What is it?
Focus on the Outcomes of Communication Under Six (FOCUS © ) is a clinical tool designed to evaluate change in communicative-participation in preschool children. ‘Communicative participation’ is the child’s communication and interaction in “real world” situations at home, school, or in the community (Eadie et al., 2006).
The FOCUS is a valid, reliable, responsive treatment outcome measure that captures ‘real world’ changes following speech and language treatment. The FOCUS links speech and language treatment to the child’s ability to communicate and participate in their world. There are two versions of the measure, one designed for parents and one for clinicians. The items on both versions are the same.
How do I get it?
By selecting the type of license and language you would like, you can purchase the FOCUS Manual and Scoresheets on the CanChild Shop. Once you provide your information and the transaction is complete, you will be emailed a ZIP file and license confirming your purchase.
Why do we need FOCUS?
Clinicians and families are always interested in knowing whether speech language therapy treatment makes a difference. To evaluate communication changes over time, we need measures (‘tools’) that are designed for the job. The Speech-Language & Audiology Canada(SAC-OAC) issued a position statement encouraging the use and development of outcome measures by speech-language pathologists and audiologists. They state that outcome measures should be used to improve practice in an evidence-based manner, in the best interests of clients (Outcome Measures Position Statement).
In order to ’measure up’, a tool needs to be validated (i.e., proven by research evidence) to be able to assess change over time in a meaningful way. The tool also needs to be reliable – that is, able to provide consistent information over time, and between times. It should also be clinically sensible (i.e., measure things we think are important) and easy to use (Rosenbaum et al., 1990).
Too often we use the wrong ‘tools’ for the job of measuring change – for example using a norm-referenced standardized test that is not designed to capture change. If the tool does not measure change when it has really happened, we may conclude (wrongly) that the treatment didn’t work, when in fact it was the measure that didn’t ‘work’!
The FOCUS measure created by Nancy Thomas-Stonell and her colleagues was developed using the principles of modern measurement science to ensure that it "does the job!"
How was the FOCUS and FOCUS-34 developed?
The FOCUS was developed over a 13 year time span. It was developed with parent and clinician input at 11 partner sites in 5 Provinces across Canada.
Parents of 210 preschool children and their clinicians were asked to describe the changes they observed following treatment (Thomas-Stonell et al., 2009). The comments aligned with the World Health Organization’s ICF-CY framework (WHO, 2007). FOCUS items were developed using the parents’ own wording.
The FOCUS measure was tested three times with 165 families and their clinicians. It was revised after each test phase using measurement science and parent/clinician feedback. Using this process, the FOCUS measure was reduced from 103 to 50 items. As the FOCUS was revised, most of the Body Function items were eliminated. There was an increased emphasis on ICF-CY Activities and Participation domain, especially performance items (Thomas-Stonell et al, 2010).
What do FOCUS items look like?
Sample FOCUS questions for Activity:
“My child uses new words.”
“My child can string words together.”
“My child uses words to ask for things.”
“My child talks a lot.”
Sample FOCUS questions for Participation:
“My child is included in play activities by other children.”
“My child gets along with other children.”
“My child is included in games by other children.”
“My child can communicate effectively with other children.”
FOCUS background information videos
FOCUS videos from the June 2012 Launch Workshop
Measures and Measurements
Development and Validation
Using the Communications Function Classification System (CFCS)
Mary Jo Cooley Hidecker
Q1: Where do I find the FOCUS outcome measure?
A: The FOCUS outcome measure can be purchased and downloaded through the CanChild Shop (https://canchild.ca/en/shop). This takes you to an online shop, where you can purchase an individual or organizational (based on size) license for the FOCUS.
Q2: How do I get the FOCUS forms?
A: You need to visit the CanChild Shop, select the FOCUS measure, add the license type and language you would like to your cart and purchase. Once this is done you will be emailed a zip file containing all relevant documents require to use the measure.
Q3: What do I do, if I have followed the procedures for downloading the FOCUS forms, but I am not able to access them?
A: If you experience any problems with purchasing on the CanChild Shop or downloading your files, please feel free to contact firstname.lastname@example.org and we will address your concern as soon as possible.
Q4: Is it preferable to use the Parent FOCUS outcome measure and only use the Clinician FOCUS outcome measure if, for some reason, the parents cannot complete the outcome measure?
A: Yes. Since the parents have the opportunity to observe their child in different environments, it is preferable to have the parent complete the FOCUS. If the speech-language pathologist is completing the FOCUS, they need to consult with the parents to obtain information about how the child communicates with others at home and in the community.
Q5: Is there a preferred time in which to administer the FOCUS (e.g., before or after a family receives feedback from an assessment)?
A: Parents can complete the FOCUS either before or after the assessment. This is left to your clinical judgment. Some clinicians ask the parents to fill out the measure while the child is being assessed. Others find it helpful to have the parents complete the outcome measure after the assessment so that the parents and clinicians have a common language.
Q6: Should speech-language pathologists coach the parents through the FOCUS items or should parents fill it out independently? Does the amount of coaching impact the validity?
A: FOCUS can be administered either way and it does not affect the validity. If the parent completed the FOCUS independently, we recommend that the clinician review it to check for missed items and to answer any questions. Use your clinical judgment about the best process for each family.
Q7: Can communication disorder assistants/therapy assistants coach the parents through the FOCUS items?
A: Yes. A communication disorder assistant/therapy assistant can assist the parents to complete the FOCUS. It does not affect the validity. The speech-language pathologist, however, must be the one that scores and interprets the FOCUS results.
Q8: What if the clinician has never had an opportunity to observe the child with other children?
A: If you have not had an opportunity to observe your client with other children, ask the parents for their input.
Q9: Would you use the FOCUS with children who do not yet have intentional communication, do not initiate or respond to communication with others and have only random play with toys?
A: Yes. Please complete the FOCUS on all children who are 18 months or older based on chronological age.
Q10: What if different parents bring the children to re-assessment appointments?
A: It is ideal for the same parents to complete all FOCUS outcome measures, but it is not always possible. It is better to collect the data than to not complete the FOCUS.
Q11: How do you respond to the items relating to playing with other children if they are not around other children very much (i.e., home with parents/grandparent)?
A: Ask the parents. It is likely that the children play with some other children such as cousins, siblings and friends.
Q12: What if it is a different speech-language pathologist that fills out the FOCUS every time for the same child. Is that okay?
A: Yes. We have established inter-judge reliability with speech-language pathologists using the FOCUS.
Q13: What do we do if a family does not read English?
A: We have developed an audio version of the FOCUS. This version is included in your purchase.
Q14: Is it best practice is to have the parent complete the outcome measure during our session or can we send it home to be filled out and have it returned the following session?
A: Use your best clinical judgment and knowledge of the family to determine if this is a possible option for the family.
Q15: Do we complete the FOCUS as an interview if parents can't read?
A: If you feel the parents need assistance, then it is possible to do the FOCUS as a parent interview or you can use the audio version of the FOCUS included in your purchase.
Q16: Should parents ask for input from preschool/daycare centers when they are not sure how to answer an item?
A: Yes. Parents can ask Early Childhood Educators for input, if they would like more information to help them score certain items.
Q17: If you are interviewing a parent, do you complete the parent or the clinician outcome measure?
A: When interviewing the parent, you just record the parents’ answers for them using the FOCUS Outcome Measure - Parent.
Q18: Why do we use the FOCUS Scoring Profile?
A: The FOCUS scoring profile is optional. It can be used to obtain further information for clinical goal setting and treatment. Rank ordering of the average scores for each communication reveals where the child has made the most change in response to treatment and if there are categories that do show less change.
Q19: Can the FOCUS be used with a family who has limited English?
A: Yes. If the family has a limited knowledge of English then the FOCUS can be completed through parent/caregiver interview and/or with an interpreter as needed. The clinician should record the parent’s responses as given.
Q20: Can the FOCUS be completed with the parent over the phone?
A: Yes. The FOCUS can be completed over the phone. Again, the clinician should record the parent’s responses as given.
Q21: Can the FOCUS be printed on both sides of the paper?
A: No. In order to reduce errors and omissions while completing the paper copy of the FOCUS, it is recommended that the FOCUS be copied on single sheets of paper, not double sided.
Q22: What is the age range for the FOCUS outcome measure?
A: Our research confirmed that the FOCUS measures change well for children between 18 months and 72 months of age. The research indicated that the FOCUS was less sensitive to change for children younger than 18 months of age. The FOCUS has been shown to measure change for children with dysarthria who are up to 7 years of age. More research is needed to determine the sensitivity of the FOCUS with older children.
1.SAC-OAC (May 2010). Position Statement on Outcome Measures. Find online here.
2. Thomas-Stonell, N., Oddson, B., Robertson, B., Rosenbaum, P. Validation of the Focus on the Outcomes of Communication under Six outcome measure
Developmental Medicine & Child Neurology. Vol. 55, Issue 6, pgs. 546-552, 2013. DOI: 10.111/dmcn.12123.
Available for free download, click here.
3. Thomas-Stonell, N., Washington, K., Oddson, B., Robertson, B., Rosenbaum, P. Measuring communicative participation using the FOCUS: Focus on the Outcomes of Communication Under Six
Child: Care, Health and Development. Vol. 39, Issue 4, pgs. 474-480, 2013. DOI: 10.1111/cch.12049
Available for free download, click here.
4. Washington, K., Thomas-Stonell, N., Oddson, B., McLeod, S., Warr-Leeper, G., Robertson, B., Rosenbaum, P. Construct validity of the FOCUS (Focus on the Outcomes of Communication Under Six): a communicative participation outcome measure for preschool children
Child: Care, Health and Development. Vol. 39, Issue 4, pgs. 481-489, 2013. DOI: 10.1111/cch.12043
Available for free download, click here.
5. Washington, K., Oddson, B., Robertson, B., Rosenbaum, P., Thomas-Stonell, N. Reliability of the Focus on the Outcomes of Communication Under Six (FOCUS)
Journal of Clinical Practice in Speech-Language Pathology, Vol. 15, Issue 1, pgs. 25-31, 2013.
6. Oddson, B., Washington, K., Robertson, B., Rosenbaum, P. & Thomas-Stonell, N. (2013) Inter-rater Reliability of Clinicians’ Ratings of Preschool Children using the FOCUS©: Focus on the Outcomes of Communication Under Six. Canadian Journal of Speech-Language Pathology & Audiology, 37(2), 170-174.
7. Eadie, T.L., Yorkston, K.M., Klasner, E.R., Dudgeon, B.J., Deitz, J.C., Baylor, C.R., Miller, R.M., & Amtmann, D. (2006). Measuring communicative participation: a review of self-report instruments in speech-language pathology. American Journal of Speech-Language Pathology, 15 (4): 207-320.
8. Rosenbaum, P., Cadman, D., Russell, D., Gowland, C., Hardy, S., & Jarvis, S. Issues in measuring change in motor function in children with cerebral palsy. A special communication. Physical Therapy, 70(2), pgs. 125-131, 1990.
9.Thomas-Stonell, N., Oddson, B., Robertson, B., Rosenbaum, P. Predicted and observed outcomes in preschool children following speech and language treatment: Parent and clinician perspectives. Journal of Communication Disorders. Vol. 42, Issue 1, pgs. 29-42, 2009.
10.Thomas-Stonell, N.L., Oddson, B., Robertson, B., Rosenbaum, P., Development of the FOCUS (Focus on the Outcomes of Communication Under Six), a communication outcome measure for preschool children. Developmental Medicine & Child Neurology, 52, pgs. 47-53, 2010.
11.World Health Organization. International Classification of Functioning, Disability and Health – Children and Youth Version 2007; Geneva: World Health Organization.