Results of Screening Questionnaire

Screened by: Erica Noel

Email: enoel@kent.edu Phone: 330-831-3438

Child’s Name: A.Y. Parents: E.N. & J.Y.

Child’s Date of Birth: June 25, 2017 Date of Screening: February 4, 2018

Child’s Chronological Age: 7 months, 10 days Location of Screening: Grandma’s house

Child’s Adjusted Age: N/A

Reason for Referral: A.Y.’s parents completed a 6-month Ages & Stages Questionnaire-Third
Edition (ASQ-3) and a 6-month Ages & Stages Questionnaire: Social Emotional-Second Edition
(ASQ:SE-2) as part of an assignment for Erica Noel’s Assessment and Evaluation course at Kent
State University.

Background information: A.Y. is the youngest child of the family. She lives with her 2-year
old brother, mother, father, paternal grandparents, and 2 paternal uncles. A.Y. stays at home
during the day with her mother and brother. She enjoys going for walks in her stroller, playing
on the floor with her toys, eating, and interacting with her family. A.Y. was born full-term, and
her parents have no concerns with her development.

Current Assessment: The 6-month ASQ-3 and ASQ:SE-2 were administered by an Early
Intervention Student from Kent State University. The ASQ-3 and ASQ:SE-2 are the two first
step measures to help parents check their child’s development and was used to provide a
screening of A.Y.’s development in the following domains: communication (e.g. making sounds
and recognizing sounds), gross motor (e.g. rolling over, sitting up), fine motor (e.g. holding toys,
picking up Cheerio), problem solving (e.g. trying to reach a toy she has dropped, holding one toy
in each hand), and personal social (e.g. reaching for herself in the mirror, trying to get a toy out
of reach). Results from the ASQ-3 and the ASQ:SE-2 can identify A.Y.’s strengths as well as
areas she may need extra support. Scores in each domain are compared to a cutoff score that is
used to determine whether a child’s development appears to be on schedule. For ASQ-3, scores
below the cutoff indicate that more support of further evaluation may be recommended. For
ASQ:SE-2, scores above the cutoff indicate that additional support or evaluation may be
recommended.
 Summary of Scores

A.Y.’s Scores ASQ-3/ASQ:SE Cutoff Score*

Communication 50 33.06

Gross Motor 40 30.61

Fine Motor 60 40.15

Problem Solving 60 36.17

Personal-Social 50 35.84

Social emotional 5 45

Communication, Fine Motor, Problem Solving, Personal-Social, and Social Emotional:

A.Y. scored well above the cut-off score in Communication, Fine Motor, Problem Solving,
Personal-Social, and Social Emotional areas. This means that A.Y.’s development appears to be
on schedule when compared to children of her same age.

Gross Motor: A.Y. scored 40 points in the Gross Motor domain, which is close to the
established cut-off. Scores that are close to the cut-off suggest that a child may need support or
exposure to more learning activities in this area, and that her development should be monitored
in this area. If caregivers express concerns related to development in this area, further evaluation
may also be warranted.

Overall Questions: A.Y.’s parents did not have any concerns regarding her health and
development except for overall questions #2, which asks about standing with feet flat on the
floor. Parent’s reported that A.Y. stands on her tippy toes more often then her flat feet.

Recommendations: In general A. Y.’s development appears to be on schedule. She is starting to

make sounds and responds to sounds she hears. She is sitting independently and rolling to get to
her toys. A.Y. is picking up Cheerios with her thumb and all of her fingers in a raking motion,
and she is picking up a toy with one hand. She puts toys in her mouth, and tries to get toys she
has dropped when she is lying on her back. She is able to feed herself a cracker and she puts her
foot in her mouth. However, A.Y. is not yet doing doing all of the skills expected of her age in
the gross motor domain. Recommendations include continuing to provide A.Y. with multiple
opportunities for tummy time during the day and encourage her to get onto her hands and knees.
To encourage A.Y. to stand and play at the furniture place some of her favorite toys on the couch
for her to reach for. Continue with your regular activities with A.Y. such as reading books and
playing with age appropriate toys while on the floor. I am providing you with a list of some other
ideas for easy age appropriate activities that are designed to support children’s development in
each developmental domain (Ages and Stages Learning Activities), so you can continue to foster
A. Y.’s development. If you have any questions, please let me know. It is recommended that you
screen A.Y.’s development again in 6-months. Contact your Early Intervention Program for the
screening. The website for Early Intervention in Ohio is https://ohioearlyintervention.org.
Student signature and date:

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*For ASQ-3, scores below the cutoff score indicate that further evaluation may be
recommended; for ASQ:SE, scores above the cutoff score indicate that further evaluation may be
recommended.