Because ASQ®-3 and ASQ®:SE-2 provide a broad overview of a young child’s development, you might think that every questionnaire item must be answered to ensure accurate results. In fact, parents and families do have the option of leaving an item unanswered—whether due to different parenting practices, cultural differences, or other factors—without affecting the validity of ASQ results.
We asked ASQ authors Jantina Clifford, Jane Farrell, Kimberly Murphy, and Liz Twombly to talk about the different reasons why a family member might choose not to respond to an item, when to reframe or adapt questions, how to calculate an adjusted score when items are left unanswered, and more.
1. Is it okay for family members to skip questions on ASQ-3 or ASQ:SE-2 questionnaires? Why might a family member choose not to answer a question?
Parents can choose not to answer a question at any time. Parents may leave items unanswered for a variety of reasons:
- Parents may have run out of time.
- Parents may not have the materials they needed to try the activity at home (for example, cutting with child-safe scissors).
- Parents may not have been able to observe a skill in the home (for example, walking up or down the stairs).
- A parent may not have understood a question due to primary language, dialect difference, or reading ability.
- A parent may not have wanted to try an ASQ activity (or materials) with their child because that activity does not match the family’s parenting practices, values, or beliefs.
2. How can a provider prepare family members for screening to gather the most information, while not interfering with a family’s parenting practices, values, or beliefs?
It is important to provide a good introduction to the purpose of screening and take time to engage with the family. When family members are ready, do a quick review of questions and activities before they get started. Does the parent have any questions or concerns about screening, activities, materials, or ASQ-3 questions? Another idea is to review a parent-friendly ASQ-3 materials list with the parent. Does the parent have the materials they need to try activities? Are there activities the parent does not want to try with their child?
Parents can choose not to respond to a question if it is asking about things that they’re not ready for their child to do or that don’t reflect their values or beliefs. Parents can write “N/A” next to any question that they are not comfortable answering. If they have questions about an activity, or don’t have everything they need to try an activity with their child, they can put a “?” next to the question—this lets the provider know that they are interested in answering the question and support may be needed.
3. What do you recommend for reviewing questions that are not answered?
Follow up by acknowledging the parents’ efforts at completing the questionnaire, and then see if you can help with any unanswered questions: “Thanks for taking time to complete the ASQ. I noticed that a few of the questions weren’t answered, so thought I would circle back to see if I could help—do you have any questions or concerns about the activities?” Having a conversation with a child’s parents can provide a lot of information for deciding next steps (i.e., whether to support a parent, adapt a question, or leave it unanswered).
4. Instead of skipping items, should professionals try to get the answers from parents?
Yes, as long as getting an answer does not interfere with the practices, values, or beliefs of the child’s family. The more information available about a child’s development, family needs, and family practices, the better providers can support the family in their decisions about next steps.
Here are some possible ideas for obtaining answers to questions left unanswered:
- Share needed materials with the parent.
- Suggest or provide alternative materials that are acceptable to the family.
- Consider other activities or routines where family members can observe the skill.
- Talk to the parents about places they can observe skills not easily observed at home, such as social events, child care, or preschool.
- If it is easy to identify the target skill of the question, adapt or reframe the question so that they make more sense to (or do not offend) the family.
If answers change based on these steps, remember to re-score the questionnaire. If any questions remain unanswered, use adjusted scoring (see #7 below for more details).
5. Can you provide an example of a question that has been adapted or reframed?
ASQ-3 Problem Solving item: Can your child drop a crumb or Cheerio into a small, clear bottle (such as a plastic soda-pop bottle or baby bottle)?
Barrier: Parent does not have a plastic bottle in their home.
Material adaptation: Child can drop the crumb or cheerio through a small opening shaped by their parent’s hand.
Barrier: Parent does not want their child to play with food. This is an important value in the parent’s religion.
Material Adaptation: Parent can use a pebble or small bead. Note: supervise carefully if using a non-food item.
See this handout with guidance on adapting ASQ-3 materials and items.
6. Can you provide examples of questions that have been skipped while working with a family?
- A mother does not want to answer a question in the Personal-Social area that asks about dressing/undressing skills. Her daughter was recently adopted and is very young. Her mother wants to be very involved in the dressing process to promote bonding.
- A family is uncomfortable allowing their son to play with dolls and stuffed animals. They do not want to answer the question in the Personal-Social area asking about this.
- A parent feeds their child with their hands and has not introduced a spoon yet. They do not want to have their child try this activity to answer the question “Does your child feed himself with a spoon, even though he may spill some food?”
7. How many items can you skip on a questionnaire and still be able to score it?
For ASQ-3 questionnaires, up to 2 items may be unanswered in each domain. An adjusted score needs to be calculated if unanswered items remain after reviewing with the parent.
For ASQ:SE-2 questionnaires, up to 3 items may be unanswered. Providers do not need to calculate an adjusted score if there are only one or two missing responses, as major results areas (typical, monitor, concern) will not change. However, if there are 3 items without responses, users should calculate an adjusted score.
The ASQ Calculator, available for free online or as an app, is an excellent resource for helping to calculate scores when there are unanswered items. ASQ recognizes the need for flexibility in administering screenings, and guidance for adjusting scores for questionnaires with unanswered items is provided in the ASQ-3 User’s Guide (see page 72) and ASQ:SE-2 User’s Guide (see page 92).
8. What can programs do if they are worried that family members will skip too many items and they won’t be able to score the questionnaires?
We recommend that providers connect and engage with families before presenting the questionnaire(s) to them. If trust is an issue, take time to establish the relationship. Learn more about any barriers the family may be experiencing (for example, materials, basic needs, literacy, stress, distrust, anxiety) and consider ways to support them in observing and sharing information about their child. Some families may benefit from completing a questionnaire with a provider who can adapt, reframe, clarify, and even model activities.
Also, incomplete questionnaires that are unable to be scored (or used for screening purposes) can still be used for conversational purposes. This can help strengthen parent–provider relationships and promote conversations regarding child development and activities parents might want to try at home.
Screening should not be required of families in any program. Families should have control over whether their child is screened or not, and what follow-up is appropriate. It is fine to use ASQ-3 and ASQ:SE-2 as conversational tools with hesitant families as a first step without the scoring piece. Over time, if the control is in a parent’s hands, if the relationship and trust are built, and if a concern arises, a parent may be willing to take next steps.
If programs are not sending ASQ questionnaires home because they are worried that family members will skip too many items, they are missing out on opportunities to open the door to conversations and exploration with parents. As long as parents have been provided with a good introduction to screening with ASQ and the provider has made themselves available to answer any questions or concerns, then sending home ASQ questionnaires may be seen as a desire to work together with the parent. If a parent does not complete and return the questionnaire, it can still be used as a joint reference in conversation about barriers or concerns a parent may have. Teachers and child care providers can also complete an ASQ-3 for a child, but we recommend waiting to mark a question as “Not yet” until they have had a chance to follow up with a parent and find out if the child might be able (or more inclined) to do an activity at home.
Whatever the reason for a parent or caregiver deciding to not answer to an ASQ questionnaire item, the information in this Q&A can help you turn it into an opportunity to increase family knowledge about screening, strengthen the school–home connection, and find new ways to support healthy development for children.