18 MONTH ASQ: SE QUESTIONNAIRE

Please provide the following information.

Child's Name

Child's Date of Birth:

Today's Date:

Person filling out this questionnaire:

What is your relationship to the child?

Your telephone:

Your mailing address:

City:

State:

Zip Code:

List people in assisting questionnaire completion:

Administering program or provider:

Please read each question carefully and

1. Check the box that best describes your child's behavior and
2. Check the circle if this behavior is a concern.

1. Does your child look at you when you talk to him?

Most of the time (z)

Sometimes (v)

Rarely or Never (x)

Is this a concern?

Yes No

2. When you leave, does your child remain upset and cry for more than an hour?

Most of the time (x)

Sometimes (v)

Rarely or never (z)

Is this a concern?

Yes No

3. Does your child smile or laugh when you play with her?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

4. Does your child look for you when a stranger approaches?

Most of the time (x)

Sometimes (v)

Rarely or never (z)

Is this a concern?

Yes No

5. Is your child's body relaxed?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

6. Does your child liked to be hugged or cuddled?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

7. When upset, does your child calm down within 16 minutes?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

8. Does your child stiffen and arch his back when picked up?

Most of the time (x)

Sometimes (v)

Rarely or never (z)

Is this a concern?

Yes No

9. Does your child cry, scream, or have tantrums for long periods of time?

Most of the time (x)

Sometimes (v)

Rarely or never (z)

Is this a concern?

Yes No

10. Is your child interested in things around her, such as people, toys, and food?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

11. Does your child do thins over and over and can't seem to stop? Examples are rocking, hand flapping, spinning, or (kindly indicate using space provided below)?

Most of the time (x)

Sometimes (v)

Rarely or never (z)

Is this a concern?

Yes No

You may write in something else.

12. Does your child have eating problems, such as stuffing, vomiting, eating nonfood items, or (kindly indicate other problems on the space provided below)?

Most of the time (x)

Sometimes (v)

Rarely or never (z)

Is this a concern?

Yes No

You may write in other problems.

13. Does your child have trouble falling asleep at naptime or night time?

Most of the time (x)

Sometimes (v)

Rarely or never (z)

Is this a concern?

Yes No

14. Do you and your child enjoy mealtimes together?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

15. Does your child sleep at least 10 hours within a 24-hour period?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

16. When you point at something, does your child look in the direction you are pointing?

Most of the time (x)

Sometimes (v)

Rarely or never (z)

Is this a concern?

Yes No

17. Does your child get constipated or have diarrhea?

Most of the time (x)

Sometimes (v)

Rarely (z)

Is this a concern?

Yes No

18. Does your child let you know how she is feeling with gestures or words? For examples, does she let you know when she is hungry, hurt, or tired?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

19. Does your child follow simple directions? For example, does he sit down when asked?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

20. Does your child like to play or be near with family member and friends?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

21. Does your child check to make sure you are near when exploring new places, such as a park or a new friend's home?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

22. Does your child like to hear stories or sing songs?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

23. Does your child hurt herself on purpose?

Most of the time (x)

Sometimes (v)

Rarely or never (z)

Is this a concern?

Yes No

24. Does your child like to be around other children?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

25. Does your child try to hurt other children, adults, or animals (for example, by kicking or biting)?

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

26. Has anyone expressed concerns about your child's behaviors.

Most of the time (z)

Sometimes (v)

Rarely or never (x)

Is this a concern?

Yes No

If you checked "sometimes" or "most of the time", please explain.

27. Do you have concerns about your child's eating or sleeping behaviors?

Yes No

If so, please explain.

28. Is there anything else that worries you about your child?

Yes No

If so, please explain.

29. What things do you enjoy most about your child?

18 MONTH ASQ: SE INFORMATION SUMMARY

Scoring Guidelines

Make sure the parent has answered all questions and has checked the concern column as necessary. If all questions have been answered, go to Step 2. If not all questions have been answered, you should first try to contact the parent to obtain answers, or if necessary calculate an average score (see pages 39 and 41 of The ASQ: SE User's Guide).
Review any parent comments.If there are no comments, go to Step 3. If a parent has written in a response, see the section titled "Parent Comments" on pages, 39, 41, and 42 of the The ASQ: SE User's Guide to determine if the response indicates a behavior that may be of concern.
Using the following point system:

Z (for zero) next to the check box = 0 points
V (for Roman Numeral V) next to the check box = 5 points
X (for Roman Numeral X) next to the check box = 10 points
Checked concern = 5 points

Add together:

Child's Total Score

Score Interpretation

1. Review Questionnaires

Review the parent's answers to questions. Give special consideration to any individual questions that score 10 to 15 points or any written or verbal comments that the parent shares. Offer guidance, support, and information to families, and refer if necessary, as indicated by score and referral considerations.

2. Transfer child's total score.

In the table below, enter the child's total score (transfer total score from above).

Questionnaire Interval

Cut of Score

Child's ASQ-SE Score

3. Referral Criteria

Compare the child's score with the cutoff in the table above. If the child's score fall about the cutoff and the factors in Step 4 have been considered, refer the child for a mental health evaluation.

4. Referral considerations

It is always important to look for assessment information in the context of other factors influencing a child's life. Consider the following variables prior to making referrals for a mental health evaluation. Refer to pages 44-46 in The ASQ:SE User's Guide for additional guidance related to these factors and for suggestions for follow-up.

Setting time factors (e.g. Is the child's behavior the same at home as at school?, Have there been any stressful events in the child's life lately?)
Development factors (e.g. Is the child's behavior related to a developmental stage or a developmental delay?)
Health factors (e.g. Is the child's behavior related to health or biological factors?)
Family/cultural factors (e.g. Is the child's behavior acceptable given cultural or family context?)

Your information will be encrypted.