# Setting Guidelines for Referrals

## A Q&A with ASQ® Developer Jane Squires

When you're planning a screening program, one key success factor is setting referral **criteria—that is, determining the guidelines your organization will follow when** reviewing screening scores and deciding whether to refer a child for further evaluation.

ASQfi-3 and ASQfi:SE-2 have empirically derived cutoff scores and three score zones: referral, monitoring, and typical development. However, your organization might want to customize referral criteria based on various factors, such as the population you serve or the availability of local services. This Q&A with ASQ developer Jane Squires provides answers to some frequently asked questions about setting guidelines for referrals.

**Q: Why is it important for my organization to think about referral criteria when establishing a screening program?**

A: The number of children that are referred after screening will vary greatly based on your referral criteria. For example, if at-risk children with scores in the monitoring zone on ASQ-3 are all referred for evaluation, significant resources and staff time will be needed to provide those evaluations. If only those children with scores below the ASQ-3 cutoff scores are referred, then fewer children will need full evaluations.

**Q: Is it okay for my organization to set referral criteria that differ from the recommended guidelines in the User’s Guides?**

A: Yes, we recommend that programs do set individual referral criteria based on program resources, eligibility guidelines in your state, and referral resources in the community.

**Q: Can you provide an example of when it might be appropriate for an organization to adjust the referral criteria?**

A: Here’s one example. Oregon is one of 20 states with strict eligibility criteria for Part C/early intervention services. Often, children with scores below the cutoff in only one ASQ-3 domain are not found eligible for services after a full evaluation. Therefore, many programs in Oregon will monitor a child with one low score closely and rescreen in 24 months, as well as provide parent support materials such as ASQ-3 learning activities and Act Early materials. If a child scores below the cutoff in multiple domains, then the program will refer.

### Q: Should the age of the children being screened factor into decisions about referral criteria? For example, should referral criteria be different when screening infants versus screening 4-year-olds?

A: Yes. Because eligibility in states is different for infants and toddlers compared with preschool children, it may be advisable for referral criteria to be different. Also, when screening 4-year-olds, your program may want to pay close attention to low ASQ-3 scores in the Communication domain, as a delay in that area may affect kindergarten performance.

### Q: Does the type of organization affect decisions about referral criteria? For example, does a home visiting program have different considerations than a pediatrician’s office?

A: Yes, there will be different criteria based on the services the agency provides, community agreements, state eligibility guidelines, and resources in a community. Some communities have agencies like 2-1-1 and Help Me Grow, whose mission is to connect families with follow-up services and eligibility evaluations as needed. In those communities, a home visiting agency may refer to 2-1-1 instead of referring the child directly to early intervention. Pediatricians, on the other hand, will have medical referral criteria as well as criteria related to state eligibility guidelines. They may refer a child and family to an autism specialist first, who then would refer to early intervention as appropriate.

**Q: What is an example of referral criteria that differs from the recommendations in the User’s Guides?**

A: A public school district that screens 4-year-old children in their prekindergarten classrooms uses the following referral criteria:

- If 1 area is below the cutoff or 1 or 2 areas are in the monitoring zone, provide parent activities and rescreen in 12 months.
- If 1 area is well below the cutoff, 2 areas are below cutoff, or 3 or more areas are in the monitoring zone, refer to early intervention/early childhood special education and/or health care provider for further assessment.

### Q: Do you have any other tips for establishing referral criteria?

A: We recommend that your program consider its resources, such as personnel, expertise, and community agreements, when establishing criteria. The number of children and families that can be served each month with available agency resources should also be considered.

When interpreting scores, it's also important to consider factors such as opportunity to try ASQ-3 items, health and biological factors, and cultural factors. Your program will not want to over-refer children whose results of concern can be explained by other factors. You can give these children learning activities to boost their development and rescreen them before referring. (Learn more about interpreting results at [http://bit.ly/ASQFactors](http://bit.ly/ASQFactors).)