Ages and Stages Questionnaire (ASQ) has been a valuable addition to the group of developmental screening tools based on parent completed questionnaire. It is simple, cost-effective, and has the advantage of parents being active participants in the evaluation of their children. After the revision of ASQ in year 1997, it has been translated into many languages. Studies on ASQ in both high risk and low risk populations have shown that it has good psychometric properties [8-13]. However, there are no published studies on the use of this questionnaire in the Indian context. This study was planned to evaluate ASQ for detecting developmental delay in Indian children.

The study was conducted at the Child Development Clinic (CDC) of Lok Nayak Hospital, New Delhi, India from February, 2009 to January, 2010. Children in the four age groups; 4±1 months, 10±1 months, 18±1 month and 24±1 months, attending the Pediatric Out Patient Department or High Risk Clinic of the hospital were included in the study. The included children were stratified into high and low risk groups. The high risk group comprised of children with any of the following risk factors: history of hospitalization in the first four days of life, birthweight <2 kg, gestation age <37 weeks, history of central nervous systems infections, known dysmorphic syndrome or chromosomal anomalies, suspected cerebral palsy or developmental delay, and or history of two or more episodes of afebrile seizures. Children with none of the above mentioned risk factors comprised the low risk group. Children with non-availability of birth records or the primary caregiver at the time of evaluation were excluded.

A convenience sample of 200 children of either sex, 50 in each of the four specified age strata were enrolled in the study. In each age group, 30 low risk and 20 high risk children were enrolled.　 A detailed history and physical examination was done in all the children at the time of enrollment, followed by administration of ASQ by a pediatric Resident to any of the available parent, mostly mothers. On the same day, developmental assessment of the child was also done by Clinical Psychologist using Developmental assessment Scale for Indian Infants (DASII). All the parents were administered ASQ by the same Resident; however, DASII was administered by any of the Clinical Psychologists at CDC. Clinical psychologists were blinded to the scores on ASQ. 　

Assessment tools: The Ages and Stages Questionnaire-Second Edition is a set of 19 age-specific parent-completed questionnaires aimed at assessing the developmental status of infants and young children up to 5 years of age. Each questionnaire is valid for 1 month on either side of the target age and consists of 30 simple worded developmental items, equally divided into five domains of child development: communication, gross motor, fine motor, problem solving　and personal social skills. The reading level of the items ranges from fourth to sixth grade. For each item, there is a choice of three responses: ‘Yes’, ‘Sometimes’, or ‘Not yet’, which are scored as 10, 5, or 0, respectively. Domain scores are then obtained by the sum of the items. Children with ASQ score below the cut off (<2SD) in any of the domain are taken as screen failed [14].

For the present study, only 4, 10, 18 and 24 months questionnaires were used. The questionnaires were translated into Hindi language and back-translated into English and this procedure was repeated until the back-translation matched the English versions.　

Ethics and consent: Informed consent was obtained from parents of all　the children enrolled in the study. Ethical approval was taken for conducting this study from the Institutional Ethical Committee. Children found to have developmental delay were offered appropriate intervention and management at CDC.　

Statistical analysis: The data was entered and analyzed using Epi Info. The psychometric properties of ASQ were calculated using DASII as gold standard. Pearson correlation coefficient was used for correlation between the ASQ and DASII scores.　

Overall, 268 children were screened for inclusion in the study. Out of these, 51 did not meet the inclusion criteria and 17 denied consent for the study. The final study group comprised of 200 children, 50 each in the 4 age groups. Table I shows the demographic characteristics of the study sample. The risk factors present in the high risk group are tabulated in Table II.

TABLE I	Demographic Characteristics of the Study Sample (N=200)

TABLE II Risk Factors of the High Risk Group (N=80)

On detailed clinical evaluation, 17 (8.5%) children were found to have feeding problems, 20 (10%) had hearing impairment, 11 (5.5%) had visual impairment, 8 (4%) had squint, and 15 (7.5%) had cerebral palsy; all of them belonged to the high risk group.

The overall sensitivity of ASQ in detecting developmental delay was 83.3% and specificity was 75.4% with a negative predictive value of 84.6% (Table III). The sensitivity was best for the 24 months questionnaire (94.7%) and the specificity was best for the 4 month questionnaire (86.4%). The sensitivity was much higher in the high risk group.　

TABLE III  Screening Test Characteristics of ASQ 

The ASQ Communication, fine motor, problem solving and personal social domain scores were correlated with the Mental DQ of DASII (Table IV). The ASQ Gross motor domain score was correlated with the Motor DQ of DASII. All correlations were found to be good (r, 0.76-0.80).　

TABLE IV	Correlation of ASQ Scores with DASII Scores 

This study shows that ASQ has strong test characteristics for detecting developmental delay in Indian children. This study also reaffirms the value of ASQ as an effective developmental screening tool.

The validity and reliability of this revised edition of ASQ was established in year 1997, in a sample of 2008 children, comprising of both high risk and normative sample. The sensitivity of ASQ was found to be 74.56%, specificity was 86.21% and percentage agreement with the standardized assessment was 84.11% [8]. After the study that validated ASQ-Second edition, a number of other authors have also evaluated ASQ in different populations and in different age groups, using a combination of multiple gold standard assessment tools and found good results [8-13]. In the present study, the sensitivity was found to be good for 10, 18 and 24 months, and modest for the 4 month questionnaire. The specificity was best for the 4 month questionnaire but was particularly low for the 18 months. The lower sensitivity in our study of 71% for the 4 month questionnaire is consistent with finding of 51% sensitivity in the study that validated the revised ASQ [8]. This may be related to the fact that parental assessment of language and cognitive delay in infancy is less objective allowing more favourable reporting at lower ages. The high sensitivity and specificity of the 24 months ASQ is also noted by other authors [11]. 　

The present study also showed that the sensitivity was higher in the high risk group whereas specificity was higher in low risk group. The over-referral and under-referral rate was also lower in the high risk group. Two Australian studies also showed similar results while evaluating ASQ in population medically at risk for developmental delay, premature infants and survivors of hypoxic ischemic encephalopathy [12,13].

In the present study, there was good correlation between the domain scores of ASQ and DASII. Most other studies have not presented this data, but in one study, the correlation of　ASQ domain scores with BSID-II scales was moderate except for ASQ fine motor and BSID-II motor scale, which was negligible [11]. This poor correlation obtained could be because the items in fine motor domain of ASQ are included in the mental scale of developmental tests and not in the motor scale.　

This study is the first to evaluate ASQ in Indian population. The test characteristics of the ASQ were studied both in low risk children and those at risk for developmental delay. It included children from different socioeconomic backgrounds and also those in early infancy, where timely intervention is more likely to be beneficial.

In conclusions, this study shows that ASQ has strong test characteristics for detecting developmental delay in Indian children, especially at 18 and 24 months of age and in high risk children. Though further large scale community based studies are needed to evaluate ASQ in Indian population at all age groups, it can be easily converted into other Indian languages and used, especially for younger age groups where early intervention is more likely to be beneficial.

Contributors: MJ, MM and SR: were involved in study designing and recruitment of the patients; MM: did assessment of the patients; MM and RJ: did literature review, statistical analysis and initial drafting of the manuscript; MJ, RJ and SR: did final revision of the manuscript. The final manuscript was approved by all authors

Funding: None; Competing interests: None stated.

1. Glascoe FP, Byrne KE, Chang B Johnson KL, Chang B, Strickland B. Accuracy of Denver II in developmental screening. Pediatrics. 1992;89:1221-5.

2. Knoblock H, Stevens F, Malone A, Ellison P, Risemberg H. The validity of parental reporting of infant development. Pediatrics. 1979;63:872.

3. Sonnander K. Parental development assessment of 18 month old children: reliability and predictive value. Dev Med Child Neurol. 1987;29:351.

4. Bartlett D, Piper M, Magill-Evans J, Warren S. Validity of mother’s assessment of infant motor development. Dev Med Child Neurol. 1992;Suppl 66:6.

5. Diamond KE. The role of parents’ observations and concerns in screening for developmental delay in young children. Topics in Early Childhood Special Education. 1993;13:68-81.

6. Glascoe FP, Sandler H. Value of parents’ estimates of children’s developmental ages. J Pediatr. 1995;127:831-5.

7. Glascoe FP. Parent’s concerns about children’s development: prescreening technique or screening test. Pediatrics. 1997;99:522-8.

8. Squires J, Brickers D, Potter L. Revision of a parent –completed developmental screening tool; Ages and Stages Questionnaire. J Pediatr Psychol. 1997;22:313-28.

9. Elbers J, Macnab A, McLeod E, Gagnon F. The Ages and Stages Questionnaire: feasibility of use as a screening tool for children in Canada. Can J Rural Med. 2008;13:9-14.

10. Rydz D, Srour M, Oskoui M, Marget N, Shiller M, Birnbaum R, et al. Screening for developmental delay in the setting of a community pediatric clinic: a prospective assessment of parent-report questionnaires. Pediatrics. 2006;118:e1178-86.

11. Gollenberg AL, Lynch CD, Jackson LW, McGuinness BM, Msall ME. Concurrent validity of the parent completed Ages and Stages Questionnaires, 2nd Ed with the Bayley Scale of Infant Development in a low-risk sample. Child Care Health Dev. 2010;36:485-90.

12. Skelleren CY, Rogers Y, O’Callaghan MJ. A parent –completed developmental questionnaire: follow up of ex- premature infants. J Paediatr Child Health. 2001; 37:125-9.

13. Lindsay NM, Healy GN, Colditz PB, Lingwood BE. Use of the Ages and Stages Questionnaire to predict outcome after hypoxic-ischemic encephalopathy in the neonate. J Pediatr Child Health. 2008;44:590-5.

14. Bricker D, Squires J Ages and Stages Questionnaire (ASQ) – Second Edition. Baltimore, MD: Paul H. Brookes; 1999.

15. Phatak P. Developmental Assessment Scales for Indian Infants (DASII) – Revised Baroda Norms Manual, 1997.

16. Mukhopadhyay K, Malhi P, Mahajan R, Narang A. Neurodevelopmental and behavioral outcome of very low birth weight babies at corrected age of 2 years. Indian J Pediatr. 2010;77:963-7.

17. Taneja V, Sriram S, Beri RS, Sreenivas V, Aggarwal R, Kaur R. Not by bread alone’: impact of a structured 90-minute play session on development of children in an orphanage. Child Care Health Dev. 2002;28:95-100.