is ASQ-TRAK?

ASQ-TRAK is a culturally appropriate structured developmental screening tool designed by Dr Anita D’Aprano in partnership with Aboriginal communities. She is a developmental paediatrician and Senior Research Fellow in Indigenous Child Health at the University of Melbourne.  It is a cross-cultural adaptation of the Ages and Stages Questionnaire (ASQ-3) developmental screening tool.

The ASQ-TRAK is used to identify Aboriginal and Torres Strait Islander children with possible developmental difficulties who should be referred on for a more in-depth assessment. It has been developed in collaboration with members of the Aboriginal community to ensure the tool has been designed and implemented in a culturally respectful, meaningful, and appropriate way.

Why do we need an adapted tool?

Developmental screening tools detect more children who have, or are at risk of, developmental difficulties than clinical judgement alone.

The Australian Early Development Census reports 20% of Australian children go to school with unidentified significant developmental problems. For Aboriginal and Torres Strait Islander Australians this figure is estimated to be as high as 40%.

Mainstream health services are often not culturally safe spaces for Aboriginal and Torres Strait Islander people, making it harder to access services. An adapted and culturally specific developmental screening tool is required to improve participation, engagement, and identification of children at risk of developmental difficulties.

ASQ-3 is currently used to screen for developmental issues as part of routine child health checks in Australia and is used by a variety of healthcare professionals. It is a tool designed and validated for US populations with predominantly non-indigenous populations. Tools like ASQ3 that are widely used across the world, do not consider culturally specific features of growing up Aboriginal and can create a distorted picture of a child’s ability, potential, and development. This can have its own knock-on effects throughout later years on long-term health and wellbeing outcomes but not using a reliable tool means crucial windows for early intervention can be missed.

How is ASQ-TRAK different?

The ASQ-TRAK is completed via interview. The healthcare worker asks the questions, and the caregiver completes each activity with the child. The traditional ASQ-3 is a parent-completed questionnaire, often filled out prior to an appointment.

The ASQ-TRAK presents information to parents and caregivers of Aboriginal and Torres Strait Islander children in a more relevant way that is easier to understand. It is shorter than the ASQ-3 and focuses on 7 age intervals instead of 21. It covers the same five domains of development: Communication, Gross motor, Fine motor, Problem-solving, and Personal-social. It uses modified, translatable English which is easier to comprehend and to translate into Aboriginal languages. At the moment each domain is available in English and two Aboriginal languages: Yolngu Matha and Western Arrarnta.

Adapted from Kwamikagami – Own work, CC BY-SA 3.0, https://en.wikipedia.org/w/index.php?curid=39809240

When an Aboriginal language version is being used, it also has the question in English. Each domain comes with a clear explanation so caregivers know what each domain is asking. Some questions have been modified to be more culturally appropriate and every item is illustrated with culturally relevant images to help increase understanding. An illustrated flip chart is also used so that the caregiver can follow along whilst the practitioner asks questions.

Key differences

Administered via interview – caregiver, child, and health practitioner

Modified, translatable English

Available in English and Aboriginal Languages

Explanation of each domain to aid understanding

Culturally appropriate questions

Illustrated with culturally relevant images

Illustrated A5 flip chart to allow a caregiver to follow along

ASQ-TRAK vs ASQ- TRAK (Western Arranta)

Why should we use ASQ-TRAK?

The ASQ-TRAK tool is as reliable as other developmental screening tools but is more accessible for Aboriginal and Torres Strait Islander people.

The tool has an adequate overall accuracy when compared to the Bayley Scales of Infant and Toddler Development (sensitivity of 71% and specificity of 92%).

ASQ-TRAK encourages stronger engagement between caregiver, child and practitioner because, rather than caregivers completing the questionnaire by themselves, ASQ-TRAK is administered in an interview. It includes illustrated items and flipcharts and is written in plain English. This provides an opportunity for the caregiver and child to interact and demonstrate each item to the practitioner. This improves caregivers’ own knowledge of development and understanding of their child’s developmental stage. Many caregivers enjoy doing the activities with their child, seeing their child laughing and observing the skills their child learned. Importantly, the screening process provides a sense of empowerment to the caregivers, allowing them to reflect on their child’s skills and their own parenting skills and raise concerns when necessary. Health practitioners also found ASQ-TRAK to be more respectful and acceptable than ASQ-3, as some adapted items were more representative of Aboriginal people.

The ASQ-TRAK is available in three local Aboriginal languages including two Yolngu Matha and Western Arrarnta. These languages are in the five most widely reported languages spoken at home by aboriginal families in the 2016 census: 10.6% and 7.3% respectively. This enhances the understanding of the family. With active involvement in the interview and improved understanding, it is likely that practitioners can obtain more accurate data from ASQ-TRAK than other tools.

How can we incorporate this into our practice?

It means including Aboriginal liaison staff and gaining experience with communicating with Aboriginal families.

If possible, include local Aboriginal staff in implementing the screening tool. However, if you are a non-Aboriginal staff, you can still administer the tool, but it is vital to undergo training to administer the tool in a culturally appropriate manner.

Taking part in ASQ-TRAK training workshops is vital to effectively use the tool. They revolve around interactive classroom training, role-plays and practise coaching in the workplace. These workshops improve skills, knowledge, competence, and confidence. There is also online facilitator training, supporting a train-the-trainer model. This increases the sustainability of implementation within an organisation.

Medical students should also take part in the developmental screening sessions and learn about communicating and building rapport with Aboriginal families. It is important for students to act in a culturally sensitive manner and incorporate the patient’s cultural beliefs and practices into their management plans. Currently, ASQ-TRAK kits have already been purchased across 111 organisations, predominantly by Aboriginal Community Controlled Health Services. ASQ-TRAK has now replaced ASQ-3 for child health checks and early childhood education in many services across Australia.

Future goals

At the moment, ASQ-TRAK contains seven questionnaires covering 2 months, 6 months, 12 months, 18 months, 24 months, 36 months and 48 months of age. Moving forward, ASQ-TRAK will adapt the remaining 14 age intervals from the ASQ-3. This will increase the number of questionnaires to 21 and, extend the developmental monitoring to include children between the ages of one month to 5½ years.  The remaining questionnaires will be illustrated with images that are more representative of the diversity of Australia’s First Nations peoples.

Moving forward, another tool, the ASQ-STEPS, is also in development as a developmental outcome measure. It targets children from two to 48 months of age and measures their developmental progress and helps evaluate the effectiveness of early childhood programs and interventions.

This graphic above shows how ASQ-TRAK and ASQ-STEPS may be utilised in the future. An Aboriginal child attends a child health check (or early learning program) and participates in the ASQ-TRAK screening tool. It tool identifies a child “at risk” of developmental difficulties, and they are referred for further assessment. After identifying their developmental needs, they are referred to the program and receive an intervention. ASQ-STEPS can then tell us if the program made a difference in the child’s development.

Bottom Line

ASQ-TRAK is a respectful and educational tool that provides a better screening process for Aboriginal children, caregivers, and healthcare practitioners.  If you work in Australia, consider learning and implementing it. Check out more here.

About the authors

  • Jessica is a Paediatrics Trainee in Perth, Western Australia

  • Laura is a paediatric registrar currently calling Melbourne home. She is interested in PEM and medical education. When not at work, she likes rock climbing, going to the gym and trying new brunch spots with pals

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