The Ages & Stages Questionnaires® 54 Month (ASQ-3™) form is designed for children aged 51 months 0 days through 56 months 30 days, offering a structured way to check on a child's development across communication, gross motor, fine motor, problem-solving, and personal-social skills. By providing spaces for detailed responses on a child's abilities, it aids in identifying both strengths and areas where a child may need support. For those ready to understand or track a child's developmental milestones, completing this form can be an informative first step. Click the button below to start filling out the form.
The Ages & Stages Questionnaires® 54 Month Questionnaire addresses a critical period in a child's development, from 51 months 0 days through 56 months 30 days. It is a comprehensive tool designed to screen the developmental performance of children in various areas, including communication, gross and fine motor skills, problem-solving, and personal-social development. Completers of the form are requested to observe and engage with the child in activities that highlight their current developmental status, indicating whether an activity is performed regularly, sometimes, or not yet commencing. The form requires attentive interaction between the adult and the child, emphasizing the importance of trying activities before marking a response, making the process enjoyable, and ensuring the child's readiness for engagement. Accurate completion involves the provision of detailed information about the child, including their name, gender, and birth date, as well as the respondent's relationship to the child and contact details. This meticulous documentation seeks to paint a clear picture of the child’s abilities and readiness for future learning stages, offering valuable insights for parents, guardians, teachers, and healthcare providers. Importantly, by addressing a broad spectrum of developmental milestones, the questionnaire underscores the multifaceted nature of child development and the need for a nuanced approach in monitoring and supporting each child's growth trajectory.
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
E101540200
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
E101540500
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
Once you're ready to fill out the Ages & Stages Questionnaires® 54 Month Questionnaire, it's crucial to ensure that the environment is conducive for your child to actively participate. Remember, engaging with your child through these activities should be enjoyable for both of you. Ensure your child is well-fed, rested, and ready to engage in this playful scenario, allowing for the most accurate representation of their abilities and development. Following these step-by-step instructions will simplify completing the questionnaire, ensuring it's both an informative and pleasant experience.
Once you have completed all the sections and filled in the circles based on your observations and interactions with your child, review the form to ensure all applicable fields are filled accurately. This process not only assesses various developmental milestones but also fosters a bond and understanding between you and your child. After thorough review, submit the questionnaire by the due date provided by your healthcare provider, school, or early education program.
The Ages & Stages Questionnaires® (ASQ-3™) 54 Month Questionnaire is a screening tool designed to understand developmental progress in children from 51 months 0 days to 56 months 30 days old. It involves a series of questions that guardians, parents, teachers, or childcare providers complete to monitor the child's communication, fine motor, gross motor, problem-solving, and personal-social skills.
The questionnaire is meant to be filled out by an adult who is closely involved in the daily activities of the child. This can be a parent, guardian, teacher, childcare provider, grandparent, foster parent, or another family member.
The ASQ 54 Month Questionnaire includes questions tailored to assess various developmental areas:
When completing the questionnaire, use black or blue ink and print legibly. It's crucial to engage with the child through the activities mentioned in the questionnaire to observe their regular behavior. Responses should be marked based on whether the child is "regularly" doing the activity, does it "sometimes," or "not yet" started to do it.
The primary use of the ASQ 54 Month Questionnaire is for early detection of developmental delays. It can help caregivers and professionals identify areas where the child might need support or intervention. Also, it can serve as a guide for engaging activities that promote developmental milestones.
If the questionnaire indicates a developmental delay, it's recommended to discuss the results with healthcare professionals, such as a pediatrician or a child development specialist, who can provide further assessment and guidance on appropriate interventions or support services.
The ASQ 54 Month Questionnaire is available through various healthcare and educational organizations. Additionally, it can be purchased from the publisher, Paul H. Brookes Publishing Co., or accessed through some child development centers' websites.
When parents or guardians fill out the ASQ 54 Month Questionnaire form, which is designed to capture the developmental progress of children who are between 51 months 0 days and 56 months 30 days old, certain common mistakes can occur. Addressing these mistakes is crucial for ensuring the accuracy and reliability of the information provided. Here's a look at some of the most frequent errors:
Using the incorrect writing utensil or color: The instructions specify the use of black or blue ink only. This requirement is made to ensure that the completed forms are legible and can be copied or scanned without issue. Utilizing different colors or pencil may lead to difficulties in reading the responses clearly.
Not printing legibly: The form asks that all information be printed legibly. This is particularly important because illegible writing can lead to misinterpretation of the responses, which in turn can affect the accuracy of the questionnaire's outcomes. Ensuring clarity in handwriting is key to the successful processing of the form.
Skipping the trial of activities with the child: Before marking a response, it is suggested to try each activity with the child. This step is crucial for two reasons. First, it ensures the accuracy of the reporting since some children may perform an activity when prompted that they do not spontaneously demonstrate otherwise. Second, it turns the completion of the questionnaire into a fun and interactive game for the child, potentially leading to more accurate responses.
Omitting or inaccurately completing personal information: The top section of the form requires detailed personal information about the child and the person filling out the questionnaire. Mistakes in this section, such as incorrect child ID numbers, wrong or missing dates, and vague relationship descriptions, can lead to data processing errors and misplaced forms.
In conclusion, to avoid these common errors, one should meticulously follow the form's instructions, use the specified ink colors, ensure legibility in writing, adequately engage with the child during activity trials, and accurately complete the personal information section. Doing so will significantly enhance the reliability of the information provided, thereby contributing to a more accurate developmental assessment.
When completing and reviewing the Ages & Stages Questionnaires® (ASQ-3™) 54 Month Questionnaire, it is often helpful to have additional documents and forms that complement the information being gathered. These forms support a comprehensive assessment of the child's development, allowing for a more holistic understanding of their abilities, challenges, and progress.
Collectively, these documents and forms create a comprehensive profile of a child's developmental status, informing better-targeted interventions, support, and monitoring. Ensuring that these materials are up-to-date and readily available can significantly enhance the effectiveness of developmental assessments and the planning of care or educational strategies.
Denver Developmental Screening Test II (DDST-II): The Denver II is a screening tool for developmental delays in children from birth through six years old. Like the Ages & Stages Questionnaires®, it covers various domains of development, including gross motor, fine motor, language, and personal-social. The ASQ-54 Month Questionnaire parallels the DDST-II in its approach to assessing developmental milestones but focuses on a specific age range.
Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III): Bayley-III assesses developmental functioning in infants and young children aged 1–42 months. It has sections similar to the ASQ, such as cognitive, language, motor, social-emotional, and adaptive behavior. Although the Bayley-III covers a younger age range, it shares the ASQ's goal of identifying developmental delays early.
Early Childhood Screening Assessment (ECSA): The ECSA is designed for early identification of children who may need special education services. It evaluates areas similar to those in the ASQ, like language, motor skills, and social-emotional development, for children up to kindergarten age. Both tools emphasize early detection to facilitate timely intervention.
Brigance Screens: Brigance offers a range of screening tools for early childhood that assess language, motor, readiness, and academic skills. Similar to the ASQ, Brigance Screens provide age-specific assessments designed to screen children to identify potential developmental delays and suggest areas for further evaluation.
Vineland Adaptive Behavior Scales, Third Edition (Vineland-3): Vineland-3 assesses personal and social skills of individuals from birth through adulthood. Although it covers a broader age range, it overlaps with the ASQ in evaluating communication, daily living skills, socialization, and motor skills, aiming to measure adaptive behaviors.
Peabody Developmental Motor Scales, Second Edition (PDMS-2): PDMS-2 measures motor skills in young children. While the ASQ assesses a broader spectrum of developmental areas, they both include evaluations of gross and fine motor abilities. PDMS-2 specifically provides detailed analysis and guidance for these areas.
Childhood Autism Rating Scale, Second Edition (CARS2): CARS2 is a tool used for diagnosing autism in children over two years of age, emphasizing social and communicative development. Although it focuses on autism, parts of the ASQ, especially in personal-social sections, can indicate areas of concern that may warrant further evaluation for autism or other developmental disorders.
Parents' Evaluation of Developmental Status (PEDS): PEDS is a parent-completed questionnaire identifying children at risk for developmental and behavioral problems. Like the ASQ, it serves as a broad screening tool aimed at early detection, relying heavily on parental observations and concerns.
Screening Tool of Feeding Problems (STEP): Though focusing specifically on feeding issues, STEP identifies potential developmental concerns in a narrow area compared to the broad scope of the ASQ. Both are used to flag issues that may require further specialist assessment.
When it's time to fill out the ASQ 54 Month Questionnaire, here's a concise guide of dos and don'ts aimed at ensuring the process is not only accurate but beneficial for your child's development:
Do try each activity with your child before marking a response. It's crucial to engage with your child to observe their current abilities thoroughly. Completing this questionnaire isn't just a bureaucratic necessity; it's a hands-on way to understand and support your child's development.
Don't guess or estimate your child's ability. Ensure each response reflects your child's actual skills by directly observing them perform the activities. Guesswork can lead to inaccuracies that might skew the assessment's outcomes.
Do make completing this questionnaire fun. Approach this activity like a game, ensuring it's an enjoyable experience for both you and your child. A positive approach can elicit a better representation of your child's natural abilities.
Don't rush through the questionnaire. Take your time to carefully consider each question and observe your child's abilities. Rushing can lead to overlooking critical developmental milestones.
Do ensure your child is rested and fed before starting. A child's performance on these activities can significantly vary depending on their mood and energy levels. Attempting the questionnaire when they're in a good state can yield more reliable results.
Don't fill out the questionnaire in one go if it's not working for your child. It's perfectly acceptable to break it down into several shorter sessions to keep it engaging and productive for your child.
Do use black or blue ink and print legibly. This ensures that your responses are clear and easy to understand for those reviewing the questionnaire.
Don't leave any items blank. If you're unsure about how to answer a question, it's better to make your best informed guess rather than skipping it. Provide notes or additional comments if a question cannot be answered with the provided options.
Do return the completed questionnaire by the specified date. Timely submission is essential for ensuring your child's developmental progress is appropriately monitored and supported.
Following these guidelines can significantly enhance the effectiveness of the ASQ 54 Month Questionnaire for you and your child, contributing valuable insights into their development.
Many people have misconceptions about the Ages & Stages Questionnaires® (ASQ) 54 Month Questionnaire. Let’s address and clarify some of these misconceptions to help parents, guardians, and educators better understand the questionnaire’s purpose and how to use it effectively.
This is not true. While parents are commonly the ones to complete the questionnaire, guardians, teachers, childcare providers, grandparents, foster parents, and other relatives can also fill it out, as long as they are familiar with the child’s daily activities and capabilities.
On the contrary, the instructions emphasize that you should try each activity with your child before marking a response. This approach not only ensures the accuracy of your answers but also turns the process into a fun game for both of you.
Actually, the questionnaire requires only basic items that you likely already have, such as a ball, paper, and crayons. Its design considers the typical home environment, making it accessible and practical.
While it helps in identifying delays, its primary purpose is broader. It aims to understand a child's current developmental stage across various domains, including communication, motor skills, problem-solving, and personal-social development.
Though thorough, the questionnaire is designed to be completed relatively quickly. Its structure allows for a straightforward assessment, ensuring that neither the child nor the adult feels overwhelmed by the process.
The ASQ is a developmental screening tool meant for all children within the specified age range, not just those who may appear to have developmental delays. Regular completion can track a child's growth and development over time.
This is incorrect. The ASQ is a screening tool designed to identify children who may need further evaluation. It does not diagnose; rather, it signals whether a professional assessment is advisable.
Sharing the results with childcare providers or educators can be beneficial. It fosters a cooperative approach to supporting the child’s development in both home and educational settings.
The Ages & Stages Questionnaires® (ASQ) 54 Month Questionnaire is a comprehensive tool designed to help parents, guardians, and educators assess the developmental progress of children aged 51 to 56 months. Below are ten key takeaways for effectively filling out and utilizing this form.
By meticulously filling out and analyzing responses on the ASQ 54 Month Questionnaire, parents, guardians, and educators can play a pivotal role in recognizing a child's developmental achievements and identifying areas where the child may benefit from additional support or enrichment.
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