Savannah Theil

Results of Screening Questionnaire

Child’s Name: CT Parents: KT & RT

Child’s Date of Birth: February 26, 2021 Date of Screening: February 18, 2024

Child’s Chronological Age: 35 months, 23 days Location of Screening: Family’s house

Child’s Adjusted Age: N/A

Reason for Referral: CT’s parents completed a 36-month Ages & Stages Questionnaires-Third
Edition (ASQ-3) and a 36-month Ages & Stages Questionnaires: Social Emotional-Second
Edition (ASQ:SE-2) as part of a school assignment for the administrator of the screenings.

Background information: CT is an only child and lives with his mother and father, who both
work full time jobs. CT attends the Kent State Child Development Center 5 days a week in a
mixed-age toddler classroom. CT’s parents report that he enjoys reading, playing with his toys,
and occasionally watching short kids’ TV shows. Mom had placenta previa, and was considered
high-risk during pregnancy. CT was born 3 weeks premature.

Current Assessment: The 36-month ASQ-3) and ASQ:SE-2 were administered by a student in
the Early Childhood Special Education Program for a class assignment. The ASQ-3 and
ASQ:SE-2 are two first step measures to help parents check their child's development and was
used to provide a screening of CT’s development in the following domains: communication (e.g.
understanding others and using words), gross motor (e.g., walking, throwing a ball), fine motor
(e.g., pushing buttons, eating with a spoon), problem solving (e.g., making toys work, learning
how to do things), personal social (e.g., showing interest in others, feeding self), and social
emotional (e.g., laugh and smile during play, calm down within 15 minutes when upset). Results
from the ASQ-3 and the ASQ:SE-2 can identify CT’s strengths as well as areas where he 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

CT’s Scores ASQ-3/ASQ:SE-2 Cutoff Score

Communication 55 30.99
Gross Motor 60 36.99
Fine Motor 45 18.07
Problem Solving 60 30.29
Personal-social 55 35.33
Social Emotional 30 105

Gross Motor, Fine Motor, Problem Solving, and Personal-social: CT scored well above the
scored well above the cut-off score in the Gross Motor, Fine Motor, Problem Solving, and
Personal-social areas. This means that CT’s development appears to be on schedule when
compared to children of his same age.

Communication and Social Emotional: CT scored well above the cut-off score in the
Communication area. He also in the lower half of the no or low risk range in the Social-
Emotional area. This means that CT’s development appears to be on schedule in both areas when
compared to children of his same age.

Overall Questions: CT’s parents did not have any concerns regarding his health and
development.

Recommendations: In general, CT’s development appears to be on track with typical

development. No recommendations for further action at this time. Continue your regular
activities with CT such as reading books and playing with age-appropriate toys.