1S.PHe M. - i i i = cher, Sc.D. Phillip Are Best tit Estat Pereeerere .ACKNOWLEDGEMENTS ‘The authors wish to express their appreciation to: Brigitte Curtis, Jinhuau Chen, Georgia Athearn, Sandra Harris, Sharon Brainard, Pamela Haglund, Clara Perez-Mendez, Gwedolyn Marier, Lucille Johnson, Helen Mcintosh, Rose Hosmer, Bradley Samuel, Judy Reflor, Reid Reynolds, Denver Department of Health and Hospitals, Denver Department of Social Services, Colorado county health departments and local nursing services, Kaiser Permanente, Plan de Salud del Valle, many private physicians’ offices, Mile-Hi Child Care centers. Head Start centers, Cheryl J. Mamdu and Renee M, Cowan for the typing of this manual, and the parents ‘and children who participated in the standardization. In addition, the authors wish to express their appreciation to Paul Levy, Professor and Chairman of the Department of Epidemiology, University of llinais, School of Public Heaith, for his consultation in the design of the standardization project. Published by Denver Developmental Material, Inc. P.O. Box 371075 Denver, Colorado 80237-5075, (803) 955-4729 - (800) 419-4729 © 1967, 1970 William K. Frankenburg and Josiah B. Dodds; 1975, 1976, 1978 William K. Frankenburg: 1990, 1992 Wiliam K. Frankenburg and Josiah B. DoddsDENVER II TRAINING MANUAL Contents L Introduction A. Objectives. a Historical Background . Description of the Test D. Training of Examiners. E. Clinical and Research Applications. ‘Standardization A. Selection of Potential items... Design of the Sample ©. Collection of Data. D. Computation of Norms E. Reliability F. Validity Administration and Interpretation A. Test Materials B. Test Form ©. Caleuating the Chics Age & Drawing he Age Lne 1. General Instructions. 2. Adjusting for Prematurity 3. Drawing the Age Line D. Test Administration 1. General Instructions... 2. Building Rapport... 3. Introduction 4. Order of Testing 5. Number of Items to be Given 6. Test Behavior Ratings 7. liem Scoring E. Interpretation 1. Interpretation of individval Items... 2. Interpretation of the Test... 3. Referral Considerations 4. Profiles of Various Test Results \V. Directions for Administration of Specific Items ‘A. Personal - Social.. 5 B. Fine Motor — Adaptive ©. Language. D. Gross Motor V. Self-Evaluation A. Short Answer B. Multiple Choice G. Interpretation of Results D. Answers Vi. Self-Administered Checklist Appendices ‘A. Age When Given Percentage of Standardization Sample Passed Items 4. Personal - Social 2. Fine Motor — Adaptive 3. Language. 4. Gross Motor B. New, Changed, and Omitted lems: Compared to Original Test 4. New Items. 2. Changed Items... 3. Omitted Items. prbooe HOLY 43, or AS 46 aT 481. INTRODUCTION A. OBJECTIVES This manual was developed to provide instruction in testing and scoring procedures of the DEN- VER II, to describe standardization data, and to clarify potential clinical and research applications, ‘The manual is designed to accompany a video training program. Screeners are advised to study both the manual and the videotape, to practice testing, and to take the proficiency test to assure that they administer and interpret the test correctly. After studying the instructional materials and practice-testing a dozen children, the screener should be able to: * Accurately prepare for the administration of the test, including calculating the child's age and drawing the age fine on the test form ‘*Roliably perform the test procedures and identify variations of pass/fail status * Subjectively assess and rate the child's overall behavior during the test ‘Identify scores as “advanced,” “normal,” “caution,” of “delayed” + Interpret test results as “normal,” “suspect,” or “untestable” + Pass the proficiency examination B. HISTORICAL BACKGROUND The Denver Developmental Screening Test (DDST) was first published in 1967 to help health providers detect potential developmental problems in young children. Since its original publication, the DDST has been widely used. It has been adapted for use and standardized in over a dozen countries and thus has been used to screen more than 50 milion children throughout the world, As a result of such wide-spread usage much has been learned, and this has prompted a major revision in the test, culminating in the DENVER I Four concems raised by past use are: the need for additional language items; the appropri- tenes of 1967 norms in 1990; specific test item characteristics (such as difficulty in administra- tion andjor scoring), and the appropriateness ofthe test for various subgroups (such as ethnic groups, sexes, maternal education levels, and places of residence when clinically significant cltfer- ences exist in subgroup norms; see DENVER I! Technical Manual.) Another concern raised has been the lack of test sensitivity in predicting later status, such as school performance. Aconcem raised primarily by the developers of the test was the occasional well-intentioned but inaccurate way in which the test was sometimes administered and/or interpreted. ‘The aforementioned concems were fundamental in the decision to revise the test, restandard- ize it, modify its interpretation, develop a new training videotape, and emphasize training and peri- odie proficiency evaluation in the administration of the test. ©. DESCRIPTION OF THE TEST The DENVER Il is designed to be used with apparently well children between birth and six years of age and is administered by assessing a child's performance on various age-appropriate tasks. The test is valuable in screening asymptomatic children for possible problems, in confirming intuitive suspicions with an objective measure, and in monitoring children at risk for developmental problems, such as those who have experienced perinatal difficulties. The DENVER II is not an IG test, noris it definitive predictor of future adaptive or intellectual ability Itis not designed to generate diagnostic labels such as learning disability language disor- der, of emotional disturbance, and it should never substitute for a diagnostic evaluation or physical cexarination, Rather, the test is designed to compare a given child's performance on a variety of tasks to the performance of other children the same age. The DENVER II consists of 125 tasks, or items, which are arranged on the test form in four sectors to screen the following areas of function: - Personal-Social - geiting along with people and caring for personal needs Fine Motor-Adaptive - eye-hand coordination, manipulation of small objects, and problem-solving - Language - hearing, understanding, and using language - Gross Motor ~ sitting, walking, jumping, and overall large muscle movement Also included are five “Test Behavior" items for completion after administration of the test: Rating the child's behavior in this way helps the screener subjectively assess the child's overall behavior and obiain a rough gauge of how the child uses his or her abilities. TRAINING OF EXAMINERS ‘The DENVER I was designed to be used in a clinical setting by a variety of professionals and paraprofessionals. Testing should only be undertaken by individuals who are thoroughly familiar with the DENVER II materials and procedures as well as the problems associated with testing young children. The test must be administered in the standardized manner, and screeners should be carefully trained and should pass the proficiency test before using the test for clinical purposes. Study of this manuel, especially the administration and scoring sections, a review of the videotape, and practice testing children of various age groups should help the potential user develop the fun- darnental skills for proper administration and interpretation of the DENVER I Persons who previously administered the ODST — as well as those who have not - are advised to go through the entire training program and proficiency evaluation since there are many differences between the two tests Persons wishing information regarding training, proficiency testing, or materials should contact William K. Frankenburg, M.D., M.S.PH., C0 Denver Developmental Materia, Inc., PO. Box 371075, Denver, CO 80237-5075, (803) 355-4729 or 1-800-419-4729, E, CLINICAL AND RESEARCH APPLICATIONS The principal value of the DENVER 1 is to provide an organized, clinical impression of a child's overall development and to alert th user to potential developmental difficulties. The DEN- VER Il should be used primarily to determine how a child compares to other children. It is not rec ommended as a predictor of later development. The DENVER i Technical Manual presents exten- sive data on the test's revision and restandardization as well as detailed information about all of the items included in the DENVER IIl, STANDARDIZATION . SELECTION OF POTENTIAL ITEMS In the process of revising and restandardizing the DDST, several modifications were made in the original 105 items. This included omitting items due to their limited clinical value or difficulty in administration or scoring. Some DDST items were revised for clarification, and many new items were added, especially in the language sector. The poo! of potential items for the standardization numbered 336. Scoring criteria for each iter and for the child's general behavior were established prior to initiating data collection, B. DESIGN OF THE SAMPLE ‘A.quota sample design was used that controlled for maternal education, residence, and eth- ricity within age groups. To facilitate field sampling, the testing age range of 2 weeks to 6-1/2 yyoars was split into 10 age groups, as follows: to 2 months 13 to 18 months 2.10 4 months 18 to 24 months 4107 months, 24 to 40 months 7 10 10 months 40 to 57 months 10 to 13 months 571078 months ©, COLLECTION OF DATA Data on the normative sample were collected curing 1988 by 17 screeners. Before data col- lection, extensive training procedures were conducted to assure high inter-rater reliability. Post- screening reliability cata were also gathered for the seven soreeners who tested over 80% of the normative samole. Screeners tested children who met the basic criteria for inclusion in the study, and whose age, race, place of residence, and mother ‘s educational level were needed to meet the quota sample. Testing locations were throughout the Denver metropolitan area, and in several urban, semi-rural, and rural regions in the state of Colorado. The children were located through the Denver Department of Social Services, the Denver and Colorado Departments of Public Health well-child clinics, pediatricians, family physicians, hospital birth records, child care centers, and private sources. Only full term children without obvious defects ~ and only one child per family ~ were included in the sample of 2,096 children, The sam- ple finally obtained is described in the DENVER /! Technical Manual. D. COMPUTATION OF NORMS The data were analyzed by logistic regression to determine the ages at which the children tested passed each of the items. A large number of observations per item were available for analy- sis, as each item was administered at least 440 times and up to 1,309 times (mean=783, 0190.7). The analysis made it possible to determine when 25%, 50%, 75% and 90% of the chit dren passed a test item. The variables of sex, maternal education, ethnicity, and place of resi- dence were also analyzed with regard to differences in the ages at which children passed the item. (The norms for items demonstrating clinically significant differences are discussed in the DENVER WTechnical Manual.) Jn addition to the quantitative data analysis, several qualitative factors were subjectively eval- uated for each item, such as ease of administration and scoring, interest value for the child being tested, and practicality. This information was used to help select items for the DENVER Il from the pool of potential items on which data were obtainedE. RELIABILITY Thirty-eight children from 10 age groups were recruited and scheduled for two evaluations on each of two occasions separated by an interval of seven to 10 days. Four trained screeners examined or observed the testing of each child. Testers and observers scored the children inde- pendently, and results rom the first evaluation were not available during the second week's evalua tion Two types of reliability assessed were concurrent éxeminer-obsetver reliability and 7 to 10 day test-retest stability. The percentage of agreement in the observed evaluations was computed for each of the items administered. The mean examiner-observer reliability for the items included in the DENVER iis 99 with a range of 95-1.00 and a standard deviation of .016. The mean 7 to 10 day test-retest reliability for the samme items is 90 with a range of .50-1.00 and a standard deviation of 12. F. VALIDITY Content validity of the original DDST items has been recognized through the test's accep- tance all over the world. The new items were written and selected by professionals specializing in child development and pediatric screening, The validity of the test rests upon its standardization, ‘not on its correlation with other tesis since all tests are constructed slightly differently. Even tests such as IQ tests, which are purported to measure the same function, do not totally agree. Persons seeking more detailed information are advised to consult the DENVER I! Technical Manual.ADMINISTRATION AND INTERPRETATION A. TEST MATERIALS ‘Tho DENVER Il utilizes the following materials: * Red yarn pom-pom (approximately 4° diameter) _* Tennis ball * Raisins. * Red pencil ‘Rattle with narrow handle = Small plastic doll with feeding bottle #10 1-inch square colored wooden blocks * Plastic cup with handle ‘+ Small, clear glass bottle with a 5/8 inch opening _* Blank paper = Small bell ‘All materials used in tosting are provided in the test kit, with the exception of blank sheets of paper (for drawing). Also necessary are a table and enough chaits for the examiner, caregiver and child (if appropriate), and adequate space to administer the gross motor items. For young babies, a blanket or cushioned examining table is helpful for items in which the infant lies down. ‘The materials provided with the DENVER II kithave been selected with care, and haphazard suo- stitutions may reduce the reliability in comparing a tested child with the norms. In lieu of raisins, “ol-shaped cereal may be substituted. When items are lost or broken, replacements should be requested from the test publisher. Children should always be carefully supervised when test materials are present to prevent injuries such as ingestion, laceration of an eye, etc. B, TEST FORM The test form has each of the items arranged within one of four sectors: Personal-Social, Fine Motor-Adaptive, Language, and Gross Motor. A sample DENVER II test form is included on the fol- lowing pages as Figures 1 and 2. ‘Age scales across the top and bottom of the test form depict ages in months and years from birth to 6 years. Each space between age marks on these scales represents one month until 24 ‘months; therealter each space represents 3 months. Each of the 125 test items is represented on the form by a bar that spans the agas at which 25%, 50%, 75%, and 90% of the standardization sample passed that item, as illustrated in Figure 3. Figure 3 ‘Age scalein months 6 8 2 6 ee es Proant of normal chron passing tom: 26% 50% TER 90% wave, a In the above example for the itern "Walk Well,” the lefl end of the bar indicates that 25% of the sample children walked well ata little over 11 months; the hatch mark shows that 50% did this at 12-118 months; the left end of the shaded area shows that 75% walked well at 13-1/2 months; the right end of the bar shows that 90% of the sample children could walk well at a little under 15 months. ‘Some of the items have a small footnote number on the left end of the bar. This numiber refers to numbered instructions found an the back of the test form that remind the examiner how to administer andor interpret such items. (See Figure 4.) Some items may be passed by report of the caregiver, and therefore have an “R located at the left end of the bar. (See Figure 4.) Only those items with an “R’ on the test form may be passed by report. Even for the report items, whenever possible the examiner should observe what the child can do. | Figure 4 | Rindeatestomay oo pasedbyropon [=i Fociote umber eer to nstucions on i [Bec cei For some ofthe ems atthe youngest ages, all ofthe percentiles (25th, 50th, 75th and 90th) are not available. Such items, while only rarely failed, are included to alert the user to the child who requires a more detailed evaluation. For example, tha item “Equal Movernents," which should be ppassed by all infants, is included to alert the examiner to the child who may have a weakness (paresis) of one limb or one side of the body. All such items occur at early ages, with more than 90% of children performing the task at birth or shortly thereafter.DENVER Il PERSONAL SOCIAL, FINE MOTOR - ADAPTIVE LANGUAGE: ‘aRioss MOTOR, Examiner Date: Figure 1 Compliance (See Note 3) ‘Always Complies Usvally Comalies Rarely Complies Interest in Surroundings Somewhat Disnirestog Sanously Disinterested Aporopriate Somewhat Distractibie Very Ostractisla ‘G1oH9, 1665, 1990 WK Frankenbarg dB, Ooads 1978 WK. FrakerburgDIRECTIONS FOR ADMINISTRATION 1. Try to gat child to smile by smiling talking oF waving, Do not touch hirwer, 2. Child must stare at hand several seconds. 3, Parent may help guide toothbrush and put toothpaste on brush. 44. Child does not have to be able to tie shoes or button/ip in the back, '5, Move yarn slowiy in an arc from one side tothe other, about a" above chil’ face. 6. Pass if child grasps rattle when its touched tothe backs of tips of fingers. 7. Pass if chid tres to gee where yarn went. Yarn should be atopped quickly from sight from fester's hand without arm movernent. 8. Child must transfer cube from hand to hand without help of bady, mouth, oF table 8, Pase'f chia picks up raisin with any part of thumb and finger 10, Line can vary only 20 dagrees or less from teste’ tne. +11. Make a fist with thumb pointing upward and wiggle only the thumb, Pase if child imitatos and does not move ary fingers other than, the thumb, 12, Pass any enciosad form, 13, Which line is longer? 14, Pass any ines crossing «15, Have child copy frst, Fail continuous round (Not bigger) Turn paper ‘ear midpoint failed, demonstrate, motions. ‘upside down and repeat (pass 3 of 9 or Sof 6) \When giving items 12, 14, and 15, do not name the forms. Do not demonstrate 12 anc 14 16, Whan scoring, each pair (2 arms, 2 lags, etc) counts as one part 17. Place one cube in cup and shake gently near childs ear, but out of sight. Repeat for other ear. 18, Point to picture and have child name it. (No credit is given for sounds only) It fees than 4 letras are named correctly, have chid point to picture as each is namad by tester cer 19. Usieg doll, tell child: Show me the nose, eyes. ears, mouth, hands, fest. tummy, hac Pass 6 of 8. 20. Using pictures, ask child: Which one fles?..says meow?...aks?...baras?..galops? Pass 2 of 8, 4 of 6. 21. Askchild: What do you do when you are cold..tired?., hungry? Pass 2 of 3, 3of 3 22. Ask child: What do you do with 2 cup? Whatis a chair used for? What is a pencil used for? ‘Action words must Oe included in answers. 23, Pass if chlid correctly places and says how many blocks are on paper. (1, 5) 124, Tell chile: Put block on table; under abla; infront of me, behind me. Pass 4 of 4 (Bo not help child by pointing, maving head or eyes.) 25. Agk child: What isa bal?...ake?...desk?,.house?.. benana?...curtair?..ence?..celing? Pass if defined in terms of use, shape, ‘what itis made of, oc ganaral category (Such as banana is ful, not just yellow). Pass 5 of 8, 7 of 26. Ask child: Ia horse is big, a mouse ie _? Iffreis hot, ice is 7 I tne sun shines duzing the day, the moon shines during the _? Pass 2f3, 27. Child may use wall or rail only, not person. May not crawl 28, Child rust irow ball overhand 3 fost fo within arm's teach of tester 29, Child must perform standing broad jump over wicth of tost shoct (8 1/2 inches). 20, Tel child to walk forward, €DEDEDED-P heal within 1 inch of tos. Tester may demonstrate, Chile must walk 4 consecutive steps. 31, In the second yea, haf of normal children are non-compliant (OBSERVATIONS:C. CALCULATING THE CHILD'S AGE AND DRAWING THE AGE LINE 4. General Instructions General information such as the child's name, birth date, and test date should be recorded first on the test form. The child's age is computed by subtracting the date of birth from the date of testing. (When itis necessary to “borrow’ in the subtraction, 30 days are borrowed from the month column, and 12 months are borrowed from the year column.) Example #1: Year Month Day | Date Of TASt nrncrnnenn OO seed saneet Date of Birth BB ne sant ‘Age of Child cee eay Daas The age of the child in Example #1 is found to be 2 years, 4 months, and 5 days. Example #2: Year Month Day 18, BO isch arcahG Deteloltest cons OO nee Mean e Date of Birth BB 10 28 ‘Age of Child eeeasienerese ei The age of the child in Example #2 is 1 year, 8 months, and 17 days. The age is calculated as follows: Step 1. [tis not possible o subtract 28 days from 15. Therefore, borrow 30 days (1 month) from 7 months. Add 20 days to 15 to make 46 days. Six months are left in the month column, Step 2. Subtract 28 days from 45 days = 17 days. Step 3. It's not possible to subtract 10 months from 6. Therefore, borrow 12 months (1 year) from 90, Add 12 months to 6, to make 18 months: 89 is left in the year column. ‘Step 4. Subtract 10 months from 18 months = 8 months ‘Step 5. Subtract 88 from 89 = 1 year. The age of the child in Example #2 is found to be 1 year, 8 months, and 17 days. Accurate age calculation is very important, and should be checked carefully before proceed- ing with tho test, The child’s age is used as 2 reference point against which all item performances are compared. 2, Adjusting for Prematurity For children who were born more than 2 weeks before the expected date of delivery and who are less than 2 years of age, the calculated age must be adjusted. To adjust the age, frst divide the number of weeks premature into months and days, using 4 weeks to a month and 7 days toa week. Then subtract the resulting month(s) and days from the calculated age. Example #3: Year Month Day Date of Test 90 oe B orn BO | Dateot Bian 90 eB snl | Age of Chia : 252 6 weeks premature AV ee | Adjusted Age of Chita A eee ‘The calculated age of the child in Example #8 is found to be 2 months 19 days. The child was orn 6 weeks (1 month 14 days) prematurely, so this amount is subtracted from the calculated age to arrive at the adjusted age of 1 month 5 days. Use this adjusted age to draw the age line. In addition, itis necessary to indicate on the test form that the child's age was adjusted for prema- tury, No age adjustment is necessary for children 2 years of age and above or for children born later than expected. (When the child reaches 2 years of age or more itis no longer necessary 10 adjust for prematurity because the weeks premature represent an incteasingly smaller fraction of the child's total age.)3. Drawing the Age Line After correctly calculating the age of the child to be tested (and adjusting for prematurity, # necessary), use the age scales and a straight edge to accurately draw an “age line” from the top to the bottom of the form. Each space between age marks at the top and bottom of the form repre- sents one month until 24 months; thereafter, each space represents 3 months. Use the exact calcu- lated (or adjusted) age to draw the age line, without rounding off days, weeks, or months. After drawing the age line, write the date of the test above it, as shown in Figure 5. Figure 5 Age scala in months 8-15-92 ® 6 ‘The child is 12% months old: tho date ofthe testis August 15, 1092, As test interpretation depends on the correct placement of the age line, the age scale should bbe carefully checked fo assure that the line has been drawn in the correct location. D, TEST ADMINISTRATION 1. General Instructions ‘The DENVER Il can be used to screen a child repeatedly from birth to six years of age. To use the same test form on more than one occasion, itis suggested that a new age line (with the date of testing entered above it) be drawn each time the child is screened, and that the scoring of items be done in such a manner as to distinguish the scores far each administration. For example, this may be accomplished by using a different colored pencil All items must be tested in accordance with standardized administration procedures: described in this manual; otherwise, the norms depicted by the bars will not be applicable. Examiners should review the directions for administration of the test periodically to guard against unintentional deviations. 2. Building Rapport In the testing situation, the examiriers efforts should be directed towerd obtaining the best test performance possible from the child and obtaining accurate information from the caregiver. Rapport with the child and caregiver is essential The test is to be given with the child’s parent or primary caregiver present. To elicit the most natural activities from the child, every effort should be made to make the caregiver and child com- fortable. Itis best to administer the test while the child is dressed, Boots or shoes that restrict the chile’s performance of motor terns should be removed before these items are administered. A young child may sit on the caregiver's lap. An older child may sit alone on a chair if he or she is comfortable and can reach the test materials easily. Ideally, the child will sit so that his or her arms can rest upon the table. The child's ellbow should be level with the table top. Ifa child sitting on a lap is too low, ask the person holding the child to put a folded blanket on the lap to raise the child A table that can be adjusted for height, or a child-sized table and chair is ideal for testing preschool-aged children. Infants may be evaluated on the floor if a safe table is not available. Introduction ‘The caregiver should be asked when the child was born and whether the child was born pre- maturely. The examiner should then calculate the child's test age and determine if the calculation is, cortect. Since the testing may cause anxiety for the child's caregiver, itis essential to explain that the DENVER II is administered to datermine the child's current developmental status, that the test is not an IQ test, and that the child is not expected to pass all of the items administered.4. Order of Testing The order of presenting the items should be flexible, and the sequence should be adjusted according to the responsiveness of the child. It is generally helpful to place one or more age- appropriate test items (such as a rattle for the infant, blocks for @ toddler, paper and pencil for a preschooler) on the table so that the child can amuse him- or herself while the examiner asks the parent the reportable items of the Personal-Social sector. The child's free activity while “report” items are being asked of the caregiver is considered part of the evaluation, and the examiner should be attentive to the child’s spontaneous behavior. Test items may be scored on the basis of any relevant behavior observed by the examiner oven if it occurs before or alter the formal testing. For example, ia child runs into the testing room, the item “Runs” may be scored as a pass. Although flexibility is very important, there are general guidelines for the order of adminis- tering the items that are favorable for most children. The following points are suggested: . In general, items requiring less active participation of the child should be administered first (such as the “report” items in the Personal-Social sector). These should be followed by the Fine Motor-Adaptive items, which do not require the child to speak: next, the Language items: and finally, the Gross Motor items. For most children itis best to administer the Gross Motor items last, since they require a sense of confidence which generally increases as testing pro- gresses. In addition, some children become excited when performing the Gross Motor items and subsequently are reluctant to return to the examining table to perform items in other test sectors. bb. Tasks that the child can perform easily should be administered frst. The child's efforts should be praised, even on items that are failed. This builds the child's confidence and may encourage him or her to attempt more difficut items. . Items that use the same materials in the test kit, such as blocks, may be administered consecu- tively to save time. This helps to avoid continued removal and retrieval of materials during the testing, which can disrupt the “tlow” of the session. d. Itis recommended that only materials used for the specific item be placed on the table to avoid istractions. Testing may also progress more smoothly ifthe test kt is kept out of sight and reach of the child (perhaps on the examiner’ lap). @. For infants, it is recommended that all items administered with the baby lying down be tested together. Regardless of the age of the child, in each sector testing should begin with items that fall com- pletely to the left of the child's age line, and continue to the right. 5. Number of Items to be Given The number of items to be given varies with the age and abilities of the child being tested. In practice the number of items administered mnay depend on: ‘= The time available for testing, and ‘= Whether the goal is to identify developmental delays and/or the relative strenaths of the child. ‘a. To determine if the child is developmentally at risk, administer the test as follows. Step 1: In cach sector, administer at least three iterns 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 the left in the appropriate sector until the child passes three consecutive items. bb. To determine a child's relative strengths (a ceiling), administer the test as follows: Step 1: In cach sector, administer at least three items nearest to and totaly to the left of the age line and every item that is intersected by the age line. ‘Step 2: Continue to administor tems to the right of any passes in each sector until three failures are recorded. The child may be given up to three trials to perform each item, when appropriate, before scoring a failure. More than three trials may teach the child an item not previously accomplished Such “teaching” would also extend the testing time6. Test Behavior Ratings ‘The “Test Behavior” ratings are scored after the completion of the test. Using the rating scale provided, the screener can compare the behavior of the child during the test with the child's previ- ‘ous performance. Always ask the caregiver if the child's performance was typical of his or her abil- ity and behavior at other times. Sometimes a child may be too il, tired, hungry, or upset when test- ed to display actual capabilities. In such cases, the test may be rescheduled on a different day at a time the child is likely to be more cooperative. Item Scoring The score for each item should be recorded on the bar near the 50% hatch mark. The following scores are used for the DENVER II: “P" for Pass ~ the child successfully performs the item, or the caregiver reports (when appro- priate) that the child doas the item. “F* for Fail the child does not successfully perform the item, or the caregiver reports (when, appropriate) that the child does not do the item. “N.O." for No Opportunity - the child has not had the chance to perform the item, due to restrictions from the caregiver or other reasons. This score may only be used on “report” items. “R” for Refusal -the child refuses to attempt the item. Refusals can be minimized by telling the child what to do rather than asking. If given instruction in proper administration, the care- giver may administer the iter. Report items cannot be scored as refusals E, INTERPRETATION ‘The DENVER 1 is used to identify the child whose development appears to be delayed in comparison to the development of other children. It can also be used to identity changes in devel- opmental rates or patterns over tima. Individual items are interpreted first, and then the entire test is interpreted. 1. Interpretation of Individual Items a. “Advanced” Items Ifa child passes an item that falls completely to the right af the age line, the child's develop- ment is considered advanced on that iter. This is because the child has passed an item that most children do not pass until an older age. This is illustrated in Figure Sa. “Advanced” items are not considered for purposes of interpreting the overall test. Figure 5a - An “Advanced” Item (Not consisered for purposes of interpreting the overal test) Age Line b. “Normal” Items Failure or refusal of individual items do not necessarily indicate a delay in development. For ‘example, if a child fails or refuses an item that falls completely tothe right ofthe age ine, the childs development is considered normal. Ths is because the child is younger than the age at which 25% of children in the standardization sample could do the item: the child is not expected 10 pass such an item unti an older age. This is illustrated in Figure Sb. Figure 5b ~ “Normal” tems (tot eonesored or purposes of interpreting te vert et) ‘ge Line ‘Ago tino ss R_ “‘As shown in Figure Sc, a child can pass, fail, or refuse an item on which the age line falls between the 25th and 75th percentile, and the child's development on that item will be considered normal. “Normal” items are not considered for purposes of interpreting the overall test Figure 5¢ ~ "Normal" Items (Not considered for purpases of iterprting the overall test) Age Line ‘Age Line ‘Age Line pa ; 7am ; c. “Caution” Items. ‘A “Caution” on an individual item is considered when interpreting the entire test. A "Caution" can be determined in one of two ways, as shown in Figure 5d. A “Caution” is scored when a child fails or refuses an item on which the age line falls on or between the 75th and 90th percentile. This is because more than 75% of children in the standardization sample can do the item at a younger age than the child being tested. A Caution’ is indicated on the test form by writing a °C" just to the right of the bar. Figure 5d - *Caution’ Items (Cauton” tems are considered for purposes ol interpreting the overall ost) ‘Age Line ‘Age Line ‘Age Line Ageune E r r d. “Delayed” Items Like "Cautions, * “Dotays" on individual items are considered when interpreting the entire test. “Delays” are indicated in Figure Se. As can be seen, a "Delay" results when a child fails or refuses fan item that falls completely to the left of the age line. This is because the child has failed or refused an ite that 90% of children in the standardization sample passed at an earlier age “Delays' are indicated by coloring in the right end of the bar. Figure Se — “Delayed” Items {CDolayed" toms ar considrad for purposes of intrpreting the overall et) ‘getune "Ago Une __ 2 . “No Opportunity” Items Report items which the parent says the child has not had an opportunity to try are scored as "N.O.”" for ‘No Opportunity” (Figure Sf) . These items are not considered in interpretation of the entire test Figure 5f - "No Opportunity’ Items (Wot considered for purpases of miorprting the overall test) Age Line ‘Age Line ji = _)o = Note: The exact ages at which 25%, 50%, 75%, and 90% of children in the standardization sample passed each item are listed in Appendix A (p. 43) and may be consulted when scoring individual items. 122. Interpretation of the Test (These are suggested guideline: ‘The DENVER Ils interpreted as follows Normal * No Delays and a maximum of 1 Caution * Conduct routine rescreening at next well-child visit Suspect: * Two or more Cautions and/or One or more Delays. ‘= Since communities’ and programe’ priorities differ in types or severity of problems they seek to identify in screening, il wil be necessary to adjust Suspect criteria to most efficiently achieve their goals. Tables of percentages of Cautions and Delays that may be expected for different demographic groups are provided in the DENVER /! Technical Manual, pages 19-21 ‘+ Rescreen in 1-2 weeks to rule out temporary factors such as fatigue, fear, illness, Untestabl ‘= Refusal scores on one or more item's completely to the left of the age line or on more than one item intersected by the age line in the 75%-90% area, * Rescreen in 1-2 weeks, 3. Referral Considerations H, upon rescreening, the test result is again Suspect or Untestable, whether or not to refer should be determined by the clinical judgement of the supervising professional based upon - profile of test results (which items are Cautions and Delays) - number of Cautions and Delays ~rate of past development - other clinical considerations (clinical history, examination, etc.) - availabilty of referral resources Monitoring the screening program is discussed in the DENVER Ii Technical Manual, pages 18-22, The use of such monitoring is strongly recommended to assist the supervising professional in establishing and adjusting reterral criteria 3. Prot 1s of Various Test Results Pages 14-16 provide examples of Interpreting tests that are Normal, Suspect, and Untestable. 13cee Normal 4. There are no Delays. Since there is only cone Caution (Throw Ball Overhand), the testis Normal Normal 2. There are no Delays and no Cautions. Failures are to the right of the age line or inter- sect between the 25th percentile and the 75th percentile. This test is Normal‘Suspect Suspect '3. There are one Delay (Hops). and 3 Cautions 4, There are 2 Delays (Work for Toy and (Pick Longer Line, Know 3 Adjectives, and Reaches), yielding a Suspect test resut. Balance Each Foot-3 Seconds), which makes the test Suspect.Untestable 5. There are 2 Cautions (Feed Doll and Tower of 2 Cubes). Since these items are Refusals, the testis Untestable, Untestable 6. There are 4 Delays (Thumb Wiggle, Use of 3 Objects, Use of 2 Objects, and Name 1 Color). Since these items are Refusals, the test is Untestable.IV. DIRECTIONS FOR ADMINISTRATION OF SPECIFIC ITEMS Follow the described procedures exactly, and carefully check the scoring criteria before passing oF failing an item. Some items may be passed by report of the caregiver. These items are distinguished by “R” in the item bars on the test form and by (R) after item names in the following directions for administration. When scoring an item by report of the caregiver, itis helpful to circle the “Rin the distribution bar on the form to distinguish reported behavior from behavior actually seen. When administering report items. avoid asking “leading questions” that may suggest an answer to the caregiver. For example, instead of asking, "Your child can drink from a cup, right?” ask, "Does your child drink trom 2 cup?” Take care to ask questions that requite the caregiver to supply the necessary information to score the iter (more details andor examples), rather than prompting the caregiver to give the desired response. In addition, asking it a child does something yet, may Nelp the caregiver feel more comfortable in reporting failures, A. PERSONAL-SOCIAL Regard Face Hold the child or place the child on his/her back and put your face about 12 inches above the child's face. Pass if the child actually looks at you. ‘Smile Responsively With the child lying on the back, smile and talk to the child. Do not tickle the child, or touch his/her face. Pass if the child smiles in response. The objective is a social response rather than a physical response. ‘Smile Spontaneously (R) During the test watch for the child to smile at you or the parent without any stimulation, either by touch or sound. If this is not seen, ask the parent if the child ever smiles at someone first, before being smiled at, talked to, or touched. Pass if the child smiles spontaneously at you or the parent during the test or reportedly at home. The objective is for the child to initiate social interaction. Regard Own Hand (R) During the test, notice if the child stares at one of his/her own hands for at least several seconds, rather than glancing at it leetingly. f you do not see this, ask the parent if the child has done this. Pass ifthe parent reports that the child does this or if you see the child do this curing the test. Work for Toy Place @ toy which the child seems to enjoy on the table a litle out of reach. Pass if the child tries to get the toy by reaching or stretching his/ner arm or body toward the toy. The child does not have to actually pick up the toy. Feed Self (R) Ask the caregiver if the child actually feeds himself/herself a cracker, cookie, or any finger food. Pass if the parent reports that the child does this, Score “No Opportunity” # the child has not been given such food, ”18 Play Pat-a-Cake (R) ‘Without touching the child's hands or arms, demonstrate the pat-a-cake game by clagping your hands together and ask the child to “play pat-a-cake" with you. If the child does not do this, ask the parent to try it If the child stil does not do it, ask the parent if the child does this at home. Pass if you observe the child clapping his/her hands or if the parent reports that the child does this. Also pass any other clapping garne in which the child participates. The objective is interaction with another person Indicate Wants (R) During the test, notice if the child lets you or the parent know that he/she wants something, without crying. If this cannot be seen, ask the parent how the child lets someone know what he/she wants. Pass if you see the child do something other than cry to communicate a specific desire, or ifthe parent reports that the child does this. Examples of passes are: pointing, reaching and making ‘sounds, putting arms up to be picked up, pulling, and saying a word. Wave Bye-Bye (R) If possible, itis best to administer this item as the parent and child are leaving, or as you are leav- ing the room. Face the child and say "bye-bye" while waving to the child. Do not touch or allow the parent to touch the child's hands or arms. If the child does not respond, ask the parent ifthe child "waves bye-bye.” Pass i the child responds by raising his/her arm or waving with hand or fingers, or if the parent reports that the child does this. Play Ball with Examiner Rall the ball to the child and try to get the child to rollit or toss it back. You may need to roll the ball back and forth several times. Pass if the child rolls or tosses the ball purposefully toward you. (Handing the ball to you is not a pass.) Imitate (Household) Activities (R) ‘Ask the parent if the child imitates activities around the house such as dusting, wiping up, sweep- ing, vacuuming, of talking on the talaphone. Pass if the parent reports that the child imitates any type of adult household activity. Drink From Cup (R) ‘Ack the parent if the child can hold a regular cup or glass and dink from it without help, spilling less than haif of the liquid. The cup or glass may not have a lid or spout. Pass if the parent reports that the child does this Help in House (R) Ask the parent if the child helps at home by doing simple tasks like putting toys away, throwing trash away, or gelling something for a parent when asked. Pass if the child actually helps rather than just imitates. The objective is to determine if the child understands and carries out a request to help Use Spoon/Fork (R) ‘Ask the parent if the child uses a spoon or fork to eat. If so, how much does he/she spill? Pass if the child uses a spoon and/or fork and gets most of the food into the mouth, spilling little “The objective is to determine if the child is essentially self-sufticient in feeding.Remove Garment (R) ‘Ask the parent if the child can remove any of his/her clothing, and if so, what items of clothing Pass if the child can remove items such as shoes that take some effort to remove, jacket, pants, oF Tshirt. Do not pass hat, socks, diaper, slippers, or shoes that slip off easily. The objective is to see if the child cen purposefully remove a garment in an effort at self-care, Feed Doll Place the doll and toy bottle on the table in front of the child. Tell the child to “feed the baby" andor “give the baby the bottle.” Pass if the child places the bottle to the doll's mouth or obviously tries to put it to the mouth, Ifthe child imitates breast-feeding, encourage himiher to use the bottle, as breastfeeding alone is not a pass, Put on Clothing (R) ‘Ask the parent if the child can put on any of his/her own clothing, and if so, which items, Pass if the child puts on any clothing, such as underpants, socks, shoes, jacket, etc. Shoes do not have to be tied, fastened, or on correct feet. A cap placed haphazardly on the head does not pass. Brush Teeth with Help (R) ‘Ask the parent if the child brushes his/her teeth with some help. If so, ask the parent to describe haw this is done. Pass if the child is reported to hold the toothbrush and move it across the teeth in a brushing motion, There may be some help from the parent in directing the toothbrush but the child must do most of the brushing, The parent may oversee and put toothpaste on the brush. Score "No Opportunity’ if the parent has not allowed the child to try this, Wash and Dry Hands (R) ‘Ask the parent ifthe child can wash and dry his/her own hands without help, except for turning on faucets that ere out of reach. Pass if the parent reports that the child does this, using soap and rinsing and drying well Name Friend ‘Ask the child to name some of his/her friends or playmates (not living with the child) Pass if the child gives the first name of at least one friend. Names of cousins or siblings are accept- able If they do not live with the child. Names of pets or imaginary friends are not acceptable, Put on T-Shirt (R} Ask the parent if the child can get his/her T-shirt or pullover on without help. Pass if the child can pull the shirt over his/her head and get his/her arms in the sleeves. The shirt ‘may be on backwards or inside out. Dress, No Help (R) Ask the parent i the child can dress without any help. Pass if the child can dress completely and correctly without help. He/she must usually pick out hisyher own clothes (at least play clothes), and may have help only for tying shoelaces, and button- ing oF zipping the back of a dress. A pass of Dress, No Help also passes Put on Clothing and Put on FShirt 19Play Board/Card Games (R) Ask the parent if the child plays simple board or card games, such as "Candy Land” or “Old Maid.” Specify that the child must really play and understand the game. Pass jf the parent reports that the child understands and plays board or card games with others, sitting and taking turns, Brush Teeth, No Help (R) ‘Ask the parent ifthe child brushes his/her own teeth without help or supervision some of the time, including putting toothpaste on the brush and brushing all teeth with back and forth strokes at the gum ire. Pass if the parent reports that the child brushes his/her teeth without help or supervision at least some of the time, (The parent should be advised to brush the child's teeth some of the time to ensure proper cleaning.) A.pass of Brush Teeth, No Help also passes Brush Teeth with Help. Prepare Cereal (R) Ask the parent if the child can prepare a bowl of cereal without help (other than being given items that are hard to reach), including getting the bowl, spoon, cereal, and milk, and pouring the cereal ‘and milk into the bowl without spiling much. If the parent says the child cannot do this because the container of milk is too large, ask if the child could pour it from a nearly empty container, 2 small pitcher, or a glass, Pass if the parent reports that the child can de this, including pouring milk from any kind of con- tainer. B, FINE MOTOR - ADAPTIVE Follow to Midline \With the child lying on his/her back, hold the red yarn above the child's face at a height where he/she focuses on it (usually about 8 inches). Shake the yarn to attract the chil’s attention and move it slowly in an arc from one side of the child's body to the other several times. The movement of the yarn may be stopped to reattract the child's attention, and then continued. Pass if the child follows the yarn to the midpoint of the arc with eyes alone, or with head and eyes. Start Past Midline 180 degrees Follow Past Midline (Refer to Follow to Midiine tor administration procedure.) Pass if the child follows the yarn past the midpoint of the arc with eyes alone, or with head and eyes. ‘A pass of Follow Past Midtine also passes Follow to Midiine. Grasp Rattle While the child is lying on his/her back or is being held by the parent, touch the backs or tips of the child's fingers with the handle of the rattle. Pass if the child grasps the rattle for a few seconds.Hands Together During the test while the child is lying on his/her back (not while cradled in the parent's arms), notice if the hands are brought together at the midline of the body over the chest or at the mouth. Pass if you see the child bring his/her hands together in this manner. Follow 180 Degrees (Refer to Follow to Mialine for administration procedure.) Pass if the child follows the yarn with head and eyes through the complete arc from one side of the body to the other. Apass of Follow 180 Degrees also passes Follow to Midline and Follow Past Midline. Regard Raisin \With the child sitting on the parent’ lap at the table, place a raisin directly in front ofthe child. The raisin should be placed on a surface that gives good contrast, such as a piece of white paper. You may paint to or touch the raisin to attract the child's attention to it. "O"-shaped cereal may be used in place of a raisin. Pass if the child clearly looks at the raisin. Reaches ‘With the child siting on the parent’ lap so that the child's elbows are level with the table top and hishher hands are on the table, place an object such as the rattle or the red yarn within easy reach and encourage the child to pick it up. Pass if you see the child reach toward or at least move hisiher hands or arms in the direction of the ‘object on the table. Look for Yarn. ‘While the child is sitting on the parent's lap, hold the red yarn high and attract the child's attention toll. When the child is looking at the yarn, drop it so that it falls out of sight. De nat move your hand oF arm except to release the yarn, Repeat if the child's response is unclear. Pass if the child definitely looks for the yarn by looking dawn ar toward the floor. Rake Ri \With the child siting on the parent’ lap so that hisfhor olbows are level with the table top and hisfher hands are on the table, drop a raisin directly in front of the child within easy reach. if neces- sary, you may point to of touch the raisin to attract the child's attention, “O"-shaped cereal may be used in place of a raisin, Pass if the child picks up the raisin, using @ raking motion with the entire hand. Make sure the raisin did not merely stick to the chile’s hand but was actually picked up. This item is also passed it the child passes Thumb-Finger Grasp. Pass Cube Notice whether the child passes a block from one hand to the other. To encourage this, give the child a block; then present a second block to the same hand. The child will often pass the first block to the ther hand so that he/she can take the second block Pass if you see the child transfer a block from one hand to the other without using histher body, mouth, or the table. 21‘Take 2 Cubes Place 2 blocks on the table in front of the child, Encourage him/her to pick up the blocks, but do not hand them to the child, Pass if the child picks up the 2 biocks and holds one in each hand at the same time, ‘Thumb-Finger Grasp (Refer to Rake Raisin for administration procedure.) Pass if the child picks up the raisin by bringing together any part of the thumb and one or several fingers. ‘A pass of Thumb Finger Grasp also passes Rake Raisin. Bang 2 Cubes Held in Hands (R) Put Place a block in each of the child's hands and encourage him/her to bang them together. You may ‘encourage the child to hit the blocks together by demonstrating with blocks heid in your own hands. Do not touch or allaw the parent to touch the child's hands or arms. Ifthe child does not bang the blocks together, ask the parent if the child hits small objects together in this manner. Pass if the child holds one biock in each hand and hits the blocks together, or ifthe parent reports ‘that the child hits small objects together. Pots, pans, lids, or other large objects do not pass. lock in Cup Place 3 blocks and the cup on the table in front of the child. Encourage the child to put the blocks in the cup by demonstration and words. This demonstration may need to be repeated several times. Pass if the child places at least one block in the cup and releases it, Scribbles Place a piece of plain paper and a pencil on the table in front of the child. You may place the pen- cilin the child's hand and encourage him/her to scribble, but do not show him/her how to scribble. (Watch the child carefully and be prepared to prevent him/her from putting the pencil in mouth or eye.) Pass if the child makes purposeful marks on the paper. Fail accidental marks or stabbing with the pencil Dump Raisin, Demonstrated ‘Show the child 2 or 3 times how to dump the raisin out of the bottle. Then ask the child to get it out. (Do not use the word “dump.") Pass if the child dumps the raisin out of the bottle or rakes the raisin close to the opening and then «dumps it out. Do not pass if the child removes the raisin wth a finger.‘Tower of Cubes - 2, 4, 6,8 With the child sitting high enough at the table so that elbows are level with table top and hands are Cn the table, place the blocks on the table in front af the child. Encourage the child to stack them by demonstration and words. It may be helpful to hand the blocks to the child, one at a time. Three trials may be given, Pass Tower of 2 Cubes ifthe child puts one block on top of another so that it does not fall when. helshe removes hiser hand. Pass Tower of 4, 6, or 8 Cubes, depending upon the greatest number of blacks the child stacks in three tials. pass of 4, 6, or 8 cubes also passes the lower tower items (for example, passing Tower of 6 Cubes also passes Tower of 2 and 4 Cubes). Imitate Vertical Line ‘The child should be seated at the table at a comfortable writing level. Place a pencil and a piece of plain paper in front of the child and tell himner to draw lines like yours. On that paper, demonstrate how to draw vertical lines, drawing toward the child. Do not guide the child's hand. Three trials may be given. Pass ifthe child makes 1 line or more on the paper, at least 2 inches long, and not varying from your vertical ine by more than 30 degrees (see example). Lines do not have to be perfectly straight. 30 Degree Angle Less than 30 Degrees ‘More tan 20 Degree Pass. Fall Thumb Wiggle Demonstrate with one or both hands by making a fist with your thumb pointing upward. Wiggle nly your thumb. Tall the child to wiggle hisner thumb (or thumbs) the same way. Do net help put the child's hand into position. You may tell the child to make a “thumbkin’. Pass if the child moves the thumb of either or both hands without moving any other fingers. Copy O Give the child a pencil and piece of plain paper. Show him/her the circle on the back of the test form. Without naming it or moving ycur finger or pencil to show how to draw it, tell the child to draw one like the picture. Three trials may be given. Pass any form approximating a circle that is closed or very nearly closed. Fail continuous spiral mations, ODO @O6AoO pass 23,Draw Person - 3 Parts, 6 Parts Give the child a pencil and a piece of plain paper. Tell him/her to draw a picture of a person (boy, gil, Mommy, Daddy, etc.) Be sure the child has finished before scoring the drawing. 3 Parts- Pass if the child has drawn 3 or more body parts. A pair (ears, eyes, arms, hands, legs, feet) is considered one part. To get credit, both parts ofthe pair must be drawn uniess the drawing is in profile (in which case one eye, ear, etc... gets credit.) Make note in your test observations of ‘any unusuel drawing, even though the child has identified the acceptable pars. I~ al Oy PASS — 3 pans FAIL-3 oats 6 Parts - Pass if the child has dravn 6 ar more body parts. (See criteria under 3 parts.) A pass of Draw Person - 6 Paris also passes Draw Porson - 3 Paris. i 4 po 4 i— aps Of os (ees a 7 - a 2 oa 2 G4 ean c ee ie Io aA PASS - 6 parts, 3 pans FAIL —6 parts PASS ~3 pars Copy + Give the child a pencil and a piece of plain paper. Show him/her the cross on the back of the test form, Without naming it or moving your finger or pencil to show how to draw it, tell the child to “draw one like the picture.” Three trials may be given Pass if the child draws 2 lines which intersect at least somewhat near the midpoint. The lines do not need to be exactly straight, but the intersecting lines do need to be drawn using only 2 strokes. + TH oo Pass Fall Pick Longer Line Making sure they are presented vertically, show the child the parallel lines on the back of the test form and ask the child, “Which line is longer?” (Do not say "bigger. Alter the child has pointed to aline, turn the paper upside down and ask the question again. Turn the paper upside down again and repeat this a ihicd time. Ifthe child does not answer correctly all three times, repeat the ques- tion three more times, turning the paper each time, Pass if the child picks the longer line 3 aut of 3 times or § out of 6 times. 24Copy [1] Note: Administer Copy] before Copy [7] Demonstrated. Give the child a pencil and a piace of plain paper. Show him/her the square on the back ofthe test form. Without naming it or moving your finger or pencil to show how to draw it, tell the child to "draw one like the picture.” Three trials may be given. Pass if the child draws a figure with straight lines and 4 square corners. The corners may be formed by lines that intersect but the corners must be approximately right angles (not rounded or pointed). The length should be less than 2 times the width, A pass of Copy(] also passes Copy[_] Demonstrated. Pass FAL Copy () Demonstrated If the child is unable to copy the square from the picture, show him/her how to draw it by drawing two opposite (parallel) sides first and then the other two opposite sides (rather than drawing the | ‘square with a continuous motion) Three demonstrations and trials may be given. Pass by the same criteria as Copy] LANGUAGE Respond to Bell Hold the bell so that the child cannot see it (to the side and a litle behind the child's ear). Ring the bell softly. If the child does not respond, try again later in the test session. Pass if the child responds in any way, such as eye movement, change in expression, change in breathing rate, or any other change in activity. Vocalizes (R) During the test, listen for sounds other than crying, such as small throaty sounds or short vowel sounds ("uh,’ “eh"). Ifnone are heard, ask the parent ifthe child makes these sounds, Pass if you hear the child make such sounds or if the parent reports that the child does this. Pass this item also if any other vocalization items are passed, “Q00"/"Aah” (R) Listen for the child to make vowel sounds, such as 000" or “aah.” If these sounds are not heard, ask the parent if the child has made these sounds. Pass if you hear vowel sounds or if the parent reports that the child does this. Laughs (R} Listen for the child to laugh aloud. If this is not heard, ask the parent if the child does this. Pass if you hear the child laugh aloud or if the parent reports that he/she does this, ‘Squeals (R) Listen for the child to make high-pitched, happy squealing sounds. If this is not heard, ask the par- ent if the child does this. Pass if these sounds are heard or if the parent reports that the child does this, 2526 Turn to Rattling Sound Stand behind the child while he/she is facing the parent, sitting either on the parent's lap or on the table. Ifnecessary, ask the parent to use the red yarn to get the child's attention. Put one block in the cup and hold it with your hand covering the top. Being careful to keep the cup quiet while mov- ing into position, bring the cup 6-12 inches from the child's ear but cut of the childs line of vision. Shake the cup gently, making a soft, ow sound. Repeat with the other ear. Pass if the child responds by turning toward the sound on both sides. Turn to Voice While the child is facing the parent, either seated on the parent's lap, seated on the table, or held in the parent's arms, approach the child from behind to within 6-12 inches of either ear. Placing your hand between your mouth and the child so that the child does not respond to feeling your breath rather than to the sound, whisper the child's name several times. Repeat with the other ear Pass if the child turns to the direction of your voice on both sides. Single Syllables (R) Listen for the child to use single syllables consisting of a consonant and a vowel, such as “ba,” “da,” “ga,” or “ma.” If this is not heard, ask the parent if the child does this. ass if you hear such sounds or if the parent reports that the child does this. Imitate Speech Sounds (R) Repeat a sound several times (such as a cough, clicking of the tongue, or kissing sound) and see if the child imitates you. If the child does not respond, ask the parent if the child imitates any speech sounds. Emphasize that the sounds must be initiated by the other person, not the child. Pass if you hear the child imitate your sound or if the parent reports that the child imitates the speech sounds of others. Dada/Mama, Nonspecific (R) Listen for the child to say “dada or “mama” during the test. If this is not heard, ask the parent i the child has said this. The words do not necessarily have to refer to a parent. Pass if the child says either “dada” or "mama," or if the parent reports that the child does this. Listen for the child to repeat the same syllable 3 or more times, such as “dadadada” or “gagaga- ga.” If this is not heard ask the parent i the child does this, Pass if the child does this or if the parent reports that the child does this. Jabbers (R) During the test, listen for the child to make unintelligible “conversation” to himself/herself, using inflection and pauses. (This isa “jibberish” in which voice patterns vary and few or no real words are distinguishable.) If this is not heard, ask the parent ifthe child “talks” to himseltMmerselt in this way or in what sounds like a foreign language. Pass if you hear the child "jabber," or ifthe parent reports having heard the child do this. Dada/Mama, Specific (R) Listen for the child to say "Dada" to the father or ‘Mama’ to the mother during the test. If this is not heard, ask the parent if the child does this. Pass if the child uses either ‘Dada’ or “Mama” meaningfully, oritthe parent reports that the child does this. Also pass other words for mother and father used by various cultures, such as “Papa.” A pass of this item also passes Dada/Mama NonspecificOne, 2, 3, 6 Words (R) ‘Ask the parent how many words the child says and what those words are. Pass One, 2, 3, or 6 Words depending upon the number of acceptable words the parent reports. Acceptable words are any words other than “Mama,” “Dada,” or names of family members and pets. A pass of 2, 3, or 6 Words also passes the lower itern(s) (for example, a pass of 3 Words also passes One and 2 Words), Point to Pictures - 2, 4 Be sure to administer the Name Pictures iterns first. f the child names less than 4 pictures correct- ly, administer this item, Show the child the pictures on the back of the form. Tell the child to "Point to the bird — man — dog - cat (kitty) ~ horse.” Name only one picture at a time, and wait for the child to point before naming the next picture, Pass Point to 2 Pictures i the child correctly points to (or names) 2 oF 3 pictures. Pass Point to 4 Pictures if the child correctly points to (or names) 4 or 5 pictures, Apass of Point to 4 Pictures also passes Point to 2 Pictures, Combine Words (R) Listen for the child to combine at least 2 words to make a meaningful phrase that indicates an action. If this is not heard, ask the parent if the child does this. Pass if you hear the child do this, or if the parent reports that the child does this Examples: Pass - ‘play ball," “want drink,” "see that," "go bye-bye.” Fail - “thank-you,” “peek-a-boo,” “bye-bye,” “Uh-oh.” Name Pictures - 1, 4 ‘Show the child the pictures on the back of the form. Point to the cat, bird, horse, dog, and man one ala time, and ask "What is this?” Pass Name 1 Picture or Name 4 Pictures according to the number of pictures correctly named. Pass if the child uses the name of a pet, providing itis the same animal as pictured. "Daddy" or “boy’ are acceptable answers for the man. Apass of Name 4 Pictures also passes Name 1 Picture, Point to 2 Pictures, and Point to 4 Pictures, Body Parts -6 ‘Show the doll to the child, Tell the child, "Point to the doll's nose — eyes ~ ears ~ mouth — hands ~ feet ~ tummy — hair,” naming them one a a time. if the child correctly points to at least 6 body parts. If the parent indicates "stomach" or “belly" are used, pass either of these if itis correctly identified. “Belly-button’ is not a pass, ‘Speech - Half Understandable, All Understandable Throughout the test, notice the intelligibility ofthe child's speech (pronunciation, enunciation, actu- al words as opposed to “jibberish,” etc.) Pass Half Understandable if you have understood at least half of the child's speech, Pass All Understandable if you have understood all or nearly all of what the child has said, A pass of Alf Understandable also passes Half Understandable. orKnow Actions - 2, 4 ‘Show the child the pictures on the back of the form. Instruct the child to point to the correct picture as the following questions are asked: “Which one flies?" “Which one says meow?" “Which one talks?" “Which one barks?" “Which one gallops?” Pass Know 2 Actions if 2 or 3 pictures are pointed to correctly Pass Know 4 Actions if 4 or 5 pictures are pointed to correctly, A pass of Know 4 Actions also passes Know 2 Actions. Know Adjectives - 2, 3 ‘Ask the child the following questions, one at a time: "What do you do when you are cold?" "What do you do when you are tired?” ‘What do you do when you are hungry?" Pass Know 2 Adjectives andjor Know 3 Adjectives depending upon the number of questions, answered correctly, Examples of correct answers: Cold - Put on coat, go inside, cover up, (Do not pass an answer about having a cold, such as “cough” or “take medicine.") Tired - Go to bad, lie down, sleep, Hungry - Eat, have lunch, ask for something to eat. A.pass of Know 3 Adjectives also passes Know 2 Adjectives. Name Colors - 1, 4 Place a red, a blue, a yellow, and a green block on the table in front of the child. Point to one block and ask the child, “What color is this?” After the child answers, move the blocks around and ask the child to tell you the color af another block. Repeat for all four colors. Pass Name 1 Color if the child correctly names 1, 2, or 3 colors. Pass Name 4 Colorsif the child correctly names 4 colors. A pass of Name 4 Colors also passes Name 1 Color Use of Objects - 2, 3 Ask the child the following questions, one at a time: "What do you do with a cup?’ "What is a chair used for?" “What is a pencil used for?” Pass Use of 2 Objects or Use of 3 Objects depending upon the number of questions answered correctly. Action words such as “drink,” *sit," and "write" must be included in the answers. Unconventional uses such as "pour" for cup or “climb on” for chair are acceptable. Answers such ‘as “milk” for cup or “table” for chair are unacceptable. A pass af Use of 3 Objects also passes Use of 2 Objects. Count 1 Block Put 8 blocks on the table in front of the child. Place a piece of paper next to the blocks. Tell the cchild, “Put one block on the paper.” When the child appears to be finished, ask "How many blocks are on the paper?" Pass if the child places one block and says that one block is on the paper. Understand 4 Prepositions While you and the child are standing, give him/her a block. Give the following directions to the child, one at a time: "Put the block on the table.” “Put the block under the table.” “Put the block in front of me.” *Put the block behind me." Pick up, or have the child pick up the block between directions. Pass if the child performs all four tasks correctly,Define Words - 5, 7 Make sure the child is listening to you and then say: “Lam going to say a word and | want you to tell me what itis.” Ask each word one at a time: “What is a ball - lake — desk — house - banana - curtain ~ fence ~ ceiling?” Each word may be asked 8 times if necessary. You may say "Tell me something about i” but do not ask the child fo tell you what the abject is for or what to do with it Pass Define 5 Words ifthe child defines 5 or 6 words acceptably in terms of: 4) use, 2) shape, 3) what itis made of, or 4) general category. Pass Define 7 Words if the child defines 7 or 8 words acceptably. Examples of correct answers Ball - bounces, circle, toy, piay with Lake - water, fish in it Desk - write on it, put papers in, wood House - to live in, made of wood (bricks, etc.) Banana - fruit, to eat Curtain - to cover the window, so people can't see in Fence - to keep the dog in. to climb on, around the yard Ceiling - top of the room, to keep the rain off A pass of Define 7 Words also passes Define 5 Words. Count 5 Blocks Put 8 blocks on the table in front of the child. Place a piece of paper next to the blocks. Tell the child, “Put five blocks on the paper.” When the child appears to be finished, ask, “How many blocks are on the paper?” Pass if the child places § blocks and says that 5 blocks are on the paper. The child does not have to count each block out loud. Only counting ("1, 2, 3, 4, 5") does not pass: the child must state "5" separately. . ‘A pass of Count 5 Blocks also passes Count 1 Block. Opposites - 2 ‘Say each of the following sentences slowly and distinctly, one at a time, and wait for the child to fill in the blank. Each sentence may be repeated 3 times if necessary. “ifa horse is big, a mouse is “if fire is hot, ice is “ifthe sun shines during the day, the moon shines during the : Pass if the child completes two sentences correctly, Examples of correct answers: Big - litle, small, tiny Hot - cold, cool, freezing, frozen (wet, melting, or water are incorrect) Day - night, dark, biack. eveningD. GROSS MOTOR Equal Movements While the child is tying on hisher back, watch the activity of the child's arms and legs. Pass if the child moves arms and legs equally. Fail if one arm andi/or leg does not move as much as the other, Lift Head (R) Place the child on his/her stomach on a flat surface, Pass ifthe child at least momentarily lifts his/her head so that the chin is off the surface without being turned to either side or if the parent reports that the child can do this. Head Up 45 Degrees Piace the child on his/her stomach on a flat surface Pass if the child lifts his/her head so that his/her face makes an approximate 45 degree angle with the surface for at least several seconds. The child will be looking at the table in front of him/her, ‘A pass of Head Up 45 Degrees also passes Lift Head. \ Head Up 90 Degrees Place the child on his/her stomach on a flat surface Pass if the child lifts head and chest up so that his/her face makes a 90 degree angle with the sur- face for at least several seconds. The child will be looking straight ahead and will usually be sup- ported on his/her forearms. ‘A pass of Head Up 90 Degrees also passes Head Up 45 Degrees and Lift Head. Sit, Head Steady Hold the child in a sitting position Pass if the child holds his/her head upright and steady with no bobbing motion for at least several seconds, Bear Weight on Legs Hold the child in a standing position so that his/her feet rest on the table. Slowly loosen your hand support to allow the child's weight to be supported on his/her legs and feet. Pass if the child supports his/her weight on the logs for several seconds, 30