MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES RESEARCH REVIEWS 11: 274275 (2005)

NEURODEVELOPMENTAL ASSESSMENT OF THE YOUNG CHILD: THE STATE OF THE ART

Marilee C. Allen*
The Johns Hopkins School of Medicine, Baltimore, Maryland

A wide variety of tests are available to assess the central nervous system (CNS) function of the toddler and preschool-aged child. These tests vary as to function; qualities and abilities tapped; facility with which they can be learned, administered, and scored; availability of test materials and manuals or training videos; and strength of standardization and validation data. Some were developed to screen development of large numbers of children. Others were developed to evaluate a child for diagnosis of disability or delineation of a childs strengths and weaknesses. Some broadly screen or assess multiple aspects of development, while some focus on specic abilities. A limitation of all these tests is that they tap only a small portion of a childs abilities at a given point in time. Administration of a variety of different tests provides a more complete evaluation of a childs abilities. Tests that can follow a childs development over time tap into the continuum of human development. The ability to measure various aspects of CNS functional development is a rst step in addressing our greatest challenge, how to promote and support a childs development.

2005 Wiley-Liss, Inc.

MRDD Research Reviews 2005;11:274 275.

Key Words: neurodevelopmental disabilities; developmental problems; functional assessment; developmental screening; children

ur greatest human challenge is to support and promote optimal central nervous system (CNS) development in our children. This challenge is signicant at all levels: individual, community, and society. We address this challenge at the individual level by trying to provide a warm, nurturing, enriched environment for our own children; at the community level by trying to devise, implement, and maintain health, developmental support, and educational services; and at the societal level by ascertaining which developmental and educational strategies are effective for promoting optimal CNS development during pregnancy, infancy, and childhood. Our goal is to provide children with the life skills necessary for them to function well as adults, contributing as much as they can to society. Addressing this challenge necessitates the development of methods of assessing CNS function during different periods of development. The ability to assess CNS function is limited by the specic abilities manifested at each period of development. Assessments of the fetus and young infant are limited to evaluations of motor abilities, sensory responses, cries, spontaneous movements, and behavior. Assessments of the older infant and toddler continue to tap both gross and ne motor abilities, but greater control over movement, posture, sensory responses, and vocalizations allow a richer assessment of cognition, sensory processing, behavior, and language development. By preschool and early school age, children are capable of a wide variety of

activities that allow them to adapt to their environment and actively seek further enrichment opportunities. It now becomes possible to evaluate subtle motor dysfunctions, sensory processing defects, a wide range of higher cognitive abilities including abstract reasoning, language understanding, and usage, control of attention and behavior, executive function, adaptive functioning, and social interactions. The reviews that comprise this issue of Mental Retardation and Developmental Disability Research Reviews (MRDDRR) highlight the large number and wide variety of methods available to assess CNS function in the young child, from toddler to preschool age. This is by no means a complete compilation of all available tests, nor is it an endorsement of any specic test(s). This issue does provides an overview of many available (and some not easily available) tests, as well as background regarding test development, what abilities are measured, how these tests are used, and what they can tell us. The authors address important questions regarding screening development in large groups of children; assessing development in children identied as at risk for neurodevelopmental disabilities; both the strengths and the limitations of various test instruments; the relative value of relying on information provided by parents versus eliciting skills from a not always cooperative child; how tests overlap; and how (and if) these tests are standardized and validated. Our ability to assess development of children is continually evolving, with new information regarding specic assessment methods emerging all the time. Many authors discuss measures that are still being developed. Others were not discussed in detail pending forthcoming data. The manual for the Capute Scales, a Cognitive Adaptive Test and Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS), has just come out [Accardo and Capute, 2005]. Ease of administration and scoring make the Capute Scales useful for following high risk infants and toddlers, and the manual now provides long-awaited standardization and validation data. Interpretation of the data generated depends on the purpose for administering the test as well as the properties of the test. Screening tests identify children who need more compre*Correspondence to: Marilee C. Allen, M.D., The Johns Hopkins Hospital, Nelson 2133, 600 N. Wolfe St., Baltimore, MD 21287-3200. E-mail: mcallen@jhmi.edu Received 11 July 2005; Accepted 29 July 2005 Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/mrdd.20080

2005 Wiley-Liss, Inc.

hensive evaluations. Some tests provide necessary information for diagnosis of a neurodevelopmental disability (e.g., the combination of cognitive tests and tests of adaptive functioning for diagnosis of mental retardation). Some more extensive tests aim to determine an identied childs degree of strengths and limitations, so as to dene effective and targeted strategies for health, developmental, and educational interventions. Some tests tap into the continuum of child development by providing the ability to follow a childs abilities as they develop over time, and have the potential of monitoring efcacy of specic targeted interventions. Each test provides data regarding how an individual child performed (or is functioning in life at home or school), and compares that performance with other children tested in a similar manner. Data regarding the comparison population are critical to interpretation of the signicance of test ndings. How generalizable are the test standardization data? What are the cutoffs for normal function, and how were they determined? Or is the test focused on determining degree of optimal functioning? The ability to detect and describe optimal functioning facilitates determination of a childs strengths as well as weaknesses. Many of the tests described in this MRDDRR issue are used for clinical research. Much research is focused on determining how well-specic risk factors (e.g., demographic, perinatal, or neonatal factors) predict development at a later period of life. Ideally, these studies would follow children to adulthood, to evaluate prediction of adult function. Few funding agencies are willing to fund such long-term followup, and so intermediate periods are chosen for the out-

come evaluations. The value of these studies hinges on the adequacy of the outcome measures used to evaluate study children. Many medications and technological advances have not been specically evaluated for use in treating the fetus, preterm infant, neonate, and infants. Recognition of their need for evaluation and the necessity of evaluating new treatments before they are introduced highlight the need for reliable and valid methods of assessing CNS function in young children. For these studies, populations exposed to specic treatments are compared with respect to developmental outcome measures with similar populations not exposed to these treatments. The best studies are those that randomly assign each child to treatment versus no treatment group, and that mask the outcome evaluators as to which group each child was assigned. Failure to do these studies, to conduct well-designed studies, or to use appropriate outcome measures can lead to the perpetuation or introduction of detrimental or harmful treatments. Devising strategies for neuroprotection of vulnerable fetal and infant populations rely on (1) studies of risk factors to provide insight into possible mechanisms of brain injury or recovery and (2) randomized controlled trials of neuroprotective interventions with valid, reliable, and appropriate outcome measures of CNS function during early childhood. Technological advances in obstetrics and neonatology have improved infant survival at all gestational ages, while preterm birth rates increase and the proportion of preterm children with neurodevelopmental disabilities is not signicantly improving [Alexander and Slay, 2002; Allen, 2002; Aylward, 2002; Bracewell and Marlow, 2002; Msall and Tremont,

2002]. Many feel that our research focus should not be on further lowering the border of viability, but on devising neuroprotective strategies and developmental supports that improve the neurodevelopmental and health outcomes of preterm survivors. No test can predict adult functioning with certainty. How a child will ourish and adapt to the environment eludes prediction. Nevertheless, our capacity to modify a childs environment provides us with the opportunity to optimize that childs neurodevelopmental outcome. Promoting optimal CNS functional development in our children requires early recognition of developmental abnormalities as well as prompt, effective, and targeted interventions, developmental support, and educational programs. f REFERENCES
Accardo PJ, Capute AJ. 2005. The Capute Scales. Cognitive Adaptive Test/Clinical Linguistic Auditory Milestone Scale. Baltimore: Paul H. Brookes Publishing. Alexander GR, Slay M. 2002. Prematurity at birth: trends, racial disparities, and epidemiology. Ment Retard Dev Disabil Res Rev 8:215 220. Allen MC. 2002. Preterm outcomes research: a critical component of neonatal intensive care. Ment Retard Dev Disabil Res Rev 8:221 233. Aylward GP. 2002. Cognitive and neuropsychological outcomes: more than intelligence quotient (IQ) scores. Ment Retard Dev Disabil Res Rev 8:234 240. Bracewell M, Marlow N. 2002. Patterns of motor disability in very preterm children. Ment Retard Dev Disabil Res Rev 8:241248. Msall ME, Tremont MR. 2002. Measuring functional outcomes after prematurity: developmental impact of very low birth weight and extremely low birth weight status on childhood disability. Ment Retard Dev Disabil Res Rev 8:258 272.

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