Indian J Pediatr (December 2014) 81(Suppl 2):S80–S84
DOI 10.1007/s12098-014-1526-0
ORIGINAL ARTICLE
CDC Kerala 3: At-risk Baby Clinic Service Using Different
Screening Tools – Outcome at 12 months Using Developmental
Assessment Scale for Indian Infants
M. K. C. Nair & Rajee Krishnan & G. S. Harikumaran Nair &
Babu George & Deepa Bhaskaran & M. L. Leena &
Paul Swamidhas Sudhakar Russell
Received: 24 March 2014 / Accepted: 23 June 2014 / Published online: 16 August 2014
# Dr. K C Chaudhuri Foundation 2014
Abstract
Objectives To describe CDC Kerala experience of establishing
an at-risk baby clinic and the comparison of different develop-
mental screening tools at 12 mo against the gold standard
Developmental Assessment Scale for Indian Infants (DASII).
Methods At risk baby clinic of CDC, Kerala was established as a
facility for follow up of NICU graduates from Sree Avittam
Thirunal Hospital at 2, 4, 6, 8 and 12 mo corrected age and during
each visit the mother is taught the CDC model early stimulation
by developmental therapists and encouraged to continue to do the
same at home. At 12 mo, assessment results of four simple
developmental tools were compared with the gold standard
DASII administered by a senior developmental therapist.
Results Out of a total of 800 babies, outcome measurements at
12 mo were available for 604 infants. The prevalence of
developmental delay using the screening tools, CDC grading
for standing, Amiel Tison angles and DDST II (Denver II)
gross motor were 24.8, 24 and 24.3 % respectively and using
DASII, a diagnostic tool (13.3 %). Also the combination of
Amiel Tison angles, CDC standing grading and DDST gross
motor against DASII motor DQ had high specificity (94.15 %)
and negative predictive value (NPV) (70.18 %) but with a
M. K. C. Nair (*) : R. Krishnan : B. George : D. Bhaskaran :
M. L. Leena
Child Development Centre, Thiruvananthapuram Medical College,
Thiruvananthapuram 695011, Kerala, India
e-mail: cdcmkc@gmail.com
G. S. Harikumaran Nair
Clinical Epidemiology Resource & Training Centre,
Government Medical College, Thiruvananthapuram, Kerala, India
P. S. S. Russell
Child and Adolescent Psychiatry Unit, Department of Psychiatry,
Christian Medical College, Vellore, Tamil Nadu, India
very low sensitivity of 14.58 % and low positive predictive
value (PPV) of 53.85 %. It was observed that a significant
odds ratio for DASII mental deviation quotient (DQ) was seen
for neonatal seizures (2.34) and low birth weight (1.49).
Conclusion The prevalence of developmental delay using the
screening tools, CDC grading for standing, Amiel Tison an-
gles and DDST II (Denver II) gross motor were 24.8, 24 and
24.3 % respectively and together they had a high specificity,
NPV and accuracy against DASII motor DQ as gold standard
at one year assessment.
Keywords At-risk baby . Developmental delay . CDC
grading . Amiel tison angles . Denver-II
Introduction
Nowadays there is an increasing effort for detection of devel-
opmental disorders at an earlier age because intervention
services are cost effective and when provided in early
childhood, have greater efficacy [1]. In order to improve the
identification of children with developmental delays so as to
enable to provide early intervention in a timely manner, a
significant emphasis has been placed on the routine use of
developmental surveillance and screening. Many children are
born with risk factors that predispose them to delayed
development and developmental disorders and the
importance of developmental screening increases in the case
of at risk babies who are neonatal nursery graduates.
Developmental screening is defined as a brief, formal,
standardized evaluation that aids in the early identification of
patients at risk for a developmental and/or behavioral disorder
[2]. The ideal screening method should use a standardized and
validated tool with established psychometric qualities, be easy
to perform and interpret, be inexpensive to administer, and
Indian J Pediatr (December 2014) 81(Suppl 2):S80–S84
have good sensitivity and specificity [3]. Finding such an ideal
screening tool that is culturally relevant remains a challenge.
The implementation of well-performed developmental screen-
ing in the early childhood setting can be very useful in the
identification of at risk babies. Developmental screening does
not result in either a diagnosis or treatment plan but rather
identifies areas in which a child’s development differs from
same-age norms and also helps to plan appropriate early
intervention. Because development is dynamic in nature and
surveillance and screening have limits, periodic evaluation
with a validated instrument should occur so that a problem
not detected by surveillance or a single screening can be
detected by subsequent evaluation [2].
This paper reports authors’ experience of establishing an
at-risk baby clinic at Child Development Centre (CDC), Ker-
ala and the prevalence of developmental delay at 12 mo of age
using different developmental screening tools like CDC grad-
ing for standing, Amiel Tison passive angles, Denver Devel-
opmental Screening Test (DDST), Vineland Social Maturity
Scale (VSMS) and comparison of the screening tools against
the gold standard, Developmental Assessment Scale for Indi-
an Infants (DASII).
Material and Methods
At risk baby clinic of CDC, Kerala was established as a
facility for follow up of NICU graduates from Sree Avitom
Thirunal Hospital, Medical College, Thiruvananthapuram,
and all babies discharged from NICU are given an
appointment for developmental follow-up at CDC, Kerala.
One side of the discharge summary sheet of NICU records the
progression in the NICU, the final diagnosis made and the
known biological risk factors. The other side of the NICU
discharge card would have the follow up record of CDC,
making the two monthly follow up also as part of the
medical care. CDC appointments are given for 2, 4, 6, 8 and
12 mo corrected age. At CDC, the mother is taught the CDC
model early stimulation [4] by developmental therapists (2 y
full time post graduate diploma in clinical child development
from CDC) and encouraged to continue to do the same at
home. At 12 mo the gold standard Development Assessment
Scale for Indian Infants (DASII) was administered by a senior
developmental therapist specially trained to administer
DASII. The other outcome measurements were done at 12
mo corrected age by separate developmental therapists, each
one administering only one screening tool out of the following
four simple developmental tools.
i. CDC grading for standing: Not standing at all (Grade 0),
stands holding on to furniture momentarily (Grade I), take
few steps with both hands supported (Grade II), can stand
alone with legs apart (Grade III), come to standing by
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throwing weight on arms (Grade IV), without support
takes few steps (Grade V) [5]. At 12 mo, Grade 0, 1 and
2 are abnormal.
ii. Amiel Tison passive angles: When it comes to neuro
developmental follow-up, rather than trying to give a
diagnosis of cerebral palsy, Amiel Tison has been
suggested to look for tone abnormalities which are
persistent or abnormal if not disappearing by 12 mo
and measured by passive angles of adductor angle,
popliteal angle, heel to ear angle, dorsiflexion angle
of foot and scarf sign [6].
iii. Denver Developmental Screening Test-II (DDST-II): This
is a simple screening tool to assess development and
categorise developmental delay under gross motor, fine
motor, language and personal social [7].
iv. Vineland Social Maturity Scale (VSMS): The VSMS
measures social competence, self-help skills and
adaptive behavior from infancy onwards and is done by
interviewing a parent or other primary care giver. Raw
scores are converted to an age equivalent score expressed
as social age and a social quotient [8].
v. Developmental Assessment Scale for Indian Infants
(DASII): The age range of DASII is from birth to 30 mo
and consists of mental and motor scale expressed as a
deviation quotient (DQ) [9].
The data was entered; cleaned and analyzed using SPSS
version 11.0 and a comparison between the tools was made
using DASII as gold standard.
Results
Out of a total of 800 consecutive cases on neuro developmen-
tal follow-up at CDC, Kerala, outcome measurements at 12
mo using the gold standard DASII apart from other four
screening tools were available for 604 infants.
Table 1 shows comparison of developmental assessment
by different tools at 12 mo. It was observed that the
prevalence of developmental delay using the screening
tools, CDC grading for standing, Amiel Tison angles and
DDST II (Denver II) gross motor were 24.8, 24 and
24.3 % respectively. However, using DASII, a diagnostic
tool, the prevalence of developmental delay were 13. 3,
15.2 and 11.6 % for DASII, DASII motor DQ and DASII
mental DQ respectively.
Table 2 shows developmental assessment results at 12
mo and comparison of standing grade, AT angles and
DDST gross motor alone or in combination against DASII
motor DQ as gold standard. It was observed that against
DASII motor DQ as gold standard, DDST gross motor had
a high specificity (83.74 %), NPV (75.33 %), accuracy
(70.2 %) and LR positive (2.53) but with a low sensitivity
S82 Indian J Pediatr (December 2014) 81(Suppl 2):S80–S84

Table 1 Comparison of developmental assessment by different tools at 12 mo

Developmental assessment tests N=604 Normal N (%) Abnormal N (%) Prevalence %

CDC, Kerala grading for standing at 12 mo 454(75.2) 150(24.8) 24.8

Amiel Tison angles (adductor, heel to ear, popliteal, dorsiflexion foot & scarf sign) 459(76.0) 145(24.0) 24.0
Denver developmental screening test (DDST) II gross motor 457(75.7) 147(24.3) 24.3
Developmental assessment scale for Indian infants (DASII) at 12 mo 524(86.8) 80(13.2) 13.3
Developmental assessment scale for Indian infants (DASII) Motor DQ at 12 mo 512(84.8) 92(15.2) 15.2
Developmental assessment scale for Indian infants (DASII) Mental DQ at 12 mo 534(88.4) 70(11.6) 11.6

(41.15 %) and PPV (54.11 %). It was also observed that
against DASII motor DQ as gold standard, CDC grading
for standing had a high specificity (83.5 %), NPV
(75.77 %), accuracy (70.53 %) and LR positive (2.59) but
with a low sensitivity (42.71 %) and PPV (54.67 %). It
was again observed that against DASII motor DQ as gold
standard, Amiel Tison angles had a fairly high specificity
(79.02 %), NPV (70.90 %), accuracy (63.62 %) and LR
positive (1.46) but with a low sensitivity (30.73 %) and
PPV (40.69 %). The combination of AT angles, CDC
standing grading and DDST gross motor against DASII
motor DQ had high specificity (94.15 %) and NPV
(70.18 %) but with a very low sensitivity of 14.58 % and
low PPV of 53.85 %.
Table 3 shows DASII mental and motor results assessed at
12 mo of age in terms of means of raw score mental & motor,
mental age, motor age and percentile rank position for different
known risk factors like low birth weight, birth asphyxia, neo-
natal seizures, meningitis, sepsis, respiratory problems, neona-
tal jaundice and hospital stay more than 7 d. It was observed
that a significant odds ratio for DASII mental DQ was seen for
neonatal seizures 2.34 (95%CI: 1.15–4.87) and DASII motor
DQ for low birth weight 1.49 (95 % CI: 1.02–2.2).
Discussion
Improving perinatal and neonatal care has led to increased
survival of infants who are at-risk for long-term morbidities
such as developmental delay and visual/hearing problems [10,
11]. A proper and appropriate follow-up program would help
in early detection of these problems thus paving way for early
intervention. Numerous studies have shown that despite sub-
stantial improvements in the neonatal mortality, the incidence
of chronic morbidities and adverse outcomes among survivors
has not declined much [12]. This highlights the need for a
follow-up care service that would ensure systematic monitor-
ing of the general health and neurodevelopmental outcomes
after discharge from the hospital. The monitoring would help
the infants and their families as well as the physicians

Table 2 Developmental assessment at 12 mo: Comparison of standing grade, AT angles and DDST gross motor alone and in multiple combination
against gold standard DASII

DASII as gold standard N=604 True False False True Sensitivity Specificity PPV NPV LR LR Accuracy
Prevalence of developmental delay +ve +ve -ve -ve +ve -ve
(DASII motor DQ)=31.8 %

DDST gross motor (GM) vs. 79 67 113 345 41.15 83.74 54.11 75.33 2.53 0.70 70.2
DASII motor DQ
CDC standing grade vs. 82 68 110 344 42.71 83.50 54.67 75.77 2.59 0.69 70.53
DASII motor DQ
Amiel Tison (AT) angles vs. 59 86 133 324 30.73 79.02 40.69 70.90 1.46 0.88 63.62
DASII motor DQ
AT angles or standing grade vs. 110 128 82 282 57.29 68.78 46.22 77.47 1.84 0.62 55.12
DASII motor DQ
AT angles & standing grade vs. 31 26 161 384 16.15 93.66 54.39 70.46 2.55 0.90 68.94
DASII motor DQ
AT angles or grading or DDST 112 132 80 278 58.33 67.80 45.90 77.65 1.81 0.61 64.78
GM vs. DASII motor DQ
AT angles & grading & DDST 28 24 164 386 14.58 94.15 53.85 70.18 2.49 0.91 68.77
GM vs. DASII motor DQ

PPV & NPV Positive & Negative Predictive Value; LR Likelihood ratio
Indian J Pediatr (December 2014) 81(Suppl 2):S80–S84 S83

Table 3 DASII at 12 mo: Means of mental & motor raw score, mental & motor deviation quotient, mental & motor percentile rank position and a
comparison of raw scores mental & motor by known risk factors

Risk factors No. (%) DASII Mental at 12 mo DASII Motor at 12 mo

N=604
Raw Mental Percentile Odds 95 % CI Raw Motor Percentile Odds 95 % CI
Score DQ Rank Ratio Score DQ Rank Ratio

Low birth weight

(<2500 g) Yes 170(28.4) 109.27 107.83 66.41 1.27 0.75–2.17 47.21 99.72 48.44 1.49 1.02–2.2
(>2500 g) No 429(71.6) 109.83 110.51 68.20 47.63 104.17 53.14
Birth asphyxia
Yes 66(10.9) 108.83 106.38 63.52 1.42 0.69–2.94 47.53 103.08 53.67 0.99 0.57–1.70
No 538(89.1) 109.77 110.15 68.20 47.49 102.74 51.42
Neonatal seizure
Yes 50(8.3) 108.02 101.86 61.74 2.34 1.15–4.87 47.34 100.81 50.34 0.99 0.54–1.85
No 554(91.7) 109.82 110.45 68.22 47.51 102.96 51.78
Sepsis
Yes 161(26.7) 109.53 108.99 66.34 0.95 0.54–1.67 47.70 104.95 53.89 1.09 0.74–1.60
No 443(73.3) 109.72 110.00 68.17 47.43 101.99 50.85
Meningitis
Yes 26(4.3) 110.46 113.73 73.59 1.41 0.47–4.22 48.04 108.61 54.58 0.49 0.18–1.32
No 578(95.7) 109.63 109.56 67.42 47.47 102.56 51.53
Respiratory problems
Yes 79(13.1) 108.76 105.15 61.25 1.80 0.95–3.4 47.67 104.71 51.62 1.27 0.77–2.07
No 525(86.9) 109.81 110.43 68.65 47.47 102.49 51.67
Neonatal jaundice
Yes 166 109.99 111.37 70.79 0.69 0.38–1.26 47.61 104.37 53.87 0.88 0.60–1.30
No 438 109.55 109.12 66.51 47.45 102.17 50.83
Hospital days
(≥7 d) Yes 203(33.6) 109.64 109.66 67.19 1.19 0.71–1.20 47.65 104.49 54.47 0.75 0.52–1.10
(<7 d) No 401(66.4) 109.68 109.78 67.94 47.42 101.91 50.24

involved in their care, but the real bottleneck is the lack of
appropriate para medical personnel specifically for early
detection and early intervention. CDC, Kerala had the advan-
tage of having the services of 2 y full time Post Graduate
Diploma in Clinical Child Development (PG-DCCD) holders
as developmental therapists, well trained to do developmental
assessment as well as interventional therapy using CDC mod-
el early stimulation in infancy. The same could be achieved in
other parts of India by 3 mo training for graduates in nursing at
CDC, Kerala.
At 12 mo of age (Table 1) there was a comparable
24 % prevalence of developmental delay using the screen-
ing tools, CDC grading for standing, Amiel Tison angles
and DDST II (Denver II) gross motor suggesting that they
could be used alone or in combination for assessment at
one year of age.
The observation that against DASII motor DQ as gold
standard, DDST gross motor had a high specificity (84 %),
NPV (75 %), and accuracy (70 %) with a relatively low
sensitivity suggests that DDST could be used as a reasonably
good evaluation tool at 1 y of age as it is not feasible to do
DASII in all clinical settings. Similarly, the observation that
against DASII motor DQ as gold standard, CDC grading for
standing had a high specificity (84 %), NPV (76 %), and
accuracy (71 %) but with a relatively low sensitivity again
suggest that when DDST also is not available, CDC grading
for standing could be effectively used as an evaluation tool at
one year follow up. Again, the observation that a combination
of Amiel Tison angles, CDC standing grading and DDST
gross motor against DASII motor DQ had high specificity
(94 %) and NPV (70 %) is clinically important.
Comparing DASII results at 12 mo of age against the
known risk factors for poor development (Table 3) the
observation that a significant 2.34 (95 % CI: 1.15–4.87)
odds ratio was seen for neonatal seizures (Mental DQ) and
low birth weight 1.49 (95 % CI: 1.02–2.2) (Motor DQ)
suggest that along with early intervention, biological risk
factors play an important role in determining the develop-
mental outcome. In a randomized controlled trial of CDC
model early stimulation using Bayley scores at 1 y, it was
shown that babies who did not have low birth weight and
neonatal seizures had a significantly higher Bayley score,
at 1 y of age and after adjusting all the significant risk
factors for development, the babies who had intervention
had significantly higher Bayley scores, at 1 y as compared
to control babies [4].
S84
Conclusions
Both CDC grading for standing and DDST gross motor have
high specificity, negative predictive value and accuracy
against DASII motor DQ as gold standard at 1 y assessment
and hence useful tools. Low birth weight and neonatal sei-
zures are significant risk factors for poor development at 1 y of
age.
Acknowledgments The authors gratefully acknowledge the cooperation
and support received from staff of Child Development Centre, Kerala,
specially Dr. G. Suresh Kumar, Registrar; Ms. Deepa N. R, PS to Director;
Mr. Asokan N, PA to Director; Ms. Suja S, Junior Programmer; CDC,
Medical College, Thiruvananthapuram, in conduction of this study.
Conflict of Interest None.
Source of Funding This study is supported by Child Development
Centre, Thiruvananthapuram.
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