e u r o p e a n j o u r n a l o f p a e d i a t r i c n e u r o l o g y 1 7 ( 2 0 1 3 ) 4 7 1e4 7 8

Official Journal of the European Paediatric Neurology Society

Original article

Ages and Stages Questionnaires: Adaptation to anArabic speaking population and cultural sensitivity

Lama Charafeddine a,e, Durriyah Sinno a,*,e, Farah Ammous c,Walid Yassin a, Laila Al-Shaar b, Mohamad A. Mikati d

aAmerican University of Beirut Medical Center, Department of Pediatrics and Adolescent Medicine, P.O. Box: 11-

0236, Riad El Solh 1107 2020, Beirut, LebanonbAmerican University of Beirut, Faculty of Medicine, Lebanonc Indiana University School of Medicine, Department of Medicine, Indianapolis, IN, USAdDuke University Medical Center, Department of Pediatrics, Chapel Hill, NC, USA

a r t i c l e i n f o

Article history:

Received 1 February 2013

Received in revised form

2 March 2013

Accepted 11 March 2013

Keywords:

Ages and Stages Questionnaire

Child development

Early intervention

Questionnaires

Screening tools

Abbreviation: AASQ, Arabic translated Ag* Corresponding author. Tel.: þ961 1 350000xE-mail address: ds03@aub.edu.lb (D. Sinn

e Equal contributors.1090-3798/$ e see front matter ª 2013 Europhttp://dx.doi.org/10.1016/j.ejpn.2013.03.001

a b s t r a c t

Background: Early detection of developmental delay is essential to initiate early interven-

tion. The Ages and Stages Questionnaires (ASQ) correlate well with physician’s assessment

and have high predictive value. No such tool exists in Arabic.

Aims: Translate and test the applicability and reliability of Arabic translated Ages and

Stages Questionnaires (A-ASQ) in an Arabic speaking population.

Methods: 733 healthy children were assessed. ASQ-II for 10 age groups (4e60 months) were

translated to Arabic, back translations and cultural adaptation were performed. Test-retest reli-

ability and internal consistency were evaluated using Pearson Correlation Coefficient (CC) and

Cronbach’salpha(Ca).MeanscoresperdomainwerecomparedtoUSnormativescoresusing t-test.

Results: A-ASQ,after culturally relevant adaptations,was easily administered for 4e36months

age groups but not for 4e5 year old due to numerous cultural differences in the later. For the 4

e36 month age groups Pearson CC ranged from 0.345 to 0.833. The internal consistency co-

efficients Ca scores ranged from 0.111 to 0.816. Significant differenceswere found in themean

domain scores of all age groups between Lebanese andUS normative sample ( p-value<0.001)

with some exceptions in gross motor, fine motor and personal social domains.

Conclusion: A-ASQ was easily translated and administered with acceptable internal con-

sistency and reliability in the younger age groups. It proved to be culturally sensitive, which

should be taken into consideration when adapting such tool to non-western populations.

ª 2013 European Paediatric Neurology Society. Published by Elsevier Ltd. All rights

reserved.

1. Introduction status throughout the life span. Detection of developmental

Early child development is a crucial determinant of an in-

dividual’s potentials namely health, education and economic

es and Stages Questionna5515, þ961 1 350000x5500o).

ean Paediatric Neurology

delay leading to early intervention and special education1 is

important for a better outcome. Since formal screening for

developmental delay is essential to initiate early intervention,

ire; ASQ- II, Ages and Stages Questionnaire 2nd edition.; fax: þ961 1 370781.

Society. Published by Elsevier Ltd. All rights reserved.

e u r o p e a n j o u r n a l o f p a e d i a t r i c n e u r o l o g y 1 7 ( 2 0 1 3 ) 4 7 1e4 7 8472

the American Academy of Pediatrics published guidelines for

pediatricians promoting early screening to identify develop-

mental delay.2

Early detection is completed by either the physician or par-

ents, using clinical impression and/or standardized screening

tools. The lattermethod is usually recommended, as physicians’

clinical impressions alone are ineffective in detecting develop-

mental delay.3 In addition, studies have shown that parents’

completed standardized questionnaires are at least equal or su-

perior to the physicians’ formal screening4e6 irrespective of

parental socioeconomic categories, geographical locations or

parental conditions.7 Despite clear guidelines and recommen-

dations, compliancewith screening is hindered bymany factors

suchascost, lackof timeandtrainingonscreeningtools.8,9These

factors are particularly true in developing countries,where there

is a pressing need to apply simple screening tools at low cost to

help ensure early detection and referral. To our knowledge there

is no screening tool available in Arabic for the Middle-Eastern

countries with the exception of the Denver II10 which is admin-

istered by physicians and as such is not being widely used.

Ages and Stages Questionnaires 2nd edition (ASQ-II), is a

standardized parent completed screening instrument that in-

cludes questionnaires for different age groups addressing all

five development domains (communication, gross motor, fine

motor, problem solving, and personal-social skills).11 ASQ has

been shown to be reliable and cost effective as well as to

correlate well with physicians’ assessment.12,13 In addition,

although ASQ was found to have poor positive predictive value

(40%) in a sample of premature infants, its negative predictive

value was excellent (98%) and it had good agreement (79%) with

formal psychometric assessments.14 Furthermore, its sensi-

tivity is 90% and specificity 77% as shown by Skellern et al.14

ASQ has been translated into many languages and stan-

dardized with different populations,15e23 though most of the

adaptations did not requiremajor changes. Given these positive

findings we speculated that, accounting for the specificities of

the Middle-Eastern culture, the adaptation and standardization

of ASQ to Arabic would be successful and very useful in this

region. Since there are no validated screening tools available for

the Arabic speaking population the aim of this study was not to

validate but to test the adequacy of administering ASQ inArabic

and to assess its reliability and its cultural acceptance in a

sample of Arabic speaking population.

2. Methods

2.1. Population

Parents and children were recruited from health care centers

(private and public sectors) and day care centers located in all

Lebanese provinces. Inclusion criteria were healthy children

between 4 and 60 months of age and whose parents were

Arabic speaking. Children were recruited if their age was in

the range of either one month younger or older than the age

category specified on the ASQ questionnaires, as per the user

manual guidelines.11 Since the aim of this study was cultural

adaptability, disabled children and those at risk such as those

with history of prematurity, birth asphyxia or other chronic

conditions were excluded.

The study was approved by the American University of

Beirut Institutional Review Board (IRB) and by equivalent au-

thorities/pediatricians in each of the participating day cares

and healthcare centers.

2.2. Sample size

Based on a review of reliability measurement scales,24 a

sample size of 94 participants per age group was needed to

obtain a reliability coefficient of 0.85 on a 30-item question-

naire, with a type I error of 0.05.

2.3. Instrument

Ages and Stages Questionnaires 2nd edition (ASQ-II), is a

standardized parent completed screening instrument that

includes questionnaires for different age groups from 4 to 66

months. It addressesmultiple aspects of development such as

communication, gross motor, fine motor, problem solving,

and personal-social skills.11

ASQ-II intervals for the ages of 4, 8, 12, 16, 20, 24, 30, 36, 48

and 60 months were used.13

2.4. Translation

The tenASQquestionnaireswere translated to formalArabic by

a skilled translator who is a communication skills expert. The

Arabic language used was comparable to a grade four literacy

level. The Arabic questionnaires were then back translated

blindly to English by another bilingual translator. The Arabic

translated ASQ (A-ASQ) and the back translated version were

compared to the original English questionnaires by the in-

vestigators (LC, DS) to detect any misunderstanding, mis-

translations or inaccuracies. Special attention was focused on

culturally sensitive items; in addition, the perceived necessary

modifications were made after reaching a consensus.

2.5. Face validity

A panel of five expert pediatricians was asked to review the

second Arabic version simultaneously with the original En-

glish ASQ. The consequent experts’ comments were reviewed

and a final version of Arabic ASQ (A-ASQ) was generated for

use in the study.

2.6. Field testing

Following translation, field testing was conducted using face to

face interviews. Five parents for each age group were selected.

The purpose of this field testing was to inquire about parents’

opinion regarding the clarity and ease of comprehension of the

questions, any raised concerns, comments or suggestions. As a

result of this field testing, the necessary changes to the ques-

tionnaires were made and a second version of Arabic ASQ was

developed for the face validity testing.

2.7. ASQ administration

University graduate-level research assistants previously

trained on ASQ- II administration obtained informed consents

e u r o p e a n j o u r n a l o f p a e d i a t r i c n e u r o l o g y 1 7 ( 2 0 1 3 ) 4 7 1e4 7 8 473

from parents who completed the questionnaires in person or

with the help of research assistants. Participants were chosen

from 27 health care facilities and day cares distributed over all

Lebanese provinces (21% in the capital area, 34% in central

area, 9% in the North, 24% in the South and 12% in the Eastern

region). Health care facilities were chosen to reflect the socio-

demographic and cultural profile of the Lebanese population.

Test-retest reliability was undertaken within a maximum

of two weeks interval after the initial interview. Parents were

contacted by phone and were asked to answer the same A-

ASQ interval. Questionnaires were completed via interview

over the telephone with parents blind to the results of their

first questionnaire.

2.8. Statistical analysis

2.8.1. ReliabilityQuestionnaires were scored according to the guidelines pro-

vided in the ASQ manual.11

Test-retest reliability was analyzed by Pearson Product

moment correlation coefficient. The internal consistency of

each domain’s items was estimated using Cronbach’s alpha

coefficient; ameasure of the coherence of the components of a

scale. In addition, Pearson coefficient was used to assess the

correlation between each developmental domain area and the

overall score in each age group (i.e. 4, 8, 12, 16, 20, 24, 30, and 36

months), and after collapsing all age groups together. Pearson

coefficients of magnitude greater than 0.6 were considered

acceptable. It should be noted that questions in each devel-

opmental area have varying developmental quotient, and

thus they are not expected to have high alphas.11 For this

reason the satisfactory cut-off point of 0.7 for Cronbach’s

alpha was not used; instead, the values obtained were

compared to those reported in the literature. Domain scores of

each age groupwere presented asmeans� standard deviation

with minimum and maximum values.

Mean scores were compared to those of US normative

sample using independent t-test assuming equal variances.11

Cutoff points of each domain were generated for each age

group by subtracting two standard deviations from the mean

score of each domain area as mentioned in the ASQmanual.11

Analysis was done using Statistical Package for Social Sci-

ences (SPSS) version 19.0. All tests were two sided and

considered to be statistically significant if p-value < 0.05.

Table 1 e Mean age and SD of the completed ASQ.

Age interval Number completed Mean age SD

4- months 84 4.0 1.2

8- months 94 7.8 0.8

12- months 98 11.9 0.7

16- months 83 15.5 2.3

20- months 97 19.6 1.7

24- months 94 23.8 1.9

30- months 84 29.7 1.0

36- months 99 35.8 0.8

3. Results

3.1. Translation and adaptation

During translation of the ASQ, few changes were required.

Results of the field-testing showed that most questionnaires

were easily understood and feasible to administer with the

exception of 48 and 60 month intervals. Increased variability

in types of schooling and learning experiences among 4e5

years old children precluded testing; almost all children in

Lebanon enroll in a preschool system at the age of 3 years, and

these preschools differ in terms of which language is taught

first. For example, many children were not yet taught the

Arabic alphabets and numerals at the age of 4 or 5; therefore,

they were unable to answer or perform the corresponding

activity in the A-ASQ. In addition, these children were taught

sight-reading first rather than letter reading. Furthermore,

many parents did not allow their children to participate in

certain activities for safety reasons (example handling scis-

sors). Hence, it was impossible to administer one standardized

questionnaire to all children in those age groups. Accordingly,

the 48 and 60 month questionnaires were excluded from

further testing. For the remainder of the A-ASQ intervals, few

changes were made in terms of cultural appropriateness. Ex-

amples of such changes include: replacing the word ‘cheerio’

with ‘biscuit crumb’, which is more commonly used and un-

derstood in our population; reference to measures in inches

were changed to centimeters; phonics like “Da, Ma” were

changed to ones that are more common as in “Ba, Ta, Na”.

Sentences used as exampleswere changed tomore commonly

used ones like replacing the reference to “fire” as a hot object

by “soup” in the sentence “Ice is cold, fire is_____” which

became “juice is cold, soup is ____”. Examples of games played

by children were also replaced by ones more commonly used

in the Arabic speaking population.

3.2. Sample

A sample of 988 participants from 8 age groups (4, 8, 12, 16, 20,

24, 30 and 36months) were screened; 879 (89%) participated in

the study. Table 1 shows the sample distribution per each age

group. Themain reasons of participants’ refusal to enroll were

time commitment, presenting with an ill child or unwilling-

ness to share a phone number for further follow up. 146 par-

ticipants were excluded because of age discrepancy (actual

age falling beyond the 1 month window), leaving a final

sample of 733 (74%) participants. 77.5% of the questionnaires

were self-completed by parents, while the remaining were

completed with help from the research assistants. Most

enrolled parents were bilingual however, Arabic was the lan-

guage spoken at home with the children by 97.7% of the

sample, followed by English in 31.9%, French in 28.5% and 3%

for other languages. All parents are native Arabic speakers

and completed the Questionnaires in Arabic.

3.3. Internal consistency

Table 2 shows the correlations between each domain area and

the overall scores per each age group. Upon collapsing the

whole age groups together, Pearson’s correlation coefficient

Table 2 e Pearson correlation coefficients between areascore and overall score per age group.

Agegroup

n Communi-cation

Grossmotor

Finemotor

Problemsolving

Personal-social

4 84 0.436 0.650 0.833 0.792 0.711

8 93 0.668 0.754 0.529 0.702 0.752

12 98 0.625 0.750 0.653 0.706 0.746

16 83 0.685 0.600 0.723 0.676 0.725

20 97 0.729 0.545 0.709 0.773 0.771a

24 94 0.703 0.563 0.770 0.768 0.690

30 83 0.345 0.499 0.746 0.720 0.629

36 99 0.719 0.589 0.793 0.708 0.632

p < 0.01 unless otherwise indicated.

a p < 0.05.

e u r o p e a n j o u r n a l o f p a e d i a t r i c n e u r o l o g y 1 7 ( 2 0 1 3 ) 4 7 1e4 7 8474

varied between 0.61 in the gross motor skills and 0.73 in the

problemsolving developmental domain (Table 3). Correlations

between domains were also calculated, showing the lowest

correlation between gross motor and fine motor domain area

(r ¼ 0.18) and the highest, between communication and per-

sonal social domain (r ¼ 0.43) as shown in Table 3.

Table 4 shows the internal consistency across domains,

with Cronbach’s alpha ranging between 0.11 for Personal-

social skills at 24monthsand0.81 for grossmotorat 12months.

The overall internal consistency after combining the whole

items of all domains together varied between 0.76 among 24

months and 30 months age groups and 0.87 in 20 months old

group. Upon collapsing the age groups together, personal so-

cial skills domain had the lowest internal consistency

(alpha ¼ 0.47) and gross motor skills had the highest

(alpha ¼ 0.69). On the other hand, across intervals, the coef-

ficient alpha ranged between 0.13 and 0.82 (mean¼ 0.52) in the

communication domain, 0.28 and 0.81 (mean ¼ 0.61) in gross

motor, 0.47 and 0.74 (mean ¼ 0.61) in fine motor, 0.32 and 0.74

(mean ¼ 0.56) in problem solving skills, and 0.11 to 0.63

(mean ¼ 0.41) in personal social domain areas (Table 4).

Table 3 e Correlations between area scores collapsing across a(n [ number of completed questionnaires).

Area Communication Gross motor

Communication

Gross motor

Lebanon 0.241a (732)

USA 0.460

Fine motor

Lebanon 0.218a (731) 0.178a (732)

USA 0.460 0.490

Problem solving

Lebanon 0.386a (731) 0.275a (732)

USA 0.640 0.520

Personal-social

Lebanon 0.428a (730) 0.333a (731)

USA 0.480 0.510

Overall

Lebanon 0.648a (730) 0.605a (731)

USA 0.770 0.770

a Correlations are significant; p < 0.05.

3.4. Test-retest reliability

The test-retest reliability was high in all domains, across all

age groups with one exception in the communication domain

for the 12 months age group as shown in Table 5.

3.5. Comparison between Lebanese and Americandomain scores

For the Lebanese sample, cutoff points of each domain were

generated for each age group by subtracting two standard de-

viations from themean score of each domain area (Table 6). In

addition, mean scores were compared to those of the US

sample. Therewas a significant difference in themeandomain

scores between the Lebanese and US normative sample in

most age groups tested ( p-value< 0.001)with someexceptions

in the gross motor domain (age groups 12 months, 16 months,

20 months, 24 months and 36 months); in the fine motor

domain (age groups 4 months, 8 months and 12 months); and

in the personal social domain (age group 4 months and 24

months) (Table 7). A clinically relevant difference ofmore than

5 points was found in most instances as shown in Table 7.

4. Discussion

This study shows that the Arabic translated ASQ was feasible

for certain age groups but not all. Although it was easily

administered in a clinical setting and appreciated by parents

as screening for development, it was culturally sensitive. The

answers to some questions were found to be culturally sen-

sitive andwere therefore adjusted to render the questionnaire

more culturally appropriate to Arabic speaking national

groups. Adequacy of translation to Arabic and back trans-

lation was ensured by two independent experts and the in-

vestigators (LC, DS).

Overall, parents felt comfortable answering the translated

version and they valued the questionnaires for its ability to

ge groups in Lebanese sample and the US sample

Fine motor Problem solving Personal-social

0.398a (732)

0.510

0.311a (731) 0.364a (731)

0.390 0.590

0.652a (731) 0.728a (731) 0.717a (731)

0.780 0.830 0.730

Table 4 e Cronbach’s alphas by area and age interval (n [ number of completed questions).

Age(months)

Communication(n)

Grossmotor (n)

Finemotor (n)

Problemsolving (n)

Personal-social (n)

All domains

4 0.125 (84) 0.573 (84) 0.700 (84) 0.737 (84) 0.421 (84) 0.815

8 0.319 (94) 0.694 (94) 0.656 (94) 0.681 (94) 0.582 (93) 0.809

12 0.380 (98) 0.806 (98) 0.469 (98) 0.612 (98) 0.433 (98) 0.807

16 0.562 (83) 0.715 (83) 0.600 (83) 0.323 (83) 0.509 (83) 0.798

20 0.816 (97) 0.767 (97) 0.559 (97) 0.568 (97) 0.625 (97) 0.865

24 0.622 (94) 0.443 (94) 0.467 (94) 0.489 (94) 0.111 (94) 0.764

30 0.684 (84) 0.282 (83) 0.629 (83) 0.445 (83) 0.282 (83) 0.760

36 0.728 (98) 0.565 (99) 0.744 (99) 0.612 (99) 0.349 (93) 0.845

All 0.604 (688) 0.685 (711) 0.574 (686) 0.511 (663) 0.471 (703) 0.797

Cronbach’s alpha >0.6 was considered acceptable.

e u r o p e a n j o u r n a l o f p a e d i a t r i c n e u r o l o g y 1 7 ( 2 0 1 3 ) 4 7 1e4 7 8 475

heighten their awareness regarding children’s developmental

skills. Despite the universality in developmental stages across

cultures, variability might still be seen based on exposure.

Acceptable behaviors might differ across cultures as shown in

our study as well as others, Table 8 summarizes the ASQ ad-

aptations in different cultures.12,14,16,17,20,22,23,25 Similar to our

results, these studies show that ASQ was easily adaptable;

however, some changes had to be made to suit the cultural

and language differences as in the Korean translation.17 In our

case, the A-ASQ was applicable, yet many items had to be

changed or re-worded into more culturally appropriate and

comprehensible expressions. Furthermore, the 48e60 months

age group questionnaires were dropped for the reasons dis-

cussed above.

Despite the fact that the internal consistency results of the

translated instrument in most parts were comparable to the

values reported in the literature, few sections had lower in-

ternal consistency, which might reflect cultural differences

rather than inadequate translation since the instrument was

translated using the back translation method. Internal con-

sistency analysis show that both Pearson correlation co-

efficients and Cronbach’s alpha values were lower than those

reported in the US sample (N ¼ 7000) where the correlation

coefficients ranged from 0.63 to 0.83 for all age groups, while

that of the Cronbach’s alpha values ranged from 0.49 to 0.87

for all developmental domains.11 The relatively small sample

size in our case may have yielded lower values of Cronbach’s

alphas by decreasing the covariance among item responses.26

Table 5 e Pearson’s correlation coefficients in each domain peinterval after the initial interview.

Age group N Communication Gross motor

4 months 17 0.605a 0.963

8 months 28 0.891 0.937

12 months 20 0.572 0.971

16 months 13 0.798 0.903

20 months 24 0.958 0.968

24 months 11 0.859 0.832

30 months 13 0.990 0.888

36 months 09 0.961 0.914

p < 0.01 unless otherwise indicated.

a p < 0.05.

The KoreanASQ,with a sample size ranging from 82 to 226 per

age group, had similar results to ours, with alphas ranging

from 0.40 to 0.91 in all developmental domains,17 which could

reflect cultural differences as well.

As for the test-retest reliability, our results show high

reliability of the translated questionnaires with only one

exception, in the communication domain of the 12 month age

group. After reviewing the corresponding questions in that

domain, it was noted that one question in particular (Does

your baby shake his head when he means “no” or “yes”?) was

answered “NO” by most parents (96%) indicating that either

parents did not understand the question or they do not nod for

“yes”/“no” therefore, nor do their children. It is worth

mentioning that after the initial administration of ASQ most

parents recognized the ability of their children to perform

certain tasks which they thought they wouldn’t be able to do

before.

As delineated above, the cutoff points between those of the

A-ASQ and the original US were different in many domains

across age groups. Our sample included healthy children only,

for the purpose of establishing cutoff points for typically

developing children; therefore it is expected to find higher

cutoff points in this sample when comparing it to that of US

which included children at risk of developmental delay or

disabilities. However, as shown in Table 6, all cutoff points

were lower with the exception of the scores in the commu-

nication domain at 12 month and gross motor domain at, 16

and 36month age groups. The lower scores in our samplemay

r age group for same subjects completed within 2 weeks

Fine motor Problem solving Personal-social

0.956 0.962 0.943

0.992 0.984 0.953

0.886 0.888 0.943

0.961 0.975 0.794

0.945 0.915 0.933

0.938 0.918 0.987

0.921 0.940 0.937

0.977 0.964 0.942

Table 6 e Cutoff points by age group and area of development in Lebanese sample compared to US sample.

Age Communication Gross motor Fine motor Problem solving Personal social

Lebanese US Lebanese US Lebanese US Lebanese US Lebanese US

4 32.4 33.3 28.8 40.1 15 27.5 20.9 35 34 33

8 25.7 36.7 13.1 24.3 32.4 36.8 24.9 32.3 24 30.5

12 19.3 15.8 18.6 18 29.2 28.4 19.2 25.2 17 20.1

16 14.7 34.5 36.4 32.3 19.5 30.6 23 26.9 20.2 26.7

20 12.5 36.3 36 36.2 20.8 39.8 23.4 29.9 24.9 35.2

24 31.1 36.5 38.1 36 28.3 36.4 26.1 32.9 35.5 35.6

30 32.2 38.8 40 30.6 12.6 25.2 28.3 28.9 35.4 36.9

36 32.4 38.7 38.6 35.7 22.3 30.7 30.4 38.6 29 38.7

e u r o p e a n j o u r n a l o f p a e d i a t r i c n e u r o l o g y 1 7 ( 2 0 1 3 ) 4 7 1e4 7 8476

be attributed to cultural practices in raising and interacting

with children in terms of stimulation practice27 and lack of

opportunity to promote child development. In our opinion,

this can be explained by several factors involving parenting

styles whereby overprotective parents tend to pay more

attention to safety rather than to allow the child to commu-

nicate and explore her environment, hence to learn from own

experiences and mistakes. For instance, during field testing,

the administering team noticed that children are not given a

chance to put on their clothes or shoes independently, nor are

they allowed to use the stairs by themselves. On the other

hand as reported by parents, finger food is also frowned upon

because of hygiene related concerns.

Table 7 e Mean score comparison between A-ASQ and US nor

Age Communicationmean (SD) [N]

Gross motormean (SD) [N]

4 months

US 50.7 (8.7) [1380] 55.3 (7.6) [1380]

Lebanese 43.8 (5.7) [84]a,c 50.8 (11) [84]a

8 months

US 53.5 (8.4) [1285] 50.5 (13.1) [1285]

Lebanese 41.5 (7.9) [94]a,c 42.7 (14.8) [94]a,c

12 months

US 42.2 (13.2) [1091] 48.6 (15.3) [1091]

Lebanese 37.3 (9) [98]a 48.4 (14.9) [98]

16 months

US 49.1 (12.3) [976] 55.3 (11.5) [976]

Lebanese 37.9 (11.6) [83]a,c 55 (9.3) [83]

20 months

US 47.7 (10.7) [845] 55.4 (9.6) [845]

Lebanese 39.1 (13.3) [97]a,c 55 (9.5) [97]

24 months

US 49.5 (11.5) [820] 54.4 (9.2) [820]

Lebanese 45.5 (7.2) [94]a 53.7 (7.8) [94]

30 months

US 55.8 (8.5) [562] 51.2 (10.3) [562]

Lebanese 46.8 (7.3) [84]a,c 54 (7) [84]b

36 months

US 54.3 (7.8) [512] 54.7 (9.5) [512]

Lebanese 47.8 (7.7) [99]a,c 54.4 (7.9) [99]

a p < 0.05.

b p < 0.01.

c >5 score difference.

Despite these mentioned differences there were some

observable similarities in both the fine and gross motor do-

mains. In the gross motor domain, specifically in the age

groups 12 to 24 and 36 months, mean scores were not signif-

icantly different from those of the US; this may be attributed

to the fact that many questions at those age groups were

answered as “not yet” resulting in scores closer to the refer-

ence rather than clearly different. The fact that skills were not

reached at the expected age may reflect caregivers’ and spe-

cifically mothers’ misconceptions regarding children’s ability

to perform certain tasks; for example in our culture, toddlers

are not encouraged to be independent rather they are over-

protected. In our sample, the main differences were in

mative values per domain per age group.

Fine motormean (SD) [N]

Problem solvingmean (SD) [N]

Personal socialmean (SD) [N]

43.9 (10.9) [1380] 53.4 (9.2) [1380] 51.2 (9.1) [1380]

44.2 (14.6) [84] 47.7 (13.4) [84]a,c 52 (9) [84]

54.4 (8.8) [1285] 51.7 (9.7) [1284] 51.3 (10.4) [1284]

53 (10.3) [94] 49.5 (12.3) [94]b 48.4 (12.2) [94]b

49.2 (10.4) [1091] 45.6 (11.7) [1091] 45.5 (12.7) [1091]

49.6 (10.2) [98] 45.4 (13.1) [98]b 41 (12) [98]a

51.8 (10.6) [976] 49.7 (11.4) [976] 48.5 (10.9) [976]

45.1 (12.8) [83]a,c 45.2 (11.1) [83]a 44.6 (12.2) [83]b

54.4 (7.3) [845] 49.1 (9.6) [845] 52.8 (8.8) [845]

44.6 (11.9) [97]a,c 45.4 (11) [97]a 48.7 (11.9) [97]a

52.8 (8.2) [820] 51.5 (9.3) [820] 52.4 (8.4) [820]

46.9 (9.3) [94]a 46.5 (10.2) [94]a 51.1 (7.8) [94]

49.8 (12.3) [562] 50.9 (11) [562] 52.7 (7.9) [562]

40.8 (14.1) [84]a,c 47.9 (9.8) [84]b 50.8 (7.7) [84]b

52.5 (10.9) [512] 55 (8.2) [512] 53.5 (7.4) [512]

48.5 (13.1) [99]a 51.6 (10.6) [99]a 48.6 (9.8) [99]a

Table 8 e Summary of ASQ adaptation studies.

Study Sample Age groups Adaptation/translation

Elbers et al. (2008)

(Canada)

111children 4e36 months English version: Not mentioned

Dionne et al. (2006)

(Canada)

285 children 42e60 months To French: Not mentioned

Tsai et al. (2006)

(Taiwan)

112 children 34e38 months To Chinese:

Culturally appropriate

Changed the use of scissors in the left hand

Heo et al. (2008)

(South Korea)

3220 children 4 months to

5 years

To Korean:

Adding examples

Substituting by equivalent words

Replacing measurement units (inch to cm). Modification of

culturally inappropriate words

Richter et al. (2007)

Norway

1172 children 4e60 months To Norwegian. No changes mentioned

Kerstjens et al. (2009)

Netherland

2072 children 48 months To Dutch: No changes mentioned

Skellern et al. (2001)

Australia

167 premature

children

corrected ages

12- to 48-months

English version: Some word changes: ‘cheerio’ changed

to make the questionnaires culturally appropriate to Australian children

Handal et al. (2007)

Ecuador

283 children 3e61 months Spanish version: references to the baby/child were changed to “guagua,”

(A Quichua term for baby or child). Question on the use of forks was removed.

Current Study 733 children 3e37 months To Arabic: The word ‘cheerio’ was replaced with ‘biscuit’; measures in inches

were changed to centimeters; phonics “Da, Ma” were changed to ones that are

more common; The reference to “fire” as a hot object was replaced by “soup” in

the sentence “Ice is cold, fire is_____” which became “juice is cold, soup is ____”.

Examples of games played by children were also replaced by ones more

commonly used in Lebanese culture.

e u r o p e a n j o u r n a l o f p a e d i a t r i c n e u r o l o g y 1 7 ( 2 0 1 3 ) 4 7 1e4 7 8 477

communication and problem solving domains in certain age

groups and in most instances scores differed by 5 points or

more which is clinically relevant; this is similar to the results

reported by both Heo et al. and Janson et al.17,18

This study has some limitations that need to be taken into

consideration. It was done in a single country thus might

constitute a limit to generalize to other Arabic speaking pop-

ulations. However, the language used in A-ASQ was the lit-

erary Arabic which is universally spoken and understood by

all Arabic speaking populations. Recall bias are inherent to the

nature of the questionnaires as the data are based on parental

reports.

Despite this limitation, a real strength of the current study

is having an adequate sample size. In addition, we believe that

our results can be generalized to Arabic speaking populations

since it involved different regions and a wide range of socio-

economic backgrounds. Furthermore, the aim of this study

was not to validate but to test the adequacy of the Arabic ASQ

and assess its reliability and cultural acceptance. It did

demonstrate the cultural sensitivity of such tests and the need

to develop culturally neutral tools to screen for development.

5. Conclusion

To our knowledge, this is the first study to show reliability

results of an Arabic adapted ASQ. Our results indicate that

special care and consideration should be taken into account

when adapting ASQ to a different culture or language, mainly

non-Western ones. Questions pertaining to certain skills

should be assessed and modified accordingly. The current

study may constitute an asset for future research in

standardization and validation of A-ASQ in the Arabic

speaking children.

Funding source

American University of Beirut Medical CenterMedical Practice

Plan and University Research Board, Lebanese National

Council for Scientific Research.

Contributors statement

Lama Charafeddine: conceptualized and designed the study,

designed the data collection instruments, coordinated and

supervised data collection, drafted the initial manuscript,

critically reviewed it and approved the final manuscript as

submitted.

Durriyah Sinno: conceptualized and designed the study,

designed the data collection instruments, coordinated and su-

pervised data collection drafted the initialmanuscript, critically

reviewed it and approved the final manuscript as submitted.

Farah Ammous: coordinated and supervised data collec-

tion, initiated data entry, carried out the initial data analysis,

drafted the initial manuscript, and reviewed it critically, and

approved the final manuscript as submitted.

Walid Yassin: coordinated and supervised data collection,

participated in data entry and analysis, critically reviewed the

manuscript, and approved the final manuscript as submitted.

Laila Al Shaar: carried out statistical analyses, critically

reviewed the manuscript, and approved the final manuscript

as submitted.

e u r o p e a n j o u r n a l o f p a e d i a t r i c n e u r o l o g y 1 7 ( 2 0 1 3 ) 4 7 1e4 7 8478

Mohamad A. Mikati: conceptualized and designed the

study, critically reviewed the manuscript, and approved the

final manuscript as submitted.

Conflict of interest

The authors have no conflict of interest to disclose.

Abstract accepted for poster presentation at the Pediatric

Academic Societies meeting April 2012 (E-PAS2012:3806.56).

Acknowledgments

We are grateful for the contribution of Jane Squires for her

valuable comments and feedback. We are also in debt to Mrs.

Sawsan Maktabi who translated the questionnaires to Arabic,

and to the panel expert of pediatricians who reviewed the

back translated questionnaires in addition to all the pediatri-

cians, health care facilities, day care centers and parents for

their participation in this study.

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