Early Literacy Research Library (ELRL) - Article

Using the Ages & Stages Questionnaire to assess later effects of an infant intervention promoting language in primary care

Domek, G. J., Silveira, L., Kuffel, H., Szafran, L. H., Jimenez-Zambrano, A., & Camp, B. W. (2023). Using the Ages & Stages Questionnaire to assess later effects of an infant intervention promoting language in primary care. BMC pediatrics, 23(1), 1-10.,

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Publication year


study description

Longitudinal; Secondary Analysis

core topic(s)

Early Literacy , Early Relational Health , Pediatric Primary Care

Population Characteristics

Medical Providers , Poverty/Low-Income

Exposures, Outcomes, Other

Clinic-Based Programs and Interventions , Parent-Child Relationships/Interactions


We explored using developmental trajectories to determine later outcomes of our early intervention program by comparing trajectories to age 36 months to assess optimal intervention timing when delivered in early versus late infancy.


Simple finger puppet intervention

outcomes evaluated

Caregiver-infant interactions promoting language and social-emotional development


University-affiliated primary care clinic that serves a primarily low-income population


Three cohorts were enrolled and given a puppet at 2 months (early intervention) and 6 or 12 months (late intervention). Child development was assessed using the Ages & Stages Questionnaires (ASQ-3), which were independently collected during well visits. Scanned ASQ-3 forms from 2 to 36 months were obtained retrospectively through the electronic medical record. To compare longitudinal scores at different ages, all raw scores were first converted to z-scores. Longitudinal mixed effects models examined the trajectories of participant ASQ-3 scores over time by comparing the average intercepts and slopes.

sample size

N = 172


Ages & Stages Questionnaires (ASQ-3) -assesses five developmental domains: Communication, Gross Motor, Fine Motor, Problem Solving, and Personal-Social.


Of 180 children enrolled, 172 (96%) completed 2 or more ASQ-3 questionnaires and were included in the analysis, with a mean of 4.9 and a total of 843 questionnaires. Most children (85%) were on government-sponsored insurance. There were no statistical differences comparing cohort intercepts, while early intervention had a significant difference in slope compared to late intervention for the Personal-Social domain (0.12, p=0.018), resulting in higher predicted scores at 36 months. Early compared to late intervention had a difference in slope approaching significance for Communication (0.14, p=0.056) and the combined non-motor score (0.33, p=0.052). There were no significant differences in slope for Problem Solving (0.05, p=0.48), Gross Motor (-0.009, p=0.84), Fine Motor (0.06, p=0.22), and total ASQ-3 (0.32, p=0.17) scores.


Finger puppets may provide a simple and scalable way to encourage responsive caregiver-infant interactions promoting language and social-emotional development, especially when provided in early versus late infancy. Our trajectory analysis also demonstrates a useful and potentially cost-effective approach to evaluating long-term developmental outcomes of an early intervention.


Our smaller sample size prevented us from being able to analyze the three study cohorts separately. While the intervention appeared to have the greatest impact when delivered in early infancy, we do not know if there were also benefits when delivered later in the first year. Furthermore, although our predicted improvements in developmental screening scores were clinically small at 36 months, the three study cohorts all received a puppet by 12 months of age and a greater effect might be found if comparing our early intervention participants to a control group not receiving the intervention.