# Evaluation of ASQ in Singapore - Low and High Risk Cohorts

## Dr. Pratibha Agarwal

### KK Women's and Children's Hospital SingHealth

### Background on KK Women’s and Children’s Hospital
- Founded in 1858
- National leader in Obstetrics, Gynaecology, Paediatrics and Neonatology
- 830 bed hospital providing tertiary services to manage high-risk conditions in women and children in Singapore

### Hospital Statistics
- Largest tertiary care perinatal center in Singapore (NICU– 40 beds, Level 2 – 60 beds)
- Annual deliveries: 11,000 per year
- Very Low Birth Weight (VLBW): 200 per year
- Extremely Low Birth Weight (ELBW): 90 per year
- Care for >2/3 of ELBW infants in Singapore

### Risk Factors for High-Risk Newborns
- Low birth weight
- Gestational age <28 weeks

## Use of ASQ in KKH
### High Risk Newborns
- Postnatal conditions leading to increased risks:
  - Neonatal seizures
- Any newborn with a greater than average chance of morbidity or mortality due to conditions overlaid on typical birth events and postnatal adaptation

### Follow-Up Programs
1. VLBW Follow-Up Program
   - Ongoing since 1990
   - Structured program of neurodevelopmental and medical follow-up for VLBW babies
   - Data collection & entry up to 8 years of life
   - Psychometric assessment at 2, 5½ & 8 years
   - Assessment of academic performance and learning disabilities

### Assessment Protocol
| Tests | 9 & 12 months | 18 months | 24 months | 5 years | 8 years | Personnel |
| --- | --- | --- | --- | --- | --- | --- |
| Medical History & Physical Examination | √ | √ | √ | √ | √ | Doctor |
| Developmental Screening | ASQ 3 | ASQ 3 | ASQ 3 | ASQ 3 | - | Doctor & parents |
| Socio-emotional | ASQ SE | ASQ SE | ASQ SE | ASQ SE | ASQ SE | Doctor & parents |
| Motor/Visuo Motor | PDMS | PDMS | - | VMI* | VMI* | PT/OT Psychologist |
| Behavior |  | CHAT | VABS | ADHD* |  | OT/Psychologist |
| Psychometric/Cognitive | - | - | BSID III | WPPSI-IIIPPVT-* | WISC IV WRAT-III | Psychologist |

## Introduction to Study 1
### High-Risk Preterm VLBW Population
- Objective: Evaluate the concurrent validity of Ages & Stages Questionnaires® (ASQ®‐3) with Bayley Scales of Infant & Toddler Development III (BSID‐III) in Preterm Very Low Birth Weight Infants
- Significance of study: Preterm infants require close neurodevelopmental surveillance and early intervention to optimize developmental outcomes.

### Primary Aim
- Evaluate if ASQ3 can validly monitor the development of PT/VLBW infants compared with BSID-III at corrected age of 24 months.

### Secondary Aims
1. Provide optimal referral cutoffs for ASQ3 total scores using ROC curves at 24 months corrected age for suspected (Bayley III score <85) and significant delays (Bayley score <70).
2. Evaluate predictive values of ASQ3 at 9, 12, and 18 months against BSID III at 24 months.

## Study Population Description
- 140 preterm VLBW infants with birth weight ≤1250g without major congenital malformations born from Jan 2010 to Dec 2011 at KK Women’s and Children’s Hospital.

### Follow-Up Protocol
- Multidisciplinary team following up at 9, 12, and 18 months:
  1. Familial interviews to gather socioeconomic data.
  2. Medical history review and physical examination by a neonatologist.
  3. Psychometric assessment by a blinded psychologist.

### Outcome Measures
- **ASQ3:** Parent-completed questionnaires covering critical developmental domains such as communication, gross and fine motor skills, problem solving and personal social skills. Relevant screening scores and definitions for developmental delays were outlined.

### Statistical Analysis Methods
- Diagnostic agreement estimations using Kappa, Sensitivity, and Specificity calculated across various domains using BSID-III as a standard.

## Results Presentation
### Demographic Characteristics of Participants
| Characteristics | No. | % |
| --- | --- | --- |
| Gender: Male | 66 | 47% |
| Chinese | 73 | 52% |
| Malay | 38 | 27% |
| Indian | 21 | 15% |
| Others | 8 | 6% |
| GA Status: <26 weeks | 31 | 22% |
| 26-28 weeks | 40 | 29% |
| >28 weeks | 69 | 49% |
| Maternal Education: <High School | 44 | 31% |
| ≥High School | 76 | 54% |
| Unspecified | 20 | 14% |

### ASQ3 Results at 24 months
- **Communication:** Normal (n=85, 61%), 1-2 SD (n=26, 19%), <2 SD (n=29, 21%)
- **Gross Motor:** Normal (n=99, 71%), 1-2 SD (n=18, 13%), <2 SD (n=23, 16%)
- Detailed results also provide insights into Gross Motor and Fine Motor skills across the developmental standards.

### Conclusions of Study 1
- ASQ3 is validated as a reliable screening tool for identifying developmental delays in high-risk preterm infants.
- Recommendations on implementation of ASQ3 to enhance early identification process.

## Study 2: Low Risk Term Infants
### Aims
- Evaluate the reliability and validity of ASQ3 for low-risk Singaporean children and compare findings with norms from the US and Korea.

### Methodology Overview
- Data collection at 9, 18, and 24 months with ASQ3 questionnaires filled by mothers, and collection method enhanced by follow-up support.

### Comparative Results
- ASQ3 scores across various cohorts highlighted internal consistency and significant differences with the US and Korean data suggesting the necessity for localized standards in Singapore.

### Conclusion of Study 2
- ASQ3 proved effective for broader cohort applicability aligned with Singapore’s unique cultural context and population diversity. Recommendations for further research and adaptation alongside targeted screening measures were provided.