TITLE: Universal Development Assessment Tools for Children 18-Months of Age:

A Review of the Clinical Effectiveness and Guidelines

DATE: 16 December 2009

CONTEXT AND POLICY ISSUES:

Different assessment tools have been developed to help acquire important information on child
development from birth to early childhood.1-7 Children with risk factors such as preterm infants,8
children with prenatal alcohol exposure,9 and children who were admitted to a general pediatric
service10 may need additional developmental surveillance. A systematic review on assessment
tools showed that the Modified Checklist for Autism in Toddlers (M-CHAT) provides high
sensitivity and specificity for screening children under 5 years of age for autism or pervasive
development delay.11 Information is limited about the best assessment tool and the optimal age
to screen for speech and language delay in pre-school children.12 This report reviews the
evidence regarding the effectiveness and the feasibility of universal development assessment
tools for children 18 months of age.

RESEARCH QUESTIONS:

1. What is the clinical effectiveness of various universal development tools for the
assessment of children 18 months of age?

2. What is the evidence to support assessing development at 18 months of age?

METHODS:

A limited literature search was conducted on key health technology assessment resources,
including PubMed, the Cochrane Library (Issue 4, 2009), University of York Centre for Reviews
and Dissemination (CRD) databases, ECRI, EuroScan, international health technology
agencies, and a focused Internet search. The search was limited to English language articles
published between 2004 and November 2009. Filters were applied to limit the retrieval to health
technology assessments, systematic reviews, meta-analyses, randomized controlled trials,
controlled clinical trials, observational studies, and guidelines.

Disclaimer: The Health Technology Inquiry Service (HTIS) is an information service for those involved in planning and providing health care in
Canada. HTIS responses are based on a limited literature search and are not comprehensive, systematic reviews. The intent is to provide a list
of sources and a summary of the best evidence on the topic that CADTH could identify using all reasonable efforts within the time allowed.
HTIS responses should be considered along with other types of information and health care considerations. The information included in this
response is not intended to replace professional medical advice, nor should it be construed as a recommendation for or against the use of a
particular health technology. Readers are also cautioned that a lack of good quality evidence does not necessarily mean a lack of effectiveness
particularly in the case of new and emerging health technologies, for which little information can be found, but which may in future prove to be
effective. While CADTH has taken care in the preparation of the report to ensure that its contents are accurate, complete and up to date,
CADTH does not make any guarantee to that effect. CADTH is not liable for any loss or damages resulting from use of the information in the
report.

Copyright: This report contains CADTH copyright material. It may be copied and used for non-commercial purposes, provided that attribution is
given to CADTH.

Links: This report may contain links to other information available on the websites of third parties on the Internet. CADTH does not have
control over the content of such sites. Use of third party sites is governed by the owners’ own terms and conditions.
SUMMARY OF FINDINGS:

What is the clinical effectiveness of various universal development tools for the
assessment of 18-month olds?

The literature did not find any health technology assessments or systematic reviews regarding
the clinical effectiveness of various universal development tools for the assessment of 18-month
olds. A randomized controlled trial evaluated the validity of parent-reported screening
instruments for developmental delays in children 18-months of age.13 Children without history of
developmental delay were assessed at their routine 18-month-old visit. There were 317 families
randomly assigned to either the Ages and Stages Questionnaire (ASQ) or Child Development
History (CDH). The accuracy of the instruments, as compared to the "gold standard" Battelle
Development Inventory (a physician-assessed instrument) is reported in Table 1. The authors
concluded that the accuracy of these screening instruments did not make them useful as a
development screening test.

Table 1: Accuracy of Developmental Screening Tools from Rydz et al.13

Sensitivity % Specificity% PPV% NPV%

ASQ 67 39 34 71
CDH 50 86 50 86
ASQ: Ages and Stages Questionnaire; CDH: Child Development History; PPV: positive predictive value; NPV:
negative predictive value

A prospective study on 172 preterm infants (born at less than 31 weeks gestational age) was
conducted to determine the validity of the Cognitive Adaptive Test/Clinical Linguistic and
Auditory Milestone Scale (CAT/CLAMS) to detect severe cognitive-adaptive delay at 18 months.
CAT/CLAMS are conducted by a physician. The Bayley Scales of Infant Development II (BSID
II) was used as the reference standard.14 The sensitivity and specificity of CAT/CLAMS was
88% and 98%, respectively for detecting cognitive-adaptive delay. The authors concluded
CAT/CLAMS are accurate tools to identify developmental delay at 18 months for preterm
children.

A prospective study from Taiwan investigated the validity of the CAT/CLAMS in 808 very low
birth weight infants (birth weight ≤ 1500g) followed up at 6, 12, 18, and 24 months, with the
BSID II as reference standard.15 The units used were co-positive scores (ie, sensitivity, or
screening instrument is positive, as is the reference standard) and co-negative scores (ie,
specificity, or both the screening instrument and the reference standard are negative). For all
tested age groups, CAT/CLAMS had low co-positive scores (range: 2.7% - 45.3%), despite
having high co-negative scores (range: 96.7% - 100%). For 18-month old children, the co-
positive score was 33.1% and the co-negative score was 100%. Because of the low sensitivity
of CAT/CLAMS, the authors concluded that they are not an appropriate instrument for screening
and early prediction of developmental delay in very low birth weight infants.

A prospective study tested the validity of the Taiwan Birth Cohort Study scale (TBCS) on 1267
families of 18-month old children, using BSID II as reference standard.16 TBSC is a parent-
reported assessment tool. The children had no history of developmental delay. The sensitivity
and specificity data was not reported. The study found that the developmental dimensions at 18
months of age as measured by the TBCS correlated well with the dimensions as measured by
the BSID II. The authors concluded that the scale fulfills the criteria of validity as a screening

Universal Development Assessment Tools for 18 Month Olds 2

instrument, with TBCS showing good correlation to BSID II in gross motor, fine motor, language,
and social abilities.

What is the evidence to support assessing development at 18 months of age?

The prospective study by Vincer et al.14 investigated the optimal age to assess cognitive-
adaptive delay. The authors used CAT/CLAMS to screen 172 preterm infants (less than 31
weeks gestation) at 4 months, 8 months, 12 months, and 18 months of age. The study showed
that testing preterm infants at 18 months of age with CAT/CLAMS provided the highest
likelihood ratios for a positive test and the lowest values for a negative test (children with
developmental delay will have the highest chance to be positive and lowest chance to be
negative), as shown Table 2. The authors concluded that 18 months is the optimal age to
perform CAT/CLAMS in preterm infants for cognitive-adaptive delay.

Table 2: Likelihood Ratios of CAT/CLAMS from Vincer et al.14

CAT/CLAMS age Likelihood ratio Likelihood ratio

for a positive test for a negative test
4 months 1.4 0.3
8 months 4.1 0.3
12 months 30.2 0.4
18 months 35.8 0.1

One randomized controlled trial13 and one cross-sectional study17 also investigated the
feasibility of development tools at 18 months of age. The randomized controlled trial13 showed
that parent-reported instruments such as the ASQ or CDH are feasible at 18 months, with 81%
and 75% of parents correctly completing the ASQ and CDH questionnaires, respectively. The
cross-sectional study assessed the feasibility of administering the Checklist for Autism in
Toddlers (CHAT) for autistic disorder at the 18-month developmental assessment.17 The
instrument was administered to 2117 infants with no history of developmental delay who
attended the routine 18-month developmental assessment. The outcomes were then compared
to clinical assessment. Following this exercise, seven children received a clinical diagnosis of
autism [33.1 per 10,000 (95% CI: 13.3 - 68.0)]. The authors concluded that the instrument gave
a good yield for autism diagnosis at 18 months of age.

CONCLUSIONS AND IMPLICATIONS FOR DECISION OR POLICY MAKING:

Evidence on the effectiveness and feasibility of universal development assessment tools in 18

month old children is very limited. The literature suggests that CAT/CLAMS may be useful as a
developmental assessment tool for preterm children at 18 months of age. While ASQ and CDH
were found to have low sensitivity and specificity, TBCS and CHAT may be valid as screening
tools at 18 months of age. The literature also indicates that children 18 months of age may be
an optimal age to assess cognitive-adaptive delay in preterm infants using CAT/CLAMS.
Additional research is needed to develop a screening protocol that will enhance the capability
for earlier detection of children with developmental delays.

Universal Development Assessment Tools for 18 Month Olds 3

PREPARED BY:
Chuong Ho, MD, Research Officer
Mary-Doug Wright, BSc, MLS, Information Specialist
Health Technology Inquiry Service
Email: htis@cadth.ca
Tel: 1-866-898-8439

Universal Development Assessment Tools for 18 Month Olds 4

REFERENCES:

1. Ozonoff S, Williams BJ, Landa R. Parental report of the early development of children
with regressive autism: the delays-plus-regression phenotype. Autism. 2005
Dec;9(5):461-86.

2. Nair MK, Russell PS, Rekha RS, Lakshmi MA, Latha S, Rajee K. Validation of
developmental assessment tool for Anganwadis (DATA). Indian Pediatr. 2009 Jan;46
Suppl:27-36.

3. Theeranate K, Chuengchitraks S. Parent's Evaluation of Developmental Status (PEDS)

detects developmental problems compared to Denver II. J Med Assoc Thai. 2005
Nov;88 Suppl 3:S188-92.

4. Edwards LC, Frost R, Witham F. Developmental delay and outcomes in paediatric

cochlear implantation: implications for candidacy. Int J Pediatr Otorhinolaryngol. 2006
Sep;70(9):1593-600.

5. Piek JP, Dawson L, Smith LM, Gasson N. The role of early fine and gross motor
development on later motor and cognitive ability. Hum Mov Sci. 2008 Oct;27(5):668-81.

6. Drachler ML, Marshall T, de Carvalho Leite JC. A continuous-scale measure of child

development for population-based epidemiological surveys: a preliminary study using
Item Response Theory for the Denver Test. Paediatr Perinat Epidemiol. 2007
Mar;21(2):138-53.

7. Visintainer PF, Leppert M, Bennett A, Accardo PJ. Standardization of the Capute Scales:
methods and results. J Child Neurol. 2004 Dec;19(12):967-72.

8. Liao HF, Wang TM, Yao G, Lee WT. Concurrent validity of the Comprehensive
Developmental Inventory for Infants and Toddlers with the Bayley Scales of Infant
Development-II in preterm infants. J Formos Med Assoc. 2005 Oct;104(10):731-7.

9. O'Leary C, Zubrick SR, Taylor CL, Dixon G, Bower C. Prenatal alcohol exposure and
language delay in 2-year-old children: the importance of dose and timing on risk.
Pediatrics. 2009 Feb;123(2):547-54.

10. Petersen MC, Kube DA, Whitaker TM, Graff JC, Palmer FB. Prevalence of
developmental and behavioral disorders in a pediatric hospital. Pediatrics. 2009
Mar;123(3):e490-e495.

11. Mawle E, Griffiths P. Screening for autism in pre-school children in primary care:
systematic review of English language tools. Int J Nurs Stud. 2006 Jul;43(5):623-36.

12. Nelson HD, Nygren P, Walker M, Panoscha R. Screening for speech and language delay
in preschool children: systematic evidence review for the US Preventive Services Task
Force [Internet]. Rockville, MD: Agency for Healthcare Research and Quality; 2006 [cited
2009 Dec 2] Available from: http://www.ahrq.gov/clinic/uspstf06/speech/speechrev.htm
Originally in Pediatrics 2006;117:e298-e319.

Universal Development Assessment Tools for 18 Month Olds 5

13. Rydz D, Srour M, Oskoui M, Marget N, Shiller M, Birnbaum R, et al. Screening for
developmental delay in the setting of a community pediatric clinic: a prospective
assessment of parent-report questionnaires. Pediatrics [Internet]. 2006 Oct [cited 2009
Dec 9];118(4):e1178-e1186. Available from:
http://pediatrics.aappublications.org/cgi/reprint/118/4/e1178

14. Vincer MJ, Cake H, Graven M, Dodds L, McHugh S, Fraboni T. A population-based

study to determine the performance of the Cognitive Adaptive Test/Clinical Linguistic
and Auditory Milestone Scale to Predict the Mental Developmental Index at 18 Months
on the Bayley Scales of Infant Development-II in very preterm infants. Pediatrics
[Internet]. 2005 Dec [cited 2009 Dec 9];116(6):e864-e867. Available from:
http://pediatrics.aappublications.org/cgi/reprint/116/6/e864

15. Wang LW, Wang ST, Huang CC. Validity of the Clinical Adaptive Test (CAT)/Clinical
Linguistic and Auditory Milestone Scale (CLAMS) as a screening instrument for very low
birth weight infants in Taiwan. J Dev Behav Pediatr. 2005 Dec;26(6):412-8.

16. Lung FW, Shu BC, Chiang TL, Lin SJ. Efficient developmental screening instrument for
6- and 18-month-old children in the Taiwan Birth Cohort Pilot Study. Acta Paediatr. 2008
Aug;97(8):1093-8.

17. VanDenHeuvel A, Fitzgerald M, Greiner B, Perry IJ. Screening for autistic spectrum
disorder at the 18-month developmental assessment: a population-based study. Ir Med J
[Internet]. 2007 Sep [cited 2009 Dec 11];100(8):565-7. Available from:
http://www.imj.ie//UserControls/Issue/paper_printout.aspx?pid=2500&type=Papers

Universal Development Assessment Tools for 18 Month Olds 6