Research Article: ASQ3 and/or the Bayley-III to support clinicians’ decision making

Date Published: February 2, 2017

Publisher: Public Library of Science

Author(s): Robin Mackin, Nadya Ben Fadel, Jana Feberova, Louise Murray, Asha Nair, Sally Kuehn, Nick Barrowman, Thierry Daboval, Karen Lidzba.


Appropriate tools are essential to support a clinician’s decision to refer very preterm infants to developmental resources. Streamlining the use of developmental assessment or screening tools to make clinical decisions offers an alternative methodology to help to choose the most effective way to assess this very high-risk population.

To examine the influence of the Ages and Stages Questionnaire-3rd edition (ASQ3) and the Bayley Scales of Infant Development-3rd edition (Bayley-III) scores within a clinically-based decision-making process.

This retrospective cohort study includes children born at less than 29 weeks gestation who had completed both psychologist-administered Bayley-III and physician-observed ASQ3 assessments at 18 months corrected age. Theoretical referral decisions (TRDs) based on each assessment results were formulated, using cut-off scores between the lower first and second standard deviation values and below the lower second standard deviation values. TRDs to refer to developmental resources were evaluated in light of the multidisciplinary team’s actual final integrated decisions (FID).

Complete data was available for 67 children. The ASQ3 and the Bayley-III had similar predictive value for the FID, with comparable kappa values. Comparisons of the physicians’ and psychologists’ TRDs with the FIDs demonstrated that the ASQ3 in conjunction with the medical and socio-familial findings predicted 93% of referral decisions.

Taking into consideration potential methodological biases, the results suggest that either ASQ3 or Bayley-III, along with socio-environmental, medical and neurological assessment, are sufficient to guide the majority of clinicians’ decisions regarding referral for specialty services. This retrospective study suggests that the physician-supervised ASQ3 may be sufficient to assess children who had been extremely preterm infants for referral purposes. The findings need to be confirmed in a larger, well-designed prospective study to minimize and account for potential sources of bias.

Partial Text

Timely identification of children at risk of developmental and medical complications and in need of support is important, as are accurate referrals to resources for targeted interventions to promote the best outcomes for high-risk populations [1,2]. For children born very prematurely, experts have been actively seeking to develop well-structured and cost effective neonatal follow-up (NNFU) programs, and to improve multidisciplinary team effectiveness in the context of limited financial and human resources [3].

ASQ3 and Bayley-III scores aligned with most of the multidisciplinary team final medical decisions for referrals to developmental resources, when assessing 18 months corrected gestational age children born prematurely, at less than 29 weeks gestational age. We did not find a statistically significant difference in the performance of the ASQ3 (83.3%) compared to the Bayley (81.1%) in relation to the FID. Furthermore, the 95% confidence interval indicated that the difference between the performances of the two tests is at most 6.4% (the upper end of the 95% confidence interval). In our context, the ASQ3 in conjunction with the qualitative information seemed sufficient to guide the majority (92.3%) of the final decisions. A total of 7.7% of decisions were made based on the Bayley-III over the ASQ3 results. Proficiency of the ASQ3 is seen most clearly for children with the most critical developmental delays such as global developmental delay or cerebral palsy requiring referral to the rehabilitation center (OCTC). The ASQ3 scores seemed sufficient to guide the multidisciplinary team referral decisions, with ASQ3 kappa score (k = 1.00) for OCTC referrals, and general proficiency in all situations.

In this retrospective study, referral to developmental resources of a very high-risk cohort of preterm infants at 18 months corrected gestational age was found to be largely congruent with findings of the ASQ3 screening tool. A complementary but novel approach to the evaluation of children at high risk of developmental delays entails the use of the ASQ3 and the Bayley-III to support referral decisions of a NNFU multidisciplinary team. Despite biases inherent in the study design, distinct from classical validity analysis, it appears that the ASQ3 along with other sources of information could potentially guide decisions when assessing development of very preterm infants in a NNFU clinic setting. The decision making process using developmental screening and assessment tools must be further explored to determine accurately the risks for over- and especially under-referral. Well-designed, larger prospective studies could investigate ways to improve developmental assessment and use of limited resources.