NEURODEVELOPMENTAL DISABILITIES

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In 1991 we were approached by a representative of the Society for Developmental Pediatrics regarding
our interest in having a new section of THE JOURNAL dedicated to children with developmental
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indicated that it is difficult to obtain sufficient material for a special section until it has become
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peer review and editorial decisions regarding publication. We, of course, retain ultimate responsibility
for all articles appearing in THE JOURNAL.
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communicating with general pediatricians and those in other subspecialties as well as with one another.
We look forward to the growth and development of this section.--J.M.G., Editor

Clinical Adaptive Test/Clinical Linguistic

Auditory Milestone Scale in early
cognitive assessment
A l e x a n d e r H. Hoon, Jr., MD, MPH, M a r g a r e t B. Pulsifer, PhD,
R a m a n a G o p a l a n , MD, MPH, Frederick B. Palmer, MD, a n d
A r n o l d J, C a p u t e , MD, MPH
From the Department of Developmental Pediatrics, Kennedy Krieger Institute, and the
Departments of Pediatrics, internal Medicine, and Psychiatry and Behavioral Sciences, ,Johns
Hopkins University School of Medicine, Baltimore, Maryland

Correlations between the Clinical Adaptive Test/Clinical Linguistic Auditory

Milestone Scale (CAT/CLAMS) and the Bayley Scales of Infant D e v e l o p m e n t - -
Mental Scale (BSID) were examined in 61 infants and toddlers with suspected
developmental delay. Highly significant correlations were found between the
two instruments. Gender, race, and gestational a g e did not influence the rela-
tionship between CAT/CLAMS and BSID scores. The CAT/CLAMS was both sensi-
tive (88%) and specific (67%) for mental retardation (BSID <70). The CAT/CLAMS
correlates with the BSID and can be used as an instrument for detecting cogni-
tive delay. (J PEDIATR1993;123:SI-8)

With federal mandates 1 and a consensus that early inter-
vention has beneficial effects on development, 2-4 it is essen-
Reprint requests: Alexander H. Hoon Jr., MD, MPH, Kennedy
Krieger Institute, 707 North Broadway, Baltimore, MD 21205.
Copyright 9 1993 by Mosby-Year Book, Inc.
0022-3476/93/$1.00 + .10 9/73/45482
tial that pediatricians detect developmental delays in in-
fants and toddlers. 5 Given the time constraints of clinical
practice, pediatricians would benefit from the availability of
a simple, accurate instrument to assess early cognitive de-
velopment. This would facilitate referral for more compre-
hensive evaluations and intervention services.
Several tests have been developed to assess the cognitive

S1
S2 H o o n et al.
BSID Bayley Scales of Infant
Development--Mental scale
CAT/CLAMS Clinical Adaptive Test/Clinical
Linguistic Auditory Milestone Scale
DQ Developmental quotient
MDI Mental Development Index
MR Mental retardation
abilities of infants and young children, beginning with the
work of Gesell6 and continuing with the adaptations and
refinements of Cattell, 7 Sheridan, s Illingworth, 9 and Bay-
leyJ ~ The Bayley Scales of Infant Development--Mental
Scale is currently the standard diagnostic test for pediatric
psychologists. It is well normed and widely used in clinical
practice and research, but it is too lengthy to be regularly
employed in pediatric practice.
To assist clinicians, researchers have developed screening
tests that are less time-consuming to administer than the
BSID.tt These tests often combine parental report with di-
rect observation. However, they are frequently limited by
inadequate standardization, low sensitivity, and a lack of
well-defined quantitative scores and diagnostic cutoff points.
The Clinical Adaptive Test/Clinical Linguistic Auditory
Milestone Scale was developed for pediatricians to assess
development in infants and toddlers with cognitive ages
from 1 to 36 months) z' 13 Advantages include brevity (usu-
ally 15 tO 20 minutes) and ease of administration with min-
imal equipment. Norms have been established for the lan-
guage component (CLAMS), which has been shown to be
of clinical utility for the identification of cognitive delay in
infancy.t4, 15
Scoring of the C A T / C L A M S is derived primarily from
parental report ( C L A M S ) and from direct assessment
(CAT), with both parental long-term recall and direct ob-
servation used to limit the possibility of inaccuracy. The in-
strument gives quantitative developmental quotients for
nonlanguage visual-motor (CAT DQ) and language
(CLAMS DQ) abilities, as well as a composite score of
cognitive function ( C A T / C L A M S DQ). An advantage of
the C A T / C L A M S is that CAT, CLAMS, and C A T /
CLAMS DQs can be interpreted to discriminate children
with mental retardation (both language and visual-motor
delay) from those with communication disorders (discrep-
ancies between separate scores, with language DQs usually
below visual-motor DQs).
Our study was conducted to measure the agreement be-
tween the C A T / C L A M S and the BSID and to explore the
clinical utility of the C A T / C L A M S for detecting cognitive
delay. For the purpose of this study, agreement was tested
by the kappa statistic and correlation coefficients.
The Journal o f Pediatrics
July 1993
Table I. Sample characteristics (N = 61)
Chronologic age (mo)* 26 _+ 11
Gestational age (wk)* 38 _+ 4
Maternal age (yr)* 26 _+ 7
Sex (%)
Male 66
Female 34
Race (%)
White 42
Black 58
BSID DQ (%)
<70 57
-->70 43
Maternal education (%)
High school or less 73
More than high school 27
* V a l u e s a r e e x p r e s s e d as m e a n + S D .
METHODS
Subjects. Subjects were chosen from children referred to
two outpatient pediatric developmental clinics for evalua-
tion of suspected language or motor delay during a 9-month
period in 1991-1992. Study inclusion criteria were (1)
chronologic age less than 48 months, (2) no significant mo-
tor or sensory impairment affecting assessment, and (3)
completion of both the BSID and the C A T / C L A M S . Six-
ty-one infants and toddlers met the criteria and formed the
sample.
Demographic characteristics are detailed in Table I. The
mean chronologic age at evaluation was 26 months. Sixty
percent were referred for language delay and the remainder
for motor delay. More than half (57%) of the sample had
mental retardation (Bayley Mental Development Index
<70), with 28% overall falling in the mild range of MR.
Measures. The C A T / C L A M S is a 100-item scale com-
posed of two parts: (1) the CAT, which assesses visual-mo-
tor problem-solving abilities and (2) the CLAMS, which
measures receptive and expressive language skills (Table
II). The CAT consists of tasks performed by the child,
whereas the CLAMS primarily utilizes parental interview.
Only a small subset of the C A T / C L A M S items are admin-
istered at a given assessment. Test items are ranked by de-
velopmental age.
Scoring is based on basal (the highest age level at which
all items are passed) and ceiling (the highest level at which
any item is passed) age levels. C A T / C L A M S scores include
both mental age levels and DQs. The mental age score for
both CAT and CLAMS is obtained by adding weighted
successes beyond the basal age level. Scores are converted
to DQs (mental age/chronologic age • 100). The C A T /
C L A M S DQ is the mean of the CAT DQ and C L A M S DQ.
The Journal o f Pediatrics H o o n et al. S 3
Volume 123, Number 1

Table II. C A T / C L A M S scoring sheet

CLAMS CAT

L a n g u a g e skills Yes No Visual-motor abilities Yes No

1 Month 1 Month
Is alert to sound (0.5)* Visually fixates momentarily
on red ring (0.5)
Is soothed when picked Chin off table, prone (0.5)
up (0.5)
2 Months 2 Months
Social smile (1.0)* Visually follows ring
horizontally and vertically (0.5)
Chest off table, prone (0.5)
3 Months 3 Months
Coos (1.0) Visually follows ring in
circle (0.3)
Supports on forearms
in prone (0.3)
Visual threat (0.3)
4 Months 4 Months
Orients to voice (0.5)* _ _ m
Unfisted (0.3)
Laughs aloud (0.5) Manipulates fingers (0.3)
Supports on wrists,
prone (0.3)
5 Months 5 Months
Orients toward bell Pulls down rings (0.3)
laterally (0.3)*
"Ah-goo" (0.3) Transfers (0.3)
Razzing (0.3) Regards pellet (0.3)
6 Months 6 Months
Babbling (1.0) Obtains cube (0.3)
Lifts cup (0.3)
Radial rake (0.3)
7 Months 7 Months
Orients toward bell (1.0)* Attempts pellet (0.3)
(Upward indirectly 90 degrees*) Pulls out peg (0.3)
Inspects ring (0.3)
8 Months 8 Months
'~ inappropriately (0.5) Pulls ring by string (0.3)
"Mama" inappropriately (0.5) Secures pellet (0.3)
Inspects bell (0.3)
9 Months 9 Months
Orients toward bell (upward Three-finger scissor grasp (0.3)
directly 180 degrees) (0.5)* Over the edge for toy (0.3)
Gesture language (0.5) Rings bell (0.3)
10 Months 10 Months
Understands "no" (0.3) Combines cube-cup (0.3)
Uses "dada" appropriately (0.3) Uncovers bell (0.3)
Uses "mama" appropriately (0.3) _ _ m
Fingers pegboard (0.3)
11 Months 11 Months
One word (other than Mature overhand pincer
"mama" and "dada") (1.0) movement (0.5)
Solves cube under cup (0.5)

Table H continued on p. $4

The numbers in parentheses refer to the score given for each correct answer. The total score is the sum of all passed items above the basal level.
*CLAMS items were done at the time of assessment.
tFrom Cotteli picture cards.
S4 H o o n et al.
Table II. Cont'd
CLAMS
L a n g u a g e skills
12 Months
One-step command with
gesture (0.5)
Vocabulary 2 words (0.5)
14 Months
Vocabulary 3 words (1.0)
Immature jargoning (1.0)
16 Months
Vocabulary 4-6 words (l.0)
One-step command without
gesture (1.0)
18 Months
Mature jargoning (0.5)
Vocabulary 7-10 words (0.5)
Points to one picture (0.5)*, t
Body parts (0.5)
21 Months
Vocabulary 20 words (1.0)
Two-word phrases (1.0)
Points to two pictures (1,0)*, t
24 Months
Vocabulary 50 words (1.0)
Two-step command (1.0)
Two-word sentences (1,0)
30 Months
Uses pronouns appropriately (1.5)
Concept of one (1.5)*
Points to seven pictures (1.5)*, ~
Two digits forward (1.5)*
36 Months
Vocabulary 250 words (1.5)
Three-word sentence (1.5)
Three digits forward (1.5)*
Follows two prepositional
commands (1.5)*
Scores from the B S I D include a mental age and a stan-
dard score, the M D I . For this study, a Bayley DQ was con-
structed (mental age/chronologic age x 100) because a
large number of subjects had Bayley M D I scores of less than
50. Unless otherwise specified, the BSID DQ was used for
analysis.
The Journal o f Pediatrics
July 1993
CAT
Yes No Visual-motor abilities Yes No
12 Months
Release one cube/cup (0.5)
Crayon mark (0.5)
14 Months
Solves glass frustration (0.6)
Out-in with peg (0.6)
Solves pellet-bottle with
demonstration (0.6)
16 31onths
Solves pellet-bottle
spontaneously (0.6)
Round block in formboard (0.6)
Scribbles in imitation (0.6)
18 Months
Ten cubes in cup (0.5)
Solves round hole in
formboard reversed (0.5)
Spontaneous scribbling
with crayon (0.5)
Pegboard completed
spontaneously (0,5)
21 Months
Obtains object with stick (1.0)
Solves square in formboard (1.0)
Tower of three cubes (1,0)
24 Months
Attempts to fold paper (0.7)
Horizontal 4-cube train (0.7)
Imitates stroke with pencil (0.7)
Completes formboard (0.7)
30 Months
Horizontal-vertical stroke with
pencil (1.5)
Form board reversed (1.5)
Folds paper with definite
crease (1.5)
Train with chimney (1.5)
36 Months
Three-cube bridge (1.5)
Draws circle (1.5)
Names one color (1.5)
Draw-a-person test with head
plus one other body
part (1.5)
Procedures. The C A T / C L A M S and the BSID were ad-
ministered to all subjects as part of a comprehensive devel-
opmental evaluation. Tests were given in random order (ei-
ther C A T / C L A M S or BSID first) in separate sessions
within 1 week. The C A T / C L A M S was given by a neurode-
velopmental pediatrician to 64% of subjects, by a fellow in
The Journal o f Pediatrics Hoon et al. S5
Volume 123, Number 1

140 -

120 -

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20 -

0 I I I I I I I I
0 20 40 60 80 100 120 1 40 160
Bayley DQ
(r = 0.95, p < 0.0001)

Fig. 4. Scatterplot of DQs for the CAT/CLAMS and the BSID (r = 0.95).

Table III. Descriptive statistics and correlations between the C A T / C L A M S and the BSID

P e a r s o n r*

Measure n Mean +- SD Range BSID D Q BSIDMDI

CAT/CLAMS DQ 61 64.8 _+ 20.2 9-119 0.95 0.85

CLAMS DQ 6l 59.8 _+ 21.8 12-118 0.86 0.77
CAT DQ 61 69.4 +_ 21.6 6-112 0.91 0.74
BSID DQ 61 65.8 _+ 18.8 11-106 -- 0.97
BSID MDI 32t 68.6 _+ 14.6 50-107 0.97
*All r values were significant at p <0.0001.
tTwenty-nine children with M D I scores <50 were excluded.

neurodevelopmental disabilities to 23%, and by a J o h n s Statistical analysis. M e a n paired differences were used to
Hopkins pediatric resident to 13%. All B S I D s were admin- evaluate C A T / C L A M S and B S I D scores. Pearson product
istered by one pediatric psychologist. Examiners were un- m o m e n t correlations were used to evaluate the degree of
aware of test results from the other instrument. association between scores. To evaluate the effects of any
S6 Hoon et al.
MR
DQ<_ 69
MR 30
DQ~ 69
CAT/CLAMS
DQ
Not MR
DQ> 70
Fig. 2. Two-by-two table of sensitivity (30/34 = 88%) and specificity (18/27 = 67%) when the CAT/CLAMS defini-
tion of MR is a composite score <70.
potential confounders, the association between test scores
was evaluated by stratification on the variables gender, race,
gestational age, and chronologic age separately. A multi-
variate model was developed to express the relationship be-
tween the C A T / C L A M S DQs and the Bayley DQs,
adjusted for the effects of these variables.
Agreement between scores was evaluated with the kappa
statistic. Using standard definitions, we evaluated the sen-
sitivity a n d specificity of the C A T / C L A M S in identifying
MR against the BSID.
RESULTS
Table I I i presents descriptive statistics and correlations
between the C A T / C L A M S DQs and the BSID scores (DQs
and MDIs). There was no systematic difference between the
C A T / C L A M S DQ and the BSID DQs; the mean paired
difference was 1.34 (not significant). The sample mean
CAT DQ was higher than the mean CLAMS DQ (t = 2.43;
p <0.025). A strong correlation was found between the
C A T / C L A M S DQ and the Bayley DQ ( r = 0 . 9 5 ;
p <0.000!) (Table III; Fig. 1). The CAT DQ and CLAMS
DQ also correlated strongly with the Bayley DQ (r = 0,91
and 0.86, respectively; p <0.0001 for both).
The potential confounding effects of gender, race, gesta-
tional age, and chronologic age on the relationship between
The Journal of Pediatrics
July 1993
Bayley DQ
Not MR
DQ>_ 70
9 39
4 18 22
34 27 61
C A T / C L A M S DQs and Bayley DQs were examined sep-
arately by stratified analysis and jointly by multivariate re-
gression. By stratified analysis with Mantel-Haenszel chi
squares, none of these variables significantly modified the
strength of the association between the two test scores. In
a stepwise regression model using BSID DQ as the depen-
dent variable and sex, race, gestational age, and C A T /
C L A M S scores as explanatory variables, the C A T /
C L A M S DQ accounted for 90% of the variance in BSID
DQ ( F = 124, d f = 4, 59; p <0.0001). Further, paired dif-
ferences in test scores showed no systematic relationship to
the training level of the examiner, the order in which the
subject was tested, or maternal educational level.
To evaluate the C A T / C L A M S in identifying MR, we
used the BSID DQ as the reference test (BSID <70 indi-
cating MR). The sensitivity and specificity of the C A T /
C L A M S in identifying M R were computed. The kappa
statistic was used to evaluate the degree of agreement be-
tween the two test results.
Two different interpretations of the C A T / C L A M S scores
were used to determine MR. With the use of a composite
C A T / C L A M S DQ score of <70 as indicative of MR, the
C A T / C L A M S had a sensitivity of 88% and a specificity of
67% (Fig. 2). The agreement between the two tests was 78%
(K = 0.56; p <0.001). With a more stringent definition of
The Journal o f Pediatrics
Volume 123, Number 1
MR
DQ_< 69
MR
DQ<_ 69 25
(Both CAT
& CLAMS)
CAT and
CLAMS DQ
Not MR 9 24
D Q > 70
34
Fig. 3. Two-by-twotable of sensitivity (25/34 = 74%) and specificity (24/27 = 89%) when the CAT/CLAMS defini-
tion of MR is more stringent (both CAT and CLAMS DQs <70).
MR (both CAT and CLAMS DQs <70), the specificity in-
creased to 89% (Fig. 3). There was 80% agreement between
the tests (K = 0.61; p <0.001).
DISCUSSION
Both composite CAT/CLAMS DQ and the individual
CAT and CLAMS DQs strongly correlated with the BSID
DQ, indicating strong agreement between these instru-
ments. None of the factors evaluated (age, sex, race,
maternal education, gestational age, or order of testing)
significantly altered the correlations between the C A T /
CLAMS and BSID scores in this developmentally delayed
sample. The CAT/CLAMS was both sensitive and specific
for the presence of MR as defined by the BSID.
At our institution, the separate CAT and CLAMS DQs
are used to distinguish children with MR from those with
communication disorders. For example, a child with a Bay-
ley DQ of 60 would be identified as mentally retarded.
However, if the same child had a CLAMS DQ of 45 and a
CAT DQ of 75 (CAT/CLAMS composite DQ also 60), this
child would be identified as having a communication disor-
der. This distinction is important for both family counsel-
ing and appropriate early intervention services. Children
with global deficits characteristic of MR require compre-
hensive early intervention, whereas those with specific lan-
Hoon et al. S7
nayley
Not MR
DQ> 70
3 2g
33
27 61
guage delays may benefit more from intensive speech and
language therapy. Whether our interpretation of CAT/
CLAMS scores more precisely reflects later outcome than
do BSID scores requires further study.
The small sample size and the high prevalence of cogni-
tive impairments in the study population limit the general-
izability of these results. Specifically, caution must be used
in extrapolating results to populations with a low prevalence
of cognitive impairments as found in most pediatric prac-
tices. Although it is anticipated that the CAT/CLAMS will
be useful, further work is required to evaluate its utility in
this setting. Subsequent work will also address interrater
reliability and prediction of later cognitive function.
We express our appreciation to Drs. Alan Gittelsohn, Bruce
Shapiro and George Capone for their contribution to this research.
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