Ages & Stages Questionnaire® and Ages & Stages Questionnaire

Ages & Stages Questionnaire® and Ages
& Stages Questionnaire®: Social‐
Emotional
Data Dictionary
ASQ: Ages and Stages Questionnaire®: screens children for developmental concerns. The
screening examines five (5) developmental domains:
1. Communication, 2. Gross motor, 3. Fine motor, 4. Problem-solving, 5. Personal-Social
ASQ: SE: Ages and Stages Questionnaire®: Social-Emotional: screens children for social and
emotional concerns.
Don’t Know: Don’t know is an answer option for several of the items and should be used by
workers when they legitimately do not know the answer to the item.
Missing: Missing is an answer option for several of the items. This is an option is to be used
when the information is not available for data entry. It is to indicate that a question was not
answered or left blank.
ASQ Child Form
Child Case No.- Enter the code that your county uses to identify the child in your records and or
files. The field accepts numbers and letters so it can accommodate most record systems. This is
a required field so data entry cannot advance if the field is blank. If your county does not use file
numbers please use the child’s last name or birth date.
Most recent case opening date: This is the date that the most recent case was opened or the
referral date.
Child’s Due Date of Birth: This is the estimated due date that a medical professional calculates
and shares with the mother. Screeners of children will need this information in order to calculate
the child’s developmental age. It is not a required field since it might not be collected on all
youth and some informants (i.e. foster parents) might not know the information.
Child’s birth weight: This is the child’s weight measured at birth. It is not a required field since
some informants may not know the information. Birth weight, particularly low birth weight, is a
risk factor for developmental concerns.
Was the child in the NICU: The NICU is the Neonatal Intensive Care Unit. Treatment in the
NICU is an indicator of risk for developmental concerns.
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required to copy, download or use any text, photographs or image files. All references to ASQ or Ages & Stages are protected by applicable
copyright laws. Copyright © 2009 ASQ is a registered trademark of the College Entrance Examination Board.

Is the child the subject or target child of a current referral to child welfare?: Some counties may
conduct screenings on children in the home who were not the subject of the initial report to the
Children and Youth Agency.
Maltreatment Types:
• Caregiver Substance Abuse
• Caregiver’s Mental Health
• Child behavior concerns
o Child sexually acting out
o Aggressive acts
• Domestic violence in the home
• Don’t Know
• Failure to Protect
o Failure to protect a child from a third party (i.e. child left with a known abuser)
o Lack of parental control
o Conduct by caregiver that places child at risk (i.e. exposure to illegal activites)
• Lacking basic needs
o Environmental concerns
o Inadequate shelter
o Inadequate food
o Inadequate clothing
o Inadequate health care
o Inadequate hygiene
• Other (explain in notes category)
• Parenting concerns
o Caregiver’s inability to cope
o Inappropriate discipline
o Caregiver/Child conflict
• Physical abuse
Any recent act or failure to act by a perpetrator that causes non-accidental
serious physical injury to a child under 18 years of age i . Serious physical injury to a child is
a physical condition that:
o Causes severe pain; or
o Significantly impairs functioning, either temporarily or permanently.
• Physical maltreatment
o Any behavior that does not meet the definitions of physical abuse.
• Physical neglect
All documents, webpages, photographs and images are the property of the University of Pittsburgh, except where noted. Permission is
required to copy, download or use any text, photographs or image files. All references to ASQ or Ages & Stages are protected by applicable
copyright laws. Copyright © 2009 ASQ is a registered trademark of the College Entrance Examination Board.

o Serious physical neglect by a perpetrator is prolonged or repeated lack of care or the
failure to provide the essentials of life, including adequate medical care, which
endangers a child's life or development or impairs the child's functioning
• Serious mental or emotional abuse
o Any act or failure to act by a perpetrator that causes non-accidental serious
mental injury to a child under 18 years of age. Serious mental injury is a
psychological condition, as diagnosed by a physician or licensed psychologist,
including the refusal of appropriate treatment, that:
o Renders a child chronically and severely anxious, agitated, depressed, socially
withdrawn, psychotic or causes reasonable fear that the child's life or safety is
threatened; or
o Seriously interferes with a child's ability to accomplish age-appropriate
developmental and social tasks.
• Sexual abuse:
o any act or failure to act by a perpetrator that causes sexual abuse or sexual
exploitation of a child under 18 years of age ii ;
o the employment, use, persuasion, inducement, enticement or coercion of a child
to engage in or assist another individual to engage in sexually explicit conduct iii .
o the employment, use, persuasion, inducement, enticement or coercion of a child
to engage in or assist another individual to engage in simulation of sexually
explicit conduct for the purpose of producing visual depiction, including
photographing, videotaping, computer depicting and filming.
o any of the following offenses committed against a child: rape iv , sexual assault v ,
involuntary deviate sexual intercourse vi , aggravated indecent assault vii ,
molestation, incest viii , indecent exposure ix , prostitution x , sexual abuse, sexual
exploitation.
• Sibling was primary referral; explain in notes category
• Student Abuse:
Serious bodily injury to or sexual abuse or exploitation of a student by an employee.
(i.e. a teacher or a daycare provider).
• Supervisory neglect:
Includes, but is not limited to, the following situations or actions by a caregiver;
o Children who are abandoned or parent refuses to take care of the child.
o Children who are left unsupervised or inadequately supervised.
Are there additional children in this household being screened: Is there another child in the
home that is also receiving an ASQ screening.
All documents, webpages, photographs and images are the property of the University of Pittsburgh, except where noted. Permission is
required to copy, download or use any text, photographs or image files. All references to ASQ or Ages & Stages are protected by applicable
copyright laws. Copyright © 2009 ASQ is a registered trademark of the College Entrance Examination Board.

ASQ Caregiver Form
Relationship to child: How is the caregiver related to the child?
Caregiver’s highest level of education: This is the caregiver’s highest level of education. If a
caregiver has a bachelor’s degree it is understood that they also have satisfied the requirements
to receive a diploma or GED and so only the bachelor’s degree needs to be selected. Screeners
generally collect education information on caregivers as part of the screening process.
ASQ Entry Form
Screening administered by: asks which agency conducted the screening.
• Child Welfare staff- staff from the county’s children and youth agency
• County MH/MR staff
• Early Intervention provider- a private agency contracted by the county to conduct early
intervention screenings and provide services.
• Other- screener that does not belong in any of the previous categories. An example might
be a private physician or a family center.
• Don’t Know- use when it is unknown who conducted the screening.
Screening methods: how did the screener gather the information to conduct the assessment?
• Don’t Know: used when it is unknown what method was used
• Interview: Discussion with the parent or caregiver that elicits information about what
they have observed and experienced related to a child’s behavior and skills.
• Observation: systematic recording of observations of the child's development/skills in
order to make a determination about what has been learned and support children's
progress.
• Test: requiring the child to demonstrate a skill of behavior.
Areas of concern: the ASQ evaluates five (5) developmental domains; these domains are the
areas of concern.
• Communication
• Gross motor
• Fine motor
• None- there are no areas of concern and should be selected if there were no areas of
concern.
• Problem-solving
• Personal-Social
Date of Referral to EI: this is the date that the child was REFERRED for an MDT evaluation or
other further evaluation; not the date of the MDT/other evaluation.
All documents, webpages, photographs and images are the property of the University of Pittsburgh, except where noted. Permission is
required to copy, download or use any text, photographs or image files. All references to ASQ or Ages & Stages are protected by applicable
copyright laws. Copyright © 2009 ASQ is a registered trademark of the College Entrance Examination Board.

ASQ: SE Form
Screening administered by: asks which agency conducted the screening.
• Child Welfare staff- staff from the county’s children and youth agency
• County MH/MR staff
• Early Intervention provider- a private agency contracted by the county to conduct early
intervention screenings and provide services.
• Other- screener that does not belong in any of the previous categories. An example might
be a private physician or a family center.
• Don’t Know- use when it is unknown who conducted the screening.
Areas of concern: the ASQ:SE screening assesses children’s social and emotional development.
Each developmental assessment has established criteria and based on the child’s score which
determines whether a referral for a further evaluation maybe indicated.
• Did not meet the threshold: indicates that the child’s score did not exceed the threshold
and a referral was NOT indicated.
• Met the threshold: indicates that the child’s score met or exceeded the threshold and a
referral was indicated.
Screening methods: how did the screener gather the information to conduct the assessment?
• Don’t Know: used when it is unknown what method was used
• Interview: Discussion with the parent or caregiver that elicits information about what
they have observed and experienced related to a child’s behavior and skills.
• Observation: systematic recording of observations of the child's development/skills in
order to make a determination about what has been learned and support children's
progress.
• Test: requiring the child to demonstrate a skill of behavior.
Date of Referral to EI: this is the date that the child was REFERRED for an MDT evaluation or
other further evaluation; not the date of the MDT/other evaluation.
.
All documents, webpages, photographs and images are the property of the University of Pittsburgh, except where noted. Permission is
required to copy, download or use any text, photographs or image files. All references to ASQ or Ages & Stages are protected by applicable
copyright laws. Copyright © 2009 ASQ is a registered trademark of the College Entrance Examination Board.

i Perpetrator‐ person who has committed child abuse and is: a parent of a child, a paramour of a child’s parent, an
individual 14 years of age or older residing in the same homes as the child, A person responsible for the child’s
welfare‐ this person maybe under the age of 14.
ii Exploitation is any of the following: looking at the sexual or other intimate parts of a child for the purpose of
arousing or gratifying sexual desire in either person, engaging or encouraging a child to look at the sexual or other
intimate parts of another person for the purpose of arousing or gratifying sexual desire in any person involved,
engaging or encouraging a child to participate in any sexually explicit conversation either in person, by telephone,
by computer or computer aided device.
iii Sexually explicit conduct is the employment, use , persuasion, inducement, enticement or coercion of any child
to engage in or assist in any sexually explicit conduct, not just for the purposes of visual depiction.
iv Engaging in sexual intercourse with a child: by forcible compulsion; by threat of forcible compulsion that would
prevent resistance by a person of reasonable resolution; who is unconscious or where the perpetrator knows that
the child is unaware that sexual intercourse is occurring; where the alleged perpetrator has substantially impaired
the child’s power to appraise or control his or her conduct by administering or employing, without the knowledge
of the child drugs, intoxicants or other means for the purpose of preventing resistance; who suffers from a mental
disability which renders the child incapable of consent; or a child who is less than 13 years of age.
v Engaging in sexual intercourse or deviate sexual intercourse with a child without the child’s consent.
vi Engaging in deviate sexual intercourse with a child: by forcible compulsion, by threat of forcible compulsion that
would prevent resistance by a person of reasonable resolution; the child is unconscious or the alleged perpetrator
knows that the child is unaware the indecent contact is occurring; the alleged perpetrator has substantially
impaired the child’s power to appraise or control his or her conduct by administering or employing, without the
knowledge of the child, drugs, intoxicants, or other means for the purpose of preventing resistance; the child
suffers from a mental disability which renders him or her incapable of consent; the child is less than 13 years of
age; the child is less than 16 years or age and the perpetrator is for or more years older than the child and they are
not married to each other.
vii Engaging in penetration, however slight of the genitals or rectum of a child with a part of the perpetrator’s body
for any purpose other than good faith medical, hygienic or law enforcement procedures: without the child’s
consent; by forcible compulsion; by threat of forcible compulsion that would prevent resistance by a person of
reasonable resolution; the child is unconscious or the alleged perpetrator knows that the child is unaware that the
penetration is occurring; the alleged perpetrator has substantially impaired the child’s power to appraise or
control his or her conduct by administering or employing, without the knowledge of the child, drugs, intoxicants or
other means for the purpose of preventing resistance; the child suffers from a mental disability which renders him
or her incapable of consent; the child is less than 13 years of age; the child is less than 16 years of age and the
alleged perpetrator is four or more years older than the child and they are not married to each other.
viii An alleged perpetrator who knowingly marries, cohabits or has sexual intercourse with an ancestor, descendant,
a brother or sister of the whole or half blood, or an uncle, aunt, nephew or niece of the whole blood. The
relationships referred to include blood relationships without regard to legitimacy, and relationship of parent and
child by adoption.
ix Exposing of the genitals in any public place where there are other persons under circumstances that the alleged
perpetrator knows or should know that this conduct is likely to offend, affront or alarm.
x Any person who is an inmate of a house of prostitution or otherwise engaging in sexual activity as a business; or
loitering in or within view of any public place for the purpose of being hired to engage in sexual activity.
All documents, webpages, photographs and images are the property of the University of Pittsburgh, except where noted. Permission is
required to copy, download or use any text, photographs or image files. All references to ASQ or Ages & Stages are protected by applicable
copyright laws. Copyright © 2009 ASQ is a registered trademark of the College Entrance Examination Board.