Support for the global feasibility of the Ages and Stages Questionnaire as developmental screener
Abstract
Objective
To investigate the psychometric properties of the Dutch version of the 48 months Ages and Stages Questionnaire (D_ASQ_48).
Design
Prospective cohort study of a community-based sample of children born in 2002 and 2003 whose parents filled out the D_ASQ_48 and a questionnaire on school status at 60 months. The ASQ was translated into Dutch and back-translated into English by three independent translators.
Setting
Well Child Centers covering 25% of the Netherlands.
Participants
Parents of 1510 preterm and 562 term children born in 2002–2003 attending routine Well Child visits at age 45–50 months.
Main outcome measures
Reliability, validity and mean population scores for D_ASQ_48 compared to other countries.
Results
Mean population scores for the D_ASQ_48 were mostly similar to those in the USA, Norway and Korea. Exceptions (effect sizes of difference > 0.5) were problem solving (USA) and fine motor (Korea). Reliability was good for the total score (Cronbach alpha 0.79) and acceptable for all domains (0.61–0.74). As expected, infants born at gestational age < 32 weeks, children from low income families, of low educated mothers, and boys were more likely to fail on several domains (odds ratios, OR ranging from 1.5 to 4.9). The only unexpected association concerned children from one-parent families. Sensitivity to predict special education at five years of age was 89% and specificity 80%.
Conclusions
The good psychometric properties of the Dutch ASQ_48 and the small differences when compared to other countries support its usefulness in the early detection of developmental problems amongst children worldwide.
Introduction
An estimated 5–10% of all children have a developmental disability [1]. The benefits of early intervention-therapy for young children at risk of developing a disability have been shown in randomized controlled trials [2], [3], [4], [5], [6]. Several countries are now setting high standards for the detection and treatment of developmental delay in children before school entrance [7], [8], [9]. However, detecting developmental delay with limited resources in the community setting is difficult [10]. Only 30% of children with developmental problems are identified before school age when relying solely on clinical judgment [11].
Developmental screening can help the pediatrician to identify more children with a possible developmental delay or disability. Screening is “a brief assessment procedure designed to identify children who should receive more intensive diagnosis or assessment” [1], [7], [8]. Child development is a dynamic process, and includes various streams of development namely fine and gross motor, language, cognitive and adaptive behavioral components which are all interrelated and therefore quite complex. Developmental screening has limited ability to predict future functioning but is a valid and reliable way to assess subject skills in a variety of domains. Developmental screening tools undergo extensive testing for validity, reliability and accuracy and are standardized with a population representative sample. Sensitivity and specificity are measured by comparing the test to a gold standard developmental evaluation tool, and should both be between 70 and 80%, because of the nature and the complexity of measuring the continuous process of child development [1], [7], [8]. This always leads to over-referral, and under-referral. But children who are not picked up by a first screen might well be found a next time if screening occurs periodically, and children who are over-referred often still benefit from more close surveillance [12]. Some well known examples of developmental screeners that can be utilized by trained professionals are the Denver II screening test, the Bayley Neuro-developmental screener and the Batelle Developmental Inventory. The major disadvantage of these tests is that they take relatively much time and effort to administer and interpret.
In the past parental reporting of current skills and concerns was considered to be too inaccurate to be used in screening, but in the last twenty years several studies have shown that parent-completed screening tools are highly accurate in detecting true problems [13]. Examples of parent-completed screening tools are the Parents' Evaluation of Developmental Status [14], the Child Development Inventories [15], and the Ages and Stages Questionnaires [16]. The parent based developmental screeners that can be completed by parents in the home setting are being used more and more frequently, due to the fact that they are relatively inexpensive and accurate [1].
Amongst the parent-completed questionnaires for young children, the Ages and Stages Questionnaire (ASQ) is currently the most widely used [18], [20]. It consists of 19 different questionnaires covering the age-range of 4 to 60 months. The reading level that is needed to fill in the various ASQ questionnaires is grade 4–6, thus ensuring easy parental comprehension. They take 10–15 min to complete. The questionnaires cover five different domains: communication, gross motor, fine motor, problem solving and personal social skills. Each domain is assessed by six questions on developmental milestones. They are chosen so as to represent a developmental quotient of 75–100%. Parents can answer them with “yes”, “sometimes” or “not yet”, with a respective score of 10, 5 or 0 points. Referral for further assessment is advised when the score on any domain falls below the cut-off point, which is set at 2 standard deviations below the mean of the reference group.
The original ASQ has been proven to be reliable and cost-effective with excellent psychometric properties. Concurrent validity ranges from 76 to 88% [19]. Overall sensitivity and specificity are 75% and 86%, respectively. In a recent multinational trial involving 18 countries in Asia, Africa, Europe, North- and South-America, sensitivity was 88% and specificity was 82.5% [17], [20]. Test–retest reliability within two weeks was 94% for the original version. Inter-observer reliability between parents and professional examiners was 94%.
The ASQ is widely used in preventive and curative health care programs in the US and in Canada. It has been translated into Spanish, Korean, Chinese, French, Danish and Norwegian, and several other local translations exist [21], [22], [23], [24], [25], [26]. Although the ASQ is translated and used all over the world, few studies have examined its psychometric properties in their own cultural setting after translation [21], [24], [26], [27].
For our study, we have selected the four year questionnaire of the ASQ, because it will help to identify children which have been missed by early developmental screening programs, who might still benefit from more formal neurodevelopmental testing at this young age. We believe that identifying children with possible developmental delays at the start of formal schooling, instead of waiting for serious problems to arise later on, could help to prevent unnecessary hardship for these children and their parents. In our country this age (4 years) coincides with a routine visit to our Well Child Preventive Health Care Clinics. The aim of this study was to determine the psychometric properties of the Dutch 48 months ASQ questionnaire (D_ASQ_48) in a large community-based sample of children, as the first step towards determining the psychometric properties of the entire series of ASQ questionnaires in the Netherlands.
Section snippets
Population
We drew a stratified sample from a community-based cohort of 45,446 children born in 2002 and 2003 from 12 Preventive Child Healthcare (PCH) organizations. In the Netherlands, 96% of all children attend routine Well Child Clinics offered by the PCH organizations [28]. All children born before a gestation of 36 completed weeks (further mentioned as preterm children) were selected, plus a sample of term-born children. The latter group comprised the first child from the same birth year with a
Sample and mean scores
Of the 3175 eligible children 2508 (79%) participated in the whole study, of which the parents of 2072 children completed the Dutch ASQ_48.
605 children (438 preterm infants and 167 term infants) completed the Dutch ASQ_48 within the time frame of 46–50 months. The other children were older or younger due to random variations in the dates of the Well Child visits due to logistical reasons.
The mean scores of Dutch children for all domains except for the fine motor domain differed significantly
Comment
This study assessed the reliability and validity of the Dutch version of the ASQ_48 months questionnaire. Its results show that the Dutch ASQ_48 months has a good reliability. Mean scores are lower than in some other countries but most of the differences are small. Performance of the Dutch ASQ_48 months questionnaire on a number of aspects of validity generally confirmed validity. There was only one exception which was the unexpected lower percentage of children from one-parent families who
Conclusions
Our results show that the ASQ 48 months questionnaire is a short parental developmental screener with excellent psychometric properties, which can be used in community settings outside the USA, to identify children who might benefit from more extensive developmental testing. The reliability and validity of the Dutch ASQ 48 months questionnaire, and the striking similarities with the data from the Norwegian and Korean validation studies are the first step in confirming the feasibility of the
Acknowledgements
The presented research is part of a larger cohort study on development, growth and health of preterm infants (controlled trials.com ISRCTN80622320), and is supported by the Beatrix Childrens Hospital research foundation, the Cornelia Foundation for the Handicapped Child, the A. Bulk-Child Health Care research fund, the Dutch Brain Foundation, and an unrestricted research grant from Friesland Diary Foods and Abbott. The financers had no role at any stage of the project including the decision to
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