The ASQ 54 Month Questionnaire is a comprehensive screening tool designed to help parents, guardians, and educators assess the developmental progress of children aged 51 months 0 days through 56 months 30 days. It evaluates a wide range of developmental milestones across various domains, such as communication, gross and fine motor skills, problem-solving abilities, and personal-social development. Encouraging active participation and meaningful interaction, this questionnaire offers a unique opportunity to observe and support children's growth and learning journey.
Filling out this form provides crucial insights into a child's developmental stages, enabling timely interventions if necessary. Click this button to start the questionnaire.
The Ages & Stages Questionnaires® 54 Month (ASQ-54) form encompasses a broad spectrum of developmental screening designed for children between 51 and 56 months (approximately 4 to 4.5 years old). This comprehensive tool solicits caregiver input across multiple domains of a child's development, including communication, fine and gross motor skills, problem-solving, and personal-social abilities. By inviting observations and specific activities to gauge the child's capabilities, the ASQ-54 seeks not only to track developmental milestones but also to foster a collaborative environment between caregivers and professionals in identifying potential developmental issues early. The questionnaire emphasizes interaction, recommending that each activity be tried with the child to create an engaging, fun, and informative experience. Details such as the child’s name, date of birth, and the individual completing the form underline its personalized approach. Additionally, the inclusion of sections for comments and concerns, such as hearing abilities, demonstrates a holistic view of the child's wellbeing. The ASQ-54 form is a critical component in early childhood development screening, serving both as a diagnostic tool and a bridge to further assessment or intervention if necessary.
Ages & Stages
Questionnaires®
54 51 months 0 days through 56 months 30 days
Month Questionnaire
Please provide the following information. Use black or blue ink only and print legibly when completing this form.
Date ASQ completed:
Child’s information
Middle
Child’s first name:
initial:
Child’s last name:
Child’s gender:
Male
Female
Child’s date of birth:
Person filling out questionnaire
Last name:
First name:
Relationship to child:
Parent
Guardian
Teacher
Child care
provider
Street address:
Grandparent
Foster
Other:
or other
parent
relative
State/
ZIP/
City:
Province:
Postal code:
Home
Other
telephone
Country:
number:
E-mail address:
Names of people assisting in questionnaire completion:
Program Information
Child ID #:
Program ID #:
Program name:
P101540100
Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.
54 Month Questionnaire
51 months 0 days
through 56 months 30 days
On the following pages are questions about activities children may do. Your child may have already done some of the activities described here, and there may be some your child has not begun doing yet. For each item, please fill in the circle that indicates whether your child is doing the activity regularly, sometimes, or not yet.
Important Points to Remember:
✓
❑ Try each activity with your child before marking a response.
❑ Make completing this questionnaire a game that is fun for you and your child.
❑ Make sure your child is rested and fed.
❑ Please return this questionnaire by _______________.
Notes:
____________________________________________
COMMUNICATION
YES
SOMETIMES
NOT YET
1. Does your child tell you at least two things about common objects? For example, if you say to your child, ÒTell me about your ball,Ó does she say something like, ÒItÕs round. I throw it. ItÕs bigÓ?
2. Does your child use all of the words in a sentence (for example, Òa,Ó Òthe,Ó Òam,Ó Òis,Ó and ÒareÓ) to make complete sentences, such as ÒI am going to the park,Ó ÒIs there a toy to play with?Ó or ÒAre you com- ing, too?Ó
3. Does your child use endings of words, such as Ò-s,Ó Ò-ed,Ó and Ò-ingÓ? For example, does your child say things like, ÒI see two cats,Ó ÒI am playing,Ó or ÒI kicked the ballÓ?
4. Without giving your child help by pointing or repeating directions, does he follow three directions that are unrelated to one another? Give all three directions before your child starts. For example, you may ask your child, ÒClap your hands, walk to the door, and sit down,Ó or ÒGive me the pen, open the book, and stand up.Ó
5. Does your child use four- and five-word sentences? For example, does your child say, ÒI want the carÓ? Please write an example:
6. When talking about something that already happened, does your child use words that end in Ò-ed,Ó such as Òwalked,Ó Òjumped,Ó or ÒplayedÓ? Ask your child questions, such as ÒHow did you get to the store?Ó (ÒWe walked.Ó) ÒWhat did you do at your friendÕs house?Ó (ÒWe played.Ó)
Please write an example:
COMMUNICATION TOTAL
page 2 of 7
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Ages & Stages Questionnaires¨, Third Edition (ASQ-3ª), Squires & Bricker
54 Month Questionnaire page 3 of 7
GROSS MOTOR
1. Does your child hop up and down on either the right foot or the left foot at least one time without losing her balance or falling?
2. While standing, does your child throw a ball OVERHAND in the direction of a person standing at least 6 feet away? To throw overhand, your child must raise his arm to shoulder height and throw the ball forward. (Dropping the ball or throwing the ball underhand should be scored as “not yet.”)
3. Does your child jump forward a distance of 20 inches from a standing position, starting with her feet together?
4. Does your child catch a large ball with both hands? (You should stand about 5 feet away and give your child two or three tries before you mark the answer.)
5. Without holding onto anything, does your child stand on one foot for at least 5 seconds without losing her balance and putting her foot down? (You may give your child two or three tries before you mark the answer.)
6. Does your child walk on his tiptoes for 15 feet (about the length of a large car)? (You may show him how to do this.)
GROSS MOTOR TOTAL
FINE MOTOR
1.Using the shapes below to look at, does your child copy at least three shapes onto a large piece of paper using a pencil, crayon, or pen, with- out tracing? (Your child’s drawings should look similar to the design of the shapes below, but they may be different in size.)
2.Does your child unbutton one or more buttons? Your child may use his own clothing or a doll’s clothing.
3.Does your child color mostly within the lines in a coloring book or within the lines of a 2-inch circle that you draw? (Your child should not go more than 1⁄4 inch outside the lines on most of the picture.)
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54 Month Questionnaire page 4 of 7
FINE MOTOR (continued)
SOMETIMESNOT YET
4. Ask your child to trace on the line below with a pencil. Does your child trace on the line without going off the line more than two times? (Mark “sometimes” if your child goes off the line three times.)
5. Ask your child to draw a picture of a person on a blank sheet of paper. You may ask your child, “Draw a picture of a girl or a boy.” If your child draws a person with head, body, arms, AND legs, mark “yes.” If your child draws a person with only three parts (head, body, arms, or legs), mark “sometimes.” If your child draws a person with two or fewer parts (head, body, arms, or legs), mark “not yet.” Be sure to include the sheet of paper with your child’s drawing with this questionnaire.
6. Draw a line across a piece of paper. Using child-safe scissors, does your child cut the paper in half on a more or less straight line, making the blades go up and down? (Carefully watch your child’s use of scissors for safety reasons.)
FINE MOTOR TOTAL
PROBLEM SOLVING
1. When shown objects and asked, “What color is this?” does your child name five different colors, like red, blue, yellow, orange, black, white, or pink? (Mark “yes” only if your child answers the question correctly using five colors.)
2. Does your child dress up and “play-act,” pretending to be someone or something else? For example, your child may dress up in different clothes and pretend to be a mommy, daddy, brother, sister, or an imag- inary animal or figure.
3. If you place five objects in front of your child, can she count them by saying, “One, two, three, four, five” in order? (Ask this question WITHOUT providing help by pointing, gesturing, or naming.)
4. When asked, “Which circle is smallest?” does your child point to the smallest circle? (Ask this question WITHOUT providing help by pointing, gesturing, or looking at the smallest circle.)
5. Does your child count up to 15 without making mistakes? If so, mark “yes.” If your child counts to 12 without making mistakes, mark “some- times.”
E101540400
54 Month Questionnaire page 5 of 7
(continued)
6. Does your child know the names of numbers? (Mark “yes” if he identi-
fies the three numbers below. Mark “sometimes” if he identifies two
numbers.)
3
1
2
PROBLEM SOLVING TOTAL
PERSONAL-SOCIAL
1. Does your child wash her hands using soap and water and dry off with a towel without help?
2. Does your child tell you the names of two or more playmates, not in- cluding brothers and sisters? (Ask this question without providing help by suggesting names of playmates or friends.)
3. Does your child brush his teeth by putting toothpaste on the tooth- brush and brushing all of his teeth without help? (You may still need to
check and rebrush your child’s teeth.)
4. Does your child serve herself, taking food from one container to an- other, using utensils? (For example, does your child use a large spoon to scoop applesauce from a jar into a bowl?)
5. Does your child tell you at least four of the following? Please mark the items your child knows.
a. First name
d. Last name
b. Age
e. Boy or girl
c. City he lives in
f. Telephone number
6. Does your child dress and undress herself, including buttoning medium-size buttons and zipping front zippers?
PERSONAL-SOCIAL TOTAL
OVERALL
Parents and providers may use the space below for additional comments.
1. Do you think your child hears well? If no, explain:
NO
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54 Month Questionnaire page 6 of 7
OVERALL (continued)
2. Do you think your child talks like other children her age? If no, explain:
3. Can you understand most of what your child says? If no, explain:
4. Can other people understand most of what your child says? If no, explain:
5. Do you think your child walks, runs, and climbs like other children his age?
If no, explain:
6. Does either parent have a family history of childhood deafness or hearing
impairment? If yes, explain:
7. Do you have any concerns about your child’s vision? If yes, explain:
E101540600
54 Month Questionnaire page 7 of 7
8. Has your child had any medical problems in the last several months? If yes, explain:
9. Do you have any concerns about your child’s behavior? If yes, explain:
10. Does anything about your child worry you? If yes, explain:
E101540700
54 Month ASQ-3 Information Summary
51 months 0 days through
56 months 30 days
Child’s name: ________________________________________________________
Date ASQ completed: __________________________________________
Child’s ID #: ______________________________________________________
Date of birth: ______________________________________________
Administering program/provider:
1.SCORE AND TRANSFER TOTALS TO CHART BELOW: See ASQ-3 User’s Guide for details, including how to adjust scores if item responses are missing. Score each item (YES = 10, SOMETIMES = 5, NOT YET = 0). Add item scores, and record each area total. In the chart below, transfer the total scores, and fill in the circles corresponding with the total scores.
Total
0
5
10
15
20
25
30
35
40
45
50
55
60
Area
Cutoff Score
Communication
31.85
Gross Motor
35.18
Fine Motor
17.32
Problem Solving
28.12
Personal-Social
32.33
2.TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See ASQ-3 User’s Guide, Chapter 6.
1.
Hears well?
Yes
6.
Family history of hearing impairment?
No
Comments:
2.
Talks like other children his age?
7.
Concerns about vision?
3.
Understand most of what your child says?
8.
Any medical problems?
4.
Others understand most of what your child says?
9.
Concerns about behavior?
5.
Walks, runs, and climbs like other children?
10.
Other concerns?
3.ASQ SCORE INTERPRETATION AND RECOMMENDATION FOR FOLLOW-UP: You must consider total area scores, overall responses, and other considerations, such as opportunities to practice skills, to determine appropriate follow-up.
If the child’s total score is in the If the child’s total score is in the If the child’s total score is in the
area, it is above the cutoff, and the child’s development appears to be on schedule.
area, it is close to the cutoff. Provide learning activities and monitor.
area, it is below the cutoff. Further assessment with a professional may be needed.
4. FOLLOW-UP ACTION TAKEN: Check all that apply.
______
Provide activities and rescreen in _____ months.
Share results with primary health care provider.
Refer for (circle all that apply) hearing, vision, and/or behavioral screening.
Refer to primary health care provider or other community agency (specify
reason): __________________________________________________________.
Refer to early intervention/early childhood special education.
No further action taken at this time
Other (specify): ____________________________________________________
5.OPTIONAL: Transfer item responses (Y = YES, S = SOMETIMES, N = NOT YET, X = response missing).
4
6
P101540800
Filling out the Ages & Stages Questionnaires® 54 Month Questionnaire is an important step in assessing the developmental progress of children between 51 months 0 days and 56 months 30 days old. This document is designed to capture a snapshot of a child's abilities across various domains including communication, gross motor, fine motor, problem-solving, and personal-social skills. Given the comprehensive nature of this questionnaire, it's imperative to approach this task with a clear focus, ensuring that all instructions are followed meticulously to obtain accurate and meaningful results.
After filling out the Ages & Stages Questionnaires® 54 Month Questionnaire, you have taken a significant step toward understanding and supporting the developmental milestones of the evaluated child. It is part of a broader approach to recognizing children's individual growth patterns and identifying areas where they may need additional support or intervention. The information gleaned from this questionnaire can be invaluable for facilitating discussions between parents, educators, and health professionals to ensure that children receive the guidance and resources they need during their developmental journey.
What is the ASQ 54 Month Questionnaire?
The ASQ (Ages & Stages Questionnaires®) 54 Month Questionnaire is a developmental screening tool designed for children aged 51 months 0 days through 56 months 30 days. It assesses a child's communication, gross motor, fine motor, problem solving, and personal-social skills. Parents, guardians, or educators complete the questionnaire, observing and interacting with the child to answer questions related to their abilities in various developmental areas.
Who should fill out the ASQ 54 Month Questionnaire?
The questionnaire should be completed by the child's parent, guardian, teacher, childcare provider, grandparent, foster parent, or another relative. The person completing the form should have regular interaction with the child and be familiar with their daily activities and abilities.
How should the questionnaire be completed?
Use black or blue ink and print legibly when completing the form. It's important to try each activity with your child before marking a response. The process should be engaging and fun for both you and your child, ensuring they are rested and fed before starting. Complete the questionnaire based on your child's regular abilities, not their best or worst performance.
What if my child has not started doing an activity listed in the questionnaire?
It is common for children to develop at their own pace, and there may be some activities your child has not begun doing yet. For each item, fill in the circle that best represents whether your child is doing the activity regularly, sometimes, or not yet, based on their current abilities.
Can I help my child with the activities described in the questionnaire?
While it is important to engage with your child while completing the questionnaire, try to limit assistance to encourage their natural abilities. The goal is to observe what your child can do independently, rather than what they can do with help.
What happens after I complete the questionnaire?
After completing the questionnaire, return it to the requesting organization by the specified date. The results will be reviewed to understand your child’s developmental progress and identify any areas where support may be needed.
Is there a scoring guide available for interpreting the results?
The ASQ 54 Month Questionnaire comes with a scoring guide that helps interpret the results. This guide provides a framework for assessing a child's development in specific areas. However, the scores are typically reviewed and interpreted by a child development professional. If you have concerns or questions about your child’s development based on the questionnaire, discuss them with your pediatrician or a child development specialist.
Filling out the Ages & Stages Questionnaires® for the 54-month mark is an important task that helps track a child's development. However, several common mistakes can occur during this process. One of the first errors is not using black or blue ink as specified in the instructions. This requirement ensures that the form is legible and that responses are clear and easy to interpret.
Another mistake involves not printing legibly. While this seems straightforward, rushed handwriting can lead to misinterpretation of answers. Given that these questionnaires play a critical role in assessing a child's development stages, clarity is paramount. Failing to print legibly can result in inaccurate assessments or the need for clarification, which could delay processing.
Not trying each activity with the child before marking a response is also a common oversight. The questionnaire specifically instructs caregivers to engage with the child in each activity to accurately gauge the child's abilities. Skipping this step could lead to under or overestimating the child's developmental progress, as some children might not perform certain actions regularly but are capable when prompted.
Many also neglect the advice to make completing the questionnaire a fun game. This approach is vital in encouraging the child’s cooperation and getting a true measure of their abilities in a stress-free environment. When treated as a tedious task, children may not participate willingly, which affects the authenticity of the recorded responses.
Ignoring the instruction to ensure the child is rested and fed before attempting the questionnaire is another mistake. A child who is tired or hungry may not perform to their actual capability, skewing the results negatively.
A significant error is not including examples of the child's work when prompted. For instance, when asked to draw a person or trace a line, these physical pieces of evidence are crucial for evaluators to accurately assess fine motor and cognitive skills. Omitting these examples can result in incomplete information for assessment.
Finally, not returning the questionnaire by the specified deadline can delay the entire evaluation process. Timeliness is crucial in developmental assessments to ensure any needed interventions or supports can be provided as early as possible. Procrastination or overlooking the deadline negates the efforts invested in accurately completing the questionnaire.
When using the Ages & Stages Questionnaires® 54 Month (ASQ-54) form to track child development, understanding and maintaining other necessary forms and documents complements the assessment process. These documents provide a thorough context for the child's development, health, and environment, ensuring a comprehensive approach to their care and education. Here are nine imperative documents often used alongside the ASQ-54 Month Questionnaire:
To support a child’s development effectively, these documents should be kept updated and readily accessible by parents, guardians, and relevant professionals. Using the ASQ-54 Questionnaire, alongside these supportive documents, ensures a well-rounded approach to monitoring and facilitating a child's growth and development. By maintaining these forms and records, caregivers and educators can provide targeted support, meet regulatory and health requirements, and foster an environment conducive to the child’s well-being and learning.
The Denver Developmental Screening Test (DDST) shares commonalities with the Ages & Stages Questionnaires® 54 Month Questionnaire, particularly in its focus on assessing the developmental milestones of young children. Both tools are designed to monitor and track the progression of children's skills in various domains, including fine motor, gross motor, language, social, and problem-solving abilities. While the ASQ specifically targets children from 51 months 0 days through 56 months 30 days, the DDST spans a broader age range, allowing for developmental screening from infancy through school-age. Despite this difference in age focus, both instruments serve similar purposes in early childhood development screening, emphasizing the importance of identifying potential delays or issues early in a child's life.
The Child Development Review (CDR) questionnaire operates in a vein similar to the Ages & Stages Questionnaires® 54 Month Questionnaire, with both being parent-completed tools intended to glean insights into a child’s developmental milestones. The CDR, like the ASQ, is structured to gather detailed information from parents or caregivers about a child's communication, gross motor, fine motor, problem-solving, and personal-social skills. The primary objective of these forms is to screen for developmental delays and foster early intervention. Although they share a foundational goal, the CDR encompasses a wider age range and focuses additionally on behavioral aspects of development, thereby providing a more comprehensive view of a child's overall well-being.
The Parents' Evaluation of Developmental Status (PEDS) is another developmental screening tool that aligns with the objectives of the Ages & Stages Questionnaires® 54 Month Questionnaire. Both tools solicit caregiver insights regarding their child's developmental milestones and behavioral issues, aiming to identify early signs of developmental delay. While the ASQ is more detailed, focusing on specific age-related tasks divided into different developmental areas, PEDS seeks to capture parents' concerns in a broader, open-ended format. This approach allows for a wide array of developmental and behavioral concerns to be expressed, emphasizing the utility of parental observations in the early detection of potential developmental challenges.
The Early Screening Inventory-Revised (ESI-R) similarly targets the early identification of children who may require specialized support or intervention due to developmental delays, much like the Ages & Stages Questionnaires® 54 Month Questionnaire. Both tools are structured to evaluate key developmental domains, including language, motor skills, and social-emotional development. The ESI-R, however, is administered through direct observation and engagement with the child by professionals, as opposed to the ASQ's parent-reported format. This difference in administration method highlights the complementary nature of these tools in providing a comprehensive approach to developmental screening, each from a different vantage point yet aiming for the same goal of early intervention.
When filling out the Ages & Stages Questionnaires® 54 Month Questionnaire, certain practices can enhance the accuracy and reliability of the information provided. Below is a list of recommendations on what to do and what not to do during this process.
When it comes to the Ages & Stages Questionnaires® 54 Month (ASQ-3™) form, several misconceptions often arise, clouding the understanding and purpose of this developmental screening tool. Let's dive into some of the common myths and clarify the realities behind them:
Myth: The ASQ-3™ is only for detecting developmental delays in children.
Reality: While identifying delays is a crucial component, the ASQ-3™ also highlights a child’s strengths, providing a comprehensive view of their development.
Myth: Professionals are the only ones qualified to complete the ASQ-3™.
Reality: The questionnaire is designed for parents and caregivers, offering a unique perspective on the child's abilities in their natural environment.
Myth: The results of the ASQ-3™ provide a definitive diagnosis.
Reality: The ASQ-3™ is a screening tool, not a diagnostic test. Its main goal is to identify children who may benefit from further evaluation.
Myth: The ASQ-3™ covers only cognitive development.
Reality: It assesses five key developmental areas: communication, gross motor, fine motor, problem-solving, and personal-social skills.
Myth: It's unnecessary to try each activity with the child before marking a response.
Reality: Engaging in the activities ensures accurate responses, reflecting the child's current abilities.
Myth: Any pen color is suitable for completing the form.
Reality: It specifies using black or blue ink to ensure clear, readable responses.
Myth: The ASQ-3™ is only useful for very young children.
Reality: It is designed to screen children from 1 month to 5½ years, providing valuable insights throughout early childhood.
Myth: The ASQ-3™ is a lengthy and complicated process.
Reality: It is user-friendly, emphasizing parent-child interaction through simple, playful activities.
Myth: Once completed, the ASQ-3™ doesn't require any follow-up.
Reality: Results should be reviewed by a professional who can offer guidance on next steps, whether it be monitoring, reevaluation, or referral for further assessment.
Myth: The ASQ-3™ replaces professional assessments.
Reality: It acts as a preliminary step, identifying children who might need in-depth evaluation by specialists.
Understanding the principles and purposes behind the Ages & Stages Questionnaires® can empower parents, caregivers, and professionals to use this tool effectively, ensuring that children receive the support and resources they need during crucial developmental stages.
Completing the Ages & Stages Questionnaires® 54 Month Questionnaire is an important step in understanding a child’s development. Here are 10 key takeaways to consider while filling out and using this form:
When used correctly, the Ages & Stages Questionnaires® 54 Month Questionnaire is a valuable tool for observing a child’s development and identifying areas where they might need support or further evaluation.
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