Elsevier

Early Human Development

Volume 87, Issue 10, October 2011, Pages 671-676
Early Human Development

Ages and stages questionnaires: Feasibility of postal surveys for child follow-up

https://doi.org/10.1016/j.earlhumdev.2011.05.007Get rights and content

Abstract

Background

The Ages and Stages Questionnaire (ASQ), completed by parents and caregivers, has been shown to be an accurate tool for screening children who need further developmental assessment.

Aims

To assess the feasibility of using the French Canadian translation of the ASQ in an epidemiological cohort of children from the French general population.

Study design

Follow-up study by postal questionnaire at 12 and 36 months, using the ASQ. Subjects: 339 French families recruited at the birth of their child in 2006 in two hospitals in the Paris suburbs.

Outcome measure

Response rates and French ASQ results at 12 and 36 months. The ASQ was scored as indicated in the manual.

Results

A high response rate of 79% was observed at the children's 1st and 3rd birthdays. Parents were enthusiastic about participating; half of them wrote comments on the questionnaires, most of them positive. Low scores at the 12-month assessment were associated with birth characteristics such as prematurity and transfer to the neonatology unit after birth, whereas at 36 months they tended to be associated with both birth and family socio-demographic characteristics.

Conclusions

Use of the French ASQ in a research cohort appears feasible as response rates were high. Moreover, known links between child development measured by ASQ and birth and social characteristics were observed. However, further French studies are needed to understand differences observed in 12-month ASQ gross motor scores compared with US norms. For research purposes, further analysis of the ASQ in innovative, quantitative approaches, is needed.

Introduction

Follow-up of large cohorts of children requires a reliable method of evaluating children's development at a low individual cost. It would indeed be too costly to have each child examined individually by a professional. One possibility is to question parents directly about their infant's behavior; however, no specific tool has been validated for child development monitoring in research cohorts. Various parent-completed questionnaires have been developed in the last twenty years to screen children who need further investigation by a medical professional. The Parents' Evaluation of Developmental Status (PEDS), the Child Development Inventories (CDI) and the Ages and Stages Questionnaires (ASQ) are described by the American Academy of Pediatrics as very good instruments with excellent psychometric properties [1]. Moreover, they are increasingly used by physicians in clinical practice for the screening of developmental delay [2], [3], [4], [5]. Thus, one possible way of monitoring child development in a large research cohort could be to use a parent-completed questionnaire [6].

The ASQ screening system was developed by the University of Oregon's Center on Human Development during the 1980s and 1990s in response to a growing need for early and accurate identification of children who have developmental delays or disorders[7]. The ASQ screening system has been validated in multiple languages, including French Canadian. This system was developed to be used originally in a mail-out format. The original ASQ screening system is composed of 19 questionnaires that span the age range of 4 months to 60 months (5 years) and are designed to be completed by parents or primary caregivers (1999 version); the newly revised 3rd edition consists of 21 questionnaires covering the 2–66 month age span (2009 version). Parents are asked to attempt every activity with their child, and to try again later if their child is noncompliant. Each questionnaire consists of 30 items that give equal cover to 5 areas: communication, gross motor, fine motor, problem solving and personal–social. For each developmental item, three responses are possible depending on how the child performs the behavior specified in the item: “yes” (10 points), “sometimes” (5 points) and “not yet” (0 points). For each area, the total score is obtained by adding the scores of the 6 items and cut-offs have been defined for each area (2 SD or less below the mean score). According to the ASQ manual, when the child does not pass at least one area (i.e. score under the cut-off), a consultation with a medical professional for further investigation is indicated. When the ASQ system is used in clinical practice, clinicians tend to refer for specialized consultation only those children who do not pass at least two areas [5]. This decreases the sensitivity of the ASQ screening but increases its specificity. Such an approach, with better balance between sensitivity and specificity, could be preferentially used when medical resources are scarce or when the objective is not clinical screening but research, as in the follow-up of large cohorts of children.

The psychometric properties of the ASQ have been studied by the authors [7] and by others in different countries [8], [9], [10], [11], [12]. In terms of reliability, internal consistency of correlations between area and overall score ranged from 0.70 to 0.83 for both the 12-month and the 36-month ASQ intervals. The percentage of agreement between two questionnaires completed by parents at a 2-week interval was used to assess test–retest reliability and was 94% (n = 175). Inter-observer reliability, measured as the percentage of agreement between results of the questionnaire completed by parents and results of those completed by two examiners, was 94% (n = 112). Questionnaire validity has been studied using various professionally administered standardized developmental tests such as the Revised Gesell and Amatruda Developmental and Neurological Examination and the Bayley Scales of Infant Development. For the 12 and 36-month ASQ, sensitivity ranged from 70% to 90% and specificity from 83% to 91% [7]. Other studies in general populations, as well as in at-risk populations, have confirmed good psychometric properties for the ASQ, with reported sensitivity that ranged from 67% to 100% and specificity from 76% to 100% [8], [9], [10], [11], [12].

The aim of our study was to assess the feasibility of using the French Canadian translation of the ASQ in an epidemiological cohort of children from the French general population [6]. Children were followed up at 12 and 36 months. We also aimed to explore the association of ASQ results with health characteristics at birth, and with socio-economic characteristics of parents.

Section snippets

Study population

Families were recruited at the child's birth, between January 1 and February 4, 2006, in two maternity hospitals in the suburbs of Paris, France [13]. The research protocol included recruitment of all women giving birth during this period. A follow-up study concerning children's activities was proposed to the 339 mothers who responded to the birth questionnaire, who accepted the follow-up and had a valid address. The study was approved by the French Data Protection Authority (CNIL;

Results

Participation figures in the two phases of the study are presented in Fig. 1. For the 1st and 3rd birthday assessments, 79% of mothers responded to the postal questionnaire (268/339 and 205/260). Among the questionnaires returned, 85% (12 months: 229/268) and 87% (36 months: 179/205) were usable. The main reason for exclusion of questionnaires was delay in response, leading the child to fall outside the “age window” for valid scoring (74%). Missing dates of questionnaire completion, meaning that

Discussion

Based on our results, using the ASQ as a means of assessing child development in an epidemiological cohort research study appears feasible. Response rates by parents at both ASQ intervals were high: 79% of parents answered the postal questionnaire. For both intervals, more than 96% of parents agreed to be contacted for a future step, and 98% wished to receive the overall results of the study. Parents' participation was high and parents were enthusiastic about participating in the study: half of

Conclusion

In conclusion, use of the ASQ for research purposes in a large child cohort study appeared a promising perspective, with very good parent involvement. The ASQ is probably a valid tool with which to explore factors associated with child development, as it exhibited known links between child development and both birth and social characteristics. However, further French studies of a larger number of children are needed to understand differences observed in 12-month ASQ gross motor scores compared

Conflict of interest statement

Except Jane Squires, who is one of the authors of the ASQ, no other authors have any conflict of interest.

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