Results of Screening Questionnaire

Anna Faust
afaust6@kent.edu

Child’s Name: O Parents: AS & BS

Child’s Date of Birth: May 2021 Date of Screening: 02/19/21
Child’s Chronological Age: 9 months and 12 days Location of Screening: O’s House
Child’s Adjusted Age: N/A

Reason for Referral: O’s parents completed a 9-month Ages & Stages Questionnaires- Third Edition (ASQ-3) and
a 12-month Ages & Stages Questionnaires: Social Emotional-Second Edition (ASQ: SE-2) as part of a project.

Background Information: O is an only child and lives with her mother and father. Her father works full time and
her mother stays full time in the home. At just a little under 1-year-old, her parents have no concerns related to her
development at this time. Her parents report that they enjoy spending time interacting with O and that she is a very
smiley child.

Current Assessment: The 9-month ASQ-3 and 12-month ASQ: SE-2 were administered by a Kent State University
Graduate student studying speech-language pathology and early intervention, virtually to O’s parents at their home.
The ASQ-3 and ASQ: SE-2 are two first step measures to help parents check their child's development and were
used to provide a screening of O’s development in the following domains: communication, gross motor, fine motor,
problem-solving, personal-social, and social-emotional. Results from the ASQ-3 and the ASQ: SE-2 can identify O’s
strengths as well as areas where 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 or 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
Child’s Scores ASQ-3/ASQ:SE-2 Cutoff Score
Communication 40 13.97
Gross Motor 50 17.82
Fine Motor 60 31.32
Problem Solving 55 28.72
Personal-Social 50 28.72
Social Emotional 40 50
Communication, Gross Motor, Fine Motor, Problem Solving, and Personal-Social: O scored well above the
cut-off score in the Communication, Gross Motor, Fine Motor, Problem Solving, and Personal-social areas. This
means that O’s development appears to be on schedule when compared to children of the same age.

Social-Emotional: O scored 40 points in the Social-Emotional domain, which is close to the established cut-off.
Scores that are close to the cutoff suggest that a child may need support or exposure to more learning opportunities
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: O’s parents did not have any concerns regarding her health and development.

Recommendations:
In general O’s development appears to be on schedule. However, due to the concerns in the social-emotional domain
regarding joint attention, it may be helpful to refer O for further social-emotional, behavioral or mental health
evaluation to learn more about her needs. 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 the social-emotional domains. If you would like
some suggestions for additional activities in other developmental domains please let me know.

● Place your baby facing you. Your baby can watch you change facial expressions (big smile, poking out
tongue, widening eyes, raising eyebrows, puffing or blowing). Give your baby a turn. Do what your baby
does.
● Play voice games. Talk with a high or low voice. Click your tongue. Whisper. Take turns with your baby.
Repeat any sounds made by him. Place your baby so that you are face to face—your baby will watch as you
make sounds.
● Gently rub your baby with a soft cloth, a paper towel, or nylon Talk about how things feel (soft, rough,
slippery). Lotion feels good, too.

Student Signature and Date:

02-19-2022
_____________________________________________________________________________________

*For ASQ-3, scores below the cutoff score indicate that further evaluation may be recommended; for ASQ: SE-2,
scores above the cutoff score indicate that further evaluation may be recommended.