Ages & Stages Questionnaires® (ASQ-3) A Parent-Completed, Child-Monitoring System Ages & Stages Questionnaires® is a registered trademark of Paul H. Brookes Publishing Co., Inc.

Training Objectives Define and discuss the benefits of developmental screening Describe features of the ASQ-3 Score the ASQ-3 Describe ASQ-3 cutoff scores Interpret ASQ-3 information in relation to other referral considerations ASQ and ASQ:SE Training Materials by Jane Squires, Jane Farrell, Jantina Clifford, Suzanne Yockelson, and Elizabeth Twombly Copyright © 2008 by Paul H. Brookes Publishing Co. All rights reserved. For more information about the ASQ and ASQ:SE, see http://www.agesandstages.com

What is the ASQ-3? Parent- or caregiver-completed screening tool that encourage parental/caregiver involvement Series of questionnaires for children ages 1 months to 5 ½ years Tool to accurately identify children at risk for developmental delay Parent/caregiver completed. All of the research on the ASQ was conducted with a primary caregiver completing the form; therefore, it is unknown how accurate the results are if, for example, a child care provider completes the tool. It is important to consider multiple perspectives. Ask participants, “Why is it important to consider more than one perspective?” Possible reasons include the following: Children exhibit different behaviors in different environments. People have different expectations for certain behaviors. New moms, cultural differences, “goodness of fit” issues, temperament, experienced versus new child care providers ASQ and ASQ:SE Training Materials by Jane Squires, Jane Farrell, Jantina Clifford, Suzanne Yockelson, and Elizabeth Twombly Copyright © 2008 by Paul H. Brookes Publishing Co. All rights reserved. For more information about the ASQ and ASQ:SE, see http://www.agesandstages.com

Domains Screened by the ASQ-3 ASQ-3 (screens 5 domains): Communication Gross motor Fine motor Problem solving Personal-social Review the slide. The ASQ:SE was developed as a companion tool to the ASQ to address the need for age-appropriate tools to monitor very young children’s behavior and to address parental concerns. ASQ and ASQ:SE Training Materials by Jane Squires, Jane Farrell, Jantina Clifford, Suzanne Yockelson, and Elizabeth Twombly Copyright © 2008 by Paul H. Brookes Publishing Co. All rights reserved. For more information about the ASQ and ASQ:SE, see http://www.agesandstages.com

Features of the Ages and Stages Questionnaires (ASQ-3) Have Participants take out their 16 month ASQ-3 while reviewing features of the ASQ-3.

Features: ASQ-3 Intervals 21 Questionnaire intervals: 2, 4, 6, 8, 9, 10, 12, 14, 16, 18, 20, 22, 24 27, 30, 33, 36 (spaced 3 months apart) 42, 48, 54, 60 (spaced 6 months apart) There are 21 ASQ-3 intervals. Note that intervals are spaced 2 months apart until 24 months, 3 months apart from 24-36 months, and 6 months apart from 36-60 months.

ASQ-3 Intervals 9 month vs. 10 month forms 9 month developed for pediatricians to use at 9 month check-up. When screening 9 month old child use 10 month ASQ-3 as it is more stringent.

Features: ASQ-3 Cover Page ASQ-3 administration windows have been “stretched” so that there is always an appropriate ASQ-3 interval to administer. The original ASQ intervals had a 2 month “window” where the ASQ could be administered. This was problematic in the preschool intervals where there are fewer intervals. At certain ages children were outside of the 2 month window. Note: If a child’s score is questionable and their age is on the younger or older end of these stretched windows, this should to be taken into consideration when making referral decisions. Administration window indicated on ASQ-3 cover page. 16 month “window” is 15 months, 0 days to 16 months, 30 days.

Features: ASQ-3 Cover Page Gathers information to choose correct ASQ-3 Interval. Date ASQ Completed Childs Date of Birth Prematurity question (up to 24 months) Calculate Age at administration or Adjusted age and compare with administration window. Choosing the correct ASQ-3 Interval is one of the major challenges to the ASQ system. Program staff should carefully calculate a child’s Age at Administration in months and days. See ASQ-3 User’s Guide for detailed guidance. Age calculators are available on-line that can assist in determining a child’s age in months and days.

Features: ASQ-3 Areas & Questions 5 developmental areas (e.g., Communication) 6 questions in each area Questions are in hierarchical order Questions #5 and #6 are average skills for children of that age interval (i.e., a 12 month skill for a 12 month child). Response options: Yes, Sometimes, Not Yet Written at 4th to 5th grade reading level Hierarchical order: This is an important feature to emphasize. Across the series of questionnaires, the questions range in difficulty from approximately a 75 developmental quotient (DQ) to a 100 DQ. DQ is calculated by taking a skill age level divided by the age of the child. For example, on the 16 month questionnaire in the communication area, the item difficulty looks like this: #1 and #2 are approximately 12 month skills (DQ=75; 12mo/16mo) #3 and #4 are approximately 14 month skills (DQ=88; 14 mo/16mo) #5 and #6 are approximately 16 month skills (DQ=100; 16mo/16mo) This is a very different tool from a screening tool such as the Denver, which can tell you that a 16 month old child has communication skills at a 20 month age. State “If a child received a yes on every question in the ASQ, what can we say about that child’s development?” Answer: That the child is typically developing, right at age level only.

Features: ASQ-3 Overall Section Un-Scored Section Looks at quality of skills (e.g., speech) Example: “Does your baby use both hand equally well?” “No” response indicates possible medical diagnosis. Important to follow up. Parent concerns very predictive. Any concerns or questionable responses require follow-up Overall section - Important for decision making. Captures qualitative information that may not be picked up on the quantitative items - example would be stuttering or stammering which could be identified by the over-all question “Does your child talk like other children his/her age?” A child may pass the “scores” in the communication area, but still need services. Responses from the overall section should always be considered when making referral decisions. Call local Early Intervention or Early Childhood Special Education to get more information about any questionable responses on the Overall Section or refer to child’s primary health care provider for health related concerns.

Features: ASQ-3 Summary Sheet Each ASQ-3 interval has unique summary sheets. Summary sheets have five sections: Child/family information Bar graph with cutoffs Overall section Follow-up action taken (new to ASQ-3) Optional section: Individual item responses The summary form provides a complete summary of questionnaire information. This form could be used to share information with other community agencies who families are involved with who also have a requirement to screen children. For example, Early Head Start may conduct the screening, but share information with a child’s Primary Health Care Provider by sending them a copy of the Summary Form. Important to Remember: If you are sending this form to another agency/person. The receiving agency must understand the ASQ-3 and how to interpret ASQ-3 scoring information.

How to Administer ASQ-3

Prescreening Activities Obtain consent. Explain purpose of screening and review questionnaire content. Schedule screening. Select Correct ASQ-3 Interval. If possible, provide parent with ASQ-3 prior to administration. Assemble materials (if necessary). Prescreening Activities Review slide. Refer to “Suggestions for Introducing or Assisting Caregivers with the ASQ-3” handout. Activity: Participants can practice introducing the ASQ-3 to a parent. Have them work in pairs. One person is the “home visitor”, one is Vicky, who has a young child named Andrew. The “home visitor” should review the first part of the Introducing ASQ-3 handout that describes the purpose of screening, describes the ASQ areas and scoring options.

ASQ-3 Administration: Andrew Scoring Exercise Participants will need to have their 16 month ASQ-3 and a pen or pencil to write with. You will need your copy of “Andrew trainer’s notes”

Andrew: ASQ-3 Cover Page Date ASQ Completed: October 14, 2008. Child’s Name: Andrew Child’s Date of Birth: April 30, 2007 Vicky (mother) filling out questionnaire. Ask participants to use any method they can to calculate the child’s Age at Administration in months and days. Have participants do this step first, before later adjusting for prematurity. What is Andrew’s actual Age at ASQ Administration in months and days?

Age at Administration: Andrew Date ASQ Completed: October 14, 2008. Child’s Date of Birth: April 30, 2007 2008 10 (9) 14 (+30) days 2007 4 mo 30 days 1 year 5 mo 14 days One way to calculate age at administration. Subtract date of birth from date ASQ completed. In this example, 30 days (1 month) was borrowed from month column. = Andrew’s Age at administration is 17 months 14 days

Choosing the correct ASQ-3 when the child is premature. Adjusted age: Subtract weeks of prematurity from child’s age at administration to create an adjusted age. Use adjusted age to choose appropriate ASQ-3 interval. Premature (defined as): Children under 2 years, born 3 or more weeks premature. We do not advocate one method over another - as long as correction is made up to the 24 month questionnaire. Adjusted Age is more commonly understood and used…it is used to determine which ASQ-3 interval should I give to the child today?

Adjusted Age: Andrew 17 months 14 days – 6 weeks = 16 months (Andrew’s Age at administration) Andrew was born 6 weeks premature. What is Andrew’s Adjusted Age? Review Slide. Before going to the next slide, have participants fill out the 16 month questionnaire. Response information is found on the Andrew Scoring Exercise Trainer's Notes. Andrew’s adjusted age is 16 months. Andrew should receive the 16 month ASQ.

Possible Responses to the ASQ Yes = the child is performing the skill Sometimes = the child is performing the skill on occasion, but not always Not Yet = the child is not yet performing the skill

Scoring the ASQ-3 Step 1: Review responses. If any missing items, try to obtain answers. If items inappropriate, omit item. Step 2. Calculate area totals: “yes”= 10; “sometimes”= 5; “not yet”= 0. Step 3: If any items omitted, calculate new area total (example to follow). Up to 2 items in one area can be omitted. See ASQ-3 User’s Guide for further guidance.

Scoring the ASQ-3 (cont.) Step 4: Review overall section responses. Ask for further clarification and make notes if needed. Step 5: Transfer information to ASQ-3 Summary Page.

Create a new total area score so child is not penalized. ASQ-3 Omitted item? Create a new total area score so child is not penalized. 1) Divide total area score by the number of items answered in that area. 45 (area score)  5 (items) = 9 points. 2): Add this average item score to the total area score to get a new total score. 45 + 9 points = new total of 54 points We use the term “best guess” and stress that the best guess is based upon the other scores in that area. For example, if 5 items were answered with “5”, what would the best guess be for the 6th item? , Show how 5*5/5 =5. Repeat with 5 items answered with “10”. Then do the average scoring technique for Andrew. After seeing the average scoring technique work in the above scenarios, participants are more comfortable with it. Important: Participants should know that the need to omit items does not happen very often. Items should only be omitted if they are really inappropriate to try with a child. For example, the mirror items are inappropriate because of cultural and spiritual beliefs to some families. It would be inappropriate to try this item with a child. However, if the only reason an item is omitted is lack of opportunity, the child should be given the opportunity to practice and try the item.

Understanding ASQ Summary Values in the chart’s un-shaded areas = child appears to be developing typically Values in the grey shaded areas (“Monitoring Zone”) = child may need extra practice and experience in this domain, child’s progress should be monitored. (-1.00-(-)1.99 SD below the mean) Values within the charts black shaded areas = child should be referred for further evaluation. (-2 SD below the mean)

16 Month ASQ-3 Scoring Chart Andrew, Case Study The stars on this scoring chart illustrate where the average (mean) scores are located for the 16 month questionnaires. Again, the monitor zone (lightly shaded) is 1SD to 2SD below the mean. The darkly shaded area begins at 2SD below the mean.

ASQ-3 “Bell Curve” 60 Number of children Scores (in points) on ASQ 60 ASQ-3 “Bell Curve” (Not to Scale) Monitor Zone 32% ASQ-3 Cutoff 52.2% 15.8% -1SD -2SD This is what the ASQ-3 “bell curve” looks like (although this graph is not to scale). As you can see, there is no right hand side of the graph. That’s because the best a child can perform on the ASQ is right at average (or 60 points). We did not test higher skills to determine if a child was above average. In addition, note that the percentages of children that score within each category of the bell curve are quite different from a standard bell curve. The percentages on this graph represent the averages of all children in our normative sample, on all intervals, all domains that fell into the following categories: 52.2% of the normative sample scored from 60 points to -1SD (in the well above cutoff area). 32% of the normative sample scored in the Monitor Zone (between -1SD and -2SD below the mean or average) in one area (or more). 15.8% of our normative sample scored at or below 2SD in one area (or more) of the ASQ-3. This information is important to know when interpreting ASQ results. While one area low is reason to refer a child, it is important to look at referral considerations closely (such as opportunity) when interpreting results. It is also important to look at the degree to which the ASQ score is below cutoff. 15.8% is a fairly high percentage of children who score below the cutoff in at least one area. However, this is a screening tool. Once results are quickly debriefed with parents, it becomes very apparent that some of these one area low children are there because of opportunity to try activities (especially in areas such as fine motor/personal social). Opportunity has to be considered prior to referring children, especially if they are only falling below cutoff in one area. It is not shown on this graph, but good to know that only 5.8% of the normative sample scored at or below 2SD in two areas (or more) on the ASQ-3. When a child scores at or below in 2 or more areas, or is significantly below cutoff in any area, it is quite unusual.

Follow-up & Referral Criteria Above monitor zone Provide follow up activities & rescreen in 6-12 months. All areas scored in white zone Monitor zone Score is between 1-2 SD below average. (1 area in grey zone) Provide follow up activities to practice specific skills. Rescreen in 6 months in areas of concern. Make community referrals as appropriate. Monitoring will depend on program’s contact with families as well as program’s resources--programs may choose to rescreen in areas of concern soon after the initial screening, or they may choose to stick with their program’s pre-determined screening schedule. For children 1 month to 3 years a 4-6 month monitoring schedule is recommended, and for children 3 - 5.5 years a 6-12 month monitoring schedule is recommended.

Follow-up/Referral Criteria (cont.) Below cutoff in one or more areas: Score is below 2 standard deviations below average. (2 or more areas in grey zone or 1 or more areas in black.) Refer for further assessment

Example of Follow-Up Actions Andrew, Case Study

Participants should fill out the ASQ-3 Summary Sheet. Instruct participants to transfer child information and complete sections 1 and 2 and review section 3. Completed summary forms should look like this one, although Section 4 will not yet be completed. Section 5 is optional. The format for transferring item responses was changed from the original ASQ format to provide additional space for section 4. Items responses may be helpful for receiving agencies, or for inputting data.

Talking to Families “The ASQ is a tool to check on your child’s development.” “Your child will be able to do some of the items, but not all of the items.” “Answers help show your child’s strengths and any areas where your child may need support or more practice” Try to avoid using pass/fail language and ‘test’ This is a screen…

ASQ-3 User’s Guide Includes information on planning screening systems and procedures Provide example letters, activities, and case studies Contain technical reports Cover all topics in depth