Developmental Screening

Mohammed Alghamdi, PT, MS, PhD

 Learning Objectives

By the end of this presentation, you should be able to:

• Define developmental surveillance, screening and
evaluation
• Discuss the importance of developmental screening
• Recognize the flow of developmental surveillance
through using the AAP’s algorithm.
• Learn how to administer and interpret Denver II.
Child development

Surveillance

Screening

Evaluation
 Definitions

Surveillance: The process of recognizing children who

may be at risk of developmental delays

Screening: The use of standardized tools to identify a

child at risk of a developmental delay or disorder

Evaluation: The complex process aimed at identifying

specific developmental disorders that are affecting a
child
 Outcome of Screening &
Evaluation
Developmental delay: The condition in which a child is
not developing and /or achieving skills according to the
expected time frame

Developmental disorder: A childhood mental or

physical impairment (or combination thereof ) that
results in substantial functional limitations in major life
activities
 Importance of Developmental
Screening
In the US, 13% of children 3 to 17 years of age have a
developmental or behavioral disability.
CDC, 2015

Only 20% to 30% of children with disabilities are identified

before entering school.
AAP, 2009

EI currently serves 2.3% children under age of 3 years old in

contrast to 10% of children who have developmental delay.
AAP, 2009
 Importance of Developmental
Screening

The Earlier, The Better

Early identification of developmental delay is
critical for:
• Further evaluation and diagnosis
• Appropriate intervention program
 Child A and Child B are 3 year old and both have gross motor
developmental delay.
Child A’s developmental delay was detected when he was 9 months old.
Child B’s developmental delay was detected when he was 27 months old.

Child A:

Year 1 Year 2 Year 3

Child B

Year 1 Year 2 Year 3

 When should we screen?

American Academy of Pediatrics (2006)

suggested:
• Developmental surveillance be incorporated at
every well-child preventive care visit.

• Standard developmental screening tests

• 9 month
• 18 month
• 30 month
(see Fig 1).6 Many children are born with risk factors may have developmental problems. Surveillance can be
that predispose them to delayed development and de- useful for determining appropriate referrals, providing
velopmental disorders; other children will show delayed patient education and family-centered care in support of
or disordered development in early childhood, which if healthy development, and monitoring the effects of de-
undetected and untreated, can contribute to early school velopmental health promotion through early interven-
failure and attendant social and emotional problems. tion and therapy.
Some children will have delayed development attribut-

When should we screen?

A great breadth and depth of information is consid-
able to a specific medical condition for which medical ered in comprehensive developmental surveillance; it is
treatments may be indicated. Early therapeutic interven- important to note, however, that much of this informa-
tion may be available for a wide range of developmental tion (eg, static risk factors such as low birth weight,
disorders. results of previous screenings) will accumulate within
2. Perform Surveillance the child’s health record, where it can be reviewed and
Developmental surveillance is a flexible, longitudinal, flagged as necessary before the visit.
continuous, and cumulative process whereby knowl- There are 5 components of developmental surveil-

Now

FIGURE 1
Developmental surveillance and screening algorithm within a pediatric preventive care visit. a Because the 30-month visit is not yet a part of the preventive care system and is often not
reimbursable by third-party payers at this time, developmental screening can be performed at 24 months of age.
 Tips on selecting a screening tool

Screening tools must:

• Culturally and linguistically sensitive
• Valid and reliable
• Age and condition appropriate

Other considerations:
• Administration and scoring time
• Training requirement
• Cost of the tool
 Denver Developmental
Screening Test II (DDST II)
 Denver II- Background

• First published in 1967 by Frankenburg, W. K.

& Dodds, J. B

• Has been used in more than 12 countries and

more than 50 million children have been
screened worldwide.

• In 1990, a revised version of Denver screening

test was published, i.e. Denver II.
 Denver II- Description

Age range: Birth – 6 years

Items: 125 items/tasks
Administration time: 10-20 minutes

Psychometric properties:
• Normed on 2096 children in Colorado
• Sensitivity: 0.56– 0.83 (low to moderate);
• Specificity: 0.43–0.80 (low to moderate)
• Test retest reliability on same items: .9
 Denver II- Description
Areas that Denver II examine:
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
 Single or Two-Stage Screening

Denver Testing

Prescreening Denver
Developmental Developmental
Questionnaire (PDQ- Screening Test
II) (Denver II)
 Denver II- Test Materials

• Red yarn pom-pom (4” in

diameter)
• Raisins or “O” shaped cereal
• Rattle with narrow handle
• 10 1”square colored wooden
blocks
• Small, clear glass bottle
• Small bell
• Tennis ball
• Pencil
• Small plastic doll with feeding
bottle
• Plastic cup with handle

• Blank paper
Denver II- Test form
 Denver II- Test Form

Sections
 Denver II- Test Form

Age scale

One 3
Month Months

Test item
 Denver II- Test Form

Test behavior:
• To be scored after the
completion of the test.
• It provides information about
the child’s behavior to allow
for comparison next
screening visit.
Steps for administrating Denver II

Calculating child’s age

Drawing the age line

Administration guidelines
Administration of items Item scoring

Interpretation of individual items

Interpretation of overall test

 Calculating Child’s Age

Full term child:

Year Month Day

Date of Test 2015 9 22
Date of Birth 2013 6 12
Age of Child 2 3 10
 Calculating Child’s Age

Premature child:
Adjust for prematurity if a child was born more than 2 weeks
before the expected date of delivery and who is less than 2 years
of age.
Note: convert 4 weeks to a month and 7 days to a week.
Year Month Day
Date of Test 2015 9 22
Date of Birth 2015 1 12
Age of Child 0 8 10
 Calculating Child’s Age

Premature child:
Calculate the adjusted age for this child
Note: convert 4 weeks to a month and 7 days to a week.
Year Month Day
Date of Test 2020 2 2
Date of Birth 2017 1 12
Age of Child
3 preterm weeks
Adjusted age
 Calculating Child’s Age

Premature child:
Calculate the adjusted age for this child
Note: convert 4 weeks to a month and 7 days to a week.
Year Month Day
Date of Test 2019 12 4
Date of Birth 2018 10 21
Age of Child
1 preterm week
Adjusted age
 Drawing the Age Line

Notes:
• No rounding off days,
weeks or months,
• Write the testing date
on the form.
• The age line should
cross both age scales
on the bottom and
the top of the form
correctly.
 Administration Guidelines

Generally:
• Make child and caregiver comfortable to elicit natural
responses.
• Young child may sit on caregiver’s lap, older child should sit so
arms can rest upon the table
• Infants may be evaluated on the floor
Recommended sequence of testing:

Personal-social
Fine motor Language Gross motor
items (Report
items items items
items)
 Administration Guidelines

Number of Items to be given.

It depends on the goal of the testing:

Identify developmental Identify relative strengths

delays of the child
 Administration of items
Identify developmental delays

Step 1: in each sector, administer at

least three 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
 Administration of items
Identify relative strengths of the child

Step 1: in each sector, administer at

least three items nearest to and
totally to the left of the age line and
every item that is intersected by the
age line

Step 2: Continue to administer

items to the right of any passes in
each sector until three failures are
recorded

Note: child may be given up to three

trials to perform each item, when
appropriate, before scoring a failure
 Item Scoring

P = Pass-child successfully performs item, or caregiver reports

that child does item

F = Fail-child does not successfully perform item, or report from

caregiver is that child does not do item

N.O.=No Opportunity-the child has not had the chance to

perform the item, due to restrictions from the caregiver or other
reasons (May only be used on report items)

R = For Refusal – the child refuses to attempt the item. You can
minimize this by telling the child to do rather than asking. Report
items cannot be scored as refusals.
Interpretation of Individual Items
• After scoring, we can interpret each item as:

– Advanced

– Normal

– Caution

– Delayed

– No Opportunity
 Interpretation of Individual Items
Left Age line Right

If child passes an item that falls completely to the right of

age line, the child’s development is considered advanced.
This is an item that most children of that age do not pass
until they are older

Advanced items are not considered for overall interpreting

of test
 Interpretation of Individual Items
Left Age line Right

If child failed or refused an item that falls completely to the

right of age line, the child’s development is considered
normal.

Normal items are not considered for overall interpreting of test

 Interpretation of Individual Items
Left Age line Right

If child pass, failed or refused an item that falls within 25th to

75th percentile of the age line, the child’s development is
considered normal.

Normal items are not considered for overall interpreting of

test
 Interpretation of Individual Items
Left Age line Right

Caution when the age line falls between 75 and 90 percentile

and child fails or refuses to do the item
 Interpretation of Individual Items
Left Age line Right

A delay is indicated when a child fails or refuses an item that falls

completely to the left of the age line.

Considered for interpreting overall tests

 Interpretation of Individual Items
Left Age line Right

These two items should be interpreted as No opportunity

Interpretation of Individual Items

Items considered in overall interpretation of the test

are:
Caution items

Delayed items
 Denver II Interpretation

Normal:
No delays and a maximum of 1 caution

Suspect:
Two 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
 Referral Consideration

If the rescreening results yielded Suspect or Untestable, the

referral decision should be determined by:
• Rate of past development
• Clinical considerations (history/clinical examinations…etc.)
• Profile of test results
– Which items are cautions/delays
– Number of cautions and delays.
 Resources

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