(For infants ages 15 through 18 months)

Please correct the errors described below.

Please provide the following information.

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.


Scoring Guidelines

  1. 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).
  2. 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.
  3. 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:

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).

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?)

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