Using the Ages and Stages Questionnaire to teach medical students developmental assessment: a descriptive analysis

Developmental assessment is a core learning outcome for paediatric and child health students, so when a survey of medical graduates' skills identified a lack of confidence in this area, a program was developed with the aims of increasing both confidence and respect for the parental role. This study evaluates that program.

Paediatric and child health practitioners advocate a family-centred care model that requires practitioners to have good interpersonal skills, to have respect for parental judgement and to be flexible in their role [1]. As well, collaborative patient-centred practice is emerging as a framework for interdisciplinary education [2]. For these frameworks to be successful, interpersonal competence, which includes an appreciation of the skill and uniqueness of all individuals involved, is required [3]. The development of these attitudinal and communication attributes in health care practitioners is one of the challenges for health educators interested in family-centred practice.

Medical student attitudes are important because they are viewed as a mediating link between clinical competence (knowledge and skills) and clinical performance and influence what the will do in clinical practice [4]. As students progress through their medical program some attitudes become increasingly negative, for example in relation to doctor-patient relationships, communication and preventative medicine [5]. A graduate survey of final year undergraduate medical students conducted in 2003 in a medical school in Western Australia showed that only 45% of them felt confident in performing a developmental assessment on a child (unpublished data).

Medical educators have suggested, that, to challenge and counter such negative attitudes, curricula could focus on the issue of respect and use structured exercises based on contact between groups as a learning tool [6, 7]. Collaboration of parents and clinicians in teaching in medical programs has been shown to be a successful way to improve mutual understanding and effect attitudinal change in the students [8]. A literature review by Wykurz and Kelly (2002) on the role of patients as teachers demonstrated that learners gained important educational benefits from meeting real patients with knowledge and teaching skills who had firsthand experience of a condition. [9]. Studies have shown that patients can successfully deliver tutorials that improve attitudes and skills for medical students [6, 10, 11].

Parents can help the medical students' learning by suggesting ways to communicate with their child and by providing information on the child's developmental milestones that complements student observations. This adaptive and active view of learning, where students utilise a naturally complex real situation to construct personal knowledge, is grounded in constructivist epistemology [12].

Surveillance of developmental progress is a process of eliciting and attending to parents' concerns, making accurate and informative longitudinal observations on children and obtaining a relevant developmental history [13]. It has been recommended that screening for development should not be limited to inquiry at one point in time and should use tools that have been demonstrated to have adequate psychometric properties [14], but screening tests have not been popular in primary care due to factors such as test length and difficulty managing children's behaviour.

However, research has shown that parents' concerns are as accurate as quality screening tests and that differences in education and child-rearing experiences make little difference in parents' ability to raise important concerns [15]. The Ages and Stages Questionnaire (ASQ) is a parent-completed child development early detection system specifically designed to be part of a child health-monitoring program [16]. However, because it is based on a parent participation model, it was also considered to be appropriate to be used for the structured experiential learning program that was set up in response to the 2003 survey findings to address the lack of confidence in final year students in performing a developmental assessment on a child.

There is a difference between the quantitative and qualitative outcomes. This is probably because they are largely addressing different things. The SPOT scores directly addressed confidence and indicated there was no significant change resulting from the program. However the qualitative research, based on student comments that were not directed, tended to be directed more towards understanding than confidence. For example, the comments indicated that the program expanded students' understanding of developmental milestones and of the two methods of assessment, as well as how to play with children and interact with their families. There was also an increased recognition of parents as partners in the assessment process.

Unfortunately, there were no examinations in the course in this area until 2005, so a more objective indication of the effect of the program on understanding was not available.

Where students commented on confidence, all but one commented that their confidence had increased. This appeared to be in contrast to the SPOT findings. However the finding is congruent with a study on teaching communication skills to medical students using a formal structured approach that found a decrease in students' confidence following the program. The authors attributed this to reflexivity and introspection in the program leading over confident students to reassess their skills and commented that under confident students were offered a model which they could use for practice [24]. From this, it may be surmised that a proportion of students in the study reported in this paper could have lost confidence but not commented on this their reports. This is supported by some students' completing more than the one required assessment recognising the differences with age of the child. If this were the case, it would not be apparent until the SPOT scores were available. Confidence could also be affected by the time delay between the writing of the report and the SPOT survey at the end of the term. Alternatively, although the students' confidence may have increased qualitatively, this may have been insufficient to lead them to choose 'strongly agree' over 'agree' in the SPOT Likert Scale.

The results cast some doubt on the underlying assumption in using the ASQ that increased knowledge would translate into increased confidence. Confidence is a complex attitude, of which knowledge is only one component. In the case of beginning practitioners, how many times and in what context a skill is attempted will influence confidence. This program deliberately placed the student in an unpredictable real-world context in order to learn about the process and to value parents' input. As students became aware of the complexities of assessing child development it is possible their confidence would be less robust. Some students commented that more of these assessments over all age groups would help increase their confidence. This makes intuitive sense from clinical experience. Correlation of objective assessment of knowledge and skill in a structured clinical exam with confidence and attitude would be of interest for future research.

Awareness of the importance of play and the use of structured validated tools is a useful outcome for future practice. The students preferred using the more structured ASQ tool as it provided better guidance than the Stycar milestones. This was appropriate for their level of competence as advanced beginners; the tool itself became part of the learning. The parent helped students relate to the child and complete a skill that may have been beyond their ability without support. This is the process of scaffolding that is central to constructivist theory, the theoretical base for the program [25]. Experiential learning requires structure, and the complexities of the skill being learnt require the components being made clear to the learner [26]. This is sometimes overlooked in apprenticeship style learning in clinical practice.

A disadvantage of a student centred program is decreased control over the learning that occurs. The results showed a 70% agreement between student and parent. This was lower than the 94% reported in ASQ reliability studies. The most likely explanation for the difference was student lack of experience: the ASQ score supported the parents' assessments over the students in many (but not all) cases. Despite this difference, or more likely because of this difference, most students acknowledged the important role parents play in developmental assessment, even though a few students continued to believe that parents may overestimate their child's abilities. Not surprisingly, parents did not feel they overestimated their child's abilities. Follow up discussion with tutors and peers to challenge the students' attitudes and reflect on their experience would be useful to address differences in perception [26]. Student discussion groups to facilitate reflection and self evaluation of learning was found to be useful in helping raise students awareness of patient-centred medical interviewing techniques in a study which aimed to compare student and maternal evaluations of simulated interviews [27].

The student comments suggest the experiential nature of the program creates more effective learning than a more didactic approach to teaching developmental assessment. The process of learning and concept development can be powerful outcomes in themselves. This illustrates double-loop learning, where the activity is part of a larger cycle, in which the reflection takes place by engaging in the activity in a real world context [28]. When there was a difference in ASQ assessment results, the students reflected on the situation and used a problem solving approach to identify what may have been real concerns for the mother; the process of 'reflecting-on-action' [29].

A limitation of the study is the use of reflective writing, especially for assessment, which can be criticised for bias in that students may write what they know the reader – in this case the educator – wants to read. However students often do more than the one required assessment and are quite animated after doing the assessment, recounting stories from their experience to the educator. The study would be more robust if a validated attitudinal test had been used, but this was not possible for this study. It would however, be a useful future study, as there is little in the literature about student attitudes to parent involvement in developmental assessment.

In this study, parents agreed they should be involved and felt the students benefited from their input. Future research could explore the effect on attitudes, knowledge and practice if parents were trained as tutors to teach developmental assessment. This knowledge could help direct future program development and evaluation.

The evaluation of the program has indicated that the ASQ can be an appropriate tool for students at the level of advanced beginners in paediatric developmental assessment. Despite contrasting research results on student confidence levels, students reported increased understanding and were positive about the program. The long-term benefits of the interpersonal skills and attitudes that they learn may be more important than confidence in the actual skill at this stage of their careers.