Zero to Three Screen Tool for Early Childhood
Clinical Examples using ADHD, Mood Disorders of Childhood, and Autistic Spectrum Disorders
Routine Mental Health Screening for the Child Ages Zero to Three
An Adaptation of the Functional Emotional Assessment Scale by Greenspan
From the series” I want you to know what I know.”
Many time children below the age of four are either not diagnosed or misdiagnosed base on some standardized test scores. The Functional Emotional Assessment [FEA] Scale developed by Stanley Greenspan M.D. is an attempt to assess and measure the younger child’s core emotional and social capacities, in a more natural unstructured setting trying to replicated what happens in everyday life between the child and the care giver.
The procedure is for the evaluating person or the caregiver to interact or play with the infant or child as they may at home under normal circumstances. This can be done in an office or at home and repeated as many times as necessary to get a true picture of the child’s and the caregivers capacities.
The scale can be used descriptively or quantitatively to profile the child’s emotional, social, language, and cognitive capacities at various developmental stages. What follows is a simplified modification of the scale found useful for screening, evaluating and treatment purposes. It is taken from Dr. Greenspan’s book “Infancy and Early Childhood”.
Three Months of Age: Alert , Focused, can Calm Self Down and Self Regulate
1. Can attend and shows interest to sounds and sights for 3+ seconds
2. Remains calm and focused for 2+ minutes
3. Relaxes/shows pleasure when held firmly or rocked
4. With physical help of caregiver recovers from distress within 20 minutes
5. Shows interest in happy and assertive caregiver
6. Vocalizes with at least one sound
Five Months of Age: Attached and Related ,showing positive loving feeling toward caregivers
1. Can focus or attend for thirty or more seconds
2. Shows interest or pleasure in caregiver’s voice, facial expressions, touch
3. Shows sense of security and relaxation when held, rocked, looked at , talked to
4. Recovers from distress with only social interventions, like talking, singing and making faces within 15 minutes
5. Shows discomfort or sadness during play if caretaker is not responding for 30 to 60 seconds
6. Vocalizes two different sounds
Nine Months of Age: Intentional Two Way Non Verbal Communication Understanding Cause and Effect
1. Can focus on toy or person for one or more minutes
2. Responds to caregivers voice, facial expressions and touch out, caretaker talking or facial expression begets a playful look
3. Initiates intentional interactions by spontaneously reaching for caregivers nose, hair, and hand movements to indicate wish for toy or to be picked up
4. Vocalizes Ma, Da, or Ba to convey emotions and intentions
5. Can recover from distress within 10 minutes by being involved in social interactions
Thirteen Months of Age: Behaviorally Organized by Stringing Communication Circles Together
1. Beginning and ending with the infant sequences 3 or more non verbal communication circles, using vocalizations, facial expressions, motor patterns like touching, handing toys back and forth, chase games
2. Meaningful behaviors expressing feelings of pleasure, exploration, fear, protest, sadness and anger
3. Can focus and attend while playing on own for 5 or more minutes
4. Can recover from distress, remaining organized, by negotiating by using gestures for what is wanted
5. Not sensitive to bright lights or loud noises, and tolerates different texture with mouth and hands, comfortable climbing off floor
6. Understands simple words, uses a few words for specific objects and jabbers
Eighteen Months of Age: Behaviorally Elaborates Sequences of Basic Emotional Themes
1. Understands and communicates non verbally using ten or more circles of interaction to deal with themes, of closeness , e.g. for a hug, of pleasure e.g. making a joke, fears e.g. hiding, anger e.g. organized tantrum
2. Copies another’s behavior and then uses it to convey a theme, e.g. putting on daddy’s hat
3. Can play on one’s own in a focused organized manner for 15 minutes or more
4. Can use imitation to deal with and recover on one’s own from distress
5. Searches for a hidden desired object or toy in more than one place
6. Can communicate across space, without the need of touching and disrupting present activity
Twenty-four Months of Age: Representation Capacity using Pretend Play and Words as Symbols to express thoughts and feelings.
1. With help of caregiver, constructing simple pretend play patterns of at least one “idea”
2. Using words or their symbol, like pictures to communicate a wish, need, intention or feeling
3. Can use pretend play or words to recover from and deal with distress
4. Can attend or focus for thirty or more minutes
5. Uses two word sentences and beginning of pronouns
Thirty Months of Age: Representational Elaboration using Emotional Ideas Beyond Basic Needs
1. Using pretend play and symbols like words and pictures to elaborate two or more ideas at a time that go beyond basic needs.
2. Using the representations to deal with 2 or more ideas dealing with closeness, pleasure, assertiveness, fear, anger, and limit setting.
3. Using play, words , and symbols to deal with and recover from distress
4. Uses sentences with two or more ideas
Thirty-six Months of Age: Representational Elaboration using Emotional Thinking
1. Pretend play , words and other symbols, no matter how unrealistic involves two or more ideas that are logically tied to one another.
2. The child knows what is real from what is unreal and switches back and forth between reality and fantasy with little difficulty
3. Understand and constructs logical bridges between ideas with full sentences.
4. Can identify objects by their function as part of developing abstract groupings
Forty-two to Forty-eight Months: Complex Representation using Emotional Thinking
1. Three or more logically connected ideas that are partially planned using elaboration of How, Why, or When, give depth to the speech, stories and play.
2. The child can use causality, and concepts of time and space to distinguish from reality and fantasy.
3. Child can now set limits for themselves by reasoning about consequences
4. Child can now relate some feelings of sadness and loss when physically separated from caregiver
One of the uses of this scale is to help clarify diagnostic picture in a younger child who may a biologically based mental health diagnosis. It also can be used to follow a problem or problem cluster to see if it is developmentally appropriate, and if it is not ,is it improving or getting worse.
Diagnoses that the FEA Scale may help clarify include, ADHD, Autistic Spectrum Disorders. Childhood Schizophrenia, Bipolar Mood Disorder, Attachment Disorders, just to name a few that often show their earliest symptoms and problems from infancy.
Though called the Functional Emotional Assessment scale it screens for basic cognitive functions like attention, logical use of communication, understanding cause and effect, relatedness, language, and development of basic emotional themes, based on a here and now practical assessment that can be learned by anyone and done anywhere.
This is one of the few tools that deals with emotions, mood and anxiety control, from the earliest ages, dealing with specific issues of closeness and dependency, pleasure and excitement, assertiveness and exploration, cautious and fearful behavior, anger, limit setting, and ability to calm oneself down after distress from these emotional states.
Some case examples illustrating how the information that is in the FEA Scale can be used for screening and diagnostic purposes follow.
ADHD in Early Childhood: A child who is 3 years of age and is overly active, doesn’t think about the consequences many times before doing things or acting, and can only play alone in an organized manner and stay focused for only 10 minutes at a time, regardless of mood, environment, and motivation. This child’s attention span is closer to what would be developmentally expected of an 18 month old, and by history developmental his ability to attend was always much less than expected. All other developmental goals have been consistently met or even exceeded as one rates the child using the FEA Scale. Family history has many people with similar deficits in attention unaccompanied by other developmental problems or delays or other mental health problems. This presentation fits with a diagnosis of Attention Deficit Hyperactivity Disorder[ADHD], and is quite typical of the developmental pattern, of all or most developmental goals being met except for the deficit in attention.
Mood Disorder Bipolar Type in Early Childhood: A child 4 years of age presents with problems with tantrums, more like rage attacks that even with the help of his parents, the child cannot calm themselves down in less than one hour. In his preschool there are no problems with anger , rage or frustration tolerance, but he has some episodic problems with paying attention, staying seated, and can be frequently socially impulsive saying things without thinking about the consequences and the child though very bright is not learning like his peers. The preschool urges the parents to get screening for ADHD , and the tests done do show elevated scales that point to a Diagnosis of ADHD, and a trial of stimulant is recommended. The child on the stimulant medication show improvement at preschool with improved learning and decreased activity and less impulsivity, but at home things seem to be getting worse, and as the stimulant is increased again the school reports continued and more improvement, but again the parents report worsening of irritability, anger, frustration tolerance and rage attacks. An evaluation is done by a Child Psychiatrist familiar with the FEA Scale and after taking a history of the child’s earliest development, and family history formulates another diagnosis and treatment plan. The child from infancy was found to not to have a consistent deficit of attention in concentration in the family setting, or in social settings like going to religious services in a church, or being with peers outside the school setting, nor was he markedly hyperactive or impulsive in these other settings. The most critical development issue present from infancy was the child’s inability to calm himself down in any reasonable length of time, based on the FEA Scale, and this was episodic and not continuous. He was a colicky infant and this colic lasted for almost a full year, he had no temper outburst until he was three years of age, and then they were present for two months, and went away, only to return now at age 4 years. He would develop fears that seemed unusual, severe and precocious that would come and go, almost of panic quality, and could not calm himself down, from about 18 months of age to the present. His speech and language was advanced even as a 2 year old, and by 3 years of age was talking more like a 8 year old, in content and process, using How, When, How, and Why, in speech and pretend play. When asked why he had problems at school he complained he found school too easy getting done whatever he was given far quicker than the others, and then became bored and restless, looking for more to do on his own, and would then socialize excessively, giving the appearance of being an ADHD child. His pretend play was filled excessively and at times exclusively with thoughts about be great, the best, in the world, in anything his imagination could conjure, and would alternate with themes of again excessive of sickness, dying, death, war and destruction. He also had much sleep disturbance with bad dreams and nightmares and gain that he was not sharing with anyone, including headaches almost of migraines proportions. This picture does not fit with ADHD, whose symptoms are continuous and not episodic, and cause impairment in across at least two domains. The child’s response to stimulants was no specific helpful in school, acting like chemical restraint rather than specifically addressing the dopamine problem that an ADHD child would have, and the stimulants were in fact making his fears and worries, and moodiness and rage attacks, that he could not recover from, worse. He also showed decreased ability to recover and calm down from his panic and worry attacks, which he often suffer through in a quiet manner not know even by his parents, because out of shame and guilt he was fearful of revealing them. Family history revealed mild drug and alcohol problems, and a moderate history of panic disorder, and a grandfather variously diagnosed with schizophrenia, and manic depressive disorder. Treatment consisted of play therapy, stopping the stimulants, putting the child on a small amount of a mood stabilizing agent, with improvement of all symptoms within a few weeks. This is not an atypical presentation for a young child with a mild to moderate bipolar spectrum disorder.
Autistic Spectrum Disorder: An 18 month old child’s mother has concerns because this little boy seems overly sensitive to certain lights and sounds, having extreme anxiety with crying that is prolonged and excessive, and the child cannot calm themselves down easily and there seems little the caregivers can do to help the situation. Mom has noticed more in retrospect that the child doesn’t mold to her body the way her other children did, and doesn’t seem to be making adequate eye contact. Generally the child seems to have difficulty expressing emotions through non verbal communication, and doesn’t reciprocate with emotional responses played with or talked too, like her other children did. The child does say certain words, and can put two words together to make his needs known but they don’t convey much if any emotions. The child is not hyperactive, seems compulsive rather than impulsive, getting stuck on playing with a toy and having difficulty with transitions and changes in routine. He can focus during his play for up to fifteen minutes which shows no emotional themes, except what can be interpreted as fear and anger. He prefers solo play with a the same toy that he difficulty parting with over play with his siblings, other children or his care takers. This child may be showing symptoms that occur in Asperger 's Disorder or Autism and need continued screening, evaluation, and likely some interventions.