Algorithm for detecting developmental delay

Growth implies increase in the size of organs and body and

development implies differentiation and maturation of function.
Factors affecting child development
• Genetic factors
• Physical factors
• Nutritional factors
• Emotional factors
• Sociocultural factors
Interaction between various factors and child
development
• Genetic factors account for 80%of development and only 20% is
accounted by the other factors
• The child’s ultimate intelligence is the result of the interaction
between host, nutrition and environment.
Assessment tools
• Denver developmental screening test
• Gesell developmental schedule
• Bayley scale of infant development
• Baroda developmental screening test
• Trivandrum developmental screening chart
• Developmental screening test
• Brazelton neonatal behavioral assessment scale
• Developmental observation card
Developmental tests
• Ages and Stages Questionnaire screening test(ASQ)
• Trivandrum developmental screening chart(TDSC)
• Denver development screening test(DDST)
• Developmental assessment scale for Indian infants(DASII)
• Bailey III
Ages and stages questionnaire screening
test(ASQ)
• Age: 4-60 months
• Assessment: Parent completed questionnaire
contains 19 age specific questions
Gross motor, fine motor, communication, problem solving,personal,
and social(pass, fail)
• Usefulness:
Can be used as screening test in well baby clinic
• Limitation:
Depends on intelligence and observation of the parents
Trivandrum developmental screening
chart(TDSC)
• Age: 0-2 years
• It takes 5 to 7 minutes only
• Assessment:
17 items from the bayley scales are used
Motor and mental items
• Sensitivity and specificity are moderate
• This is a simple developmental screening chart designed and validated at
the child development centre and is being used in large scale community
developmental screening programs using anganwadi workers.
• There 17 test items in the chart carefully chosen after repeated trial and
error method
• It was validated both at the hospital and community level against the
standard DDST
• Among the 17 tests, items for testing hearing and vision are also included
• This is a developmental assessment in community setting
• Usefulness:
Can be used as a screening test in a well baby clinic
• Limitation:
DDST used as a gold standard, which in itself is a screening
test
Denver development screening test(DDST)
• Age: 0-6 years
• Assessment:
Motor behavior, adaptive behavior, personal and social behavior,
language development, risk category(Normal, questionable and
abnormal)
• Usefulness:
For use in a busy clinic
• Limitation:
• Misses mild delay, resulting in under-referrals
• The original DDST was criticized for under identification of developmental disability
especially in the area of language. The revised DDST-II has greater sensitivity particularly
for language delays
• Designed to compare a given child’s performance with the performance of
other children of the same age
• Consists of 125 tasks or items
• Includes four areas:
1. Personal social: getting along with people and caring for personal needs
2. Fine motor-Adaptive: eye hand coordination, manipulation of small
objects and problem solving
3. Language: hearing, understanding and using language
4. Gross motor: sitting, walking, jumping and overall large muscle
movement
• Includes five “test behavior” items to be completed after the test
• Subjectively allows screener to assess the child’s overall behavior
• Designed to be used in a clinical setting by a variety of professionals
• Must be administered in the standardized manner
• Provides an organized clinical impression of a child’s overall
development
• To alert the user to potential developmental difficulties
• Used to determine how a child compares to other children
• It is not a predictor of later development
Test materials
• Red yarn pom-pom(4” in diameter)
• Raisins or O shaped cereal
• Rattle with narrow handle
• 101” square colored wooden blocks
• Small, clear glass bottle with a5/8 inch
• Small bell
• Tennis ball
• Red pencil
• Small plastic doll with feeding bottle
• Plastic cup with handle
• Blank paper
Materials
• Items come in a test kit(except for blank paper)
• Access to table and chairs(examiner, caregiver and child if
appropriate)
• For babies, a blanket or cushioned pad is needed
• Substituting materials may reduce reliability in comparing a tested
child with the norms
• Children need to be supervised appropriately with test materials to
prevent choking or injury
Test form
• Locate four sections on far left: Personal-social, fine motor, language
and gross motor
• Locate the age scales on the top of the test form and at the bottom
• Each mark on the scale from the first mark to the 24 month mark
represents one month
• After 24 months, each mark equals 3 month intervals
• It should be shared with parent that the tool is to determine the
child’s current developmental status and that the child is not expected
to pass all of the items
• Allow child to have appropriate item to manipulate while we ask
parent the “Report” questions
• Items requiring less active participation and can be performed easily
should be administered first
• Items in fine motor- adaptive next
• And lastly the gross motor items
• Keep test kit out of sight of child. Keep only materials being used for
current activity on the table
• For infants, it is recommended that all items be administered with the
baby lying down to be tested together
• Testing should begin with items that fall completely to the left of the
child’s age line and continue to the right
 Number of items to be tested

• Depends on age and ability of child

• Step 1: in each sector, administer at least 3 items nearest to and totally to
the left of the age line and every item that is intersected by the age line
• Step 2: if the child is unable to perform any item in step 1(fails, refuses,
has had no opportunity), administer additional items to left in the
appropriate sector until child passes three consecutive items
Scoring
• P= pass
• F= fail
• NO= No opportunity
• R= refusal
• Continue to administer items to the right of any passes in each sector
until 3 failures are recorded
• Thd child may be given upto three trials to perform each item, when
appropriate before scoring a failure
• Ask the caregiver or parent if the results are typical of child’s
performance. Consider if the child is ill, hungry, upset etc
• Rescheduling may be necessary if child is not being cooperative
• Advanced item: if the child passes an item that falls completely to the right
of age line, the child’s development is considered advanced
• Normal item: child is not expected to pass items on right
• Caution item: caution when line falls between 75 to 90 percentile and child
fails or refuses
• Delayed item: a delay is indicated when a child fails or refuses an item that
falls completely to the left of the age line. Child has failed an item that 90%
of children in the standardization sample passed at an earlier age
• No opportunity item: these items are not considered in interpretation of
entire test
Interpretation of the test
• Normal: no delays and a maximum of 1 caution
• Suspect: 2 or more cautions and/or one or more delays. Rescreen in
1-2 weeks
• Untestable: refusal scores on one or more items completely to the left
of the age line or on more than one item intersected by the age line in
the area of 75-90% area
Gesell’s developmental schedule
• The test consists of selected items for assessing maturity in infants or
preschool children in the four developmental areas:
1. Motor behaviour: includes both gross bodily control and fine motor
coordination like head balance, postural reaction and locomotion
2. Adaptive behavior: includes perceptual, orientational, manual and
verbal adjustments.
3. Language development: includes all means of communication such
as facial expression, gestures, postural movements and vocalization
4. Personal-social behavior: includes the child’s personal reactions to
others play behavior, social smile, feeding and toilet training
• This measures the four functional areas of development in children
between 0-5 years of age
• It will take 30 -40 minutes
• It is more concerned with the diagnosis and evaluation of
abnormalities than the attainment of various milestones
• For quick assessment, Gesell has provided the concept of key areas,
which are the basic stages of maturity like 4,16,28,40weeks, 12,
18 ,30 months respectively
• It is necessary to test the child in two adjacent age levels, while
assessing at their key ages
Developmental assessment scale for Indian
infants(DASII)
• Age: 0-30 months
• Assessment:
Mental(163 items)
Motor(67 items)
• Usefulness:
confirmatory test after screening tests have identified delay
• Limitations:
needs a trained psychologist, a soundproof room and a special kit
Bayley Scale of infant development (BSID)
• Age: 16 days to 42 months
• Much longer test. Takes 30 mins for children <13 months and 50
minutes for children >13 months
• Assessment:
covers cognitive, language, fine and gross motor and socioemotional
development
• Limitation:
Gives much higher scores. Hence may lead to under referral
• Advantages:
1. Bayley scale is the only developmental assessment tool for babies
less than 30 months of age which is standardized for Indian
population
2. It gives an objective score for mental and motor performances and
hence most appropriate for research purposes
3. Raw score can be converted to percentile performance position and
hence appropriate for comparing wide range of performance
• Disadvantages:
1. The Bayley sample is drawn from a population of normal children
and hence there are problems for using the scale among abnormal
babies
2. Babies with problem may perform at lower levels because many of
the mental items are closely interlinked with motor capability
Baroda developmental screening test
• This is a screening test based on BSID, Baroda norms. The Baroda
norms were standardized on Indian children. An abbreviated BSID is
also available for follow up of high risk neonates
Developmental screening test
• This is a simple scale that can be administered upho the age of 15
years.
• It was standardized on indian children
Brazelton neonatal behavioral assessment
scale
• This scale is based on the observation of the baby and the response to
20 primitive reflexes
• Evaluates the newborn’s behavior response on these items
• Each response is scored on a 9 point continuum
• A rating of 5 mid point is the standard
• The scale includes observation of the child, when asleep and awake,
alertness, eye following, response to sound, irritability, social interest
in the examiner, passive movements of the arms, vigor, tremulousness
and the response to 20 primitive reflexes
Developmental observation card(DOC)
The large majority of developmental delays could be identified by using
cut off points for four simple developmental milestones
1. Social smile: baby smiling back in response to your smile
2. Holds head steady: keeping head steady when baby is held upright
3. Sits alone: baby able to sit alone with minimal support
4. Stands alone: baby able to stand on both legs with minimal support
Assessment of intelligence
• This is generally done in children above three years of age
• Intelligence tests measure several brain functions including auditory,
memory, visual-spatial capability and receptive and expressive
language
• The Intelligence Quotient (IQ) is computed using the following
formula:
Mental age÷chronological age ×100
Various levels of retardation according to IQ
Level of retardation IQ Remarks

Borderline/ Average 70-90 Vulnerable to educational problems

Mild/ educable 50-70 Often need special classes

Moderate/trainable 35-50 Trainable in workshop setting

Severe 20-35 Trainable for self-care skills

Profound <20 Need custodian care

Intelligence tests
• Stanford-Binet Intelligence scale
• Binet-Kamat test
• Wechsler Intelligence scale for children (WISC)
• Malin Intelligence scale for Indian children
• Goodenough’s Draw-A-Man Test for Indian children
• Tests of cognitive Functions
Stanford-Binet intelligence scale
• This takes into account verbal ability, perceptual skills, short term
memory, and hand and eye coordination
• It takes 45-60 minutes
• This test provides an estimate of basal age, mental age and
intelligence quotient (IQ)
• This test also has certain limitations as it is cross-cultural and the
items are mainly dependent on formal schooling
• Age range is 2 years to adult
 Binet-Kamat test
• It is an exclusively used verbal test for mentally retarded persons
• It gives a pattern analysis for 7 primary abilities: language, memory, conceptual thinking,
reasoning, numerical reasoning, visuo-motor coordination and social intelligence
• The test consists of 90 items, covering age group of 3 years to 22 years
• At each age level, it has six items with some alternate items (which may replace one of
six). The scoring in each item gets 2 months credit if answered correctly
• For example, if the child answers all the six items at the 3 years level, this means the
child’s mental age is 3 years. This is called as basal year, then we have to proceed further
till the child fails in all six items of a particular age level. This is called as terminal year,
here we have to stop the test. The credits are added to the basal year so the total score is
the mental age
Wechsler intelligence scale for
children(WISC)
• This has an age range of 5-15 years
• Time taken is approximately 45-60 minutes
• This scale has two large subsections: verbal and performance, each
consisting of several subjects