Concurrent validity of the parent-completed Ages and Stages ...

Child: care, health and development
Original Article doi:10.1111/j.1365-2214.2009.01041.x
Concurrent validity of the parent-completed Ages
and Stages Questionnaires, 2nd Ed. with the Bayley
Scales of Infant Development II in a low-risk sample
A. L. Gollenberg,*† C. D. Lynch,‡ L. W. Jackson,§ B. M. McGuinness¶ and M. E. Msall†
*Eunice Kennedy Shriver, National Institute of Child Health and Human Development; National Institutes of Health; Department of
Health and Human Services; Rockville, MD
†University of Chicago Comer Children’s Hospital, Department of Pediatrics, LaRabida Children’s Hospital and JP Kennedy Research
Center on Intellectual and Developmental Disabilities; Chicago, IL
‡The Ohio State University College of Public Health, Division of Epidemiology, Columbus, OH
§Case Western Reserve University; Department of Epidemiology & Biostatistics; Cleveland, OH
¶State University of New York at Buffalo. Department of Social and Preventive Medicine; Buffalo, NY, USA
Accepted for publication 12 August 2009
Keywords
child development,
developmental screening,
diagnostic tests,
sensitivity and specificity
Correspondence: Audra L.
Gollenberg, Epidemiology
Branch, Division of
Epidemiology,
Biostatistics, and
Prevention Research,
Eunice Kennedy Shriver
National Institute of Child
Health and Human
Development, 6100
Executive Boulevard,
Room 7B03. Rockville, MD
20892, USA
E-mail:
gollenba@mail.nih.gov
Background
Abstractcch_1041 485..490
Background This study assessed the concurrent validity of the Ages and Stages Questionnaire
(ASQ) compared with Bayley Scales of Infant Development II (BSID II) amongst children aged 24
months.
Methods Data were collected from 53 infants and mothers who participated in the New York State
Angler Cohort Child Development Study. Parents completed the 24-month ASQ to assess
communication, personal-social, problem-solving ability, and fine and gross motor control. The BSID
II was administered by a clinical psychologist at the 24-month home visit for cognitive and
psychomotor assessment. The ASQ was scored using age-specific norms of

486 A.L. Gollenberg et al.
administration. A screening instrument that can be administered
by parents may alleviate problems with the implementation
of more costly screening programmes, like the BSID II. The
Ages and Stages Questionnaires (ASQs) are a parent-completed
developmental monitoring system for screening large numbers
of children with ease of administration, low cost, and suitability
for diverse populations (Squires et al. 1999; Hix-Small et al.
2007).
While the ASQs have been validated against the BSID and
other standardized tests (Squires et al. 1997, 1998; Skellern et al.
2001), a validation of the ASQs has not been conducted exclusively
against the BSID II. However, one study validated the
ASQs against a combination of multiple developmental examinations,
one of which was the BSID II (Yu et al. 2007). As part of
a population-based longitudinal study of infant health and
development, we had the opportunity to assess the validity of
the 24-month ASQ as compared with the BSID II amongst
children aged 24 months.
Methods
Study population
We used data from infants born to mothers who participated
in the New York State Angler Cohort Prospective Pregnancy
Study (NYSAC PPS) from 1998–2002 (Senn et al. 2005). At
the time of post-partum blood collection, a research nurse
informed mothers of the prospective child development study
(NYSAC CDS) and requested informed consent for their
child’s participation. Because of a lag in funding, some children
were asked to participate after this time frame, but before
they reached age two. Data were collected via monthly diaries
and ASQs, 2nd edition, completed by parents or primary caregivers.
Parents completed the ASQs, 2nd edition, at various
time points, including at age 24 months for the assessment of
communication, socialization, fine motor control, gross motor
control, and problem-solving ability. Standardized physical,
psychological, and developmental assessments were conducted
by a clinical psychologist, research nurse, and developmental
paediatrician during home visits at 12 and 24 months of age.
The BSID II was administered to all children by the same
clinical psychologist at both home visits to assess cognitive and
psychomotor development and behavioural status within �2
weeks of the ASQ administration. The BSID II has three components,
the mental scale, the motor scale, and the behaviour
rating scale (BRS). The mental and motor scales are administered
via a series of questions and observations conducted by a
trained professional. Raw scores for the mental and motor scales
are converted to a standardized index for each age group with a
mean of 100 and standard deviation (SD) of 15, termed the
Mental Development Index (MDI) and the Psychomotor Development
Index (PDI), respectively. The BRS accounts for behavioural
aspects of the infant during the testing session that may
have affected cognitive performance, but is not used for screening
purposes (Bayley 1993).
In addition, the study psychologist administered the
Kaufman Brief Intelligence Test to mothers at the 12- or
24-month home visit to ensure the participating parents did not
have a significant cognitive limitation. Gestational age at delivery
was calculated by subtracting the last menstrual period date
that was collected during the NYSAC PPS from the date of
delivery (Senn et al. 2005). Infant birthweight was self-reported
by the mother at the first follow-up visit.
Data analysis
© 2009 The Authors
Journal compilation © 2009 Blackwell Publishing Ltd, Child: care, health and development, 36, 4, 485–490
Due to the missing data for the 12-month assessment resulting
from the funding lag, we limited our analysis to data collected at
the 24-month assessment. Agreement between the ASQs, 2nd
edition, and BSID II was determined by computing Spearman
rank-order correlation coefficients for ASQ domain scores
versus relevant BSID II mental and motor scores, as the data
were not normally distributed. ASQ communication, problemsolving,
and personal/social domains were compared with the
BSID II MDI, and ASQ gross motor and fine motor domains
were compared with the BSID II PDI.
Overall validity of the ASQ, 2nd edition compared with the
BSID II was determined by comparing pass/fail status on each
test. The ASQs were scored according to the manual (Squires
et al. 1999) using age-specific norms of less than two SDs below
the mean of any domain to define a failure. Failure on the BSID
II MDI and PDI was defined by two cut points based on an
age-standardized normal distribution of scores: a score of less
than one SD below the mean (i.e.

except for those infants who are born

488 A.L. Gollenberg et al.
Table 2. Cutpoints, median scores, and ranges for the Ages and Stages
Questionnaire (ASQ) domains and Bayley Scales of Infant Development
II (BSID II) indices at age 24 months, New York State Angler Cohort
Child Development Study (n = 40), 1998–2002
24 Month assessment
Pass/fail cutpoint Median Range
ASQ
Gross motor 36.0 60 0–60
Fine motor 36.4 55 25–60
Communication 36.5 60 25–60
Problem-solving 32.9 50 10–60
Personal/social
BSID II*
35.6 55 10–60
Mental Index (MDI) 85; 70 98 50–140
Psychomotor Index (PDI) 85; 70 96 50–110
*BSID II indices have two cut points:

is developing at a typical rate, while those who fail an ASQ
domain might be in need of developmental follow-up. Given
the low PPV, some children who screen positive with the ASQ
will be found upon further testing to be developing typically.
However, over-referrals in screening programmes are not
necessarily a problem and can provide an opportunity to assess
children’s needs for improvement as this group (i.e. falsepositives)
tends to score on the lower range of screening tools
and come from disadvantaged backgrounds (Glascoe 2001). To
this end, the use of ASQs as a screening tool will decrease the
number of children requiring a full developmental assessment
resulting in a cost-effective screening programme.
The negligible correlation between the ASQ fine motor
domain and the BSID II motor scale at 24 months was unexpected.
However, previous studies have speculated the BSID II is
less appropriate for assessing fine motor skills as compared with
gross motor skills based on the number of applicable questions
(Bayley 1993; Liao et al. 2005). Furthermore, the Yu et al. ASQ
validation study found similar results in that the fine motor and
problem-solving domains contributed little to neurosensory
disability detection (Yu et al. 2007), as compared with the other
ASQ domains.
The two main limitations of our study are the homogenous
nature of the study population and the modest sample size of a
low-risk nature. Given that the mothers of our study participants
were white, married, and of middle to upper socioeconomic
status, it was not unexpected that the distribution of
scores was restricted to the medium/high range on both screening
tools. This may explain, in part, why so few infants failed
both tests, thus limiting our ability to calculate sensitivity and
positive predictive value with great precision. However, since
the prevalence of severe developmental delay in our study (5%)
is similar to that reported by others (3.5–6.5%) (Boyle et al.
1994), our findings are likely generalizable to other low-risk US
populations. While our sample size was small, a comparison of
selected characteristics of those included in the analysis and
those without assessments showed that there were no significant
differences between the groups at 24 months. Given the high
costs associated with conducting in-home standardized assessments
like the BSID II, it is not uncommon for validation
studies to report small sample sizes (Skellern et al. 2001; Voigt
et al. 2003; Johnson et al. 2004; Liao et al. 2005). Nevertheless,
our findings should be interpreted with caution and should
serve as an impetus for additional work in this area.
It should be noted that while the BSID III became available in
2006, they do not yet appear to be widely used (Bayley 2006). In
addition to providing a new overall growth score, the main
difference between the BSID II and the BSID III is that the BSID
III was renormed to include clinical cases in the normative
sample (Bayley 2006). It has been reported that overall the BSID
III index scores have been found to be 7 points higher on
average as compared with the BSID II scores (likely due to the
renorming) (Bayley 2006).
We did not formally examine intra-rater reliability for
administration of the BSID II. However, one highly trained
clinical psychologist administered the BSID II to all children;
therefore, we do not believe that reliability was an issue in this
study.
In conclusion, our findings suggest that the ASQs are a valid
screening tool for the identification of infants with a severe
developmental delay at 24 months of age. The 24-month ASQ
provides a simple, cost-effective alternative to formal standardized
assessments for use in both screening programmes and
field-based research. Results of this study suggest that further
assessment of ASQ validity in larger, more diverse populations
of infants is warranted.
Acknowledgements
This work was supported, in part, by grants from the Great
Lakes Protection Fund (RM 791-3021), the Agency for Toxic
Substances and Disease Registry (H75/ATH 298328), and the
Gerber Foundation as well as intramural funds from the Eunice
Kennedy Shriver National Institute of Child Health and Human
Development, National Institutes of Health.
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Validity of Ages and Stages Questionnaires vs. BSID II 489
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The ASQs may be more effective at screening for severe
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The ASQs are a valid and cost-effective screening tool for
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