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.