Ages and Stages
Questionnaires
A Tool for Developmental Screening
Developmental Screening
of young children in NH
• Ardis Olson MD
• Professor of Pediatrics, Geisel School of Medicine
• Medical Director of NH Pediatric Improvement
Partnerships (NH PIP)
• Research Director The Dartmouth CO-OP primary
care research network
• May 29, 2015
• Annual Meeting of NH AAFP, Whitfield NH
Approaches to
Development
• Developmental Survellience
o Informal observation at every visit of major topics of development:
communication, fine and gross motor and social interation
• Developmental Screening
o Using Structured validated measures at regular intervals with linkage to
community resources
ASQ System – What is it?
• Parent completed screening tool
• Series of questionnaires for age 4 – 60
months
• Monitors developmental progress (ASQ) and
social emotional development (ASQ:SE)
• Identifies children in need of further
assessment
o ASQ ( Developmental Concerns)
o ASQ:SE (Social Emotional Concerns)
• Encourages parent involvement
ASQ System:
2 Components
• ASQ
o Areas screened: communication, gross motor,
fine motor, problem solving and personal-social
o We will use at : 9, 18 and 36 months (consistent
with AAP recommendations-more later)
• ASQ:SE
o Social Emotional Development: self- regulation,
compliance, communication, adaptive
functioning, autonomy, affect and interaction
with people
The ASQ is:
• Recommended by the experts
• Accurate - Rigorous research with more than 12,000
children shows that ASQ is reliable and valid with
high levels of sensitivity and specificity, the two most
important indicators of accuracy for a screener.
• Color-coded by age - Written at a 4th–6th-grade
reading level, and accompanied by simple
illustrations to enhance understanding.
• Available in English or Spanish
.
The ASQ is:
• Includes photocopiable activity sheets - Designed
to help parents encourage their children's
development and make it easier to educate
parents.
• Can be reproduced - As many times as needed by
a single site.
• Includes clear instructions - In the User's Guides,
which address special situations such as how to
score questionnaires with unanswered items and
what to do when a child's age falls between the
given age intervals.
The ASQ is:
• Helps educate parents - Because ASQ
questionnaires are completed by the caregivers
who know the child best, they get the most
accurate results and save time. Parents become an
integral part of the screening process and ASQ
helps teach parents about child development and
their own child's skills.
• Strengths based - ASQ questionnaires reveal a
child's strengths as well as areas of concern, so it's
easier to develop a rapport with parents and share
results.
The ASQ is:
• Easy for Parents - Parents can complete ASQ
questionnaires at home, in a waiting room, during a
home visit, or as part of an in-person or phone
interview.
• Includes clear instructions - In the User's Guide,
which addresses special situations such as how to
score questionnaires with unanswered items and
what to do when a child's age falls between the
given age intervals.
• Efficient - Takes just 2–3 minutes to score
Usefulness of ASQ
• Concurrent validity : 76%- 91% when compared
to standardized assessment
• Sensitivity: (ability to correctly identify those
children with delays) – 72%
• Specificity: (ability to correctly identify typically
developing children) - 86%
• AAP considers 70-80% ‘high quality’ for
developmental screening tools
Usefulness of ASQ: SE
• Concurrent validity ; 81-93% when compared with
assessment measures
• Sensitivity : 71-85% (avg – 78%)
• Specificity : 90-98% (95%)
Ages & Stages-3
• Test-retest reliability: 90%
• Can still score if 1 or 2 items per domain are missing
(prorate)
• Need materials to allow parent to try items when
they “don’t know” (see list in toolkit)
• Grey areas now on score sheet accommodate
“watchful waiting”
Using the ASQ
• Parent answers : ‘yes’ (10 points), ‘sometimes’(5
points) or ‘not yet’ (0 points)
• Add up scores in each developmental area and
transfer to score sheet – 2-3”
Ages and Stages
Questionnaire (ASQ-3)
4 months to 6 years
•19 color-coded questionnaire for use at 4, 6, 8, 9,
10, 12, 14, 16, 18, 20, 22, 24, 27, 30, 33, 36, 42, 48, 54,
and 60 months
•30 – 35 items per form describing skills
•Completed by parent report
•Taps most domains of development
•Takes about 10-15 minutes, and 3 to score
•ASQ-Social-Emotional works similarly and measures
behavior, temperament, etc.
•Can be photocopied, in Spanish
Interpreting the ASQ
• Scores beneath the cutoff points (darkened
portion) indicate need for further assessment
• Scores at the cutoff point indicate need for further
discussion and monitoring (we will discuss tis more
later)
• Scores above the cutoff point suggest child is on
track developmentally
Information sheet for
parents
•
What is the Ages & Stages Questionnaire?
•
As our child grows, it is important that your doctor understands what kinds of things he or she can do.
The Ages & Stages Questionnaire asks some questions about what your child is doing now based on his
or her age. When you finish filling it out, your doctor will read your answers and talk to you about your
child’s growth and development.
•
Please read each question(s) and answer them using these definitions:
•
Most of the time - If your child does the activity regularly, or if he used to-do it but has outgrown it, or if
he can do it but refuses to.
•
Sometimes -
•
Rarely or Never - If your child has not started to do this activity yet.
•
IMPORTANT: If you are not sure if your child can do something, discuss with your doctor and we will help
you try it in the exam room to answer.
If you child is just beginning to do the activity.
Information sheet for
parents
•
Questions to ask your doctor about:
•
Communication skills: Your child’s ability to talk and understand what you
say to him or her.
•
Gross Motor skills: How your child moves around, like crawling, walking,
climbing.
•
Fine Motor skills: How your child uses his or her hands for picking up things and
drawing.
•
Problem Solving skills: How your child plays with toys and figures things out.
•
Personal-Social skills: What your child does when eating, dressing, playing
with other children.
“Toy Box”
•
•
•
•
•
•
•
•
Baby bottle (clear)
Ball: large
Ball: small
Beads: small, to string
(10 included)
Book: wordless picture
book
Book: storybook with
pictures
Blocks: small (15 )
Bowl
• Shoelace (may be
used for "string")
• Spoon (child size) (may
be used for "stick")
• Stuffed doll or animal
with buttons and zipper
(may be used for "doll")
• Toy: keys on a ring
(may be used for "small
toy" or "rattle")
• Toy: small, easy to
grasp
“Toy Box”
• Coloring book (with
tear-out pages)
• Crayons: two sizes (one
4-pack of small; one 3pack of chunky)
• Cup
• Fork (child size)
• Scissors (child-safe)
• Jars: clear plastic with
screw lid, one short and
one tall (short one may
be used for "jar with
screw lid" or "wind-up
toy"; tall one may be
used for "clear bottle" if
baby bottle is not used)
• Mirror
• Puzzle (5-7 pieces,
interlocking)
Case Example - ASQ
• Jenny - 9 months old
• As you review the questionnaire compare to
eliciting parents concerns without benefit of the
screening questionnaire)
Jenny --• You review the ASQ 9 month questionnaire Mom
has just completed, scoring it as you go
• You see that Jenny scores in the concerning range
for her motor development
• You say to Mom, “ Thank you for completing the
questionnaire about Jenny. As I review it, I see that
you might be concerned about Jenny’s motor
development?
• Mom responds, “Well, I’m not sure. Her older sister
was slow walking. She doesn’t like to be on her
tummy and seems content sitting – although I still
need to put pillow behind her because she
sometimes still falls over. I am a bit concerned
because she doesn’t seem to be taking to baby
foods very well.”
Jenny • Your observation and exam reveal a
content baby who sits with a rounded back
• She reaches for the reflex hammer and
brings it to her mouth; when you try to hand
her a rattle instead, she drops the hammer.
• She leans on you when you put her in
standing. You think maybe her tone is a bit
low. Her exam is otherwise unremarkable.
• She turns to her Mom when she calls,
“Jenny, look at Mommy.” She is very quiet.
Experience Implementing
ASQ
• Devito and colleagues at Concord
o ASQ done only at age 18 months. Change visit to developmental focus
where clinician does the ASQ with the Parent. Uses it aw a teaching
opporuntity for teaching about development.
o Physical exam is optional
o Quality Improvement Process to implement
• Family Medicine at Keene Hitchcock is
implementing as part of q Quality Improvement
learning collaboration with other Pediatric Practices
Challenges
• Whether to allow time in office for completion or
mailed home
• Staff routines to have screening tools available
o More challenging with fewer children seen in family medicine site
• Setting up EHR reporting to be able to download
from record completion and pass/fail rates
o Allows ongoing tracking of data
Alternative Approach
• Other screening tools
• PEDS
• SWYC
Next Steps to Consider
Commitment of Champion
and Staff
Select Screening tool
Establish methods of tracking outcomes