1. Using the Brief-ITSEA (BITSEA) in Primary Care CTAIMH Workshop
Margaret Briggs-Gowan, Ph.D.
University of Connecticut Health Center, Dept. of Psychiatry
April 30th, 2007

2. Acknowledgements
All research has been in collaboration with Alice S. Carter, Ph.D., University of Massachusetts, Boston.
Special thanks also to Darcy Lowell, Carol Weitzman, and Michelle White for their ongoing insights about real world implementation and interpretation.

3. Funding and Disclosures
Grants from the National Institutes of Mental Health.
A grant from the Astra Foundation.
Fellowship support from ZEROTOTHREE.
Disclosure: The ITSEA and BITSEA are published by Psychological Corporation of Harcourt Assessment.

4. Presentation Goals Present the Brief-ITSEA (BITSEA)
Discuss how to use the BITSEA

5. Brief-ITSEA (BITSEA)©
Screener for 12- to 36-month-olds
Problems and delays in competence
Autism/Pervasive Developmental Delay
Developmentally salient items
42 questions
5 to 7 minutes to complete
Easy to hand score
Multiple informants (parent, childcare)
Many settings (pediatrics, early intervention, childcare)
Reliable and valid

6. BITSEA Scores
The BITSEA yields two scores…
Problems
Competence

7. Measurement Development
Reviewed relevant literatures
Included symptoms described in DC 0-3 and relevant DSM diagnoses
Expert panel review to ensure age-appropriateness, coverage of intended domains, and face validity

8. Problem behaviors Two types of problem behaviors:
Behaviors that have normal manifestations but are problematic when they are of extreme intensity or frequency (e.g., tantrums) or when they present as part of a cluster of problem behaviors.
Unusual or atypical behaviors (e.g., autism spectrum behaviors).

9. Areas Addressed Externalizing Internalizing Aggression Overactivity
Defiance Oppositional behavior
Temper tantrums
Shyness Anxiety Separation distress
Behavioral Inhibition
Fear of unfamiliar situations
Fear of unfamiliar people Specific fears Depression
Social withdrawal
Internalizing

10. Areas Addressed Dysregulation Atypical Maladaptive Sleep problems
Eating problems Emotionally reactive (upset easily) Difficulty regulating emotions Difficulty recovering from distress
Sensory sensitivities
Atypical Maladaptive
Behaviors related to unusual disorders (e.g., autism spectrum,
Tourette Disorder), abuse, neglect, and trauma.

11. Competencies
Social and emotional competencies expected to emerge in early childhood.

12. Social-emotional Competence
Areas Addressed
Age-appropriate… * Symbolic and imitative play
* Play with peers
* Cooperation
* Compliance with adult requests
Social-emotional Competence
* Curiosity, interest in new things * Mastery motivation (tries even when challenged) * Awareness of others’ feelings (early forms of empathy) * Attention skills (listens to a book for a few minutes) * Social relatedness (responds when name called, interested in babies, looks for parent when upset)

13. BITSEA identifies children at-risk for persistent problems
59% of toddlers with problems continued to have problems one year later
Toddlers with high BITSEA scores were 4 to 5 times more likely than other children to have significant problems in elementary school

14. Administration
Please refer to cheat sheet included in your packets for administration details about how to introduce it, self-report versus interview, etc.

15. Hand-Scoring Walk Thru

16. What does Possible Deficit or Delay in Competence mean?
The child’s score is in the lowest 10-15% for the child’s age group and sex
May indicate social-emotional delays
May indicate autism spectrum disorders
Note that some children with scores in this range may have cognitive or language delays. However, the BITSEA is not intended as a screen for these types of delays.

17. What does Possible Problem mean?
The child’s score occurs in 25% or fewer of children of the same age and sex
The child may be having social-emotional problems

18. Eye of the beholder
It is important to recognize that as a parent-report measure, scores on the BITSEA are the perception of the parent.
Scores may be influenced by factors, such as knowledge about child development, parental depression or anxiety, stress in the family, and difficulties in the parent-child relationship.
BITSEA scores should never be considered “diagnostic.”
Therefore, follow-up is always important.

19. How to follow-up?
Review with the parent
Assess further
Refer
Monitor

20. Follow-up…
Determine whether parent is concerned or worried about any specific behaviors.
Explore frequency, intensity, duration, pervasiveness and impairment.
Be aware that cultural differences may influence whether or not behaviors are viewed as problematic.

21. Considerations for follow-up
Cluster: Is there a pattern of similar behaviors that seem to go together?
Frequency: How often does the behavior occur?
Intensity: How strongly is it expressed?
Duration: How long does it last?
Triggers: What, if anything, causes behavior?
Pervasiveness across relationships
Pervasiveness across settings
Impairment
Frequency: How often does this occur? Does this happen every day, a few times a week, once a month…?
Intensity: Is the quality extreme/unusual?
How long does behavior last? Can child calm/settle herself on own?
Duration/Onset:
How long has this been going on? Environmental triggers?
What brings the behavior on? What precipitates the behavior? What happens before the behavior starts? What is child trying to accomplish or what is the purpose for the child?
Pervasiveness across people: With whom does this happen? (Look for one parent, both parents, other caregivers)
Pervasiveness across settings: Does this happen in many settings or only at home, childcare, play group, doctor’s office, etc.?

22. Forms of Impairment Limit learning opportunities
Limit acquisition of age-appropriate social-emotional skills
Interfere with development of peer relationships
Interfere with child/parent functioning
Cause marked distress
Prevent child from attending childcare or preschool program, expulsion
Strain the parent-child relationship

23. Example with separation distress:
You told me that Louis “often”
Cries or hangs onto you when you try to leave.
How often does this happen?
Does this happen every time you leave him or just some of the time?
Who does this happen with? …new people? …even people he knows well?
How long does he stay upset?
How upset is he – what does he do?
Do you avoid leaving him with others because of this?

24. Example with night-waking:
You said that Louis “Often” Wakes up at night and needs help to fall asleep again.
How often does this happen? Most nights? A few times a week?...How many times a night?...Does he ever sleep through the night?
How long is Louis awake?
You said he needs your help to fall asleep again – what do you do to help him?

25. When to assess further or refer:
Cluster of problems
Frequent occurrence
Intense
Pervasive
Interfere with age-appropriate activities/cause impairment
Multiple behaviors associated with autism spectrum disorders are reported/observed

26. Questions and Discussion