The Ages & Stages Questionnaires® 54 Month Questionnaire is a developmental screening tool designed for children aged 51 months to 56 months. This questionnaire assists parents and caregivers in assessing a child's growth in various areas, including communication, motor skills, problem-solving, and personal-social development. To ensure accurate results, complete the form thoughtfully and return it by the specified date.
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The Ages & Stages Questionnaires® (ASQ) 54 Month Questionnaire is a valuable tool designed to assess the developmental progress of children aged 51 months to 56 months. This questionnaire serves as a guide for parents, guardians, and caregivers to evaluate key areas of growth, including communication, gross motor skills, fine motor skills, problem-solving abilities, and personal-social skills. By engaging in a series of fun activities with the child, the questionnaire encourages interaction while gathering insights into the child's capabilities. Each section prompts the respondent to indicate whether the child performs specific tasks regularly, sometimes, or not yet, providing a clear picture of the child's developmental milestones. It is essential to complete the questionnaire thoughtfully, ensuring the child is well-rested and fed, and to approach the activities as a playful game. This form not only aids in identifying areas where a child may need additional support but also fosters a collaborative environment for parents and caregivers to share observations and insights about the child's growth journey.
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.”
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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:
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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
Completing the ASQ 54 Month Questionnaire form involves several steps to ensure accurate and comprehensive information about a child's development. After filling out the necessary details, the form will guide the respondent through a series of questions regarding various developmental activities. Each question will require the respondent to indicate the child's ability to perform specific tasks.
The ASQ 54 Month Questionnaire is designed to assess the developmental progress of children aged 51 months to 56 months. It helps identify areas where a child is developing well and areas that may need further attention or support. The questionnaire covers various domains, including communication, gross motor skills, fine motor skills, problem-solving, and personal-social skills.
The questionnaire should be completed by a person who is familiar with the child's daily activities and development. This could be a parent, guardian, teacher, or childcare provider. It is important that the person filling out the form knows the child well to provide accurate responses.
When completing the questionnaire, use black or blue ink and print legibly. For each activity listed, indicate whether the child performs it regularly, sometimes, or not yet. It is advisable to try the activities with the child before marking a response. Making the process enjoyable can help engage the child and yield more accurate results.
It is common for children to develop skills at different rates. If your child has not yet completed certain activities, simply mark "not yet" for those items. The purpose of the questionnaire is to gauge current abilities and identify areas for potential growth, not to create a checklist of completed tasks.
The completed questionnaire should be returned by the specified date indicated on the form. Timely submission is important for ensuring that the child's developmental assessment can be reviewed and any necessary follow-up actions can be taken.
The questionnaire includes space for additional comments. Use this area to express any specific concerns or observations regarding your child's development. This information can be helpful for professionals reviewing the questionnaire and planning appropriate support or interventions.
After submission, the completed questionnaire will be reviewed by a qualified professional, such as a pediatrician or early childhood educator. They will assess the child's developmental progress based on the responses provided. Depending on the results, they may recommend further evaluation, resources, or activities to support the child's development.
Using the wrong ink color: It's important to use black or blue ink only. Using other colors can make the form difficult to read.
Illegible handwriting: Printing legibly is crucial. If the handwriting is hard to read, it may lead to misunderstandings or errors.
Incomplete personal information: Failing to provide all required details, such as the child's full name or date of birth, can delay processing.
Not following instructions: Ignoring important instructions, like trying each activity with the child before marking a response, can lead to inaccurate answers.
Rushing through the questionnaire: Completing the form quickly without taking the time to think about each question can result in errors.
Not involving the child: The questionnaire is meant to be a fun activity. Not engaging the child can lead to missed opportunities to observe their skills.
Failing to provide examples: When asked for examples, not providing them can limit the understanding of the child’s abilities.
Not checking for accuracy: Skipping a review of the answers before submitting can lead to mistakes going unnoticed.
Missing the submission deadline: Not returning the questionnaire by the specified date can delay assessments and services.
Ignoring the assistance section: Not listing people who helped complete the questionnaire can hinder follow-up communication.
The Ages & Stages Questionnaires® (ASQ) 54 Month Questionnaire is a vital tool for assessing developmental milestones in young children. Along with this questionnaire, several other forms and documents are commonly utilized to provide a comprehensive overview of a child's development and to facilitate effective communication among parents, caregivers, and professionals. Below is a list of these documents, each serving a specific purpose.
Using these documents in conjunction with the ASQ 54 Month Questionnaire can enhance understanding of a child's development and ensure that appropriate measures are taken to support their growth. By collaborating effectively, parents and professionals can create a nurturing environment that fosters healthy development.
The Ages & Stages Questionnaires (ASQ) is a developmental screening tool that shares similarities with the Denver Developmental Screening Test (DDST). Both instruments aim to assess the developmental milestones of young children. The DDST includes a series of tasks that children are asked to complete, similar to the activities listed in the ASQ. Each questionnaire focuses on different developmental domains, such as communication, motor skills, and problem-solving, allowing parents and caregivers to identify areas where a child may need additional support. Just like the ASQ, the DDST emphasizes the importance of observing a child in a natural setting, making the process engaging and informative for both the child and the evaluator.
The Battelle Developmental Inventory (BDI) is another document that aligns closely with the ASQ. This comprehensive assessment tool evaluates a child's development across various domains, including cognitive, social-emotional, and physical skills. The BDI, like the ASQ, is designed for parents and educators to use in evaluating children's developmental progress. Both tools provide a structured way to collect information about a child's abilities and can help identify any delays or areas for growth. The BDI also offers insights into how children interact with their environment, similar to the ASQ's focus on practical activities.
The Child Development Inventory (CDI) is yet another assessment tool that bears resemblance to the ASQ. This inventory focuses on a child's developmental progress from birth to age 6, covering areas such as language, self-help, and social skills. The CDI, like the ASQ, relies on parental input to gauge a child's abilities through specific tasks. Both documents serve as valuable resources for parents and professionals alike, facilitating discussions about a child's development and guiding interventions when necessary. The CDI's emphasis on parental observations mirrors the ASQ's approach, making both tools user-friendly and effective.
The Parent's Evaluation of Developmental Status (PEDS) is a screening tool that parallels the ASQ in its goal of assessing children's developmental progress. PEDS consists of a series of questions that parents answer regarding their child's behavior and development. Similar to the ASQ, PEDS allows for early identification of potential developmental concerns. The focus on parental input in both tools underscores the importance of caregivers' perspectives in understanding a child's growth and development. This shared emphasis on parent engagement enhances the effectiveness of both assessments in identifying children who may benefit from further evaluation.
The Developmental Indicators for the Assessment of Learning (DIAL) is another document comparable to the ASQ. The DIAL assesses young children's developmental milestones in areas such as motor, language, and social skills. Like the ASQ, the DIAL is designed for use by educators and parents to gather insights into a child's development. The structured format of both assessments allows for easy comparison of a child's skills against typical developmental benchmarks. By providing a clear framework for evaluation, both the DIAL and the ASQ facilitate the identification of children who may require additional support or intervention.
Finally, the Ages & Stages Questionnaires: Social-Emotional (ASQ:SE) is specifically focused on a child's social and emotional development, making it closely related to the ASQ. While the original ASQ covers a broader range of developmental domains, the ASQ:SE zeroes in on behaviors that reflect emotional well-being and social skills. Both tools encourage parents to observe their child's behavior in various situations, fostering a comprehensive understanding of their development. The ASQ:SE complements the ASQ by providing additional insights into how children interact with others, thereby enriching the overall assessment of a child's growth.
When filling out the ASQ 54 Month Questionnaire form, it's important to keep a few guidelines in mind. Here’s a list of things to do and avoid:
Following these simple guidelines will help ensure that the questionnaire is completed correctly and effectively, providing valuable insights into your child's development.
Misconceptions about the ASQ 54 Month Questionnaire can lead to misunderstandings regarding its purpose and use. Here are four common misconceptions:
Understanding these misconceptions can enhance the effectiveness of the ASQ 54 Month Questionnaire, ensuring it serves as a valuable resource for parents and caregivers alike.
Filling out the Ages & Stages Questionnaires® (ASQ) 54 Month Questionnaire form is an important step in assessing a child's developmental progress. Here are key takeaways to consider: