The Indian Journal of Pediatrics

https://doi.org/10.1007/s12098-021-03671-2

CLINICAL BRIEF

Development Assessment Scale for Indian Infants: A Systematic

Review and Perspective on Dwindling Cutoffs
Priyanka Madaan 1 & Lokesh Saini 1 & Vishal Sondhi 2

Received: 24 September 2020 / Accepted: 15 January 2021

# Dr. K C Chaudhuri Foundation 2021

Abstract
The Developmental Assessment Scale for Indian Infants (DASII) remains the mainstay in India for diagnostic confirmation and
validation of upcoming screening tools for development in infants and toddlers. This is an Indian adaptation of Bayley Scales of
Infant Development which is the globally accepted gold standard. However, the DASII cutoff points used for categorizing
development and distinguishing normal from abnormal development are not in agreement across different studies conducted
over the last two decades in India. This is probably due to a lack of mention of cutoff points in the DASII manual and existing
literature. The current systematic review summarizes the heterogeneity in literature for interpretation of DASII and its cutoff
points. Also, a perspective on the ideal cutoff points is presented.

Keywords DASII . Infants . Cutoff points . Developmental screening

Introduction movements [3]. DASII (applicable for 1–30 mo age) is

Over the last five decades, with advent of improved peri-
natal and neonatal care, the concept of developmental de-
lay and developmental assessment in infants and toddlers
has gained new dimensions altogether. Several screening
and diagnostic tools have been devised over the due
course to ease the developmental assessment in India
[1]. Globally, the most widely used tool for development
assessment in infants is the Bayley Scale of Infant
Development (BSID). However, the Developmental
Assessment Scale for Indian Infants (DASII) remains the
mainstay in India since it has been standardized in Indian
babies [2]. Developmental outcomes on DASII are being
used for the validation of screening tools and evaluation
of various predictors of development such as general
an Indian adaptation of BSID, based on Baroda norms [2].
DASII consists of 67 and 163 items for motor and men-
tal developmental assessment respectively [2]. For the clin-
ical context, it provides developmental motor quotient
(DMoQ), developmental mental quotient (DMeQ), and
composite developmental quotient (DQ) [2]. With a mean
DQ of 100 and standard deviation (SD) of 15, 1SD and
2SD below mean correspond to DQ of 85 and 70, respec-
tively. However, the cutoff points on DASII used for
distinguishing normal from abnormal development are
not in agreement across different studies. This is probably
due to a lack of mention of cutoff points in the DASII
manual and existing literature. With DASII being the gold
standard for validation of screening tools, there is a dire
need to maintain uniformity. Hence, the current review was
undertaken to analyze the heterogeneity in the literature for
interpretation of DASII.

* Lokesh Saini
drlokeshsaini@gmail.com Material and Methods

1
Pediatric Neurology Unit, Department of Pediatrics, Postgraduate
PubMed and Web of Science were systematically searched
Institute of Medical Education and Research, Chandigarh 160012, in August 2020, to list the original articles where DASII
India had been used. Search terms used were “Development as-
2
Department of Pediatrics, Armed Forces Medical College, sessment scale for Indian infants (All fields)” or “DASII
Pune, Maharashtra, India (All fields)” or “Pramila Phatak (All fields).” Besides, the
 Indian J Pediatr

Fig. 1 Flow diagram for search

and evaluation of studies.
DASII Developmental
Assessment Scale for Indian
Infants

bibliography of included articles was also searched. Titles Results

and abstracts were then screened independently by the au-
thors to check whether DASII had been used. In case of
doubt, full-text manuscripts were assessed. Full-text arti-
cles, where DASII (with specified cutoff points) had been
used, were evaluated independently by the authors and
included for qualitative synthesis.
The literature search revealed 232 studies (Fig. 1). Among
these, DASII had been used in 31 studies and cutoff points
had been mentioned in 23 studies. These included descriptive
studies illustrating developmental outcomes (20 studies) and
validation studies for screening tools (3 studies).

Table 1 Comparison of cutoff points in studies which have used DASII (or Baroda norms) as gold standard for validation of screening tools

Sno Author Medical college/Hospital Journal Study Cutoff points used

1. Jain et al., Maulana Azad Medical College Indian Pediatrics Validation of parent self- Developmental delay— 2 cutoffs
2017 [4] and associated Lok Nayak report development were used: -1 SD (DQ < 85) and
Hospital, New Delhi screening tool -2 SD (DQ < 70)
2. Bhave et al., Chhatrapati Shahuji Maharaj Journal of Child Development and validation Both DMeQ and DMoQ less than 85
2010 [5] Medical University, Lucknow Neurology of a New Lucknow were considered for validation
Development Screen
3. Juneja et al., Maulana Azad Medical College Indian Pediatrics Ages and Stages Either DMoQ or DMeQ < 70 in
2012 [6] and associated Lok Nayak Questionnaire validation DASII used as cutoff for
Hospital, New Delhi validation
4. Phatak et al., King Edward Memorial Hospital, Indian Pediatrics A study of Baroda Delayed:
1991 [7] Pune Development Screening DMoQ and/or DMeQ ≤ 77.5 (-1.5
Test for Infants SD) on Baroda norms of BSID

BSID Bayley Scale of Infant Development; DASII Development Assessment Scale for Indian Infants; DMeQ Mental development quotient; DMoQ
Motor development quotient; DQ Development quotient; SD Standard deviation
Indian J Pediatr
Among the descriptive studies, the cutoff points used for
developmental delay/adverse developmental outcomes ranged
from 70 to 85 (any of DQ, DMoQ or DMeQ; supplementary
Table 1). The descriptive studies either demonstrated the out-
comes in follow-up neonatal/antenatal cohorts (13 studies) or
in specific disorders like severe acute malnutrition, infantile
epilepsy, etc. (7 studies). Among the follow-up studies, 8/13
considered DQ of 71–85 as borderline or mild delay while the
rest considered scores ≤ 70 as delay (Supplementary Table 1).
In the other group, 3/7 studies considered a category of
borderline/mild delay. Similarly, in the validation studies, cut-
off points varied from 70 to 85, with a recent study validating
against two cutoff points (DQ of 70 and 85) (Table 1) [4–7]. It
is interesting to note that the same study groups used different
cutoffs in different studies (Supplementary Table 1, Table 1).
Discussion
The current study brings forth the conspicuous diversity in the
terminology and cutoff points used in the interpretation of
DASII across India. A DQ cutoff of 75 [> -1.5 standard error
(SE)] had been considered as normal for building
the reference Baroda norms [8]. Baroda Development
Screening Test (BDST), a screening tool developed by Dr.
Phatak, was also validated using the Baroda norms with a
cutoff of 77.5 (-1.5SD) taken as delayed development [7].
Further studies by the same group used the categories of de-
velopment as- normal (> 85), delayed (70–85), and grossly
delayed (< 70) based on the DQ on Baroda norms or DASII
[9].
The validation cutoff points on BSID or DASII, which may
be apt for screening in a specific country, are unclear.
International studies validating screening tools such as Ages
and Stages questionnaire (ASQ), have also been assuming
different cutoff points on BSID for validation. A recent
Chinese study validated -1SD and -2SD cutoff points in
ASQ-3 with those in BSID-III [10].
In the Indian context, the -1SD cutoff point may lead to
over-referral and -2SD cutoff point may underestimate the
children with delay. Hence, a cutoff point somewhere between
-1 to -1.5SD may be apt for screening. Furthermore, screening
tools should be ideally validated against all three cutoff points
(1SD, 1.5SD, and 2SD below mean). Besides, the validation
should be done against DMoQ and/or DMeQ.
Conclusion
There is marked heterogeneity in the terminology and cutoff
points used in Indian literature for interpretation of DASII
scores. Considering the nonuniformity, it becomes imperative
to evaluate and develop a consensus, especially for the studies
using DASII for validation of screening tools. Validating
screening tools against all three cutoff points (1SD, 1.5SD,
and 2SD below mean) on DASII may be a good initial step.
Further, a meta-analysis evaluating the impact of different
cutoffs on the prevalence of developmental delay may be
useful.
Supplementary Information The online version contains supplementary
material available at https://doi.org/10.1007/s12098-021-03671-2.
Authors’ Contribution PM contributed by literature search, qualitative
synthesis, and writing of the initial draft. LS and VS contributed by
planning the study, literature search, qualitative synthesis, and critical
review of the manuscript. All authors approved the final version of man-
uscript to be published and agreed to be accountable for all aspects of the
work in ensuring that questions related to the accuracy or integrity of any
part of the work are appropriately investigated and resolved. VS will act
as guarantor for this paper.
Compliance with Ethical Standards
Conflict of Interest None.
References
1. Mukherjee SB, Aneja S, Krishnamurthy V, Srinivasan R.
Incorporating developmental screening and surveillance of young
children in office practice. Indian Pediatr. 2014;51:627–35.
2. Phatak P, Misra N. Developmental assessment scales for Indian
infants (DASII) 1-30 months - revision of Baroda norms with in-
digenous material. Psychol Stud. 1996;41:55–6.
3. Saini L, Madaan P, Naik MRR. General movements: longitudinal
assessment better than cross-sectional. Brain Dev. 2019;41:563–4.
4. Jain R, Arora A, Anand R, Malhotra S, Mittal M, Juneja M.
Designing and validation of a hindi-language parent self-report de-
velopmental screening tool. Indian Pediatr. 2017;54(7):550–5.
5. Bhave A, Bhargava R, Kumar R. Development and validation of a
new Lucknow development screen for indian children aged 6
months to 2 years. J Child Neurol. 2010;25(1):57–60.
6. Juneja M, Mohanty M, Jain R, Ramji S. Ages and stages question-
naire as a screening tool for developmental delay in Indian children.
Indian Pediatr. 2012;49(6):457–61.
7. Phatak P, Dhapre M, Pandit AN, Kulkarni S. A study of Baroda
development screening test for infants. Indian Pediatr. 1991;28:
843–50.
8. Phatak P. Motor and mental developmental profiles of normal
babies of 1-30months of age, and their use as reference profiles in
therapeutic work. Indian J Clin Psychol. 1995;22:36–42.
9. Chaudhary S, Kulkarni S, Pajnigar F, Pandit AN, Deshmukh S. A
longitudinal followup of development of preterm infants. Indian
Pediatr. 1991;28:873–80.
10. Yue A, Jiang Q, Wang B, et al. Concurrent validity of the ages and
stages questionnaire and the Bayley Scales of Infant Development
III in China. PLoS ONE. 14(9):e0221675. https://doi.org/10.1371/
journal.pone.0221675.
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