Ages & Stages Questionnaires®: Social-Emotional ‘A Parent-Completed, Child-Monitoring System for Social-Emotional Behaviors By Jane Squires, Diane Bricker, & Elizabeth Twombly with assistance from Suzanne Yockelson, Maura Schoen Davis, & Younghee Kim | Copyright © 2002 by Paul H. Brookes Pubishing Co. } ASQéSE 48 Month/4 Year Questionnaire (For children ages 42 through 58 months) Important Points to Remember: @ Please return this questionnaire by if you have any questions or concerns: about your child or about this questionnaire, please call: ee Thank you and please look forward to filling out another ASQ:SE questionnaire ir months. ASQ@SEAgos & Stages Questionnaires®: Social-Emotional A Parent-Completed, Child-Monitoring System for Social-Emotional Behaviors | By Jane Squires, Diane Bricker, & Elizabeth Twombly with assistance from Suzanne Yockelson, Maura Schoen Davis, & Younghee Kim | Copight © 2002 by Paul H. Brookes Publshing Co | 48 Month/4 Year ASQ:SE ~ Questionnaire © (For children ages 42 through 53 months) Please provide the following information. Child's name: Child's date of birth: - Today's date: Person filing out this questionnaire: What is your relationship to the child? Your telephone: Your mailing address: city: State: ‘up code: — List people assisting in questionnaire completion: —————— ‘Administering program or provider: eaePlease read each question carefully and 4. Check the box © that best describes your child's behavior and 2. Check the circle O if this behavior is a concern 4, Does your child took at you when you talk to him? 2. Does your child cling to you more than you expect? 3. Does your child talk and/or play with adults she knows well? 4, When upset, can your child calm down within 16 minutes? 5, Does your child like to be hugged or cuddled? 8. Does your child seem too friendly with strangers? 7. Can your child settle himself down after periods of exciting activity? 8. Does your child cry, scream, or have tantrums for long periods of time? 9. Is your child interested in things around her, such as people, toys, and foods? ‘Ages & Stagas Quotanstes®: SoclaEmotiona, S109 9 (Sioa Paul Brookes Pushing Co. Most OF THE TIME Qz Qz Qz Qz Q: RARELY OR SOMETIMES NEVER av Ox : Qv Qz QQ ox Qv Ox Qv ux av av Qv CHECK IF THSISA CONCERN Go5 CHECK IF THSIBA SOMETIMES: CONCERN | 10. Does your child stay dry during the day? Does your child have eating problems, such as stuffing foods, vomiting, eating nonfood items, or 2 (You may write in another problem.) Do you and your child enjoy mealtimes together? Does your child do what you ask her to do? Does your child seem happy? Does your child sleep at least 8 hours ina 24-hour period? ‘Does your child seem more active than other children his age? Does your child use words to tell you what she wants or needs? Can your child stay with activities he enjoys for at least 10 minutes (not including watching television)? TOTAL POINTS ON PAGE — i ASQESE’ eee ‘Ages & Stages Qusstonnarad® Soil Emotions Squres el Goce Pa Brookes Putting Co,Raney | CHECKIF | OR; THISIGA SOMETIMES NEVER CONCERN Does your child use words to describe her feolings and the feelings of others, such as, “tm happy," “I don't like that," or "She's sad”? ax Can your child move from one activity to the next with little difficulty, such as from playtime to mealtime? Does your child explore new places, such as a park or a friend’s home? Does your child do things over and over ‘and can't seem to stop? Examples are rocking, hand flapping, spinning, or 7 (You may write in something else.) Does your child hurt himself on purpose? Does your child follow rules (at home, at chile care)? Does your child destroy or damage things on purpose? . Does your child stay away from dangerous things, such as fire and moving cars? ‘TOTAL POINTS ON PAGE sxe olny Stet : ASQSSE 48 monthalé years tages Quostonnaes®, ri Brokes Pushing Co f SCan your child name a friend? . Does your child show concern for other people's feelings? For example, does she look sad when someone is hurt? Do other children like to play with your child? Does your child like to play with other children? try to hurt other children, als (for example, by kicking or biting)? Does your child show an interest or knowledge: of adult sexual language and activity? Has anyone expressed concems about your child's behaviors? If you checked “sometimes” or *most of the time,” please explain: CHECK IF THIS IBA ‘CONCERN ‘ges 8 Sagoo Qusstennatod®: Seta! Emotlna, Sites 2 (fooce Poa. Brookes Pubisheg Co. TOTAL POINTS ON PAGE — ASQOSE «month years34, Do you have concerns about your child's eating, sleeping, or toileting habits? If so, please explain: 35. Is there anything that worries you about your child? If so, please explain: 36, What things do you enjoy most about your child? sa Spe eo sector santa ASQOSE’ 48 montnstt yoors48 Month/4 Year ASQ:SE Information Summary (Ohies name: (hike date of ir Person fing out the ASOLSE: Relationship to chi Maling secress: 3 oy: stat: a Telephone: ‘Asset in ASO:SE compli: Ty's date: ee ‘Administering programa: SCORING GUIDELINES 1. Make sure the parant has answered all questions and has checked the concern column as necessary I all questons have been answered, go 10 ‘Step 2. If not al questions have boen answered, you should fst tr to contact the parent to obtain answers or, if necessary, calculate an average soore (808 pages 39 and 41 of The ASQ:SE User's Gul) 2, Review any parent comments. there are no comments, go to Step 8. H a parent has writ n @ response, see the section tied “Parent Comments! (on pages 89, 41, and 42 of The ASQ:SE User's Guldo lo determine ifthe response indcales a behavior that may be of concern, 3. Using the falloning pint system: 2 (for 260) next othe checked box = O points (lor Roman numeral V) next to the checked box 5 prints X (lor Roman numeral X) pax tothe checked box 10 pots ‘Checked concer 5 points ‘Add together “ola pons on page 3 “Total points on page 4 “otal poins on page 5 puias “otal points on page & . Childs tata seo SCORE INTERPRETATION 1. Reviow questionnaires Review the parant’s answers to questions. Give spacial consideration fo any individual questions that score 10 oF 18 pons an any writen or ver bal comments thatthe parent chares. Ofer guidance, support, and information to familes, and rfor i nooossary, as indicate by score and referral considerations, 2, Thanstor chit total score In tho table below, onto the cis toll score (rancfor total core from above). Clete ASCASE scare 2, Retna ctonla Compare tho chi’ totalccore with he cut i the lable above the cis sooe fl above the oiot and he aco in Step 4 have been con- sléore, refer he child or @ mental heath evaluation 4, Rojeral considerations Its atnaysingotant to look at essessment formato inthe context of ther factors infuensing a cies e. Conde the folowing variables prior to making efor fr montalhoath evaluation Refor to pagos 4@-4 in The ASQ:SE User's Guide for addon guidance related to thes ta: tor and for suggestions for elowrup. + Setinghin fctors (@., Is te cds behavior the sam al home as at schoo, Have there been any sss events inthe childs le recent?) + Davslopment actors (@.9, 1s be chiles behavior rete toa dvelopmentl stage oa developmental dele?) + Heath actxs (6.3, 18 bw cles bahavoe lated to heath or bloga factors?) ‘+ Famlyfoutural factors (03, Is he childs behavior acceptable given cultural or arly context?) AS Ages & Stages Cunaerasitd® Soctatmotona, Squtes a 2 (672002 Pal H Brooke Patsnng Co, QE’ 48 month years