Results of Screening Questionnaire

Kaitlin Hards
khards@kent.edu

Child’s Name: Jack Parent: Jack’s mom

Child’s Date of Birth: March 2020 Date of Screening: 2/19/22
Child’s Chronological Age: 22 months, and 20 days.
Location of Screening: Jack’s home
Child’s Adjusted Age (if necessary): N/A

Reason for Referral: Jack’s parents completed an 22-month Ages & Stages Questionnaires-
Third Edition (ASQ-3) and a 24-month Ages & Stages Questionnaires: Social Emotional-Second
Edition (ASQ:SE-2) as part of an assignment for assessment and evaluation course at Kent state
university.

Background information: Jack is an only child who lives with his mother and father. His
mother is a board-certified behavior analyst, and his father works in sales. Jack’s family enjoys
reading and playing with him. His mother describes him as adventurous and silly. They are not
experiencing any delays or concerns currently.

Current Assessment: The 22-month ASQ-3 and ASQ:SE-2 were administered by a Kent state
student pursing an early intervention certificate. The ASQ-3 and ASQ:SE-2 are used to measure
the child’s development and identify any concerns the family may have. Results from the ASQ-3
and the ASQ:SE-2 identify Jack’s strengths as well as areas that he may need extra support.
Scores in each area are compared to a cutoff score and this helps determine a need for extra
support in each area. For the ASQ:SE-2, recommendations for further evaluation will be made
for scores lower than the cutoff. For the ASQ-3, recommendations for further evaluation will be
made for scores higher than the cutoff. The ASQ-3 screenings are used to provide a screening of
Jack’s development in the following domains: communication (e.g., using words), gross motor
(e.g., walking, jumping), fine motor (e.g., stacking blocks, turning pages of a book), problem
solving (e.g., getting snacks out of a container when they are stuck, rotating a bottle when it is
upside down), personal social (e.g., copying activities that parents engage in, caring for stuffed
animals like a child), and social emotional (e.g., self soothe after 5 minutes, smile and laugh
while playing). These results are listed below with cutoff scores for each domain.
 Summary of Scores

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

Communication 60 13.04
Gross Motor 60 27.75
Fine Motor 55 29.61
Problem Solving 45 29.30
Personal-social 60 30.07

Social emotional 25 110

Gross Motor, Fine Motor, Communication and Personal-social: Jack scored well above
the cut-off score in the Gross Motor, Fine Motor, communication, Problem Solving, and
Personal-social areas. When we compare these scores to children of Jacks age, he appears to be
on schedule in all of these areas. No further assessments are recommended at this time.

Social emotional: Jack scored well below the cut-off score in the social emotional area
according to the ASQ:SE-2 report. No further assessments are recommended at this time.

Overall Questions: Jack’s parents did not have any questions regarding Jack’s growth and
development currently.

Recommendations: In general Jack’s development appears to be on schedule. Jack is

completing all gross motor goals listed on this assessment including kicking his leg forward
without support, jumping with both feet, and walking up or down the stairs with added support.
Jack is using a couple 2-word combinations, saying 15 or more words, and identifying his body
parts when asked. Jack is utilizing fine motor and problem-solving skills to turn lids or book
pages, scribbling with a pencil, and flipping this right side up when given upside down. Some
suggestions to improve these skills include increasing Jack’s time with arts and crafts activities
to improve his imitation shills with art supplies. Jack is drinking from a cup with minimal
spillage, eating with a fork, and copying parents when performing simple actions. Jack is
showing great development in his social emotional assessment. He is calming his body within an
hour of being upset, eating well, and enjoying mealtime with his family, and recognizing his own
feelings with words or gestures). Jack’s mother expressed a concern regarding eating new foods
at the end of this assessment. It is suggested that Jack increases his time with new foods in fun
and art settings where he can play and touch new foods with no expectation to eat the food. It is
also suggested to continue monitoring his eating habits and reach out to a pediatrician if the
concern persists. If you would like some more suggestions for food crafts and play, please let me
know.
Kaitlin Hards-Kent state university
khards@kent.edu

Student signature and date: Kaitlin Hards 2/19/22