Information on The Denver Developmental Screening Test

DENVER DEVELOPMENTAL SCREENING TEST

The Denver Developmental Screening Test (DDST) is a screening test for cognitive and behavioral problems in children from birth until the age of 6. It was developed by William K. Frankenburg at the University of Colorado Medical Center, Denver, USA. It was first introduced by him and Josiah.B. Dobbs in 1967. The test is currently marketed by Denver Developmental Materials, Inc., in Denver, Colorado.

There have been many criticism of this tool because of its widespread usage and this prompting a major revision and restandardization of the test. Hence, Denver II was developed in 1992. “The reasons for updating the DDST included;

1. The need for additional language items,
2. Questionable appropriateness of 1967 norms for 1990,
3. Changes in items that were difficult to administer or score,
4. Appropriateness of the test various subgroups and predicting later performance in children,
5. New methods for ensuring accurate administration and scoring of the test.”

“The major additions to and differences between the Denver II and DDST are;

• 86% increase in language items,
• Two articulation items,
• A new age scale,
• A new category of item interpretation to identify milder delays,
• A behavior rating scale,
• New training materials.”

The purposes of the DDST and Denver II are to screen children or possible developmental problems and to verify suspected problems with an objective measure. The purpose of Denver II depend on the age of the child:

•Newborn Child: To determine if there is a neurological problem like cerebral palsy.

• Infants: To identify nature of the possible problems for the early intervantion.

•Children: To define academic and social problems in order to give en early intervention.

Test Measures and Target Population

The Denver II screens general development in four areas:

• Social – Personal: Aspects of socialisation inside and outside the home – eg, smiling.
• Fine motor function – Adaptive: Eye/hand co-ordination, problem solving and manipulation of small objects – eg, grasping and drawing.
• Language: Production of sounds, and ability to recognise, understand and use language – eg, ability to combine words

• Gross motor functions: Motor control, sitting, walking, jumping, and overall large muscle movements.

Also included five items documenting “test behavior” to be completed after administration of the test.

The Denver II is not an IQ test. Also, it is not designed to bring diagnostic labels or foresee future adaptive and intellectual abilities. The test is best used to compare a given child’s performance on a variety of tasks to the performance of other children of the same age. The appropriate population for the test is children between birth and 6 years of age. Trained paraprofessionals and professionals administer the test and testing takes 10 to 20 minutes, on average.

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The Format

Type: The test is norm referenced, with data presented as age norms, similar to physical growth curve. Subnorms for various subgrous that differ in a clinically significant manner from norms indicated on the reference chart are presented in the technical manual.

Content: The Denver II has 125 items arranged on the test form in four sections: Personal-Social, Fine motor functions- Adaptive, Language and Gross motor functions. Age scales across the top and bottom of the test form show ages, expressed in months and years. Each test item is represented on the form by a bar that spans the ages at which 25%, 50%, 75% and 90% of the standardization sample passed that item.

DDST and Denver II has been adopted for use ad restandardization in many countries. DDST was adopted in 1981(Yalaz,Anlar) and Denver II was adopted in 1992 and 2009 (Anlar,Bayoglu,Yalaz) by standardising by departmant of Child Neurology of Hacettepe University Medical Faculty and Developmental Child Neurology Association in Turkey.

There are five unique features of the test that generally differentiates it from most other developmental screening tests:

• It was carefully standardized. Its validity build upon its careful standardization reflecting the US 1980 census population whereas validty of most other developmental screening tests rest upon measures of sensitivity and specificity.
• The test shows in graphic form the ages at which 25%, 50%, 75% and 90% of children performed each item and it allows the examiner to visualize at any age from birth to six years how a given child’s development compares with that of other children.
• The test consists of separate norms for subgroups of the population based on sex, ethnicity and maternal education when the subgroups differed by a clinically significant amount from the total group or composite norms.
• The test is primarily based upon an examiner’s actual observation rather than parental report.
• It is ideal for visualizing on one page the developmental progress of children.

APPLICATION OF DENVER-II

First step is calculation of chronological age. Day of application of Denver minus birthday of the child gives us chronological age of child.

Calculation of Choronological Age:

For Example:

25.04.2014 Day of application of Denver

12.05.2009 Birthday of the child

13. 11. 4 4 years 11 months 13 days

Afterthat, a line is made to show chronological age.The normal child can do left of the line.

• Tester starts from the leftmost item of the line.
• Some items can be asked to parents by tester if the child cannot give an answer.

‘’ÇocuÄŸunuz bardaktan su içebilir, deÄŸil mi?’’ Sorusu yerine;

‘’ÇocuÄŸunuz bardaktan su içebilir mi?‘’ Sorusu sorulmaldır.

Therefore, one of the parents can be in test application.The child’s anxiety level should be low to be applied Denver.

• Another example, if the child enters the class through running, there is no need to test the item of ‘’run’’.
• Tester should encorage the child for giving answer or doing items because…
• If he refuses, ‘’R’’ ; if he cannot do item, ‘’F’’ is written by the tester.If doing of the item is not possible,right now ( bec.of various reasons), ‘’N.P’’; if he passes the item, ‘’P’’ is written.

R- REFUSE

F- FAIL

N.P- NO POSSIBILITY

P- PASS

The end of test, lower right corner of test, there are 5 items about behaviours of the child in testing which measures anxiety and attention level of the child.

Chronological age line

25 90 90%

The child should do this, his peer group can do. 90% of them can do.

The child has a time to do this, he can do later. 25% of children can do it.

Assignment

There are 3 conclusions:

Abnormal: Falling behind in peer groups. Medical identification should be made by doctors and so time to go hospital.

Doubt: In some items, there are abonormal situations. Information about the child should be given to parents. After 3 months, test should be repeated.

Normal: No problem.

• Over the age of 6 ,
• Autistic children,
• Visually handicapped and hearing impaired children cannot get the Denver.
• Child development experts, child nurses, kindergarten teachers can apply this test in hospitals, schools and RAM’s..

PSYCHOMETRIC PROPERTIES OF DENVER-II

STANDARDIZATION

For standardization, 2096 children from the state of Colorado who aged from birth to six years were sampled. The sample was startified by gender, maternal education, SES and ethnicity in order to approximate the distribution of Colorado population. (Lee&Harris, 2005)

Reliability and Validity of the Denver-II

Frankenburg et al (1992) assessed the item reliability of the Denver-II. Subjects were 38 children, 34 of whom were tested again at another time within 10 days (as cited in Lee&Harris, 2005) The Denver-II indicated excellent interrater reliability (k ≥ 0.75).4; for 59% of items it showed perfect test-retest reliability (k ≥ 0.75) while 23% of items demonstrated fair to good inter-rater reliability (k ≥ 0.40). This numbers demonstrate a very high reliability in comparison to its antecessors’ reliability degree. Despite, the first Denver Developmental Screening Test was revised and restandardized with the intention of making up previous inadequacies, concurrent validity or predictive accuracy of the Denver-II had not been studied yet when it was published and distribute. Later in 1992, a study was published by Glascoe et al that is evaluating the accuracy of the Denver-II in identifying children with atypical development (as cited in Lee&Harris, 2005). In order to determine the sensitivity, specificity, and positive predictive value of the Denver-II Glascoe et al assessed the Denver-II and see if the categorical classifications on it correspond to categorical classifications on other reference screening tests (as cited in Lee&Harris, 2005). 104 children with the age of 3 to 72 months were gathered from five different daycare centers. Firstly, they were assessed by using the Denver-II; within seven days of that assessment, each child was assessed on a battery of standardized assessments, including the Vineland Adaptive Behavior Scale, the Kaufman Assessment Battery for Children Achievement Subtests, the Fluharty Preschool Speech and Language Screening Test, and one of the following cognitive tests: the Bayley Scales of Infant Development, the Stanford-Binet Intelligence Scale, 4th edition, or the Kaufman Assessment Battery for Children.The results from this battery of tests were compared to those derived from performance on the Denver-II in terms of classifications for children’s development. 38% percent of the children in the study scored within the normal range on the Denver-II, 26% received abnormal scores, 33% received questionable or suspect scores, and 3% were not testable. According to the scores demonstrated by the battery of criterion assessments, only 17% of children showed evidence of developmental problems. When questionable scores were grouped with normal scores, the Denver-II yielded sensitivity of 56%, specificity of 80%, and a positive predictive value of 37%. When grouping abnormal scores with suspect scores, the sensitivity of the Denver-II was 83%, specificity was 43%, and positive predictive value was 23%. Based on these findings, the American Academy of Pediatrics noted that ‘‘the Denver-II screening test is used widely but has modest sensitivity and specificity depending on the interpretation of questionable results.’’(2001). Glascoe et al (1992) suggested that interpreting questionable scores as abnormal was more plausible than the alternative because questionable scores tend to lead to referrals for more comprehensive testing (as cited in Lee&Harris, 2005). Although, by using this recommended grouping, the desired level of sensitivity was acquired; more than 50% of normally developing children would then be categorised as suspect for developmental delay. As a result, there could be need for further diagnostic examination of about 60% of the children tested if Denver- II was used for developmental screening. This means that Denver- II has very low specificity which produces concern for an unnecessarily high referral rate, leading to increased expense and excessive parental distress (Lee&Harris, 2005). A study published the following year by Glascoe and Byrne (1993) examined the relative accuracy of the Denver-II, the Developmental Profile II, and the Battelle Developmental Inventory Screening Test when compared to scores on a criterion battery of standardized assessments (as cited in Lee&Harris, 2005). As observed in the earlier study, specificity for the Denver-II was unacceptably low (46%) when grouping questionable with abnormal scores, although sensitivity was 83%. Using this grouping, positive predictive value was only 28%, however. Again, as Fletcher et al (1996) have noted, interpretation of acceptable levels of sensitivity and specificity should be based on the philosophy of individual clinics or treatment settings and positive predictive value will be affected by the prevalence of the disability in the actual clinical setting in which test will be administered (as cited in Lee&Harris, 2005). When grouping questionable scores with normal scores, specificity increased to 80% but sensitivity fell to 56%. The positive predictive value using this grouping was 42%. Glascoe and Byrne, concluded that the Denver-II ‘‘produced more incorrect than correct classifications.’’ Although revision and restandardization represented an improvement over the original DDST, the failure to address the revised test’s accuracy based on standard criteria for the development of new tests is a major shortcoming (as cited in Lee&Harris, 2005). Because early identification is essential for initiating family support and increasing the opportunity for positive outcomes in children with developmental delays, it is crucial that screening instruments demonstrate high degrees of both sensitivity and specificity. More than a decade ago, it was proposed that the authors of the Denver-II extensively study the test’s validity so that changes could be implemented to improve test accuracy. Unfortunately, those studies have not yet been undertaken. (Lee & Harris, 2005)

Standardization of The Denver-II to Turkey

Item Selection

Items in Denver II has formed by making carefull changes in the items of Denver Developmental Screening Test. Due to restrictions in utilization, difficulties in administration and scoring some items from the first test were not included in Denver-II and a lot of new items added to language part. Pass/fail criterion for each and every item was determined before collection of data for Denver II. Moreover the scoring of the “Testing Behaviour“ part which is new in Denver was determined. (Yalaz, et al.,2009)

Selection of Sample

The sample was stratified by child age and sex, and maternal education.

According to age:

0-2 months13-18 m

2-4 m18-24 m

4 -7 m24-40 m

7-10 m40-57 m

10-13 m57-78 m

According to mother education:

Illiterate

Literate/ Primary School Grad.

Secondary School Grad.

High School Grad.

Higher Level

It was assured that distribution to each group is compatible with the 15-45 ages women population in Ankara (1990 census)

Data Collection

Data for normative sample was collected by 9 tester in 1995. In order to ensure reliability, particular education was given to testers; reliability between 6 testers was later measured.

Data was collected from children in child nursing home, mother-child care centers, health centers, kindergartens and primary schools. It was required child to not to have any disability and serious disorder, never hospitalized, not to be premature birth or caesarean birth, to born at least 2500 gr. It was also not allowed to collect data from more than one child from a family.(Yalaz, et al., 2009)

Determination of Norms

Data were analysed with logistic regression to designate the age scores for each item that children get. This analyse provided the information for each item that which percent (25%, 50%, 75%, 90%) of the children pass the item at which age. The items which cause variation between different graduate level mothers’ children were not included. Items with high “refusal“ and “No Possibility“ were excluded and the items which require mother’s involvement and result in application problems were also excluded. (Yalaz, et al., 2009)

Reliability

When 10 children from different age groups were tested by more than one tester at the same time, scores were found to be congruent of 90%. Retesting the same children withing 5 days also resulted in congruency of 86% and above. (Yalaz, et al., 2009)

Validity

Newly added items were selected by specialists on child development and developmental screening methods, therefore validitiy depends on their speciality and the standardization of the test. (Yalaz, et al., 2009)

CRITICISMS ON DENVER-II

Positive Critics

• It can be used in many different settings: pediatric offices, public health clinics, early intervention programs, home visitation programs, Early Start and Head Start programs, childcare centers, and preschools.
• Since there is interaction with the child and parent, the Denver-II is particularly useful for a high-risk people.

Negative

• The test has been criticized to be unreliable in predicting less severe or specific problems. *Frankenburg (2002) has replied to such criticism by pointing out that the Denver Scale is not a tool of final diagnosis, but a quick method to process large numbers of children in order to identify those that should be further evaluated (as cited in Wikipedia, 2014)

References:

*American Academy of Pediatrics (2001). Committee on Children with Disabilities.

Developmental surveillance and screening of infants and young children. Pediatrics.

*Denver Developmental Screening Test. (n.d.). In Wikipedia. Retrieved April, 2014, from http://en.wikipedia.org/wiki/Denver_Developmental_Screening_Test

*Early Childhood Michigan. Developmental screening tools. Retrieved April, 2014, from http://www.earlychildhoodmichigan.org/articles/7-03/DevScrTools7-03.htm#denver

*Frankenburg, W.K., Dodds, J., Archer, P. et al.: The DENVER II Technical Manual 1990, Denver Developmental Materials, Denver, Co.

*GeliÅŸimsel Çocuk Nörolojisi DerneÄŸi. Denver II geliÅŸimsel tarama testi “ türk çocuklarına uyarlanması ve standardizyonu”. Retrieved April, 2014, from http://www.gcn.org.tr/?pnum=22&pt=Denver%20II%20Geli%C5%9Fimsel%20Tarama%20Testi

*Gibaga, J.G. (2007, August 3). Denver developmental screening test II. Retrieved April, 2014, from http://www.docstoc.com/docs/88997890/Denver-Developmental-Screening-Test-II-DDST-II-Jonie-Gibaga

* Lee, L. L., & Harris, S. R. (2005). The Denver II. Psychometric Properties and Standardization Samples of Four Screening Tests for Infants and Young Children: A Review. : Lippincott Williams & Wilkins, Inc..

*Prof.Dr.Kalbiye Yalaz & Prof.Dr.Banu Anlar & Uzm.Birgül U.BayoÄŸlu, (2009). DENVER-II

GELİŞİMSEL TARAMA TESTÄ° “TÜRK ÇOCUKLARINA UYARLANMASI VE

STANDARDÄ°ZASYONU”. : GeliÅŸimsel Çocuk Nörolojisi DerneÄŸi, Ankara

*Ringwalt, S. (2008, May). Developmental screeining and assessment instruments. Retrieved April, 2014, from http://www.allbookez.com/pdf/669o1/ * Value in Practice, Denver Developmental Materials, Inc. © 2014. Retrieved April, 2014, from http://denverii.com/denverii/index.php?route=information/information&information_id=4

*Willacy, H. , Tidy, C. (2014, April 12). Denver developmental screening test. Retrieved April, 2014, from http://www.patient.co.uk/doctor/denver-developmental-screening-test