Brigance basics: a guide for Maternal and Child Health Nurses DVD facilitation guide

Brigance basics: a guide for Maternal and Child Health Nurses DVD facilitation guide

Published by the Programs and Partnerships Division Department of Education and Early Childhood Development Melbourne October 2010 State of Victoria (Department of Education and Early Childhood Development) 2010 The copyright in this document is owned by the State of Victoria (Department of Education and Early Childhood Development), or in the case of some materials, by third parties (third party materials). No part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968 the National Education Access Licence for Schools (NEALS) (see below) or with permission. NEALS is an educational institution situated in Australia which is not conducted for profit, or a body responsible for administering such an institution may copy and communicate the materials, other than third party materials, for the educational purposes of the institution. Authorised by the Department of Education and Early Childhood Development, 2 Treasury Place, East Melbourne, Victoria, 3002. This document is also available on the internet at www.education.vic.gov.au/mchservice

Contents 1. Background... 3 The Brigance training... 3 2. Introduction... 3 Tips for the facilitator... 4 Layout of the DVD... 5 Using this DVD as an educational resource... 5 3. Case Study One: Ruby (4 months)... 8 Overview... 8 Preparation Steps... 8 Getting Started... 8 The 4 month Brigance Screen: teachable and discussion points... 8 Observations and Next Steps... 9 4. Case Study Two: Logan (8 months)... 10 Overview... 10 Preparation Steps... 10 Getting Started... 10 The 8 month Brigance Screen: teachable and discussion points... 10 Observations and Next Steps... 11 5. Case Study Three: Jacob (12 months)... 12 Overview... 12 Preparation Steps... 12 Getting Started... 12 The 12 month Brigance Screen: teachable and discussion points... 12 Observations and Next Steps... 15 6. Case Study Four: Ellie (18 months)... 16 Overview... 16 Preparation Steps... 16 Getting Started... 16 The 18 month Brigance Screen: teachable and discussion points... 16 Observations and Next Steps... 18 7. Case Study Five: Chelsea (2 years)... 19

Contents continued Overview... 19 Preparation Steps... 19 Getting Started... 19 The 2 year Brigance Screen: teachable and discussion points... 19 Observations and Next Steps... 21 8. Case Study Six: Hugo (3.5 years)... 22 Overview... 22 Preparation Steps... 22 Getting Started... 22 The 3.5 year Brigance Screen: teachable and discussion points... 22 Observations and Next Steps... 23

1. Background The Key Ages and Stages (KAS) Framework was developed to further progress the implementation of the Future Directions for the Victorian Maternal and Child Health (MCH) Service (2004), realign the MCH universal service activities framework in accordance with current evidence, and strengthen the clinical role of the MCH nurse. The Blueprint for Education and Early Childhood Development sets out the Victorian Government s five year agenda for learning and development from birth to adulthood. As part of this agenda, the revised MCH KAS Framework was implemented throughout the Victorian MCH Service in 2009. The revised KAS framework introduces a new approach to the ten KAS consultations provided to families within the universal MCH program. This new framework sets out evidence based activities for each of the ten KAS consultations with additional emphasis on health promotion across a range of domains that address both maternal and child health and wellbeing. The framework includes: Parents Evaluation of Developmental Status (PEDS) as a primary developmental screening tool to engage parents in discussion about the development of their child; Brigance as a secondary developmental screen, used when concerns are identified through the PEDS; Provision of consistent, evidence based and relevant health promotion handouts, activities and messages at each of the KAS consultations; and Provision of consistent, evidence based and relevant interventions that include a SIDS risk assessment, Quit smoking intervention, and screening of maternal health and the presence of family violence. The Brigance training In 2009, 42 Brigance training sessions were conducted. There were a total of 1088 participants including MCH nurses, MCH Coordinators, MCH students and regional Program and Service Advisors (PASAs). The objectives of this training session were to: Gain an understanding of what Brigance Screens are; Become familiar with the Brigance Screening tools and supporting resources; Learn how to use Brigance Screens in MCH practice; and Develop the skills to use Brigance as a referral tool. Evaluations of these training sessions indicated that participants were very positive about the introduction of the new tool, and noted that this would create a consistent standard throughout MCH practice. Recommendations for more resources to support training and implementation were made; which included the development of an educational DVD demonstrating the implementation of Brigance Screens in MCH practice. 2. Introduction The Brigance Basics: A Guide for Maternal and Child Health Nurses DVD has been developed by the Department of Education and Early Childhood Development (DEECD) to support implementation of Brigance Screening in MCH practice. DEECD would like to acknowledge the MCH nurses and families from the City of Wodonga for offering their time and experience to help make this educational resource. The DVD: Builds on the initial Brigance training received; Provides MCH nurses with the opportunity to observe and participate in scoring Brigance on six individual children at each of the KAS consultations from 4 months to 3.5 years; Can be viewed individually or in a group; Background 3

Is intended as an interactive educational tool; Includes a facilitation guide that has been written to support the educational purpose of the DVD; and Needs an identified facilitator to lead educational sessions, using the facilitation guide. Tips for the facilitator The facilitator needs to familiarise themselves with the Brigance screens, each case study and the supporting notes. Each case study includes a time clock to help identify key teachable and discussion points (note the 18 month does not have a clock and will have to rely on the DVD player s timer). Complete one case study at a time. Allocate one hour for each case study. MCH nurses need to have a Brigance kit with them. The facilitator needs an MCH Coordinators Brigance kit (this includes the Technical Report for Brigance). Follow the preparation steps. View through first time with minimal stops and ensure all nurses are completing the data sheet. When completed, allow time for discussion. View through a second time using the key times identified in each case study. Key Times Teachable Points: Identified points in the Brigance screen that provides an opportunity to explore the skills more closely. Discussion Points: Identified points in the Brigance screen that provide an opportunity to discuss the issues raised. Use the key Teachable Points and Discussion Points to develop and strengthen the MCH nurses understanding of how to implement Brigance Screens. The MCH nurses may at times want to further explore information that has not been covered in the DVD. Encourage this discussion, but also be prepared to move it forward if necessary. Remember: these screens are captured moments, not scripted, and do not offer the opportunity to go back and ask more questions or try another way. The DVD offers the opportunity to watch the interactions between nurse, parent and child. Scores identified by the MCH nurses should be similar to what is reported in the DVD, but may vary slightly. 4 Brigance basics: a guide for Maternal and Child Health Nurses

Layout of the DVD Section Child s age Using Brigance in MCH Practice Introduction Social emotional screens are found separately in the 2, 3 and 4 year old Brigance screens. These additional screens are optional. Ruby 4 months Overview The Brigance Screen Observations and Next Steps Logan 8 months Overview The Brigance Screen Observations and Next Steps Jacob 12 months Overview The Brigance Screen Observations and Next Steps Ellie 18 months Overview The Brigance Screen Observations and Next Steps Chelsea 2 years Overview The Brigance Screen Observations and Next Steps Hugo 3.5 years Overview The Brigance Screen Observations and Next Steps Overview The MCH nurse provides a brief introduction and discusses the PEDS findings in the KAS consultation. The Brigance Screen Goes through a complete Brigance screen for each of the KAS from 4 months to 3.5 years. Note that this is not scripted and is filmed in one session. Observations and Next Steps The MCH nurse provides a summary and discusses next steps Using this DVD as an educational resource Step 1: Resources Required Brigance Basics: A Guide for MCH nurses DVD A Facilitator MCH Standard Brigance kits - preferably one for every two nurses MCH Coordinator Brigance kit - for facilitator Step 2: Select one case study at a time Provides opportunity to complete the Brigance Screen through observation There are six to choose from (4 months, 8 months, 12 months, 18 months, 2 years and 3.5 years) Step 3: Prepare for viewing the case study Determine the age of the child (provided in the DVD) Introduction 5

Note for training purposes assume all children are exactly the age stated. Select the appropriate Brigance Tip sheet Example below - the 4 month Brigance Tip Sheet Step 4: Use the Brigance Tip sheet to identify: The correct Brigance Screen The correct Brigance Data sheet The cut off score for the age identified Refer to page xx of the Preschool Screen II- this provides the cut off scores for all ages from birth until 6 years of age Starting skill in each domain Mark on left of the starting skill number in each domain Further clarification of some of the skills in the screen. Step 5 View the selected case study Using the correct Brigance Screen, data sheet and tip sheet, view the complete Brigance screen for the case study selected. View through first time with minimal stops and ensuring all nurses are completing the data sheet. Mark the data sheet appropriately (/= not demonstrated or O= mastery of skill) Make notes When completed - discuss Remember that domains can be completed in any order but skills within each domain should be completed in order. Step 6: View the selected case study again with facilitator stepping through the Teachable and Discussion points Using a different colour pen - remark the data sheet if necessary View through a second time referring to the Teachable and Discussion points in the respective case study. Use the identified teachable points and discussion points to facilitate a deeper exploration of this Brigance Screen These key points will help to develop and strengthen the MCH nurses understanding of how to implement Brigance Screens. Be conscious of the time and prepared to move the discussion on if necessary. Remember: these screens are captured moments, not scripted, and do not offer the opportunity to go back and ask more questions or try another way; therefore scores will not be the same. Scores should be close but may vary. Score and discuss what next. 6 Brigance basics: a guide for Maternal and Child Health Nurses

Step 7: Referral pathways Introduction 7

3. Case Study One: Ruby (4 months) Overview Identifies that PEDS scored Path B. Developmental concerns are not identified in introduction Sleep issues discussed Provides insight of future development Preparation Steps Step 1 Select the correct Brigance Tip sheet Step 2 Select the correct Screen, Correct Data Sheet Step 3 Complete section A of data sheet Step 4 Determine corrected age Step 5 Identify correct cut off score and write this on top right hand side of data sheet Step 6 Mark starting points for each domain Getting Started With prepared data sheet, the Infant and Toddler Screen and the Infant (I) data sheet, and the 4 month Brigance Tip sheet, commence the Brigance screen. Mark the data sheet appropriately (/= not demonstrated or O= mastery of skill) Domains can be completed in any order The items within each skill area need to be completed in the order they present. In this scenario the skills are completed in the following order: 1A Fine Motor Skills 2A Receptive Language Skills 3A Expressive Language Skills 5A Self Help Skills 6A Social-Emotional Skills 4A Gross-Motor Skills The 4 month Brigance Screen: teachable and discussion points Start at skill 3 for each domain 1.05 Use of rattle note vague response by Ruby Ruby does follow rattle 1A Fine Motor Skills These skills observed and discussed during the assessment 2.30 3A Expressive Language Skills Talking about Ruby s response to sounds- as within normal expectations Keep in mind previous response to rattle 8 Brigance basics: a guide for Maternal and Child Health Nurses

4.15 5A Self Help Skills Reference to breastfeeding good Need to refer to MCH Brigance Tip sheet for guidelines on what can be asked Skill 4 - could have asked Is Ruby opening and closing her mouth - like munching when watching others do the same? Skill 6 - refer to Brigance Tip sheet, could have asked this in relation to breastfeeding. As Ruby was assessed as not being able to do skills 4, 5 and 6, the MCH nurse went back and discussed and observed skills 1 and 2. 4.50 6A Social Emotional Skills Note Skill 3 here can also be linked to Skill 3 Receptive Language and Skill 3 Expressive Language 5.00 6A Social Emotional Skills Skill 4 - Note Ruby s excitement Skill 5 - seen earlier in assessment 5.50 4A Gross-Motor Skills Squeaky toy response - difficult to interpret Great eye engagement noted Blanket on floor great idea 7.05 4A Gross-Motor Skills When rolled to prone position, the comment is made that Ruby likes this position. Note that not lifting up and arms not straightening. Opportunity here to discuss prone play time. Observations and Next Steps Determine the score by completing the data sheet during this assessment Discuss score in relation to cut-off Cut off score for 4 month is less than 23 Although not discussed here, audiology referral could be considered Discussion also on how to improve head and upper body strength Case Study One: Ruby (4 months) 9

4. Case Study Two: Logan (8 months) Overview Identifies that PEDS scored Path A. Born 8 weeks premature Now 10 months (corrected age = 8 months) Consultation occurs at home Preparation Steps Step 1 Select the correct Brigance Tip sheet Step 2 Select the correct Screen, Correct Data Sheet Step 3 Complete section A of data sheet Step 4 Determine corrected age Step 5 Identify correct cut off score and write this on top right hand side of data sheet Step 6- mark starting points for each domain (refer to Brigance 8 month Tip sheet) Getting Started With prepared data sheet (Infant = I), the Infant and Toddler Screen and the 8 month Brigance Tip sheet, commence the Brigance screen. Mark the data sheet appropriately (/= not demonstrated or O= mastery of skill). Domains can be completed in any order. The items within each skill area need to be completed in the order they present. In this scenario the skills are completed in the following order: 4A Gross-Motor Skills 1A Fine-Motor Skills 3A Expressive Language Skills 5A Self Help Skills 2A Receptive Language Skills 6A Social Emotional (throughout) The 8 month Brigance Screen: teachable and discussion points Note - MCH Nurse refers to cut off score as 41, the cut off score for an eight month is 40 Early insights Logan at ease with camera and sound men Comfortable at home and with Jane (Nurse) Does not bring arms up to be picked up Start at skill 5 for each domain 1.30 4A Gross-Motor Skills Falls forward- not sitting unassisted When prone not straightening arms 10 Brigance basics: a guide for Maternal and Child Health Nurses

2.10 1A Fine Motor Skills Skill 5 reaches for objects. Mum explains how Logan can do this much more easily when he is on his back and thus doesn t need to use his arms to balance. Torso is not strong enough to hold balance. 2.20 3A Expressive Language Skills Note that nurse starts at skill 1 2.35 5A Self Help Skill 5 demonstrates this with teething rusk Note that this skill assessment links with Skill 5 Fine Motor 5.10 2A Receptive Language Skills Note rattle response- is this a definite response? 7.10 Nurse Summary Explaining the cut-off score Note that although the explanation is given out of 100 it is best to discuss score in relation to cut off and areas of concern. Observations and Next Steps Good discussion and referrals made from this assessment The nurse explains that many of the starting skills in this assessment were 6 months Not structured Clearly demonstrates the flexibility to move about within the domains which is possible once the nurse is familiar with the skills. Case Study Two: Logan (8 months) 11

5. Case Study Three: Jacob (12 months) Overview PEDS score not mentioned on DVD. Mother s concerns were around Jacob s speech. Preparation Steps Step 1 Select the correct Brigance Tip sheet Step 2 Select the correct Screen, Correct Data Sheet Step 3 Complete section A of data sheet Step 4 Determine corrected age Step 5 Identify correct cut off score and write this on top right hand side of data sheet Step 6- mark starting points for each domain Getting Started With prepared data sheet, the Infant and Toddler Screen, and the 12 month Brigance Tip sheet view the Brigance Screen Mark the data sheet appropriately (/= not demonstrated 0r O= mastery of skill) Domains can be completed in any order The items within each skill area need to be completed in the order they present. In this scenario the skills are completed in the following order: 9B Gross-Motor 1B Fine-Motor 2B Receptive Language General 6B Expressive Language Skills- General 11B Social-Emotional 10B Self Help The 12 month Brigance Screen: teachable and discussion points Start - note how the MCH Nurse discusses how Brigance is scored and how this relates to age specific cut off scores Note also that this screening commences with gross motor as Jacob is busy walking about and exploring. Start 9B Gross-Motor Start skill 3 Jacob able to do skill 3, 4 and 5 Skill 7 reported by mum Unable to do skill 6 Skill 8, 9 & 10 not attempted 12 Brigance basics: a guide for Maternal and Child Health Nurses

2.50 1B Fine-Motor Start skill 3 Skills 3, 4 & 5 observed together 3.30 1B Fine-Motor Skill 6 Unwraps object Tip - get Jacob s attention first 4.00 1B Fine-Motor Skill 7 deliberately pours or dumps note that Jacob shows no understanding, therefore unable to do refer to tip sheet the word dump is not a common word 1B Fine-skills 8, 9 & 10 As unable to do skill 6, 7 & 8, moved onto another domain 5.00 Fine-Motor Skill 6 Unwraps object Attempted again - not able to do 6.00 2B Receptive Language- General Start skill 2 Note these skills are not done in order Skill 6 - Gives block on command (no gesture) Jacob unable to do Skill 5 Understands the word give with gesture. Mum initiates this skill with gesture and saying to Jacob ta for mum - Jacob understands and responds. Skill 3 - responds to commands. Here it is important to observe Jacob throughout the screening; Jacob asked to come to mum and responded appropriately. Skill 2 - Responds to word no. Not seen nor discussed during this screening. (To follow up from this screening- Jacob does respond to no Note: Skill 4 Waves bye-bye also not done ( following this screening it was identified that skill 2 and 4 were observed at the previous consultation by nurse when PEDS completed) 6.10 Expressive Language- General- Skill 3 Imitates sounds or words Start skill 3 Listen to Jacob - he copies mum when she says Mark 6.40 6B Expressive Language- General- Skill 4 Pretend Talks Tip - need to explore further here goo gaa is not pretend talk Discuss- How much have you heard from Jacob? Skill 5 Says real words - mum reports that Jacob is saying Mark, Mum, Pup and Ma Remember mama and Dada do not count Mark and pup would count here Case Study Three: Jacob (12 months) 13

7.15 & 7.25 6B Expressive Language- General- Skills 6, 7, & 8 Skill 6 Pretend talk with some real words - Jacob not doing Skill 7 at both these time points Jacob holds up objects to get the nurse s attention. Skill 8 not pointing 8.40 As Jacob was unsuccessful in 6B items 6 and 8, it is not necessary to administer 7B and 8B. 11B Social-Emotional Skills 3, 4 and 5 Start Skill 3 Note that while the nurse was finding the appropriate question, Jacob has ventured off to interact with Dale, the camera man. Skill 4 - reported by mum Skill 5 - reported by mum 9.45 11B Social-Emotional Skill 6 - Explores and returns Note the nurse references here her observations during this screening where we have seen Jacob explore and return several times. 9.50 11B Social-Emotional Skills 7, 8 and 9 Skills 7 and 8 mum reports no and nurse discusses that these skills are commonly seen in older children Note skill 9 not discussed 10.20 10B Self Help Skill 3 Start skill 3 Refer to Brigance Tip sheet in relation to offering food 10.35 10B Self Help Skill 4 Refer back to observations completed throughout this screening Avoid repeating this skill - Jacob has already demonstrated this. 10.45 10B Self Help Skills 5 & 7 12.10 Summary Note how the MCH nurse refers back to her observations at the previous consultation here. Undressing can be avoided here if observed at previous consultation when Jacob was weighed and measured. (There are many Brigance skills that could be observed at the previous consultation when PEDS is completed) Note - Skill 7 also answered here 10B Self Help Skills 6, 8, 9 & 10 Skills 6, 8 & 9 reported to do so most of the time Note Skill 10 not discussed MCH nurse talks about score in relation to cut-off. Score noted here as 37 - what did you score? Scores will vary here as some skills were not observed or discussed. This highlights the value of documenting any Brigance skills observed when PEDS completed. 14 Brigance basics: a guide for Maternal and Child Health Nurses

Observations and Next Steps Parent concern addressed and reassured that Jacob is developing well. Case Study Three: Jacob (12 months) 15

6. Case Study Four: Ellie (18 months) Note- time missing off this screen- Ensure that DVD tracking number is set at zero when starting the Brigance Screen (timer does not start at Overview ). Overview Identifies concerns relating to speech Preparation Steps Step 1 Select the correct Brigance Tip sheet Step 2 Select the correct Screen, Correct Data Sheet Step 3 Complete section A of data sheet Step 4 Determine corrected age Step 5 Identify correct cut off score and write this on top right hand side of data sheet Step 6 Mark starting points for each domain (refer to Brigance 18 month Tip sheet) Getting Started With prepared data sheet, the Infant and Toddler Screen and the 18 month Brigance Tip sheet, commence the Brigance screen. Mark the data sheet appropriately (/= not demonstrated or O= mastery of skill) Domains can be completed in any order The items within each skill area need to be completed in the order they present. In this scenario the skills are completed in the following order: 1B Fine-Motor 2B Receptive Language -General 3B Receptive Language Body Parts 4B Receptive Language Picture Naming 5B Receptive Language Environmental Sounds 6B Expressive Language Skills- General 7B Expressive Language Object Naming 8B Expressive Language Skills- Phrases 9B Gross-Motor 10B Self Help 11B Social-Emotional The 18 month Brigance Screen: teachable and discussion points Start at skill 5 for each domain 2.30 1B Fine-Motor Suggestion - just fold the tissue, don t twist. Skill 7 Deliberately pours or dumps refer to tip sheet the word dump is not a common word 16 Brigance basics: a guide for Maternal and Child Health Nurses

2.50 1B Fine-Motor- skill 7 Demonstrates pours or dumps Note the MCH nurse asks Ellie to perform this initially without demonstrating. When Ellie is unable to complete this skill the nurse then demonstrates. Could have demonstrated first. Suggestion - try the triangle pencils in the Brigance toolkit to help promote a more mature pencil grasp. Remember that children at this age are not expected to know the shapes by name, just be able to copy. Thus a circle is not referred to as a circle but as a shape. 3.45 1B Fine-Motor- skill 8 Builds five block tower Nurse initiates with first 3 blocks - try and encourage child to start again. Note how well Ellie places block 4, 5 & 6 on the tower and attempts the 7th. Note - by adding the 6th block Ellie has achieved skill 10. 5.45 2B Receptive Language- General- skill 4 Skill 4 Waves bye-bye can ask mum this question as credit is given if Ellie waves or is reported to wave most of the time. 6.35 2B Receptive Language- General- skill 5 Ellie gives mum the paper when asked to give the cup to mum. Refer to scoring criteria- Give credit if the child gives any toy or is reported to do so most of the time. Not necessary to repeat requests 8.25 2B Receptive Language- General- skill 8 Note that Ellie has already demonstrated this 8.55 3B Receptive Language- Body parts Note - as Ellie was successful on 2B, items 6,7,and 8 Feet and toes are not the same 9.50 3B Receptive Language- Body parts Note that Ellie has no idea about hair Mum reports yes to ears Therefore Ellie scores 2 correctly here - nose and ears Observe- Ellie loses interest here - ensure to only attempt a maximum of 3 times and then move on. 11.35 4B Receptive Language Picture Naming Ellie able to show where the cat is and where the dog is Ellie says car for key 11.55 4B Receptive Language Picture Naming Note that Ellie is able to identify the car and apple Unsure about the aeroplane, therefore does not score on this one. Case Study Four: Ellie (18 months) 17

12.35 5B Receptive Language Environmental Sounds Note Ellie able to clearly meow for cat Mum reports that Ellie can correctly make the sounds for cow, elephant and dog. Ellie therefore scores 3 correctly (cat, cow, and dog). 14.15 6B Expressive Language- General Observe Ellie s response to the squeaky toy the rabbit Skill 4 Pretend Talks is observed well here - as Ellie is telling her mum and the nurse about her feelings about that rabbit Skill 5- is not assessed separately here as observed throughout this assessment 15.25 7B Expressive Language- Object Naming Note the rabbit does seem to distract Ellie At this time unable to name any of these objects 8B Expressive Language- Phrases Not completed separately Assessed throughout the Brigance screen, by observation and mum reporting Ellie did not score in this domain 17.45 9B Gross-Motor A moment the bunny is defeated Ellie is being ignored, gets louder and removes the bunny 18.45 9B Gross-Motor Ellie picks the spoon up off the floor and clearly says spoon This is scored in 7B 18.55 9B Gross-Motor 19.15 10B Self-Help Ellie clearly shows her understanding and gross motor skills by jumping with both feet when discussed by mum and the nurse. Note Ellie is allowed to explore and play while Mum and the nurse discuss this domain Note although Ellie sits down and shows an understanding of taking off her shoes clearly not interested at this time. 21.30 11B Social-Emotional Note that Ellie is allowed to explore and play during this last domain The nurse and Mum explore these skills through conversation This domain is mostly scored through parent reporting Note how Ellie interacts with the nurse and the 2 camera men in the room Skill 5 Showing pride and pleasure is demonstrated through this assessment Skill 6 Explores and returns is demonstrated through this assessment. Observations and Next Steps Note that Ellie was able to complete the extended Brigance Screen Speech concerns were allayed MCH nurse will review at 2 years 18 Brigance basics: a guide for Maternal and Child Health Nurses

7. Case Study Five: Chelsea (2 years) Overview Identifies that PEDS scored Path B. Preparation Steps Step 1 Select the correct Brigance Tip sheet Step 2 Select the correct Screen, Correct Data Sheet Step 3 Complete section A of data sheet Step 4 Determine corrected age Step 5 Identify correct cut off score and write this on top right hand side of data sheet Step 6 Mark starting points for each domain Getting Started With prepared data sheet, the Early Preschool Screen II and the 2y Brigance Tip sheet, commence the Brigance screen. Mark the data sheet appropriately (/= not demonstrated or O= mastery of skill) Domains can be completed in any order The items within each skill area need to be completed in the order they present. In this scenario the skills are completed in the following order: 8A Builds a tower with blocks 6A Visual Motor Skills 1A Identifies Body Parts 2A Gross Motor Skills 3A Picture Vocabulary 4A Identifies People in Picture by Naming 7A Verbal Fluency 5A Knows Use of Objects The 2 year Brigance Screen: teachable and discussion points Start at skill 1 for each domain Start MCH nurse reiterated concerns raised through PEDS. Talks about score out of 100, and expected score at this age. Note Start point = skill 1 for all these domains 1.20 8A Builds Tower with Blocks Note that can start with any domain Blocks were already on the table Chelsea in fact had already stacked 6 blocks prior to filming Note Chelsea s refusal to do this again for the camera Therefore this can be scored with 10 points Case Study Five: Chelsea (2 years) 19

2.20 6A Visual Motor Skills. Observe and discuss mum s use of language eg when she says not not 4.00 1A Identifies Body Parts Chelsea is unable to identify legs when asked repeatedly Once completed these skills and Chelsea gets up, the MCH nurse asks again about legs and Chelsea clearly identifies one of her legs. 4.25 2A Gross-Motor Skills Skill 1 lots of attempts to get interested Skill 2 lots of attempts - at 5.15 Chelsea jumps but is not noticed Skill 3 Chelsea does immediately 6.05 3A Picture Vocabulary MCH nurse asks what s that one? Refer to Screen - What is this? What do you call this? Note that speech is very unclear- no clear words here. Unable to score this domain 7.05 3A Picture Vocabulary Mum and Chelsea explore the pictures on the floor mat Speech sounds- ba dad choo choo 7.30 4A Identifies People in Picture by Naming Chelsea identifies daddy s and mummy s For girl Chelsea says mummy s For boy - Chelsea says daddy s 7.50 MCH Nurse asks which one is mummy, where is mummy Both these questions are asked incorrectly- refer to wording in Screen 8.10 MCH nurse asks Mum who is a boy Chelsea knows? Mum responds Tate Then Chelsea is asked Where is Tate? Chelsea then points to boy Note although this is a useful exercise for screening understanding it does not equate to a pass for boy (brother, son) 8.35 When referring to the scoring in this domain, the MCH nurse discusses that I will give all of these meaning that Chelsea mastered all the skills. In fact Chelsea only mastered two skills (Mummy and Daddy). 20 Brigance basics: a guide for Maternal and Child Health Nurses

10.05 7A Verbal Fluency Note that a valid sampling of speech can occur throughout the screening MCH nurse attempts to initiate conversation with questions asking Chelsea what she did today. (exploration of speech) 10.35 Expressive Language discussion Great questioning by MCH nurse to Mum what is Chelsea saying to you now? 11.50 5A Know use of objects see if you can talk to me about the use of things Refer to Screen- Criteria- give credit for correct verbal responses as well as other responses that convey comprehension of use of the object such as pantomiming driving when asked what a car is for or sleeping when asked what a bed is for. Tip - have room set up with a chair, a car and perhaps a doll s bed and observe child at play. Note this observation could occur in the waiting room and when completing the PEDS. 12.50 Chelsea relates the car with Dad. Mum explains that Dad and Chelsea drive the car out each morning. Score this 13.00 Chelsea knows what to use a chair for as she sat on one when she walked in 13.10 Discussion with Mum about talking to Chelsea Good opportunity to explore this further and provide tips on promoting Chelsea s language development. 13.30 MCH nurse provides a clear picture that she cannot understand what Chelsea is saying. 13.50 Discussion of score Discussed score in relation to cut off Identifies the domains where Chelsea did not score well Discusses referral Observations and Next Steps Discusses referral to speech and audiology If Chelsea scored below the cut-off of 47 then a full paediatric developmental assessment would have to be completed Case Study Five: Chelsea (2 years) 21

8. Case Study Six: Hugo (3.5 years) Overview Identifies that PEDS scored Path B. Preparation Steps Step 1 Select the correct Brigance Tip sheet Step 2 Select the correct Screen, Correct Data Sheet Step 3 Complete section A of data sheet Step 4 Determine corrected age Step 5 Identify correct cut off score and write this on top right hand side of data sheet Step 6 Mark the starting points for each domain Getting Started With prepared data sheet, the Preschool Screen II and the 3Y Brigance Tip sheet, commence the Brigance screen. Mark the data sheet appropriately (/= not demonstrated or O= mastery of skill) Domains can be completed in any order The items within each skill area need to be completed in the order they present. In this scenario the skills are completed in the following order: 8A Builds a tower with blocks 7A Number concepts 1A Personal data response 2A Colour recognition 3A Picture vocabulary 4A Knows use of objects 5A Visual motor skills 10A Repeats sentences 11A Prepositions and irregular plural nouns 9A Identifies body parts 6A Gross motor skills The 3.5 year Brigance Screen: teachable and discussion points 5.40 4A Knows use of objects Number 1 is the book and Hugo answers read which is correct. Note can refer to a book not just a picture of one. Number 2 is the scissors and Hugo answers cut which is correct. Number 3 is the refrigerator and Hugo answers making pictures which is incorrect. What do you think this is? is not the right question to ask here. Need to ask Why do we have refrigerators? or How can we use a refrigerator? Hugo goes on to identify this as a freezer and answers correctly when asked to explain the use. 22 Brigance basics: a guide for Maternal and Child Health Nurses

6.20 5A Visual Motor Skills Note the MCH nurse has provided Hugo with a photocopied page to use here. Suggestion - try the triangle pencils in the Brigance toolkit to help promote a more mature pencil grasp. Remember that children at this age are not expected to know the shapes by name, just be able to copy. Thus a circle is not referred to as a circle but as a shape. 8.10 10A Repeats Sentences Feel free to cover and show just one picture at a time Need to ask the questions as written in the screen (these are provided in bold with each skill description). Hugo could say 1A therefore 1B was not attempted. Hugo could do 2A therefore 2B was not attempted. Note MCH Nurse allows Hugo another attempt Hugo could do 3A therefore 3B was not attempted. 9.20 11A Prepositions and Irregular Plural Nouns Feel free to cover and show just one picture at a time Need to ask questions as written in screen (in bold). Hugo answers 1A What is the boy doing? but is not asked What is the girl doing? Therefore this score would be 2.5 out of a possible 5. Hugo could answer 1A therefore 1B was not attempted. Hugo answered 2A feets. This is not a credit and 2B should have been attempted. 11.10 6A Gross Motor Skills This assessment can be completed more quickly and with greater validity if you demonstrate the skills as you give the directions. Skill 1 and 2 require a steady stance for 5 seconds. Skill 3 note use of fine rope as prop. Heel and toes do not have to touch but be in alignment and close. Unfortunately the timing pad gets a little in the way on this one. Hugo could achieve this skill. Note that the criteria for scoring on Skill 3 states give credit if the child walks four steps without waving his/her arms excessively and without stumbling. Observations and Next Steps Scored 91 by MCH Nurse This score equates to giving full points on 11A If 11A scored as discussed in this guide would only score 2.5 rather than 10. This score would still be above the cut-off score of <71. The Social and Emotional Scales are found at the back of the screens and are not used routinely within the Victorian MCH practice. Case Study Six: Hugo (3.5 years) 23