BITSEA Brief Guide for Professionals

Margaret Briggs-Gowan & Alice S. Carter, 2006©

What is the BITSEA?

The Brief Infant–Toddler Social-Emotional Assessment (BITSEA) (Briggs-Gowan & Carter, 2006) is
designed as a tool that is quick, efficient and easy to use and score, for identifying children ages 12
months to 36 months with Possible Social-emotional/Behavioral Problems and/or Possible
Deficits/Delays in social-emotional competence.
The BITSEA is appropriate for many different settings, including pediatrics, early intervention, and
home visitation programs. Knowledge gained from parents’ responses on the BITSEA may be used to
open a conversation with a parent about a child’s behavior and social-emotional development and to
determine whether additional assessment or referral is indicated.

What types of problems and competencies are covered by the BITSEA?

internalizing problems (e.g., fears, anxieties, worries, social withdrawal, sadness)
externalizing problems (e.g., aggression, defiance, high activity level)
regulatory problems (e.g., sleep, eating, negative emotionality, sensory sensitivities)
rare behaviors that may be indicative of autism spectrum disorders or other significant
psychopathology (e.g., repetitive behaviors, eating non-nutritive substances, head-banging)
social-emotional competencies that are expected to emerge in early childhood

Administration Steps
Introduce the BITSEA to the parent
It is important to introduce the BITSEA in a way that helps the parent to feel comfortable.
When introducing the BITSEA you might say:
“I’d like to learn more from you about [child name]’s behavior and development.”
“The questions on these pages describe young children’s behavior and development.”
“By answering these questions you will be helping me to understand more about how s/he
behaves and how s/he is developing.”
“It is important for you to know that there are no ‘right’ or ‘wrong’ answers – just answers that
you think describe your child the best.”
“For each question, please circle the answer you think describes your child in the Past Month.”
Other issues to keep in mind:
The BITSEA may be completed by parents on their own or as a structured interview (see below).
A Spanish version is available.
Sometimes two parents wish to complete the BITSEA. In this case, parents should do so
independently so that their responses do not influence each other.

Completing the BITSEA as a self-administered questionnaire

Before giving the form to the parent, detach the Score Summary Page from the parent form
(the scoring information on this page may influence a parent’s answers).
Have the parent read the items on the Parent Form and circle his or her responses on the form.
Encourage the parent to read all of the instructions and to ask questions if anything is not clear.

Completing the BITSEA as an interview

To administer as an interview, read the instructions and questions verbatim. Try not to interpret
the meaning of the items for the parent. If a parent asks for help rating a question, encourage her
to provide the answer that she thinks best describes her child.
©Adapted from Briggs-Gowan & Carter (2006). BITSEA Examiner’s Manual. San Antonio. TX: PsychCorp, Harcourt Assessment.

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Scoring
Instructions for scoring the BITSEA Parent Form are provided on the Score Summary Page (page 3) of
the form (and described in detail in the BITSEA Manual.) Scoring steps are listed briefly below:
1. Transfer the parent’s responses onto the Score Summary Form. This process sorts the problem
and competence items from one another, thus facilitating summing the items in each area.
2. Count the number of non-answered items in each area. If more than 5 problem items are non-
answered, the problem scale should not be scored and used. If more than 2 competence items are
non-answered, the competence sum should not be scored and used.
3. Calculate Total Scores. The Problem Total Score is the sum of the items in the two problem
columns and the Competence Total Score is the sum of the items in the two competence columns.
4. Calculate child age in months. If a child was born prematurely, you may wish to adjust for
prematurity; this is often done until the child reaches 24 months of chronological age (since birth).
5. Look up Cut Score Values on page 3 of the Score Summary.
Possible Problem - If the Problem Total Score is greater than or equal to the cut score value
listed for the child’s age and sex, the child’s score is in the Possible Problem range.
Possible Deficit/Delay - If the Competence Total Score is less than or equal to the cut score
value listed for the child’s age and sex, the child’s score is in the Possible Deficit/Delay range.
6. Look up and record Percentile Ranges on page 11 of the BITSEA Manual.

Interpretation
Individuals interpreting the BITSEA should understand that Possible Problems or Possible
Deficit/Delay scores mean that clinically significant problems or delays/deficits may be present.
However, not all children (or parent-child dyads) with scores in the Possible Problems or Possible
Deficit/Delay will have clinically significant problems. Additional follow-up is required to determine
clinical significance. The BITSEA should never be used in isolation to determine presence of disorder
or deficit/delay. In addition, it is very important to recognize that the results of the BITSEA reflect the
parent’s perspective on the child. Thus, BITSEA scores may be influenced by many factors such as
psychosocial stress, parental symptomatology, or difficulties in the parent-child relationship.

Review
It is always important to review the BITSEA items and score results, even when the child’s scores are
not in the Possible Problem or Possible Deficit/Delay range. Some individual behaviors can indicate
clinically significant problems.
1. Review the cut scores
Possible Problem means that the child’s Problem Total Score is in the 25th percentile for the child’s
age and sex. This means that the child’s problem score is higher than the scores obtained by 75% of
children in the normative sample.
Possible Deficit/Delay means that the child’s Competence Total Score is in the 15th percentile for
the child’s age and sex. This means that the child’s competence score is lower than the scores
obtained by 85% of children in the normative sample.
2. Review the percentile rankings
This helps you to understand how unusual (or how typical) a child’s scores are for his or her age
group and sex. The lower the percentile score, the more unusual.
3. Review individual items
Refer to the Item Map (Appendix A of Manual) to determine whether a cluster of behaviors are
reported in a specific domain, and to determine whether any clinically concerning Red Flag
behaviors are reported.
4. Review worry questions to gauge parent’s perception of the child’s behaviors and competencies.
This can help you to determine how to frame the conversation with the parent.
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Follow up Strategies
Many different strategies may be used to follow up on BITSEA results. The strategy chosen will vary
depending on the setting, time constraints, resources, and why the parent was asked to complete the
BITSEA. This section describes just a handful of the approaches that may be used.
1. The BITSEA may be used to open a dialogue with the parent about the child’s social-emotional
adjustment. Asking about parental worry about the behavior; frequency and intensity; timing or
onset; context(s) in which the behavior or attribute tends to occur; conditions that elicit or diminish the
behavior; and meaning and cultural context may help you to determine whether additional assessment
or referral is needed. Ways to talk with parents about these topics are described in the Opening a
Dialogue section below, and are described in detail in the BITSEA Manual.
2. Administer the ITSEA or additional assessment to gather more comprehensive information about
the child and insight into how the child’s problems and competencies in specific areas compare to other
children of the same age group and sex, before discussing results of the BITSEA with the parent.
3. Make a referral to an on-site or off-site mental health professional or child development specialist
who reviews the results of the BITSEA with the parent and follows up as needed.
4. Review the BITSEA and determine whether it may be appropriate to monitor the child, for example,
by having the parent complete the BITSEA again in six months. This approach may be well-suited to
settings in which professionals have repeated contacts with children (e.g., pediatric primary care, early
intervention).
5. Conduct (or refer for) additional screening or formal assessment for developmental delays/deficits
in other areas (such as cognition, language, or motor), if these types of delays are suspected.

Opening a Dialogue – Topics to Explore

The BITSEA may be used to open a dialogue with the parent about the child’s social-emotional
adjustment. Asking about the topics in this section may help you to determine what the appropriate next
step should be.

Worry: Talking with the parent about his/her worry about the child can help to open the dialogue.
Sample probes:
You said that you were A little worried/Worried/Very worried about [child]’s behavior, emotions or relationships
(or language). Would you mind telling me a little bit more about this? What kinds of things are you most worried
about?
You said that you were Not at all worried about [child], but I would like to talk about the things you said that
your child is doing. Can you tell me more about [problem behaviors endorsed as Somewhat True/Sometimes or
Very True/Often]?

Frequency, intensity & quality: Knowing more about the frequency, intensity and
quality of the behaviors described may be helpful in determining whether the behaviors reported are in
the “normal” range or whether additional assessment or referral is appropriate.
Sample probes:
Can you tell me about how often your child does this?...Would you say every day?
A few times a week? Once a week? Once a month?
Would you mind giving me an example of this behavior?
Maybe you can describe the last time this happened?
Can you try to describe for me what happens when your child behaves this way?
When your child hits, shoves, bites or kicks other children, how hard does he or she hit/bite, etc.?
Does he or she leave a mark? Break the skin when biting?

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You said that your child Cries or tantrums until he is exhausted. How long do the tantrums last?
Does he or she ever get hurt or hurt someone else when this is happening?
Is there anything that you can do to help [child] calm down?
You circled that your child has trouble falling asleep or staying asleep.
How long does it take him to fall asleep?
What usually happens?
How do you get your child to fall asleep?
You said that [child] Wakes up at night and needs help to fall asleep again.
Can you tell me what happens?
How long is your child awake?
Are you able to help [child] go back to sleep in a few minutes?
You said that [child] Does not make eye contact.
When does this usually happen?
Is it only when your child is upset with you or in trouble?
Does it happen at other times?
You said that [child] Is restless and can’t sit still.
Does this happen a lot of the time or just in certain situations?
Are there times when [child] is able to sit still?
When [child] Cries or hangs onto you when you try to leave, what usually happens?
Does it happen every time you try to leave or just some of the time?
How long does it take for [child] to calm down after you leave?
Does [child] get back to a “normal” mood after 5 minutes or so?
Does [child] calm down with help from a caregiver? For example if the caregiver tries to distract [child] with an
interesting activity or toy?

Timing or onset of the behavior is an important consideration. When did the behavior first start to
happen and when did it become a “problematic”? Parents may not recognize that even young children may react
to changes in their lives. For example, parents may not make the connection that a young child’s increased
negativity and clinginess emerged shortly following a change in childcare providers or settings. Similarly,
children may undergo behavioral or emotional changes during critical developmental shifts. For example, many
children become fussy or irritable when they are about to master a new developmental skill.
Sample probes:
When did you first notice [child] doing this?
Did it start after any changes in [child]’s life…moving to a new home, starting at a new childcare setting, or birth
of a brother/sister?
Did it occur when [child] was not feeling well?
How about when s/he was trying very hard to learn to do something new?

Context and pervasiveness: It is helpful to determine whether a behavior is specific to one

person or setting or if it occurs with more than one caregiver (e.g., with both parents, with grandparents, with
other caregivers) and across different settings (e.g., at home, at child care, at a play group). Children who manifest
problem behaviors in multiple settings and with multiple caregivers are typically more impaired than those who
only exhibit a problem behavior in a single context or with a single person.
Sample probes:
Does [child] do this in some situations but not others?
For example, does your child only do this at home but not at childcare?
Does your child do this with you, but not with the other parent?
How about with other adults your child knows well, such as grandparents?

Meaning and cultural context: It is also important to gauge the “meaning” of the behavior
to the parent. Cultural factors, family history, and developmental expectations may influence whether a parent is
concerned about the presence (or absence) of particular behaviors, and can influence BITSEA scores.
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