Evaluating the FOCUS: A New Communication
Outcome Measure for Preschoolers
Thomas-Stonell, N., Robertson, B., Oddson, B., Walker, J., & Rosenbaum, P.
BACKGROUND
• Communication disorders are very common in children, affecting 6% of the preschool
population.¹
• Evaluating the outcomes of treatment is essential for improving services in an
evidence-based manner.2
• The field of speech pathology is lacking reliable and valid outcome measures that
evaluate the impact of treatment for pre-school children.
The FOCUS
• The FOCUS 3 (Focus on the Outcomes of Communication Under Six) is a new
outcome measure for preschool children, based on the WHO’s ICF-CY framework. It is
designed to detect changes in communicative-participation for preschool children
following speech-language therapy.
• Communicative-participation is defined as communication in life situations where
knowledge, information, ideas, or feelings are exchanged.4
• FOCUS items were based on prospective observations of change collected from 210
parents of preschool children receiving speech-language therapy and their clinicians.
Next, the measure was tested with 165 different parents and their clinicians. It was
revised according to parent/clinician feedback and item analysis. The FOCUS was
reduced from 103 items to 50 items. A parent and a clinician version was developed. The
FOCUS takes 10 minutes to complete and uses a 7-point Likert scale to measure
communication changes.
METHOD
• The Ages & Stages Questionnaire – Social Emotional6 is a validated measure of social and
emotional skills for children from 6 to 60 months. The ASQ-SE evaluates seven behavioural
areas: adaptive functioning, self-regulation, autonomy, compliance, communication, affect, and
interaction with people.
• Parents completed the ASQ-SE and the FOCUS three times. Time 1 was assessment. Time 2
was start of treatment, and Time 3 was end of treatment. Communication facilitation strategies
were provided to parents between Time 1 and Time 2. Nine hours of individual/group speechlanguage therapy was provided between Time 2 and Time 3.
“He is not learning words or able to communicate what he wants. Very frustrating for
him - tantrums.”
Hypothesis 2
• Level 3: the child is an effective sender and/or receiver with familiar partners.
• FOCUS significantly improved from Time 1 to Time 2. ASQ-SE scores also
• Pearson correlations examined the convergence between FOCUS and ASQ-SE total scores at
each time point. FOCUS and ASQ-SE change scores between Time 1 – 2 and Time 2 – 3 were
also examined.
RESULTS
Hypothesis 1
FOCUS 1
ASQ 2
ASQ 3
r = -.41 p < .01*
r = -.38 p < .01*
FOCUS 2
• A previous study established the convergent validity of the FOCUS with the PEDS-Q, a
paediatric health-related quality of life measure.
Hypothesis 2
FOCUS
ASQ-SE
Time 1 – Time 2
t = 4.22, p < .001*
t = 1.98, p = .053,
Time 2 – Time 3
Time 1 – Time 3
t = 6.97, p < .001*
t = 6.20, p < .001*
t = 4.58, p < .001*
t = 4.23, p < .001*
• To establish convergent validity between the FOCUS and the ASQ-SE.
• Hypothesis 1: A moderate correlation (r = .30 - .505) will be found between FOCUS
and ASQ-SE total scores at Time 1, Time 2 and Time 3.
• Hypothesis 2: Both the FOCUS and ASQ-SE will measure significant change
significant change from Time 2 to Time 3.
• Hypothesis 3: Scores from the ASQ-SE Communication and Interaction with People
domains will be more significantly correlated with FOCUS scores than scores from the
other domains.
improved, but not significantly. Since communication strategies were provided to parents
during this interval, positive changes in communication skills were expected. Both
the FOCUS and ASQ-SE measured significant change from Time 2 to Time 3.
Hypothesis 3
• FOCUS correlations were higher for the Communication and Interaction with
People domains than the Autonomy, Affect and Compliance domains. FOCUS
scores were also more highly correlated with the Adaptive Functioning domain,
perhaps because it included several feeding questions. FOCUS shows evidence of
both convergent and divergent validity.
Limitation
r = -.37 p = .01*
FOCUS 3
Objective
• Parents’ comments about their children reflect this association between socialemotional skills and communicative-participation:
• The Communication Function Classification System (CFCS)7 was used to rate the severity of
the communication disorder. Children’s communication skills ranged from 1 (least severe) to 5
(most severe). The median CFCS score was 3.
• My child plays well with other children.
• FOCUS test-retest reliability has also been established with both parents (r > .95) and
clinicians (r > .90) achieving excellent reliability. Clinician inter-rater reliability was also
very high (ICC = 0.93; CI = .87-.97).
• As predicted, ASQ-SE and FOCUS scores were moderately correlated. A moderate
correlation was expected because the ASQ-SE and the FOCUS measure similar,
but not identical constructs. Specifically, the ASQ-SE measures social-emotional
skills, while the FOCUS examines communicative-participation.
“Socialization is compromised for lack of verbal skills. All behaviors are due to poor
communication.”
ASQ 1
• My child is confident communicating with adults who do NOT know my child well.
Hypothesis 1
• Data from 93 participants was collected from 11 centers across Canada. There were 65 boys
and 28 girls. The ages ranged from 7 months to 59 months old (M = 31.9 mo).
Sample FOCUS Items
• My child conveys her/his ideas with words.
DISCUSSION
Hypothesis 3
• Correlations between FOCUS scores and the ASQ-SE Communication, Interaction
with People and Adaptive Functioning domains were significantly (p = .05) higher
than those from the Affect, Autonomy and Compliance domains.
• Parents and clinicians were not
blind to the assessment and treatment intervals.
CONCLUSION
• FOCUS demonstrates construct validity and is a valid outcome measure. It
measures changes in communicative-participation and the impact of these changes
on children in their community.
ACKNOWLEDGEMENTS
We would like to thank the families and children who participated and our research partners: Alberta Health Services,
Calgary; BC Centre for Ability, Vancouver; Early Years Communication Program KidsAbility, Waterloo; ErinoakKids
Centre for Treatment and Development, Mississauga; Hamilton Health Sciences: Technology Access Clinic,
Hamilton; Hamilton Preschool Speech and Language Service, Hamilton; Holland Bloorview Kids Rehabilitation
Hospital, Toronto; Nova Scotia Hearing & Speech Centres, Halifax; Wee Talk, St. Joseph’s Health Centre, Guelph.
Funded by: Canadian Institutes of Health Research (CIHR) & Bloorview Children’s Hospital Foundation.
REFERENCES
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3Thomas-Stonell, N.L., Oddson, B., Robertson, B., Rosenbaum, P.L. (2009). Development of the FOCUS (Focus on the Outcomes of Communication Under Six), a communication outcome measure for preschool
children. Developmental Medicine & Child Neurology, 52, 47-53.
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