International Journal of Nursing Studies 79 (2018) 104–113

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/locate/ijns

Implementation of the Alarm Distress Baby Scale as a universal screening T

instrument in primary care: feasibility, acceptability, and predictors of
professionals’ adherence to guidelines
⁎
Johanne Smith-Nielsena, , Nicole Lønfeldtb, Antoine Guedeneyc, Mette Skovgaard Vævera
a
Department of Psychology, University of Copenhagen, Denmark
b
Child and Adolescent Mental Health Center, Mental Health Services, Denmark
c
Hospital Bichat Claude Bernard APHP, University Denis Diderot Paris, INSERM U 1178 CERP, France

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Infant socioemotional development is often held under informal surveillance, but a formal
ADBB screening program is needed to ensure systematic identification of developmental risk. Even when screening
Acceptability programs exist, they are often ineffective because health care professionals do not adhere to screening guide-
Feasibility lines, resulting in low screening prevalence rates.
Early detection
Objectives: To examine feasibility and acceptability of implementing universal screening for infant socio-
Implementation
emotional problems with the Alarm Distress Baby Scale in primary care. The following questions were addressed:
Health visiting practice
Professionals' perceptions of universal Is it possible to obtain acceptable screening prevalence rates within a 1-year period? How do the primary care
screening workers (in this case, health visitors) experience using the instrument? Are attitudes toward using the instrument
Public health related to screening prevalence rates?
Social withdrawal in infants Design: A longitudinal mixed-method study (surveys, data from the health visitors’ digital filing system, and
Universal screening of infants qualitative coding of answers to open-ended questions) was undertaken.
Setting and participants: Health visitors in three of five districts of the City of Copenhagen, Denmark (N = 79).
Methods: We describe and evaluate the implementation process from the date the health visitors started the
training on how to use the Alarm Distress Baby Scale to one year after they began using the instrument in
practice. To monitor screening prevalence rates and adherence to guidelines, we used three data extractions (6,
9, and 12 months post-implementation) from the electronic filing system. Surveys including both quantitative
and open-ended questions (pre- and post-implementation) were used to examine experiences with and attitudes
towards the instrument. Descriptive and inferential statistical and qualitative content analyses were used.
Results: Screening prevalence rates increased during the first year: Six months after implementation 47%
(n = 405) of the children had been screened; 12 months after implementation 79% (n = 789) of the children
were screened (the same child was not counted more than once). Most (92%) of the health visitors reported that
the instrument made a positive contribution to their work. The majority (81%) also reported that it posed a
challenge in their daily work at least to some degree. The health visitors’ attitudes (positive and negative) toward
the Alarm Distress Baby Scale, measured 7 months post-implementation, significantly predicted screening pre-
valence rates 12 months post-implementation.
Conclusions: Adding the Alarm Distress Baby Scale to an established surveillance program is feasible and
accepTable Screening prevalence rates may be related to the primary care worker’s attitude toward the in-
strument, i.e. successful implementation relies on an instrument that adds value to the work of the screener.

What is already known about the topic? children who need further assessment and intervention.
• Even when universal screening programs are implemented, they are
• Identification of socioemotional problems in infants is often held often not effective, and screening prevalence rates are often low. A
under informal surveillance, but systematic universal screening growing, but small, body of literature suggests that this is partly due
using a validated instrument is needed to prevent overlooking to low adherence to screening guidelines among the professionals

⁎
Corresponding author at: Department of Psychology, Oester Farimagsgade 2 A, DK-1353, Copenhagen, Denmark.
E-mail address: Johanne.smith@psy.ku.dk (J. Smith-Nielsen).

https://doi.org/10.1016/j.ijnurstu.2017.11.005
Received 24 May 2017; Received in revised form 12 November 2017; Accepted 14 November 2017
0020-7489/ © 2017 Elsevier Ltd. All rights reserved.
J. Smith-Nielsen et al.
responsible for screening.
• The Alarm Distress Baby Scale (ADBB) is a validated screening in-
strument for identification of socioemotional problems in infants
and it is well suited for use in a busy ‘real-life setting’.
What this paper adds
• The ADBB has not previously been implemented as a universal
screening instrument in a primary care setting, and this study pro-
vides a good starting point for policymakers, planners, and man-
agers who intend to undertake quality improvement initiatives
aiming at early detection and prevention of socioemotional pro-
blems in infancy.
• This study extends the growing literature on implementation of
routine developmental screening into a busy health visiting practice
focusing on feasibility and the professionals’ perceptions of using the
screening instrument.
• Moreover, this study confirms the often untested assumption that
low screening prevalence rates is related to the practitioners’ atti-
tude toward the screening instrument and to the extent to which
conducting the screening is perceived as meaningful and positively
contributes to his/her practice.
1. Background
An infant’s ability to engage in social interaction is one of the most
important indicators of socioemotional development linked to a range
of long-term outcomes such as language development, socioemotional
competencies, and behavioral, attachment, and autism-spectrum dis-
orders (e.g., Feldman, 2007; Guedeney et al., 2013, 2014). Intervention
becomes increasingly more difficult as problems in infancy become
more complex and severe with development (e.g., Phillips and
Shonkoff, 2000). As such, early identification of socioemotional pro-
blems and referral to intervention services is a public health imperative.
Although psychiatric disorders, e.g. behavioral or attachment dis-
orders, are rarely diagnosed in children under the age of two years,
recent research has shown that these problems can be reliably detected
as early as infancy (0–2 years) (Bagner et al., 2012). Furthermore, early
detection of behavioral and emotional problems lead to successful in-
tervention efforts to ameliorate these problems (Bagner et al., 2012;
Zeanah and Gleason, 2009). Despite internationally agreed upon re-
commendations of preventive strategies that target the general popu-
lation (Bagner et al., 2012), many countries lack a systematic approach
to screening and referral for mental health problems in infancy
(Huffman and Nichols, 2004).
Existing assessment procedures for infant socioemotional develop-
ment include parent- or caregiver–report questionnaires, observational
coding procedures, and diagnostic classification systems.
Questionnaires and observational coding procedures have demon-
strated sound psychometric properties for use in infancy (for a sys-
tematic review, see Bagner et al., 2012). Observational coding proce-
dures provide more objective and detailed information than
questionnaires, however, they are more time consuming, and it has
been discussed whether observation-based methods are feasible in
primary care settings (Bagner et al., 2012).
The first critical step in identification and intervention is high-
quality, universal screening, i.e., screening of all infants, not just those
with suspected problems (e.g. Pinto-Martin et al., 2005; American
Academy of Pediatrics, 2006). Developmental screening refers to the
standardized use of a validated screening tool at established time points
to distinguish children at risk for developing problems from those who
are not (Glascoe et al., 2013). In contrast, developmental surveillance
refers to an informal, ongoing process that provides a broad clinical
picture based on parental concerns, continued monitoring of develop-
mental history, observations of the child, and input from other pro-
fessionals when necessary (American Academy of Pediatrics, 2006).
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International Journal of Nursing Studies 79 (2018) 104–113
The American Academy of Pediatrics cautions that without systematic
use of a validated screening tool, children at risk will be missed. This is
consistent with results from other screening studies, not limited to the
infant mental health domain, that have demonstrated that formal
screening programs are far more effective than general health surveil-
lance (Evins et al., 2000; Miller et al., 2011; Wickberg and Hwang,
1996).
However, when formal screening programs have been established,
they are often not effective, and implementation studies have reported
very low screening prevalence rates, despite recommendations for
universal screening (Rice et al., 2014; King et al., 2010; Sand et al.,
2005). Similarly, a growing literature has demonstrated that health care
professionals responsible for screening often do not adhere to screening
guidelines (Allen et al., 2010; King et al., 2010; Arunyanart et al., 2012;
Aylward, 2009; Guerrero et al., 2010). For example, it was reported
that only 23% of pediatricians consistently used a standardized devel-
opmental screening tool despite official guidelines that all children
should receive a developmental screening (Sand et al., 2005). Failure of
successful implementation has been linked to time constraints, inability
to adequately train health care professionals, lack of reimbursement,
unfamiliarity with the screening instrument, the health care profes-
sionals’ fear of having a positive screen, poor communication with
parents, and viewing the screening instrument as burdensome and
useless (King et al., 2010; Pinto-Martin et al., 2005, for a review, see
Gellasch, 2016).
Regardless of the cause, the existing literature highlights a gap be-
tween research and practice resulting in poor implementation of re-
search-based methods in practice, which in turn results in under-de-
tection of infants in need (Blase et al., 2012; Fraser, 2013; Guerrero
et al., 2010). Although the ultimate goal is to improve outcomes for
infants with socioemotional problems, such research also stresses the
need for studies investigating factors important for successful im-
plementation of universal screening for socioemotional problems in
infancy as well obstacles that cause low adherence to screening
guidelines among health care professionals. In other words, to suc-
cessfully transfer research-based knowledge on infant mental health
factors to practice, research must focus on specific implementation
outcomes and so-called ‘drivers of implementation’ (Fixsen et al.,
2009).
1.1. The current study
Our study evaluated the process of implementing a systematic
screening program for socioemotional problems in an established de-
velopmental surveillance program, i.e., the public health home visiting
program of the City of Copenhagen, Denmark. In the City of
Copenhagen, the home visiting program includes six routine visits
during the first postpartum year: three visits during the first three
weeks, a visit at two months, at four-six months (for new parents only),
and at eight-ten months. Home visits typically last 60 min. The service
is widely used and well-accepted among parents: over 99% of all Danish
families receive the regular home visits (Dansk Sygeplejeråd, 2010).
The home visits are conducted by health visitors: specialized nurses
who have completed the “Advanced Nurse Health Visitor Education
Program”. As a prerequisite, nurses must have at least 24 months of
relevant work experience, e.g., pediatric nursing, infant psychiatric
nurse, or neonatal nursing. Health visitors measure and weigh the baby,
guide and support parents in matters of breastfeeding, physical and
mental health, family dynamics, parent-child attachment, and co-
ordinate with other health care services.
In 2015, the Alarm Distress Baby Scale (ADBB; Guedeney and
Fermanian, 2001) was added to the public health visiting surveillance
program in Copenhagen. The ADBB is a well-validated screening tool
designed to identify infant socioemotional problems in primary care
settings, such as in the context of routine pediatric examinations or
during routine well-infant visits. More specifically, the ADBB assesses
J. Smith-Nielsen et al.
infant social withdrawal, which is an important indicator of infant
distress regardless of the cause (Guedeney et al., 2013). The scale
comprises eight items (facial expression, eye contact, motor activity,
self-stimulating gestures, vocalizations, rapidity of response to stimu-
lation, interaction with the observer, attention to the observer) and can
be used with children aged 2–24 months. It yields a total score ranging
from 0 to 32 with higher scores reflecting more severe signs of social
withdrawal. A cut-off score of five has demonstrated acceptable levels
of specificity and sensitivity in several studies, using the developmental
risk as a gold standard (Guedeney and Fermanian, 2001), or diagnostic
in the DC 0-3 frame (Lopes et al., 2008; De Rosa et al., 2010). Moreover,
the ADBB can detect a broad range of concurrent or emergent socio-
emotional problems, as excessive withdrawal from social interactions is
a sign of infant distress, regardless of the cause. Indeed, preterm infants,
infants of parents with mental health problems, children with in-
tellectual disabilities, attachment disorders, acute and severe pain,
auditory and/or visual deficits, and autistic spectrum disorders tend to
score high on the ADBB (Braarud et al., 2013; Guedeney et al., 2013,
2012, 2014; Mantymaa et al., 2008, 2006).
1.2. Objectives
The overall objective of the current study was to examine feasibility
and acceptability of implementing universal screening with ADBB in
primary care, i.e., in the practice of health visitors in three (of five)
districts of Copenhagen, Denmark. Moreover, we aimed to investigate
whether the health visitors’ adherence to guidelines was related to how
they perceived using the instrument in their daily practice. We describe
and evaluate the implementation process from the date the health
visitors started the training on how to use the ADBB to one year after
they began using the instrument in practice. The City of Copenhagen
aims to screen all infants with the ADBB at the 2-month-, the 4–6-month
(first time families only) and at the 8–10-month-visits. As a minimum,
they aim to screen all infants at least once during the first year of life.
We set this minimum of one screen per infant as the overall success
criterion for the implementation of the ADBB. The following three re-
search questions were addressed:
1.2.1. Research question 1
Is it feasible to successfully implement universal screening with the
ADBB in primary care? Feasibility was evaluated in terms of the par-
ticipating health visitors’ screening prevalence after a one-year period
and time spent on training (pre-implementation) and conducting the
ADBB during home visits (post-implementation).
1.2.2. Research question 2
How do health visitors experience using the ADBB as part of their
daily practice? We approached this research question in two ways: (a)
we evaluated the acceptability of the ADBB from the professionals’
point of view, i.e., did the health visitors perceive using the ADBB
positively or negatively? and (b) to gain a better understanding of po-
tential barriers associated with implementing ADBB screening in prac-
tice, we used a qualitative approach to explore how the health visitors
experienced using the instrument.
1.2.3. Research question 3
Are the health visitors’ attitudes toward using the ADBB related to
adherence to guidelines? Professionals often do not follow screening
guidelines, and it is likely that the health visitor’s attitude toward the
screening instrument is related to adherence to screening guidelines
(Gellasch, 2016; Pinto-Martin et al., 2005). Therefore, we hypothesized
that (a) a positive attitude towards using the ADBB (measured seven
months after starting to use the instrument) is associated with higher
adherence to screening guidelines one year after the ADBB was im-
plemented and (b) that a negative attitude towards using the ADBB
(also measured seven months after health visitors started using the
106
International Journal of Nursing Studies 79 (2018) 104–113
ADBB) is associated with lowered adherence to screening guidelines
one year after the ADBB was implemented in practice.
The ADBB has not previously been implemented as a universal
screening instrument in a primary care setting, and the current study is
the first to evaluate the feasibility of universal screening with the ADBB
in a ‘real life setting’.
2. Methods
2.1. Setting and recruitment
The present study was part of an ongoing research program, The
Copenhagen Infant Mental Health Project (CIMHP) with the overall
objective to evaluate methods for early detection and interventions for
infants at risk for poor socioemotional outcomes (Væver et al.,
2016a,b). CIMPH is a collaboration between the health visitors in the
City of Copenhagen and the Center for Early Intervention and Family
research, University of Copenhagen. The health visitors in the City of
Copenhagen are organized into five districts. We requested all five
districts participate, however, the management decided that initially
the ADBB would only be implemented in three of the five districts. To
be included in this study nurses had to be health visitors employed in
one of the three districts at the start of the project, who did not intend
on retiring or going on leave within the next year, who work with
children under the age of one year (as some health visitors only work
with school-aged children), and able to participate in the ADBB-
training, which took place in the pre-implementation phase (Fig. 1).
Thirty-two health visitors employed in the three districts were not able
to participate in the first training period (e.g., due to planned vacation,
attending other training programs during the same period, or being on
sick leave). The remaining health visitors participated in the study and
comprised the current sample (N = 79).
2.2. Implementation strategy and procedures
An overview of the implementation process and time points for data
collection is provided in Fig. 1. Our implementation strategy was
guided by the principles provided by Fixsen and colleagues who pro-
vide an overall framework for successful implementation of evidence-
based methods into practice, which is applicable across various prac-
tices within human services (e.g., Blase et al., 2012; Fixsen et al., 2009,
2005). Implementation drivers, or core elements of successful im-
plementation, include focused and qualified training prior to im-
plementation, the possibility of consultation and coaching, facilitative
managerial support, staff evaluation and program evaluation (Fixsen
et al., 2009).
Below we describe one of the vital implementation components of
the current project, i.e., the pre-implementation training and the cer-
tification of the health visitors. To facilitate the implementation process
following the training and certification phase, we applied Fixsen’s et al.
(2009) core implementation elements as follows: provided ongoing
consultations for the health visitors in cases of doubt (via telephone),
gave feedback to the health visitors on screening rates and progress
reports in the form of newsletters five times during the first year
(program evaluation). We collaborated closely with the three partici-
pating districts by establishing a project group that met every sixth
week the first year post-implementation. In this project group, we in-
cluded participants representing all levels of stakeholders, i.e., health
visitors, team leaders, managers, and ADBB experts. The group’s main
tasks included ongoing evaluation of the implementation process from
the health visitors’ perspective as well as from a program evaluation
perspective (staff evaluation and program evaluation) and supporting
the health visitors’ ongoing learning process (i.e. to facilitate manage-
rial support and communication between the research group and the
health visitors). As emphasized by Fixsen et al. (2005), implementation
research needs to be conducted to determine the effectiveness of
J. Smith-Nielsen et al.
Fig. 1. Overview of the Implementation Process and Time Points for Data Collection.
implementation and procedures as they are actually used in practice.
Therefore, an overall principle that guided the project was to change as
little as possible of the existing conditions, and first and foremost de-
scribe and evaluate the implementation process.
2.2.1. Training and certification
Training and certification involved a two-day training seminar that
lasted seven hours each day. The seminar included lectures on infant
social behavior, an introduction to the ADBB and its use, a thorough
introduction to scoring criteria, and training in the use of ADBB by
rating videos of infants in clinical assessments. After the seminar, all
health visitors (N = 79) were given three sets of videos, 11 in total, to
rate individually, and their ratings were discussed and compared with
reference scores during three two-hour group supervision sessions. The
majority of videos used during the seminar, the training period, and the
“gold standard” score were provided by the third author, who devel-
oped the ADBB. The set of training videos also included three Danish
videos, for which the developer of the ADBB provided reference scores.
Training and supervision of the health visitors was provided by the first
author and a clinical psychologist who were reliable ADBB-coders,
trained and supervised by the developer of the method. After the
training period, each health visitor individually rated and submitted
their ratings of four new videos. To evaluate the nurses’ reliability in
the use of the method, their scores were compared with reference scores
in order to judge inter-rater agreement with the gold standard. As the
ADBB in the current study is implemented as a screening instrument
used to detect infants who might need additional assessment and/or
referral, the overall goal of the training was for the health visitors to
correctly determine whether the total score was below or above the cut-
off score of five. However, to rate a video correctly, the rater’s total
score should fall into one of the following categories, also listed in the
ADBB training manual (Guedeney, 2015): total score = 0–4 (‘Normal’);
total score = 5–10 (‘Some concern’); total score > 11 (‘Significant
concern’). If three out of the four videos were rated correctly, the health
visitor was certified in the use of ADBB for screening purposes in pri-
mary health care. The training and certification phase lasted approxi-
mately three months (March 2015–June 2015).
2.2.2. Implementation and screening guidelines
On July 15, 2015 the ADBB was implemented as part of the health
visitors’ routine home visits (T0). From this date, the health visitors
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International Journal of Nursing Studies 79 (2018) 104–113
were instructed to conduct ADBB-screenings at all regular 2, 4, and
8–10-month visits and to enter their ratings into a digital scoring sheet
integrated in the digital filing system used in the City of Copenhagen
(NOVAX). If it was not possible to conduct a screening at any of the
regular visits, for example because the infant was sleeping or sick
during the visit, the health visitor was allowed to schedule an extra visit
to ensure that all infants were screened at least once.
2.3. Data collection and analysis
We used surveys and data extractions from the health visitors’
electronic journal system and database (NOVAX) to evaluate the im-
plementation of the ADBB in the health visiting program (Fig. 1).
During the first day of the training seminar, using a questionnaire, we
collected information about the health visitors’ ages, years of experi-
ence prior to completing their education as a health visitor and years of
experience as a health visitor (Survey 1). In this questionnaire, we also
included the question, “At present, do you have adequate skills for
detecting infants whose psychological well-being are at risk?” The item
had four anchor points ranging from, “to a high degree” to “not at all”.
When the health visitors were certified, they received a digital, online
survey (Survey 2), and seven months post-implementation the health
visitors received a second digital, online survey (Survey 3).
2.3.1. Research question 1a
In order to evaluate the feasibility of successful implementation, i.e.
whether the health visitors consistently used the ADBB according to the
screening guideline, we calculated the screening prevalence rate for the
group of participating health visitors at three time points during the
first year after implementation. We extracted data from NOVAX at three
time points: 6, 9, and 12 months post-implementation (T1, T2, T3).
Only the first registered ADBB score was used for each child, as we were
interested in the number of children who had received at least one
ADBB screening within the child’s first year of life (i.e., the success
criterion for the implementation process). We created a binary variable
reflecting whether each child had a registered ADBB score at the spe-
cific time point (ADBB score, yes/no). This variable was used to cal-
culate the screening prevalence rates by dividing the number of chil-
dren with an ADBB-score by the total number of children seen by the
group of trained health visitors, as ideally, all of these children should
have at least one ADBB-score at the point of measurement. For each
J. Smith-Nielsen et al.
Table 1
Health Visitors’ Ages and Years of Experience.
District 1 (n = 30)
Age (pre implementation): M (SD) 46 (7.99)
Years of experience as health visitor: M (SD) 11.5 (5.98)
Range 1–26
Skills adequate (pre implementation), as self-reported, % (n)
To a high degree 6.7% (2)
To some degree 83.3% (25)
To a small degree 10.0% (3)
Number of children seena (only children aged 9,10, 11 months)
6 months post-implementation, M (SD) 42 (13.56)
9 months post-implementation, M (SD) 40 (13.78)
12 months post-implementation, M (SD) 40 (14.68)
a
For analyses on number of children seen n = 72
time point, we only included children aged 9, 10, and 11 months at the
time of measurement. This ensured that there was no overlap between
the groups of children for which we calculated the screening prevalence
rate. For example, if a child was 9 months old at time point 1, the same
child would be 12 months old at time point 2, and thus the child would
not be included a second time. As the health visitors were instructed to
conduct an ADBB-screening at the 2–3-month visit, the 4–6-month visit,
and at the 8–10-month visit, this approach also gave the best chance of
including all screenings of children at each specific time point, i.e. the
health visitor would have had several home visits in which the ADBB-
screening should have been conducted and registered.
2.3.2. Research question 1b
In Survey 2, we asked the health visitors to estimate the number of
hours they spent on scoring videos during training and certification,
and how much time they spent studying information on the ADBB. In
Survey 3, health visitors were asked to estimate 1) how much time
(in min) they typically used on an ADBB screening including registra-
tion of the score in NOVAX, and 2), how much time they typically used
to talk to parents about the evaluation. In Survey 3, we also asked
whether the health visitors spent less time on conducting an ADBB
screening after seven months of experience with the method compared
to immediately after certification. The response scale had three anchor
points: “No, not at all”, “yes, to some degree”, “yes, to a high degree”.
2.3.3. Research question 2a
To investigate how the health visitors perceived using the ADBB in
their practice, in Survey 3 they were asked to rate how much they
agreed with the following statements, “the ADBB makes a positive
contribution to my daily practice,” and “using the ADBB during home
visits is challenging”. The response scales had four anchor points ran-
ging from “strongly agree” to “strongly disagree”.
2.3.4. Research question 2b
Using separate, open-ended questions, after each of these questions,
we asked health visitors to specify how the ADBB positively contributes
to and presents challenges in their daily practice. The second author
content analyzed the responses and categorized them under common
themes. Then, the first author, blind to the second author’s categor-
ization, coded the responses using the categories created by the second
author. The first and second authors largely agreed in their coding of
responses, and they reached consensus in the three cases of disagree-
ment. Finally, to further address how the health visitors perceived the
implementation of the ADBB in their daily work, the following item was
included in Survey 3: “Using the ADBB is a burden that decreases my
job satisfaction,” with three anchor points: “not at all”, “to some ex-
tent”, “to a high degree”.
2.3.5. Research question 3
To evaluate whether the health visitors’ attitudes toward using the
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International Journal of Nursing Studies 79 (2018) 104–113
District 2 (n = 12) District 3 (n = 28) Total (n = 70)a p
47.25 (7.81) 47.41 (2.20) 47 (7.56) 0.781
13.67 (8.82) 13.14 13 (6.82) 0.544
2–33 2–33 1–33
0.310
25.0% (3) 21.4% (6) 15.7% (11)
75.0% (9) 75.0% (21) 78.6% (55)
– 3.6% (1) 5.7% (4)
33 (10.34) 40 (12.36) 40 (12.70) 0.158
36 (14.50) 40.0 (13.84) 39 (13.83) 0.604
33 (16.09) 39 (16.68) 38 (15.86) 0.420
ADBB seven months post-implementation related to adherence to
screening guidelines 12 months post-implementation, the following two
items from Survey 3 were used: (1) “The ADBB makes a positive con-
tribution to my daily practice” (reflecting a positive attitude). As only
six health visitors in total answered “strongly disagree” (n = 2) and
“somewhat disagree” (n = 4), we merged these two categories in the
analysis. (2) “Using the ADBB has lowered my job satisfaction” (re-
flecting a negative attitude). Because only one health visitor answered,
“to a high degree”, we merged the two latter answer categories, re-
sulting in a binary variable. “Adherence to screening guidelines” was
operationalized as the proportion of children screened by the health
visitors 12 months post-implementation. “Adherence to screening
guidelines” was calculated by dividing the number of children each
individual health visitor had screened at T3, by the number of children
aged 9–11 months seen at T3. Thus, adherence scores ranged between 0
(none of the children seen were screened) and 1 (all of the children seen
were screened). To test whether attitudes toward the ADBB at seven
months post-implementation predicted guideline adherence at 12
months post-implementation, we conducted two Analyses of
Covariance analyses (ANCOVAs) with the proportion of screened chil-
dren as the dependent variable, thus comparing the mean proportion of
screened children with differing attitudes towards the ADBB. We ad-
justed both models for age, years of experience as a health visitor, and
self-reported skill-level pre-implementation, as these variables may
confound the results, i.e., affect health visitors’ attitudes towards using
the ADBB in their work and affect how many children they manage to
screen. As reported in Table 1, there were no significant statistical
differences across the three districts in any of the background variables,
or in the number of children seen. Therefore, to increase power, we did
not adjust for district in the models. Moreover, a planned contrast was
included in the first ANCOVA to respectively compare health visitors
who strongly agreed that the ADBB was positively contributing to their
work with the two other groups. Thus, the first ANCOVA was conducted
to compare the effect of the degree to which health visitors believe that
ADBB makes a positive contribution to their work seven months post-
implementation on adherence to guidelines 12 months post-im-
plementation. The second ANCOVA was conducted to compare the ef-
fect of the degree to which nurses believed that the ADBB lowers their
job satisfaction at 7 months post-implementation on screening pro-
portion.
3. Results
3.1. Sample description
The participating health visitors (N = 79) were all women and had
an average of 9.7 years of nursing experience before they started their
education as a health visitor (range: 3–23, SD = 4.4) and an average of
13.5 years of experience as health visitors (range: 2–34, SD = 6.82).
Table 1 displays the health visitors’ ages, years of experience, and self-
J. Smith-Nielsen et al.
reported skills in relation to detecting infants at-risk for adverse so-
cioemotional development. As shown in Table 1, the participants did
not differ in these variables across the three districts. Table 1 also shows
that the average number of children within the relevant age group seen
by each health visitor at the three post-implementation points of
measurement (of screening prevalence rates) did not differ across the
three districts. During the project period the sample size varied to some
extent: seven participants stopped conducting home visits after they
entered the study (due to changing jobs, being promoted, or going on
maternity leave). Therefore, data for monitoring screening prevalence
were available for 72 health visitors. Of the 79 participating health
visitors, 68 answered Survey 3 on experiences with the use of the ADBB,
which was distributed seven months post-implementation. For analyses
including data from both the post-implementation survey and screening
prevalence rates, complete data are available from 58 health visitors.
Finally, a group of the health visitors (n = 9) did not participate in the
training seminar (pre-implementation) because they had already com-
pleted a similar seminar 10 months earlier. However, all of these health
visitors participated in the subsequent supervision and training and
completed a survey on the training and certification process. As ques-
tionnaires on background information were completed during the
seminar, background data was not collected for this group.
3.2. Feasibility
3.2.1. Screening prevalence rates
As shown in Table 2, screening rates gradually increased at each
time point: less than half of the children seen by the participating health
visitors were screened with the ADBB six months after the ADBB was
implemented; 79% of the children had at least one ADBB screening 12
months after the health visitors started using the ADBB.
3.2.2. Time, training, and certification
The majority (86.1–89.9%) of health visitors spent no more than
two hours on scoring videos for each of the three supervision sessions.
Most (93.7%) health visitors spent no more than three hours on
studying information about the ADBB, and 87.3% spent no more than
four hours on scoring videos for submitting scores for the reliability
check for certification. When we combined the number of hours spent
on the 2-day seminar, scoring videos, independent study and super-
vision, we estimated that on average health visitors spent a total of 29 h
on training and certification.
3.2.3. Time conducting ADBB-screenings
ADBB screening, including registration, took an average of 11.4 min
(SD = 7.9, range: 4–40) as retrospectively estimated by the health
visitors. If the health visitor chose to talk to the parents about the
screening (which was not always the case when the child received a
score of 0) they used on average 6.7 min (SD = 4.0, range: 4–20). When
asked if the health visitors used less time on ADBB administration seven
months after implementation compared to directly after certification,
22.9% (n = 16) believed they did not use less time, 67.1% (n = 47) of
the health visitors believed to some degree that they used less time, and
Table 2
Screening Prevalence Ratesa 6, 9, and 12 Months Post-Implementation.
Time point Children seenb Children with ADBB-score
N N %
6 months post (Jan 2016) 869 405 47
9 months post (April 2016) 972 647 67
12 months post (July 2016) 1000 789 79
a
Only children included seen by health visitors using ADBB from project start
(n = 72).
b
Only children aged 9,10, and 11 months at each time point included.
109
International Journal of Nursing Studies 79 (2018) 104–113
10% (n = 7) believed to a high degree that they used less time on the
ADBB (n = 7). In sum, 77% of the health visitors reported that they
spent less time on conducting the ADBB during a home visit than im-
mediately after they completed training.
3.3. Acceptability and health visitors’ experiences with using the ADBB
3.3.1. Acceptability
Most of the participating health visitors reported that the ADBB
made a positive contribution to their current work (58.6% agreed and
32.9% strongly agreed). Simultaneously, most of the health visitors
reported that the ADBB posed a challenge in their daily work to a small
degree (48.6%) or to some degree (32.4%). Post hoc descriptive ana-
lyses showed that 78% of the health visitors reported that the ADBB
contributed positively to their work (agreed or strongly agreed) and at
the same time that using the ADBB posed challenges in their daily work
(to some or a small degree). When asked if using the ADBB was a
burden that decreased the health visitors’ job satisfaction, about 78%
(n = 62) of the health visitors responded that using the ADBB did not
decrease their job satisfaction at all, about 20% (n = 16) found that it
somewhat lowered their job satisfaction, and about 1% (n = 1) re-
ported that using the ADBB greatly lowered her job satisfaction.
3.3.2. Experiences with using the ADBB
When answering the open-ended questions regarding how the
health visitors experienced the ADBB contributed positively and how
the ADBB posed challenges to their work, several health visitors wrote
lengthy and varied responses. Therefore, it was possible for one re-
spondent to receive a score in more than one category. Four main ca-
tegories of comments emerged for health visitors’ responses to how the
ADBB positively contributes to their work. One health visitor’s response
fell into a fifth category: “the ADBB makes no positive contribution”.
Four main categories emerged from the health visitors’ responses to
what aspects posed particular challenges. Table 3 presents the response
categories for positive and challenging aspects of using the ADBB, an
example response for each category, and the number of health visitors
whose responses fit into each category.
3.4. Predictors of adherence to guidelines
3.4.1. Positive attitude towards the ADBB
We found a significant effect of a positive attitude towards using the
ADBB, i.e., the degree to which health visitors believed the ADBB makes
a positive contribution to their work on the proportion of children
screened, at the p < 0.05 level for the three groups (“strongly agree,”
“agree,” “somewhat disagree + strongly disagree”) [F(2,51) = 6.84,
p = 0.002], adjusting for health visitor age, years of experience, and
self-reported skill-level pre-implementation. Planned contrasts revealed
that health visitors who strongly believed that using the ADBB made a
positive contribution to their work as reported seven months post-im-
plementation had a significantly higher mean proportion of screened
children 12 months after implementation, than both health visitors who
agreed that the ADBB contributed positively to their work [p = 0.003]
and health visitors who somewhat disagreed or not at all agreed that
the ADBB contributed positively to their work [p = 0.004]. Table 4
shows estimated means and standard errors for the three groups.
3.4.2. Negative attitude toward the ADBB
The second ANCOVA, also including age, years of experience, and
skills as covariates, revealed a significant effect of whether the health
visitors believed that the ADBB lowered their job satisfaction, as re-
ported seven months post-implementation, on guideline adherence five
months later, F(1,52) = 6.77, p = 0.01. Health visitors who did not
believe that the ADBB lowers their job satisfaction administered sig-
nificantly more ADBB screenings than health visitors who believed that
the ADBB lowered their job satisfaction (please refer to Table 4).
J. Smith-Nielsen et al. International Journal of Nursing Studies 79 (2018) 104–113

Table 4

41

29

26

26
%
Health Visitors’ Attitude Toward Using the ADBB 7 Months Post-Implementation in

28

20

18

18
Relation to Adherence to Screening Guidelines 12 Months Post-Implementation.
n

threshold for what is normal and abnormal – especially if the child

“It sometimes creates a negative atmosphere because parents are

“I sometimes am in doubt about what I am seeing. Where is the

Independent n Screening SE p

“It is without a doubt registering the screening in[the system],

variable proportion, Ma

Positive attitude ADBB makes a

positive contribution
Strongly agree 20 77.8% 0.04 –
Agree 32 64.6% 0.04 0.003
”It takes time in a visit that is already busy.”

is tired? I hope it comes with experience.” Somewhat 6 56.8% 0.06 0.004

disagree/not at all
Negative attitude Using the ADBB
which is really not user-friendly” decreases job
satisfaction
–
very concerned about tests.”

Disagree 41 71.2% 0.30

Somewhat agree/ 17 60% 0.40 0.01
agree
What are the challenges associated with using the ADBB?

a
Means are estimated marginal means taken from models adjusted for health visitors’
age, experience, and skills as self-reported pre-implementation.
Example

4. Discussion

A prerequisite for any universal screening program to be effective is

Uncertainty about scoring (and the

high screening prevalence rates, i.e. that the professionals adhere to the
Registration is difficult/not user
May complicate communication

screening guidelines. Informed by previous implementation studies that

problem of tired children)

have demonstrated that it is often difficult to obtain acceptable

screening rates, an essential part of our study was to investigate the
and/or cause worry

practitioners’ experiences and attitudes towards using the ADBB in their

Time Consuming

daily practice, and to examine whether attitudes toward the ADBB were
related to screening prevalence rates. Therefore, our study extends the
friendly
Theme

growing literature regarding implementation of standardized screening

tools into primary care by describing the experiences of practitioners
using the ADBB and by investigating implementation drivers as well as
54

39

16

10
%

obstacles that prevent practitioners from embracing universal screening

44

32

13

with validated tools.

8

3
n

Our study demonstrates that it is feasible to implement the ADBB as

evaluation is not just based on “clinical impression” but is based on an
”It has sharpened my evaluation of social contact. It enables me to be

“ADBB screening helps me to remember to attend to the child’s social

development at every visit, no matter what else happens during the
It has given me a language I can share with colleagues… I feel like

a universal screening instrument as a part of a general infant health

surveillance program. Consistent with findings from the implementa-
health visitors make a more professional impression when our
“It is easier to describe a child’s challenges to the parents.”

tion science literature, that implementation does not happen all at once
more specific about what is good and what is worrisome.”

(Fixsen et al., 2005), we found that screening prevalence rates in-

creased with time. Six months after the health visitors were instructed
to use the ADBB the screening rate was 47%, after nine months it was
67%, and after 12 months the screening rate reached nearly 80%
(Table 2). In other words, after one year, health visitors achieved 80%
of the goal set by the City of Copenhagen that all children receive at
least one ADBB score before the age of one. The exponential increase in
Health Visitors’ Experiences with the ADBB: Responses Ordered in Themes.

screening prevalence rates matches the increase observed in previous

studies (King et al., 2010) and likely follows the learning curve of the
evidence-based method.”

Note. N = 69. Survey distributed seven months post-implementation.

health visitors.
As this is the first time the ADBB has been implemented as a uni-
versal screening instrument in a primary care setting, it is not possible
How does the ADBB contribute positively to your work?

to directly compare our findings with other studies. In previous im-

Example

plementation studies that used validated screening instruments for in-

visit.”

fants and young children in universal screening programs, the screening

tools were typically questionnaires completed by parents, e.g., the Ages
Increases and maintains focus on infant's
Provides mutual frame of reference and

and Stages Questionnaire (Bricker et al., 1999).

Facilitates communication with parents

It has been discussed whether observational coding is feasible to

promotes professional identity
Increases competence in assessing

socioemotional development

implement in primary care settings due to their time consuming nature

(Bagner et al., 2012). Whereas questionnaires tend to be more time-
infant's social behavior

efficient, observational coding procedures provide more objective and

No positive contribution

detailed information. The ADBB is a screening instrument based on

observations made by a clinician and certified ADBB raters go through
thorough training to become reliable. In our program, the health visi-
tors used, on average, 30 h on training, supervision, and the reliability
Theme

test before starting to screen infants with the ADBB. Yet, the actual
Table 3

scoring of the child only takes a few minutes, and the ADBB can be

110
J. Smith-Nielsen et al.
incorporated fairly easily into a range of routine settings in which the
professional interacts with the child. Therefore, once, the health care
professional has been trained, the ADBB is a convenient, quick, objec-
tive, and informative screening tool.
In general, our screening prevalence rates 12 months post-im-
plementation were higher than those found for developmental
screening programs. For example, a quality improvement initiative in-
corporating validated developmental screening into two primary care
practice settings resulted in screening 61% of targeted children
(Schonwald et al., 2009). Other studies have reported much lower
screening prevalence rates (Rice et al., 2014). Thus, the current project
has accomplished the overall goal of changing the practice of the health
visitors, i.e., the first step of translating knowledge from infant mental
health science into practice in public health care. We attribute our high
rates to a variety of factors, which together likely have functioned as
implementation drivers in the current project. First, the health visitors,
generally, had a positive attitude toward using the ADBB seven months
after implementation. Indeed, about 92% of the health visitors believed
that the ADBB made a positive contribution to their work, and 78% did
not experience a decrease in job satisfaction as a result of using the
ADBB. When answering the open-ended question about how the ADBB
contributed to their daily practice, 54% of the participating health
visitors reported that using the ADBB had increased their feeling of
competence in regard to evaluating infants’ socioemotional develop-
ment. This may, in turn, have increased a feeling of empowerment and
arguably improved the quality of care. Accordingly, about one third
responded that using the ADBB during home visits facilitated commu-
nication with the parents, some believed that the ADBB promoted their
professional identity, and some health visitors answered that the ADBB
helped them to maintain focus on the infant’s socioemotional devel-
opment even during busy visits. Second, we worked closely with the
municipality at the management and practitioner level to agree on goals
and procedures for implementation, as well as to support the ongoing
learning processes. This aspect is often highlighted as a key aspect in
successful change of practice in organizations by training the frontline
staff in using new methods (e.g., Salas et al., 2012). Third, we provided
a rigorous training and certification program before implementation,
and after implementation, we monitored adherence, provided the
health visitors feedback and progress reports in the form of newsletters
and offered health visitors consultations with an ADBB expert. Fourth,
the health visitors, who participated in the current study, were ex-
perienced nurses, who had completed the Danish Advanced Nurse
Health Visitor Education program, the majority had extensive work
experience as health visitors and with examining and monitoring infant
physical and mental health, and finally, they generally felt confident in
regard to detecting infants with socioemotional problems when they
entered the project (Table 1). Finally, we added the ADBB to an es-
tablished, popular developmental surveillance program. Staff selection
(i.e., ensuring that the practitioners who are to change behavior have
the required competencies prior to training), high quality pre-im-
plementation training, on-going coaching and consultation, staff per-
formance evaluation, facilitative support from the leadership, and a
well-functioning system in which a program is implemented are all
thought to be essential implementation drivers (Blase et al., 2012); and
as such, our results provide support for the assumptions regarding de-
terminants of successful implementation of evidence-based methods
into service provided by Fixsen and colleauges (Fixsen et al., 2013,
2009).
Another important finding from this study was that the health
visitors’ attitudes toward using the ADBB at 7 months post-im-
plementation was associated with the screening prevalence rate at 12
months post-implementation. While a positive attitude toward the
ADBB predicted higher screening prevalence rates, a negative attitude
toward the ADBB was significantly related to lower screening pre-
valence rates, i.e., if a health visitor experienced that the ADBB to a
high or some degree was a burden that decreased her work satisfaction,
111
International Journal of Nursing Studies 79 (2018) 104–113
she would be more likely to have a lower screening prevalence rate than
those who did not report the ADBB to decrease work satisfaction. This
finding may help explain the low screening prevalence rates and lack of
adherence to official screening guidelines reported in previous im-
plementation studies (e.g. Gellasch, 2016; McBride, 2010). Problems of
overcoming the research-to-practice gap, often highlighted within im-
plementation science literature (Fixsen et al., 2013; Nilsen, 2015),
likely involve acknowledging and working with the frontline staff’s
attitudes and perceptions of whether the new initiative adds value to
his/her practice, or whether the new tasks are merely perceived as
burdensome and meaningless.
Although our screening prevalence rates were relatively high, about
20% of children did not receive a single ADBB score 12 months after
implementation. These children were under general health surveil-
lance, but for some reason the health visitors did not manage to screen
them for social withdrawal. Based on previous research demonstrating
that surveillance misses more children with developmental delays than
screening (Miller et al., 2011; Schonwald et al., 2009), it is possible that
some of the 20% of children who were not screened have problems with
socioemotional development.
Obstacles to screening, which may explain the 20% absence of
ADBB scores, vary. The ADBB cannot be performed when babies are
sleeping or irritable. Although most health visitors had a positive atti-
tude toward the ADBB, after seven months of using the instrument in
practice, about 82% also viewed using the ADBB as challenging. The
most commonly cited challenges in using the ADBB included the fol-
lowing: difficult and time-consuming score registration, time-con-
suming screening, uncertainty about scoring and concern about causing
worry in parents. The difficulty in registering scores is likely a specific
problem for Denmark/Copenhagen, as health visitors in the current
study had to register the ADBB score in a module of their electronic
journal system, which many did not find user-friendly. Nevertheless,
this result suggests that using the necessary resources to develop an
efficient and user-friendly way of registering screening results is an
essential part of successful implementation of a universal screening
instrument in a busy real-life setting. As noted by Blase et al. (2012), a
core element of successful implementation is facilitative technical and
administrative support, and our finding confirms this. The fact that
many health visitors reported that uncertainty about the scoring was
part of why they experienced using the ADBB as challenging, stresses
the importance of ongoing consultation and coaching to facilitate
feelings of competence in the practitioner in order to ensure that the
screening program is effective. Moreover, it is important to acknowl-
edge that the health visitors who participated in the current study have
many tasks to complete in a short amount of time, and it is under-
standable that even a brief, additional screening procedure can be
challenging to add to a busy schedule. With more experience in using
the ADBB, health visitors are likely to become faster at completing
screenings, more confident in assigning scores, and more effective in
communicating with parents. If this is not the case, a practical im-
plication may be to increase the duration of health visits, provide more
clinical supervision to the health visitors, provide incentives and re-
minders for performing the screening, or increase the length of training.
4.1. Limitations and directions for future research
In the current study we have obtained good implementation out-
comes, i.e., acceptable levels of adherence to screening guidelines and
acceptability among the health care professionals whose practice was
affected. However, good implementation outcomes can occur regardless
of the effectiveness of the intervention practices and without producing
benefits for individuals (Blase et al., 2012). Therefore, a critical ques-
tion to address in future research is whether universal screening for
socioemotional problems with the ADBB in fact results in detection of
more infants who are at risk as compared with holding the socio-
emotional domain under informal health surveillance, which is
J. Smith-Nielsen et al.
currently the case in most health care systems around the world. An
aspect of this will involve evaluating the ADBB in terms of fidelity and
validity of the instrument when used during home visits. As all health
visitors in the current study went through a formal reliability test prior
to implementation, we did ensure a certain level of competence and
fidelity prior to implementation. However, “drifts” can occur when the
method is used in practice. For example, it is likely that the presence of
the parents could impact scoring. Screening of infants may cause worry
in the parents, and it has previously been reported that the fear of
having a positive screen can be an obstacle to obtaining adherence to
screening guidelines among practitioners (Pinto-Martin et al., 2005).
Indeed, 29% of the health visitors reported that a challenge when using
the ADBB was that it may affect the communication with the parents
negatively. Related to this is the question of the ‘parent side’ of ac-
ceptability. In the current study, we only investigated acceptability of
the ADBB from the health care professionals’ perspective. Another cri-
tical venue for future research is to investigate how parents experience
routine screening for socioemotional problems in their children and
how this affects the parent-professional alliance.
Successful implementation of any program within health care de-
pends on factors on multiple organizational levels. We primarily fo-
cused on so-called core implementation components, and in particular
how factors on the individual level play a role. However, context-re-
lated factors were not represented in our data, limiting our ability to
investigate how organizational components, such as management style,
general work environment, or local cultures and attitudes towards
systematic screening for infants’ socioemotional problems impact the
implementation process. These are all factors known to be important for
change in organizations (Salas et al., 2012). Conducting in-depth in-
terviews with a group of the health visitors and managers would
doubtless provide policy makers, planners, and managers of organiza-
tions valuable knowledge on how to implement universal screening for
infant socioemotional development in primary care settings in the most
cost-effective way.
Another limitation of our study is that we used questionnaires to
investigate how the health visitors perceived using the ADBB in their
daily practice as opposed to approaching this question by using inter-
views. When completing a questionnaire, the respondent may not feel
encouraged to provide accurate, honest answers. Also, survey questions
may lead to unclear data because certain questions may be interpreted
differently by respondents. While conducting interviews is more re-
source intensive, often limiting the number of participants included in a
study, it cannot be discounted that the interview method provides ri-
cher data because it allows the interviewer to openly explore the in-
formant’s opinions and experience with open-ended questions and
follow-up questions. To gain a more nuanced view of the factors im-
pacting the implementation process, future implementation studies
would benefit from including qualitative interviews with the frontline
personnel and/or the management.
Internationally, as well as in Denmark, there is a growing quest for
evidence-based mental health policies and a need for solid knowledge
of how we become better at translating research into practice, without
losing the effect of the intervention (Prewitt et al., 2012). Therefore,
detailed studies of implementation processes, like the current one, are
important. However, evaluating the effect of training of frontline staff
in randomized controlled designs would provide us with even stronger
data to guide decisions and policymakers, and this would be an im-
portant next step in the evaluation of the effects of universal screening
with the ADBB.
5. Conclusions and implications for practice
By highlighting important factors that may hinder successful im-
plementation, our results provide a good starting point for policy-
makers, planners, and managers who intend to undertake quality im-
provement initiatives aiming at early detection and prevention of
112
International Journal of Nursing Studies 79 (2018) 104–113
socioemotional problems in infancy. First, if the practitioner does not
perceive the screening instrument as a positive contribution to his/her
practice, low screening prevalence rates may occur. Though not sur-
prising, the implications of this finding are of high importance for
practice, as they suggest that a key aspect of successful implementation
is to manage practitioners’ attitudes towards the new practice. In other
words, developing a good policy and training the frontline staff in using
a new screening method is not sufficient for improving infant mental
health care practice. Second, ineffective registration systems may also
function as an obstacle to successful implementation in a busy real-life
setting. Our results stress the importance of investing resources in de-
veloping user-friendly and effective systems for registering screening
results, making it feasible for managers of implementation projects to
monitor the implementation process and thus be able to provide feed-
back to the practitioner regarding screening rates.
In sum, our findings suggest that adding the ADBB to an existing
routine developmental health surveillance practice is feasible and may
also add value to the practice of the health care worker in terms of
improved knowledge about infant socioemotional development.
Funding
The project is funded by a grant from the charitable foundation Tryg
Foundation (Grant ID no 107616).
Acknowledgements
The authors wish to thank the health visitors and The Children and
Youth Administration (Børne- Ungdoms Forvaltningen) in the City of
Copenhagen and the CIMHP project group for a fruitful collaboration.
The authors also acknowledge the valuable contribution of Rie
Krondorf von Wowern to the translation of the ADBB-manual into
Danish, the development of the training seminar in collaboration with
the first author and training, and to the supervision of the health visi-
tors. Finally, the authors acknowledge the contribution of Karin
Mathiesen in contributing to data management in this study.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in the
online version, at https://doi.org/10.1016/j.ijnurstu.2017.11.005.
References
Allen, S.G., Berry, A.D., Brewster, J.A., Chalasani, R.K., Mack, P.K., 2010. Enhancing
developmentally oriented primary care: an Illinois initiative to increase develop-
mental screening in medical homes. Pediatrics 126, S160–S164.
American Academy of Pediatrics, 2006. Council on Children with Disabilities. Identifying
infants and young children with developmental disorders in the medical home: an
algorithm for developmental surveillance and screening. Pediatrics 118, 405–420.
Arunyanart, W., Fenick, A., Ukritchon, S., Imjaijitt, W., Northrup, V., Weitzman, C., 2012.
Developmental and autism screening: a survey across six states. Infants Young Child.
25, 175–187.
Aylward, G.P., 2009. Developmental screening and assessment: what are we thinking? J.
Dev. Behav. Pediatr. 30, 169–173.
Bagner, D.M., Rodríguez, G.M., Blake, C.A., Linares, D., Carter, A.S., 2012. Assessment of
behavioral and emotional problems in infancy: A systematic review. Clin. Child
Family Psychol. Rev. 15 (2), 113–128.
Blase, K.A., Van Dyke, M., Fixsen, D.L., Bailey, F.W., 2012. Key concepts, themes, and
evidence for practitioners in educational psychology. Handb. Implement. Sci.
Psychol. Educ. 13.
Braarud, H.C., Slinning, K., Moe, V., Smith, L., Vannebo, U.T., Guedeney, A., et al., 2013.
Relation between social withdrawal symptoms in full-term and premature infants and
depressive symptoms in mothers: a longitudinal study. Infant Ment. Health J. 34,
532–541.
Bricker, D., Squires, J., Mounts, L., Potter, L., Nickel, R., Twombly, E., Farrell, J., 1999.
Ages and Stages Questionnaire. Paul H. Brookes, Baltimore.
Dansk Sygeplejeråd, 2010. Fremtidens Sundhedspleje. Dansk Sygeplejeråd, Copenhagen.
De Rosa, E., Curr, V., Wendland, J., Maulucci, S., Maulucci, M.L., De Giovanni, L., 2010.
Psychometric properties of the Alarm distress Baby Scale (ADBB) applied to 81 italian
children. Devenir 22, 209–223.
Evins, G.G., Theofrastous, J.P., Galvin, S.L., 2000. Postpartum depression: a comparison
J. Smith-Nielsen et al.
of screening and routine clinical evaluation. Am. J. Obstet. Gynecol. 182, 1080–1082.
Feldman, R.1, 2007. Parent-infant synchrony and the construction of shared timing;
physiological precursors, developmental outcomes, and risk conditions. J. Child
Psychol. Psychiatry 48, 329–354.
Fixsen, D.L., Naoom, S.F., Blase, K.A., Friedman, R.M., 2005. Implementation Research: a
Synthesis of the Literature.
Fixsen, D.L., Blase, K.A., Naoom, S.F., Wallace, F., 2009. Core implementation compo-
nents. Res. Social Work Pract. 19 (5), 531–540.
Fixsen, D., Blase, K., Metz, A., Van Dyke, M., 2013. Statewide implementation of evi-
dence-based programs? Except. Child. 79 (2), 213–230.
Fraser, J.G., 2013. Bridging the gap between implementation science and parenting in-
tervention. Am. J. Public Health 103, e11.
Gellasch, P., 2016. Developmental screening in the primary care setting: a qualitative
integrative review for nurses. J. Pediatr. Nurs. 31, 159–171.
Glascoe, F.P., Marks, K.P., Poon, J.K., Macias, M.M., 2013. Identifying and Addressing
Developmental-behavioral Problems: a Practical Guide for Medical and Non-medical
Professionals, Trainees, Researchers and Advocates. PEDStest.com, Nolensville,
Tennessee.
Guedeney, A., Fermanian, J., 2001. A validity and reliability study of assessment and
screening for sustained withdrawal reaction in infancy: the alarm distress baby scale.
Infant Ment. Health J. 22, 559–575.
Guedeney, A., Marchand-Martin, L., Cote, S.J., Larroque, B., EDEN Mother-Child Cohort
Study Group, 2012. Perinatal risk factors and social withdrawal behaviour. Eur. Child
Adolesc. Psychiatry 21, 185–191.
Guedeney, A., Matthey, S., Puura, K., 2013. Social withdrawal behavior in infancy: a
history of the concept and a review of published studies using the Alarm Distress baby
scale. Infant Ment. Health J. 34, 516–531.
Guedeney, A., Pingault, J.B., Thorr, A., Larroque, B., Mother-Child Cohort Study Group,
E.D.E.N., 2014. Social withdrawal at 1 year is associated with emotional and beha-
vioural problems at 3 and 5 years: the Eden mother-child cohort study. Eur. Child
Adolesc. Psychiatry 23, 1181–1188.
Guedeney, A., 2015. Alarm Distress Baby Scale (ADBB), Danish Version Translated from
version 5.2. Crncec, Rudi and Matthey, Stephen. Unpublished Work.
Guerrero, A.D., Garro, N., Chang, J.T., Kuo, A.A., 2010. An update on assessing devel-
opment in the pediatric office: has anything changed after two policy statements?
Acad. Pediatr. 10, 400–404.
Huffman, L.C., Nichols, M., 2004. Early detection of young children’s mental health
problems in primary care settings. Handbook of Infant, Toddler, and Preschool
Mental Health Assessment. pp. 467–489.
King, T.M., Tandon, S.D., Macias, M.M., Healy, J.A., Duncan, P.M., Swigonski, N.L., et al.,
2010. Implementing developmental screening and referrals: lessons learned from a
national project. Pediatrics 125, 350–360.
Lopes, S.C.F., Ricas, J., Mancini, M.C., 2008. Evaluation of the psychometrics properties
of the alarm distress baby scale among 122 Brazilian children. Infant Ment. Health J.
29, 153–173.
113
International Journal of Nursing Studies 79 (2018) 104–113
Mantymaa, M., Tamminen, T., Puura, K., Luoma, I., Koivisto, A.M., Salmelin, R.K., 2006.
Early mother-infant interaction: associations with the close relationships and mental
health of the mother. J. Reprod. Infant Psychol. 24, 213–231.
Mantymaa, M., Puura, K., Luoma, I., Kaukonen, P., Salmelin, R.K., Tamminen, T., 2008.
Infants' social withdrawal and parents' mental health. Infant Behav. Dev. 31,
606–613.
McBride, D.L., 2010. Implementing developmental screening. J. Pediatr. Nurs. 25 (4),
302–303.
Miller, J.S., Gabrielsen, T., Villalobos, M., Alleman, R., Wahmhoff, N., Carbone, P.S.,
et al., 2011. The each child study: systematic screening for autism spectrum disorders
in a pediatric setting. Pediatrics 127, 866–871.
Nilsen, P., 2015. Making sense of implementation theories, models and frameworks.
Implement. Sci. 10 (1), 53.
Phillips, D.A., Shonkoff, J.P., 2000. From Neurons to Neighborhoods: The Science of Early
Childhood Development. National Academies Press.
Pinto-Martin, J.A., Dunkle, M., Earls, M., Fliedner, D., Landes, C., 2005. Developmental
stages of developmental screening: steps to implementation of a successful program.
Am. J. Public Health 95, 1928–1932.
Prewitt, K., Schwandt, T.A., Straf, L.M., 2012. Using Science as Evidence in Public Policy.
National Academies Press, Washington D.C.
Rice, C.E., Van Naarden Braun, K., Kogan, M.D., Smith, C., Kavanagh, L., Strickland, B.,
et al., 2014. Screening for developmental delays among young children – National
Survey of Children's Health, United States, 2007. MMWR Surveill. Summ. 63, 27–35.
Salas, E., Tannenbaum, S.I., Kraiger, K., Smith-Jentsch, K.A., 2012. The science of training
and development in organizations: what matters in practice. Psychol. Sci. Public
Interest 13 (2), 74–101.
Sand, N., Silverstein, M., Glascoe, F.P., Gupta, V.B., Tonniges, T.P., O'Connor, K.G., 2005.
Pediatricians' reported practices regarding developmental screening: do guidelines
work Do they help? Pediatrics 116, 174–179.
Schonwald, A., Huntington, N., Chan, E., Risko, W., Bridgemohan, C.1, 2009. Routine
developmental screening implemented in urban primary care settings: more evidence
of feasibility and effectiveness. Pediatrics 123, 660–668.
Væver, M.S., Smith-Nielsen, J., Lange, T., 2016a. Copenhagen infant mental health pro-
ject: study protocol for a randomized controlled trial comparing circle of security-
parenting and care as usual as interventions targeting infant mental health risks. BMC
Psychol. 4, 57.
Væver, M.S., Smith-Nielsen, J., von Wowern, R.K., Wendelboe, K.I., 2016b. Copenhagen
Infant Mental Health Project (CIMHP): Effects of infant mental health screening and
indicated prevention approaches − evidence from a randomized control study.
Campbell, P., Keren, M., Puura, K., oppenheim, D., Tomlinson, M. (Eds.), Paper
Presented at The World Association for Infant Mental Health 15th World Congress
350–351 Infant Mental Health Journal.
Wickberg, B., Hwang, C.P., 1996. Counselling of postnatal depression: a controlled study
on a population based Swedish sample. J. Affect. Disord. 39, 209–216.