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Bol Med Hosp Infant Mex 2017;74:5-12 - DOI: 10.1016/j.bmhimx.2016.07.008
Review article
Ages and Stages Questionnaire: a global screening scale
Ages and Stages Questionnaire: una escala de evaluación global
Ajay Singha,, , Chia Jung Yehb, Sheresa Boone Blanchardb
a College of Education and Technology, Eastern New Mexico University, Portales, New Mexico, USA
b Department of Human Development and Family Science, College of Health and Human Performance, East Carolina University, Greenville, North Carolina, USA
Recibido 28 febrero 2016, Aceptado 07 julio 2016
Abstract

With standardized screening tools, research studies have shown that developmental disabilities can be detected reliably and with validity in children as young as 4 months of age by using the instruments such as the Ages and Stages Questionnaire.

In this review, we will focus on one tool, the Ages and Stages Questionnaire, to illustrate the usefulness of developmental screening across the globe.

Resumen

Mediante el uso de herramientas de evaluación estandarizada, algunos estudios de investigación han demostrado que discapacidades de desarrollo se pueden detectar con fiabilidad y validez en niños desde los 4 meses de edad mediante el uso de los instrumentos estandarizados como el Ages and Stages Questionnaire (Cuestionario de las Edades y Etapas).

Para ilustrar la utilidad de la evaluación del desarrollo infantil a escala global, en este trabajo se revisará la herramienta Ages and Stages Questionnaire.

Keywords
Developmental assessment, Developmental screening, Early identification, Early intervention services, Ages and Stages Questionnaire (ASQ), Global screening scale
Palabras clave
Evaluación del desarrollo, Pruebas de desarrollo, Identificación temprana, Servicios de intervención temprana, Cuestionario de Edades y Etapas (ASQ), Tamiz a escala global
1Introduction

Early childhood is a critical period because the first five years of life are fundamentally important, and early experiences provide the base for brain development and functioning throughout life.1,2 Early intervention services can provide educational and therapeutic services to children who are at risk.2,3 Early identification of developmental disabilities is essential for timely remedial intervention and leads to early treatment and ultimately improved long-term outcomes.4–6 It has been estimated that only about half of the children with developmental problems are detected before they begin school.7–9Early intervention for children with developmental delay is crucial for enhancing their outcomes.10,11 To meet the needs of children during the most important phase of their growth, many countries have established programs and facilities designed to mitigate disabilities.12 Early intervention (EI) and early childhood special education (ECSE) serve a growing number of young children with developmental delays and their families.13–17 It has been shown that high-quality EI and ECSE improve children's developmental outcomes.18–20

2Developmental screening

Optimal development and early identification and detection of delays rely on developmental screening.19,21 To emphasize the importance of developmental screening in early childhood, the American Academy of Pediatrics (AAP) developmental screening policy has included the following strong statement: “Early identification of developmental disorders is critical to the well-being of children and their families.”22,23 Developmental screening can be thought of as a preliminary step in the identification of risk at school-age children.24 An effective screening tool should be inexpensive, simple, accurate, valid, reliable, culturally appropriate, easy, and quick to administer.25–27To be eligible for Individuals with Disabilities Education Act (IDEA) services, children must qualify in terms of impairment or delay. Approximately 10 to 20% of young children will experience delays28–30 with significantly higher rates among children who live in poverty.31,32 It has been estimated that only about half of the children with developmental problems are detected before they join the school.33–35 Developmental screening and developmental surveillance constitute ongoing processes of monitoring the status of a child by gathering information about his development from multiple sources, including skillful direct observation from parents/caregivers and relevant professionals.26,36,37 The AAP and the British Joint Working Party on Child Health Services recommend developmental surveillance as an effective means to identify children with developmental delay.38 Parents’ reports of current attainment of developmental tasks have been shown to be accurate and reliable.39,40 In keeping with recommendations from the American Pediatric Association (USA), National Screening Committee (NSC) UK: Child Health Sub-Group Report 1999 and Best Health for Children (Ireland) consideration should be given to the use of parental reports as a part of the process of assessment.

The AAP41 policy statement set forth screening algorithms and methods, including those that use standardized parent-completed tools, such as the Parental Evaluation of Developmental Status (PEDS),39,40 the Ages and Stages Questionnaire (ASQ),42 and the Child Development Inventories (CDI).43 These have the benefit of good psychometric properties (70-80% specificities and sensitivities), and require much less time than direct developmental assessment by a professional. A parent-completed screening questionnaire can decrease costs and increase accuracy, and parents can report successfully at regular intervals.19,44,45

Developmental screening identifies those who are in need of further evaluation for eligibility for specialized services.46–48 Eligibility assessment assists in identifying the nature of the delay and connecting children and families to appropriate services and supports. Several screening tests have been recommended for accurate ongoing developmental screening, including the PEDS, CDI, ASQ. The ASQ will be highlighted in the review as a preferred screening test that works well in a variety of screening settings.

3Ages and Stages Questionnaire

The Ages and Stages Questionnaire (ASQ) is a parent-completed questionnaire that may be used as a general developmental screening tool. The ASQ was designed and developed by J. Squires and D. Bricker42,49,50 at the University of Oregon and can be completed by parents in 12-18minutes. The ASQ-3 is a parent reported initial level developmental screening instrument consisting of 21 intervals, each with 30 items in five areas: (i) personal social, (ii) gross motor, (iii) fine motor, (iv) problem solving, and (v) communication for children from 2-66 months. In most cases, these questionnaires accurately identify young children who are in need of further evaluation to determine if they are eligible for early intervention services.42,50 The ASQ is cost-effective and widely used in the United States and other countries.51–53 The ASQ has been translated into several languages, such as Spanish, French, Dutch, Chinese, Norwegian, Hindi, Persian, and Turkish. Furthermore, the number of international studies on its psychometric properties with diverse cultural environments is increasing (e. g., Australia, Brazil, Canada, Chile, China, Denmark, Ecuador, France, Ghana, India, Iran, Korea, Lebanon, Netherland, Norway, Republic of Macedonia, Spain, Taiwan, Thailand, Turkey). It has excellent psychometric properties, test-retest reliability of 92%, sensitivity of 87.4% and specificity of 95.7%. Validity has been examined across different cultures and communities across the world.51–54 The ASQ-3 is designed to be an in-depth general screening instrument with a reading level from fourth to eighth grade and illustrations assist in providing a clear, user-friendly format. The ASQ is available in several languages, including Turkish, Norwegian, Dutch, Persian, Arabic, English, Hindi, French, Thai, Korean, Spanish, Chinese, and Vietnamese. Another advantage of the ASQ is its flexibility. Evidence has shown that the ASQ is very useful in a wide variety of settings: home, doctors’ office, head starts, early intervention units, preschools, early childhood, health clinics, and teen parenting programs. The ASQ can be completed by parents/caregivers independently or with the assistance of professionals or administered by a trained professional who is familiar with the child. Scores are normed to indicate whether children are developing in an age-appropriate manner.

Psychometric parameters of the ASQ have been examined based on completion of 18,000 respondents.42 Evidence shows that the ASQ is an accurate, cost-effective, parent-friendly instrument for screening and monitoring of preschool children. In addition, it is recommended for early detection of autism by the Joint Committee on Screening and Diagnosis of Autism as well as for general developmental follow-up and screening and developmental surveillance in office settings. Furthermore, research shows that the ASQ has been successfully used for follow-up and assessment of premature and at-risk infants and children in the public health,55,56 and follow-up of infants born after assisted reproductive technologies. The ASQ can also be used for teaching medical students in higher education and research about early intervention.57 In 2006, the ASQ was used for evaluating the developmental surveillance and screening algorithm by AAP (2001, 2006). Also, the ASQ was used to determine the prevalence of late language emergence and to investigate the predictive status of maternal, family, and child variables. Finally, the ASQ have been translated and used cross-culturally with success.51–54

4Comparison or agreement with other developmental instruments

The agreement between the ASQ and Developmental Assessment Scale for Indian Infants (DASII) was studied.58,59 The overall sensitivity of the ASQ in detecting delay was 83.3% (n=200) and specificity was 75.4% (n=200). All correlations were found to be acceptable (r 0.76-0.80). The sensitivity was higher in the high-risk group whereas specificity was higher in the low-risk group. There was a solid correlation between the domain scores of ASQ and DASII.42,58 Australian studies showed similar results while evaluating the ASQ in a medically at-risk for developmental delay population.60,61

The agreement between the ASQ and the Battelle Developmental Inventory, 2nd Edition (BDI-2) was also examined.62 The ASQ accurately identified and classified children as being eligible or those in need of further evaluation for eligibility status when the classification criterion was the BDI-2, with the ASQ accurately identifying over 90% of eligible children. Interobserver reliability was also strong, with most correlations over 0.70.63

The agreement between the ASQ and pediatrician estimates of development (i.e., Pediatric Developmental Impression (PDI)) was studied in 2007. Findings showed that the agreement between PDI and ASQ was 81.8%. The ASQ results indicated that 78.4% (n=548) were typically developed, while the PDI indicated that 89.4% (n=625) were typically developed.64

The agreement between the ASQ and the Bayley Scales of Infant Development II (BSID-II) was studied. The researchers calculated the sensitivity and specificity of the ASQ. They reported a sensitivity of 100% and a specificity of 87% for children of 24 months of age.65

5ASQ study samples

The ASQ has been used internationally in a variety of settings and contexts. The following tables summarize the overall results: research studies in the United Sates (Table 1);66–72 comparison of results from international research studies with those from the United States (Table 2);73–75 international research studies (Table 3);76–101 and some international research studies using the ASQ in different settings (Table 4).

Table 1.

ASQ studies in the United States, including original normative studies.

Country  Sample  Year  Age (months)  Keywords  References 
USA  224  1995a  4-48  Infant/Child Monitoring Questionnaires, children, ASQ, families from low-income backgrounds  Bricker et al.50 
USA  7,000  1997  4-48  Developmental screening, infants at risk, early identification, early intervention  Squires et al.49 
USA  96  1998  4-36  Early identification, parents, developmental screeners, developmental questionnaire  Squires et al.67 
USA  112  1999  4-60  Infants, child development, testing, development, diagnosis  Bricker et al.66 
USA  1,428  2007  12-24  Ages and Stages Questionnaire, developmental delay, developmental screening, developmental surveillance, early intervention, parent-completed screening  Hix-Small et al.64 
USA  18,000  2009  4-60  Family-friendly, developmental delay, developmental scanner, screen children  Squires et al.68 
USA  53  2010  24  Child development, developmental screening, diagnostic tests, sensitivity, and specificity  Gollenberg et al.65 
USA  1,363  2009  12-24  Ages & Stages Questionnaire, developmental delay, developmental screening, developmental surveillance, early intervention  Marks et al.69 
USA  798  2012  9-30  Culturally sensitive assessments, families, young children, Spanish ASQ-3  Pomes70 
USA  2,103  2013  < 30  Child development, primary care, randomized controlled trial, screening, urban  Guevara et al.71 
USA  26  2013  4-48  Developmental screening, developmental delay, neurocognitive delay, Ages and Stages Questionnaires-3® (ASQ-3)  Quigg et al.72 
a

Formerly called the Infant/Child Monitoring Questionnaires (series of 11 questionnaires designed to be completed by parents at 4, 5, 8, 12, 16, 18, 20, 24, 30, 36, 48 months; each questionnaire contains 30 items).

Table 2.

ASQ International research results compared with those in the United States.

Country  Sample  Year  Age (months)  References 
USA and Canada  67  2009  2.5-12.5  Westcott et al.73 
USA and Norway  1,341  2004  4-60  Janson and Squires74 
USA, Norway, Spain (Galicia), Korea, Iran  34-1,380  2013  4-60  Vameghi et al.51 
Guatemala, Pakistan, Democratic Republic of Congo, Zambia  1,050  2011  3-4  Krebs et al.75 
Table 3.

International ASQ research studies.

Country  Sample  Year  Age (months)  References 
Australia  167  2001  12-48  Skellern et al.61 
Australia  55  2008  12-14  Lindsay et al.60 
Brazil  45,640  2013  6-60  Filgueiras et al.76 
Canada  317  2006  18  Rydz et al.77,78 
Canada  236  2012  12-24  Simard et al.79 
Chile  306  2013  8-30  Schonhaut et al.80 
China  269  2010  3-31  Yao et al.81 
China  519  2012  3-66  Bian et al.5 
Denmark  230  2006  26-27 weeks  Plomgaard et al.82 
Denmark  298  2012  9-21  Østergaard et al.83 
Ecuador  283  2007  3-61  Handal et al.84,85 
France  703  2011  24  Flamant et al.86 
France  339  2011  12, 36  Troude et al.87 
Ghana  330  2013  3-5  Bello et al.88 
India  200  2012  4-24  Juneja et al.58 
India  422  2013  12-36  Kvestad et al.89 
India*  100  2014  4-24  Gulati et al. 
Iran  100  2013  4-60  Vameghi et al.51 
Japan  240  2013  2-69  Hashimoto et al.90 
Korea  3,220  2008  4-60  Heo et al.53 
Korea  129  2010  8-39  Kim and Kim91 
Korea  226  2011  4-60  Ga and Kwon92 
Lebanon  733  2013  4-60  Charafeddine et al.93 
Mexico  2,843  2012  14-59  Angeles et al.94 
Netherlands  927  2011  32-49  Kerstjens et al.95 
New Zealand  1,848  2010  > 48  Wills et al.96 
Norway  2,392  2003  4-60  Janson97 
Republic of Macedonia*  100  2014  4-24  Vladimir et al. 
South Africa  65  2011  Silva98 
Spain  222  2008  24  Eixarch et al.99 
Spain  615  2011  4-42  Sarmiento-Compos et al.52 
Taiwan  112  2006  36  Tsai et al.100 
Thailand  267  2009  24-36  Saihong54 
Turkey  978  2010  3-72  Kapci et al.101 
UK  2,046  2007  12-60  Yu et al.56 
*

Ongoing research.

Table 4.

Comparative results of ASQ at different ages among samples from different countries.

ASQ (months)SampleNCommunication  Gross motor  Fine motor  Problem solving  Social-personal 
Mean (SD)  Mean (SD)  Mean (SD)  Mean (SD)  Mean (SD) 
24-35  Ecuador  52  41.2(13.5)  39.9(10.7)  38.6(14.9)  38.8(12.4)  42.7(12.6) 
24  USA  820  50(11)  54(9)  53(8)  51(10)  52(8) 
24  Norway  128  53(10)  56(6)  53(8)  50(9)  51(8) 
24  Spain  56  44(17)  50(12)  53(11)  48  48(10) 
24  Thailand  55  51.27(11.23)  50.18(10.05)  39.73(11.80)  41.55(14.56)  47.82 (10.17) 
24  Korea  144  48.9  55.3  48.3  48.8  48.5 
24  Iran  554  53.9  52.4  47.4  50.4  51 
30  USA  562  56(9)  51(10)  50(12)  51  53(8) 
30  Norway  134  57(7)  56(6)  50(13)  52  53(7) 
30  Spain  86  54(10)  53(8)  53(11)  49  51(8) 
30  Thailand  102  53.77(9.02)  51.52(9.69)  43.28(12.38)  46.67(13.97)  50.25(9.50) 
30  Korea  223  53.2  53.4  49.5  51.1  49.8 
30  Iran  498  55.3  53.2  47.9  53.7  52.3 
36  USA  512  54(8)  55(10)  52(11)  55  53(7) 
36  Norway  126  54(7)  56(7)  52(10)  54  53(8) 
36  Spain  70  54(9)  52(11)  54(9)  48  51(9) 
36  Thailand  110  53.41(9.62)  52.60(11.71)  47.14(13.35)  52.09(9.12)  51.50(7.15) 
36-47  Ecuador  44  37.6(12.7)  46.6(11.3)  45.9(11.9)  37.3(10.4)  39.6(11.6) 
36  Korea  226  54.8  55.2  53.3  53.2  50.1 
36  Iran  548  54.9  53  49.1  53.7  49.6 
36  Taiwan  96  53.6(11.6)  52.8(11.4)  46.7(15.8)  49.8(13.1)  52.6(9.7) 
6Cross-cultural adaptation, validation, and standardization of the ASQ

Results from the ASQ studies in North America (USA), South America (Ecuador), Europe (Norway, Spain), and Asia (Korea, Taiwan) are summarized for selected groups of age. ASQ study results including children's mean scores and standard deviation are included for studies conducted in Ecuador, USA, Norway, Spain, Thailand, Korea, Taiwan, and Iran (Table 3).51–54,74,84,85,100

These samples followed a distribution pattern and very closely resembled the North American, South American, Asian, and European profiles. These results suggest that the ASQ performance did not diverge significantly from performance data collected in any other studies.

To demonstrate the usefulness of developmental screening across the globe, the authors of this paper have reviewed the ASQ as one example of a recommended tool that has a worldwide use for the goal of early detection and identifying developmental disabilities. It is important to promote early detection efforts using a valid and reliable global screening scale to control the healthy children population < 5 years of age. These studies reflect that the ASQ is very useful for early identification of the at-risk population and used to improve the early identification of young children and improve outcomes before disabilities become more established.12,26,27,102 Within only a few years, the ASQ has become widespread and increasingly used worldwide as a parent-completed questionnaire, a global screening scale. International studies yielded standardized parent-completed scores that were effective and comparative across languages and cultures. The ASQ has shown to be reliable and cost-effective as well as correlate well with pediatricians’ and service providers’ assessment.102 International interest has been building based on demonstrated benefits of the ASQ. Since some of the research studies reported here are ongoing, a number of additional international publications concerning the ASQ can be expected in the near future. Collaboration across the world will further enhance the utility of the ASQ because the establishment of norms from datasets with specified characteristics allows for cross-country comparisons of developmental outcomes in diverse cultures.

Conflict of interest

The authors declare no conflicts of interest of any nature.

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