Submit your question for ASQ developer Jane Squires! Dr. Squires will regularly answer selected questions, drawing from her up-to-date wisdom from the field and the latest research.
Jane Squires
Q: I know that you must adjust for prematurity when using ASQ-3™, but do we need to adjust for prematurity with ASQ:SE?
A: No, you do not need to adjust for prematurity when using the ASQ:SE. The ASQ:SE questionnaire intervals cover a larger time frame than the ASQ-3 questionnaires. And the relationship between prematurity and social-emotional development is less significant than the relationship with physical development. However, if your program is already adjusting a child’s age for the ASQ-3, you can use corrected date of birth for the ASQ:SE as well.
Q: Can my program use ASQ:SE for ongoing progress monitoring?
A: It is possible to use the ASQ:SE for progress monitoring by using a 25 point reduction in a child’s score as a general guideline to quantify improvement in behavior. It is important to keep in mind that a reduction of a child’s score over time from a score near the cutoff to below the cutoff (e.g., 80 to 55) may show more significant improvement than a similar numerical reduction in a score well above the cutoff (e.g., 225 to 200). Programs can also compute ratio scores for ASQ:SE by dividing the child’s score by the total possible points and compare the ratio scores over time.
There are several programs currently using ASQ:SE for progress monitoring; however, the ASQ:SE authors have not yet conducted research on this use of ASQ:SE.
Q: We have a child in our program that was taught baby signs for communication—for example, more, eat, all done. On the 14 month ASQ-3™ questionnaire, the first item of the communication section asks if the baby can say three words. If this child communicates through signs, does that count as ‘yes’ to this item?
A: Yes, signs qualify as a means of communication because though a child is not saying the words, he or she is communicating the meaning with the use of signs. You should note in the overall section if there is family history of childhood deafness or hearing impairment or if the parent has concerns that his or her child is too quiet. These items may be indicators for issues related to a child’s communication development.
Q: The parent of a child in our program questioned the ASQ-3™ age interval that we selected for her child even though her child fell within the appropriate age administration window. The parent was concerned that the selected age interval was setting her child up for failure. How can we accurately explain why a given age interval was chosen and help alleviate parent concerns that the age interval is inappropriate?
A: It is not entirely uncommon for parents to express concerns about the ASQ-3™ questionnaire interval chosen for their child, especially if a parent perceives the child’s skills as being delayed. Completing the ASQ-3™ is designed to be a positive experience for parents so it is important to address these concerns by explaining the purpose of developmental screening and the development of the ASQ-3™ questionnaires.
Items on each age interval of the ASQ-3™ were carefully selected based on the criteria that they are skills that guide important developmental milestones. Each questionnaire includes items that target a skill that occurs at the middle to low end of the developmental range for that particular age interval. This range was chosen because many standardized tests use 1.5–2.0 standard deviations below the mean as the lower end of the typical developmental range; therefore, it is reasoned that any child who was generally unable to perform items in the middle to low end of the developmental range should be referred for further assessment.
Informing parents of the reasoning behind the inclusion of items on each questionnaire will help them understand how the ASQ-3™ accurately identifies young children who are in need of further assessment. You can also explain to a concerned parent that a large number of children were used at each age range to establish the cut-off points on the questionnaires.
If a parent is still concerned with the difficulty of the items, you can use an earlier age interval, and if the child has no problem with that interval, the next interval could be given.
If a child has been previously identified with a disability, it not recommended that professionals continue administering ASQ-3™ questionnaires to the child. Parents of children with disabilities may be discouraged when completing questionnaires because their child can do only a few of the skills targeted. If you are interested in figuring out where a child is within a domain that may not be affected by the delay (for instance, gross motor skills on a child with language delays), selected domains on the ASQ-3™ could be completed.
Q: For children born 3 or more weeks premature, a child’s adjusted age is used to select the correct ASQ-3 questionnaire. After the age of 2, their age is calculated without adjusting for prematurity. What do you do when using the correct questionnaire for a premature child after age 2 means skipping an age interval?
For example: For a child 22 months chronological age, born 8 weeks premature (20 months adjusted age), the 20 Month ASQ-3 is administered. For the same child at 24 months, the 24 Month ASQ-3 would be administered. Is it okay to skip the 22 month questionnaire for this child?
A: Adjusting for prematurity for children younger than 24 months of age is essential to ensure that the correct age interval questionnaire is selected. Once the child reaches 24 months of age, there is no need to adjust for prematurity so you should administer the appropriate age interval questionnaire, even if it means skipping an age interval. Going forward, questionnaires can be administered every 4-6 months, unless more frequent monitoring is called for due to circumstances such as parent concerns or change in health status.
In the example described above, I’d recommend administering the 24 Month ASQ-3 questionnaire. If the child is in the monitoring zone for any domain, then the child should be followed very closely, learning activities could be provided, and the 27 Month questionnaire should be administered in 3 months. If the child is below the cut-offs on any domain, I’d suggest a referral for further assessment.
Q: Are there required credentials or training requirements for administering ASQ-3™ or ASQ:SE?
A: Use of ASQ-3 and ASQ:SE does not require certain credentials or formal training. After a thorough reading of the ASQ-3™ User’s Guide or The ASQ:SE User’s Guide and several weeks of practice, an experienced early childhood professional should be able to implement the tools effectively. It is also beneficial for a new user to partner with someone with ASQ experience during the first few times he or she administers the tools with families.
Many programs use the training DVDs to introduce ASQ and show staff how to screen, score, and interpret results. Attending an official ASQ Training Institute can also be very helpful, especially when a number of people in your organization will be using the instrument. Learn more about the 2012 ASQ Training Institute.
Q: In our program, home visitors conduct ASQ-3™ screenings during home visits. Sometimes a questionnaire cannot be completed during just one visit. For example, the child’s naptime may occur during the home visit, limiting the amount of time that a child’s skills can be observed. If the home visitor administering a screen can gather some information during an initial visit and the remaining information during another visit, will the screen remain valid and reliable? If so, how soon would a follow up need to be made?
A: We recognize that sometimes it is not possible to have a professional (or a parent) complete a questionnaire all at one time. Sometimes it’s better not to complete the ASQ all on one visit and tire the child and parent. As long as the questionnaire is completed within a week or two from the initial visit, the results should still be valid. With older children (children 4–5 years of age), completion of the questionnaire within a 3- or 4-week time frame will be okay.
However, if a child’s score falls in the monitoring zone or below the cutoff on ASQ-3™, it would be good to go over the items with “sometimes” and “not yet” answers with families to see if the child has acquired these skills during the time between visits. If so, then the score should be recalculated. If a child transitions to a new questionnaire (from the 6 month questionnaire to the 8 month questionnaire, for example) during the time period between visits, it makes it very difficult to continue the earlier questionnaire. When we researched test-retest reliability with a 2- to 3-week time frame, we did find that some infants and toddlers had learned new skills during the time frame and thus didn’t get exactly the same score on the questionnaire.
Q: I have heard that research shows that parents are good reporters of their child’s development. Can you share more information about this research?
A: Research has indeed shown that parents—regardless of socioeconomic status, location, or well-being—give accurate information about their child’s development (Rydz et al., 2005; Squires et al., 1998). Parent report is most accurate if questions are straight-forward and ask about their child’s current, observable behaviors. While there are some parents such as those with substance abuse issues or severe mental health problems that may not provide accurate information, most parents can accurately answer simple questions about their child’s current repertoire of behaviors. Cultural and language issues must be considered, however, in all types of assessment.
Because parents (and other primary caregivers) have expert knowledge about their child’s abilities and skills, parental involvement in developmental screening important. Several research studies have shown that parents’ observations and report of their children’s development are predictive of developmental delays. Studies published in Topics in Early Childhood Special Education have shown that parents as observers are effective identifiers of children with delays (Diamond, 1993) and that use of parent-completed questionnaires was an accurate way to monitor children’s development (Bricker & Squires, 1989). Furthermore, studies by Frances Glascoe and colleagues (Glascoe, 1997; Glascoe & Dworkin, 1995) showed that parental concerns about language, fine motor, cognitive, and emotional-behavioral development are highly predictive of actual problems.
These studies establish parent-report tools, like ASQ-3 and ASQ:SE, as an accurate method of developmental screening. In addition, parent-completed tools are time- and cost-efficient, and they help educate parents about typical child development.
For more detailed information about parent reporting of children’s developmental skills, I encourage you to review the research literature. Several useful articles are listed below.
Bricker, D., & Squires, J. (1989). The effectiveness of parental screening of at risk infants: The infant monitoring questionnaires. Topics in Early Childhood Special Education, 9(3), 67–85.
Diamond, K. (1993). The role of parents’ observations and concerns in screening for developmental delays in young children. Topics in Early Childhood Special Education, 13(1), 68-81.
Diamond, K., & Squires, J. (1993). The role of parental report in the screening and assessment of young children. Journal of Early Intervention, 17(2), 107-115.
Rydz, D., Shevell, M.I., Majnemer, A., & Oskoui, M. (2005). Developmental screening.Journal of Child Neurology, 20(1), 4–21.
Glascoe, F.P., & Dworkin, P. (1995). The role of parents in the detection of developmental and behavioral problems. Pediatrics, 95(6), 829–836.
Glascoe, F.P. (1997). Parents’ concerns about children’s development: Prescreening technique or screening test? Pediatrics, 99, 522–528.
Glascoe, F.P. (1999). The value of parents’ concerns to detect and address developmental and behavioural problems. Journal of Paediatrics and Child Health, 35(1), 1–8.
Squires, J. (2000). Early detection of development delays: Parents as first level screeners. Journal of Intellectual Disability Research, 44(3 & 4), 471.
Squires, J., Potter, L., Bricker, D., & Lamorey, S. (1998). Parent-completed developmental questionnaires: Effectiveness with low and middle income parents.Early Childhood Research Quarterly, 13(2), 345-354.
Tervo, R. (2005). Parent’s reports predict their child’s developmental problems. Clinical Pediatrics, 44, 601-611.
Q: We have some children whose parents are aware of their child’s delays or special needs. How can ASQ-3™ be used to best serve these children?
A: The ASQ was designed to identify children with delays. Parents of children with disabilities may be discouraged when completing ASQ-3™ questionnaires because their child can do only a few of the behaviors targeted. We do not recommend that parents complete an ASQ-3 on a child with moderate to severe disabilities.
If you are interested in having parents experience observing and completing a screening questionnaire, the age range can be covered up on a questionnaire and parents can be asked to complete a “younger” interval for children with mild/moderate disabilities (for example, a 16 Month ASQ-3 Questionnaire for a 24-month old child).
If you are interested in figuring out where a child is within a domain that may not be affected by the delay (for instance, gross motor skills on a child with language delays), selected domains on the ASQ-3 could be completed.
The ASQ:SE can be completed by all parents, however, as a measure of behavior and social-emotional skills. We do know that children with disabilities often score above the ASQ:SE cutoff points. The ASQ:SE can provide a profile of the child’s strengths and competencies and problem behaviors for parents and caregivers and would not be used in most instances to compare the child’s profile with normative cutoff scores.
Q: Our pediatric medical clinic would like to implement the 9, 18, & 30 Month ASQ-3™ for developmental screening. However, we are a very busy practice and have very little resources to provide support to families in completing ASQ-3 questionnaires. We barely have time to score the questionnaires! How have other clinics found ways to effectively implement ASQ-3 screening? What steps do you recommend for achieving the highest questionnaire completion rates?
A: (from ASQ developer Jane Squires and pediatrician Kevin Marks, M.D.): We’re glad that your pediatric practice recognizes the importance of using a standardized tool for developmental screening. Most pediatric practices are very busy so it’s important to realize that screening doesn’t have to be overly time consuming. Simple strategies can be incorporated into office visits to help identify children at risk.
Some pediatric practices choose to have caregivers complete ASQ-3 questionnaires before scheduled well-child visits. With the new ASQ Family Access, pediatric practices can enable caregivers to complete questionnaires online at home through a secure, customizable website. ASQ Family Access eliminates postage costs associated with mailing questionnaires and questionnaires are scored automatically, which saves staff time and ensures scoring accuracy. Pre-visit screening can also occur through a mail-out program, where office staff mail ASQ-3 questionnaires to caregivers 2–4 weeks prior to the appointment and caregivers bring the completed questionnaire to the visit. If a caregiver arrives at the visit without having completing the questionnaire, either online or on paper, the questionnaire can be completed in the waiting room.
For practices with high percentages of parents who may require assistance when completing the questionnaires, it is recommended that questionnaire administration occur in the office setting for maximum completion rates. Caregivers should arrive at the well-child visit 15 minutes earlier than the appointment to allow time for questionnaire completion in the waiting room. Items necessary for questionnaire completion, such as cups, books, and stuffed animals, can be stored together in a quiet corner. A practice can order an ASQ-3 Materials Kit to ensure that all the needed items are available. If a computer with internet access is available in the waiting room, ASQ-3 questionnaires can be completed online with ASQ Family Access.
Ideally, ASQ-3 questionnaires are scored by office staff or through ASQ Family Access before the pediatrician meets with the child and caregiver. With practice, a questionnaire can be scored in 2–3 minutes. The pediatrician interprets the questionnaire results, questioning the caregiver if any questions were left blank. The pediatrician then shares results and any necessary next steps with the child’s caregiver.
Q: We are conducting research about maternal health and infant health and development in a low-income, rural commune in Viet Nam. Have the ASQ-3 or ASQ:SE have been used in a developing country context, such as Vietnam? What are your views about the use of the tools in these contexts?
A: (From ASQ developer Jane Squires and ASQ researcher Jantina Clifford): While the ASQ and ASQ:SE have been translated into many different languages, research on using the tools in other countries has only been published for some of these translations. Currently, the ASQ is commercially available in 4 languages (English, Spanish, French, and Korean), and the ASQ:SE is available in 3 languages (English, Spanish, and Norwegian).
Research that has been conducted examining the use of translated versions of the ASQ and ASQ:SE in other countries suggests that most questionnaire items do not exhibit significant differences in average scores. In fact, data collected in Norway, using a Norwegian translation of the ASQ, was so similar to U.S. data that for a time the Norwegian data set was used to help establish cut-offs for newer questionnaire intervals in the U.S. for which little data were available. This being said, using a translated version of the ASQ or ASQ:SE with a population culturally different from the U.S. should always be approached with caution.
Current studies that have been conducted with commercially available translations of the ASQ and ASQ:SE have been mostly done in developed countries, where it is quite likely that children’s caregiving environments offer many of the same opportunities as in the U.S., and developmental expectations for young children are also likely similar. When using an adapted version of the ASQ or ASQ:SE in the context of a developing country or with rural populations, it is important to closely examine results when concerns are detected, looking closely to see if low scores on the ASQ may be due to lack of exposure or opportunity to the skill or materials. In addition, items may be misinterpreted if there is ambiguity or misrepresentation in the translation. For many languages there may be different dialects, such that translated items may be misinterpreted across dialects. In addition, as previously mentioned, cultural practices and expectations may vary. Most often differences in cultural practices will be found in the personal-social domain in the ASQ, which includes a combination of adaptive (self-help) and social skills, both of which are highly influenced by caregiver expectation. For example, in Vietnam, children may not be encouraged to dress or feed themselves until much older than many American children such that two or more questions in the personal-social domain that addressed dressing or eating might cause a low score, which would likely be due to lack of opportunity as opposed to developmental delay.
Ideally, item functioning and mean scores would be examined for each adaptation of the ASQ and ASQ:SE and its intended population. Currently, we are just finishing experimental versions of Vietnamese and Chinese translations of the ASQ-3 and are looking for sites in the U.S. and Vietnam where large populations of Vietnamese-speaking and Chinese-speaking families are served to pilot test our adaptations. We are interested in learning more about a) the quality of the translation, b) the appropriateness of skills and suggested materials for the Vietnamese and Chinese cultures, and c) if there are large differences in developmental expectations that might warrant separate cut-offs for use with Vietnamese and Chinese children, especially in Vietnam and China. If your program is interested in participating in the pilot studies of the Vietnamese and Chinese translations of ASQ-3, please contact Kimberly Murphy at kamurphy@uoregon.edu.
If you are interested in learning more about the process we used in adapting the ASQ into Vietnamese or Chinese, please consult the ASQ-3 User’s Guide where we have provided recommendations for the adaptation process. We are very interested in pursuing our examination of the Vietnamese and Chinese translations, and look forward to continuing this process with other languages and cultures as the need arises.
Q: Are the ASQ-3 and ASQ:SE reliable screeners for detecting autism?
A: We are currently conducting research on the reliability of the ASQ-3 and ASQ:SE related to early detection of autism. Developmental pediatrician Robert Nickel, M.D., has conducted two pilot studies related to ASQ and autism detection, each with about 100 children, and has found over 95% agreement between the ASQ classification (i.e., typical, risk) and children with DSM-IV diagnoses of autism. That is, he has found that children who were brought to a developmental clinic for suspected ASD and who failed the ASQ (most often in the communication and personal-social domains) were identified as having ASD on clinical tests and assessments. Because this is a clinical population with suspected developmental problems, however, the agreement with the ASQ is inflated.
We hear from many programs around the United States that are using the ASQ:SE for autism screening and feel that it works very well together with an interview with parents. Some programs that use the ASQ-3 choose to follow up with the M-CHAT for children that score in the risk range, particularly in the communication and personal social-domains. We hope to have more empirical data about the use of ASQ-3 and ASQ:SE and autism detection by the end of 2012.
Q: How were the developmental items chosen for inclusion in ASQ-3? Why is each developmental item important?
A: Each ASQ-3 questionnaire includes 30 questions that are divided into five areas of development (communication, gross motor, fine motor, problem solving, and personal-social). Each item addresses important developmental milestones, targets behavior appropriate for the developmental quotient range of 75-100 for each age interval, and addresses behavior that is easy for parents to observe.
These items were developed by examining the content of developmentally based, norm-referenced tests and resources, such as Gesell Developmental Schedules Knobloch, Stevens, & Malone, 1980), the Revised Parent Developmental Questionnaire (Knobloch, Stevens, & Malone, 1980), and The Developmental Resource (Cohen & Gross, 1979), and the Assessment, Evaluation, and Programming System (Bricker, 2002). For more detailed information on typical child development, I recommend Sarah Landy’s Pathways to Competence, available from Brookes Publishing and Laura Berk’s Infants and Children, available from Pearson Education.
Q: There is overlap between the age administration windows for the 9 Month ASQ-3 and 10 Month ASQ-3 questionnaires. The new 9 Month questionnaire has an age administration window of 9 months, 0 days through 9 months, 30 days, while the 10 Month questionnaire has an age administration window of 9 months 0 days through 10 months 30 days. Which questionnaire should my program use to screen children between 9 months, 0 days and 9 months, 30 days?
A: We developed the new 9 Month ASQ-3 questionnaire for use by medical practitioners who are conducting developmental screening at 9-month well-child visits, as recommended by the American Academy of Pediatrics. With the previous edition of ASQ, pediatricians found it difficult to switch between administering the 8 Month and 10 Month questionnaires depending on the child’s age.
The developmental skill items and overall questions are identical on the 9 and 10 Month ASQ-3 questionnaires; the difference between the two questionnaires is in the cutoff scores for each age interval. If your program screens children along a continuum, as opposed to a one-time screening, I would recommend using the 10 Month ASQ-3 questionnaire for children ages 9 months, 0 days through 9 months, 30 days as we currently have more data collected on the 10 Month interval.
Q: As our program moves toward a Response to Intervention/Recognition and Response model with our infant through 5 year olds, we would like to use ASQ-3 as a tool for progress monitoring, as well as a screener for possible disabilities. Is ASQ currently being used as a progress monitoring tool? Does doing so violate any of the statistical properties of the instrument?
A: ASQ was developed and has been validated as a developmental screening tool. ASQ-3 reliably and accurately identifies children with delays that should receive in-depth assessment. The developers recognize that programs are interested in using ASQ for other purposes, such as eligibility determination, goal development, and progress monitoring. We suggest that programs follow the recommended practices issued by professional organizations in the field and use tools and other measures that have been specifically developed for assessment or progress monitoring. We do not recommend using ASQ-3, or other screening tools, for assessment or progress monitoring purposes until research has been conducted that demonstrates the validity of ASQ for those purposes.
However, we recognize that programs are limited by expertise, time, and cost. Using ASQ-3 for assessment or progress monitoring purposes is superior to using a measure that lacks adequate psychometric data or conducting no assessment or progress monitoring at all. If you choose to use ASQ-3 for purposes other than developmental screening, we advise you to qualify the outcome or results by noting the use of ASQ and how the choice may potentially affect the outcomes.
For more detail on using ASQ for purposes other than developmental screening, please read Developmental Screening Measures: Stretching the Use of the ASQ for Other Assessment Purposes in the January/March 2010 issue of Infants & Young Children.
Q: Why was ASQ, 2nd edition, revised? Why should I purchase ASQ-3™ rather than continuing to use the 2nd edition?
A: Since the publication of the second edition of ASQ in 1999, there has been widespread use of ASQ by a variety of education, health, and social services programs. Over the past ten years, many of these programs have shared their questionnaire results with us, and we amassed a large amount of data across all age intervals from a variety of families and children in diverse settings. Knowing that this information would be helpful in improving the generalizability of ASQ results, we used data from more than 18,000 completed questionnaires to restandardize the cutoff scores for ASQ-3™. We believe ASQ-3™ results will be more accurate for a variety of populations, resulting in less overreferral and underreferral. We also received lots of constructive feedback about administration and scoring from thousands of ASQ users, which we’ve incorporated into the new edition.
We recommend that programs screening children for developmental delays purchase the new ASQ-3™. In addition to improved reliability based on the new cutoff scores, the third edition includes two new questionnaires: the 2 Month questionnaire, which lets programs screen infants as young as 1 month, and the 9 Month questionnaire, which meets the American Academy of Pediatrics guideline to screen children at 9 months. The new edition also allows for anytime screening—the administration age ranges for each questionnaire have been widened to accommodate screening of children between 1 month and 66 months of age.
We added a monitoring zone to the scoring results for ASQ-3™, which assists programs by highlighting children’s skills that are not below the cutoff scores but may need close attention and monitoring. Item revisions and new overall questions have also been added to each questionnaire, making the questionnaires easier for parents to understand and asking about important skills such as behavioral concerns. The translation for ASQ-3™ in Spanish was revised and reviewed by a panel of Spanish-speaking experts, ensuring that the questionnaires are clear for Spanish-speaking parents.
Another benefit of ASQ-3™ is its compatibility with the new online management and questionnaire completion system. Programs can now manage all of their ASQ screening results and follow up electronically, and they can choose to allow parents to complete questionnaires online.
Q: A new monitoring zone has been added to ASQ-3™. How should my program use the monitoring zone?
A: The scoring summary sheet for ASQ-3™ now includes a monitoring zone, which represents a range of scores that are at least 1 but less than 2 standard deviations below children’s mean performance in each developmental area. This monitoring zone helps programs identify a child’s skills that are not below the cutoff but may need close attention and monitoring.
When a child’s score falls in the monitoring zone, your program has several options. Your program may decide to schedule a follow-up screening for the child, perhaps in 3 months. Your program may also choose to send ASQ learning activities to the child’s parents to encourage practice of skills in a certain developmental area. ASQ learning activities are provided in the ASQ-3™ User’s Guide and in the separate book Ages & Stages Learning Activities. Your program also has the option of referring children with scores that fall in the monitoring zone, based on parent and caregiver concerns. We encourage programs to use the monitoring zone in the way that works best for them.
Q: We have a child in our program that was taught baby signs for communication—for example, more, eat, all done. On the 14 month ASQ-3™ questionnaire, the first item of the communication section asks if the baby can say three words. If this child communicates through signs, does that count as ‘yes’ to this item?
A: Yes, signs qualify as a means of communication because though a child is not saying the words, he or she is communicating the meaning with the use of signs. You should note in the overall section if there is family history of childhood deafness or hearing impairment or if the parent has concerns that his or her child is too quiet. These items may be indicators for issues related to a child’s communication development.
Submit your question for ASQ developer Jane Squires! Dr. Squires will regularly answer selected questions, drawing from her up-to-date wisdom from the field and the latest research.
About Jane:
Jane Squires, Ph.D., is Professor and Director, Center on Human Development/University Center for Excellence in Developmental Disabilities and the Early Intervention Program, University of Oregon, Eugene.
Dr. Squires has directed several research studies on the Ages & Stages Questionnaires® and Ages & Stages Questionnaires®: Social-Emotional and has also directed national outreach training activities related to developmental screening and the involvement of parents in the monitoring of their child’s development.
