Questionnaire a First Step to Find Developmental Delays

The commonly used but sometimes debated Ages and Stages Questionnaire (ASQ), has modest utility for identifying developmental delays in young children, an Australian review and meta-analysis found.

On this easily administered parent-completed screening tool, scores of more than 2 standard deviations below the mean in more than one of five domains had moderate sensitivity and specificity to predict any delay, severe delay, motor delay, and cognitive delay, according to neonatologist Shripada Rao, PhD, a clinical associate professor in the neonatal intensive care unit at Perth Hospital and the University of Western Australia, also in Perth, and colleagues.

If a child of 12-60 months passes all ASQ domains, there is a moderate probability that child does not have severe developmental delay, the researchers concluded. If a child in that age range fails the motor or cognitive domain, there is a moderate probability that some motor or cognitive delay is present. The authors say the tool may work best as a screening test to identify children in need of more formal assessment.

“Our meta-analysis found that ASQ was somewhat more predictive in older children (older than 24 months), compared with younger age groups of 12-24 months,” Rao said in an interview. “However, the sample size for these comparisons was too small to reach definite conclusions, and we have called for future studies to evaluate ASQ separately for different age groups.”

Early identification of developmental delay in children is essential to enable timely intervention,” Rao and associates wrote in JAMA Pediatrics.

While formal assessments such as the Bayley Scales of Infant and Toddler Development are the gold standard, they are time-consuming and expensive, need the physical attendance of both the child and caregivers, and “thus may not be feasible in resource-limited settings or in pandemic conditions.”

According to Barbara J. Howard, MD, commenting on a recent update to the Center for Disease Control and Prevention’s developmental milestones guide, Learn the Signs. Act Early, fewer than 25% of children with delays or disabilities receive intervention before age 3 and most with emotional, behavioral, and developmental condition, other than autism spectrum disorder receive no intervention before age 5.


As an accessible alternative, the ASQ consists of questions on communication (language), gross-motor, fine-motor, problem-solving (cognitive), and personal-adaptive skills. The survey requires only 10-15 minutes, is relatively inexpensive, and also establishes a sense of parental involvement, the authors noted.

“Based on the generally accepted interpretation of LR [likelihood ratio] values, if a child passes ASQ-2SD, there is a moderate probability that the child does not have severe delay,” the investigators concluded.

The Analysis

The final meta-analysis reviewed 36 eligible ASQ studies published from 1997 to 2022. Looking at the four indicators of pooled sensitivity, specificity, and positive and negative likelihood ratios, the following respective predictive values emerged for scores of more than 2 SDs below the mean across several domains: sensitivity of 0.77 (95% confidence interval, 0.64-0.86), specificity of 0.81 (95% CI 0.75-0.86), positive likelihood ratio of 4.10 (95% CI 3.17-5.30), and a negative likelihood ratio of 0.28 (95% CI, 0.18-0.44)

They cautioned, however, that the certainty of evidence from the reviewed studies was low or very low and given the small sample sizes for comparing domains, clinicians should be circumspect in interpreting the results.

An Initial Step

Commenting on the paper but not involved in it, David G. Fagan, MD, vice chairman of pediatric ambulatory administration in the department of pediatrics at Cohen Children’s Medical Center, New York, agreed that screening tools such as the ASQ have a place in clinical practice. “However, the purpose of a screening tool is not to make the diagnosis but to identify children at risk for developmental delays,” he said in an interview. “The meta-analysis highlights the fact that no screening is 100% accurate and that results need to be interpreted in context.

“Before screening tools were widely used, pediatricians trusted their gut,” Fagan continued. “‘I know it when I see it,’ which obviously resulted in tremendous variability based on experience.”

He added that, even if a child passes this validated questionnaire, any concern on the part of a parent or pediatrician about developmental delay should be addressed with further assessment.

The Future

According to Rao, clinicians should continue to screen for developmental delays in young children using the ASQ. “Given the long wait times to see a developmental pediatrician or a clinical psychologist, a screening tool such as ASQ will enable appropriate triaging.”

Going forward, however, studies should evaluate this questionnaire separately for different age groups such as less than 12 months, 12-23 months, and at least 24 months. They should also be prospective in design and entail a low risk of bias, as well as report raw numbers for true and false positives and negatives. “Even if they use their own cutoff ASQ scores, they should also give results for the conventional cutoff scores to enable comparison with other studies,” the authors wrote.

The authors disclosed no specific funding for this study and no competing interests. Fagan disclosed no competing interests with regard to his comments.

This article originally appeared on, part of the Medscape Professional Network.

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