Indian Pediatr Suppl 2009;46: S63-S66
Developmental Evaluation Clinic – CDC
MKC Nair*, Babu George*, K Padma*, N Potti*, KE
Elizabeth†, L Jeyaseelan‡
From *Child Development Centre, †Department of
Pediatrics, Medical College, Thiruvananthapuram, Kerala; and
‡Department of Biostatistics, Christian Medical College, Vellore,
Correspondence to: Dr. MKC Nair, Professor of Pediatrics
and Clinical Epidemiology and, Director,
Child Development Centre, Medical College, Thiruvananthapuram 695011,
We describe our five year experience of conducting
developmental evaluation clinic at CDC. We have also assessed the
prevalence of developmental delay (defined as delay in any two areas in
Denver Development Screening Test II [DDST II]), documented the possible
prenatal, natal, postnatal risk factors for developmental delay and,
also identified the pattern of developmental disorders. A total of 2111
children were screened. DDST II results were abnormal for 953 (45.1%)
children. On multivariate analysis, delayed cry at birth, increasing age
of the child, presence of feeding problems, assisted delivery, and birth
injury were found to be associated with increasingly abnormal DDST II
results. Nearly 50% of referred babies had developmental delay without a
specific clinical diagnosis, 13.9% had speech problems, 9.5% had
neurological problems and 5.2% had chromosomal anomalies. Birth related
events are important risk factors for developmental delay.
Keywords: DDST II, Developmental delay, Developmental evaluation
clinic, Risk factors.
Child development is a dynamic process
optimally utilizing the genetic potential of the baby, within the context
of the available environment, enabling achieve-ment of full potential. It
has been shown that 40% reduction in poor performance could be achieved by
CDC model early stimulation(1,2). Severe forms of disability are less
common and are often due to congenital, genetic, metabolic causes or
intrauterine infections and need specific preventive strategies(3). The
observed 2.5% prevalence of developmental delay in the less than 2 year
olds of deprived urban settlements, the presence of risk factors for
developmental delay like low birthweight, birth asphyxia, coupled with
poor environment of home and alternate child care services, highlights the
need for simple cost-effective community model for promoting early child
development(4). Although simple developmental assessment in the community
could be done using Trivandrum Developmental Screening Chart (TDSC)(5), it
is important that there are regional Child Development Clinics, where more
sophisticated testing could be done in suspected cases and also
developmental therapy could be offered.
Developmental evaluation clinic at Child Development
Centre has been functioning for the last 5 years as a regional referral
clinic for children under six years with suspected developmental delay or
deviation. Assessment, therapy and counseling services are offered by
prior appointment. A consultant pediatrician does detailed clinical
assessment for confirming the type and extent of the developmental problem
and to identify potential risk factors. A physiotherapist provides therapy
service and a child psychologist counsels the parent. Wherever necessary,
the services of a consultant neurologist, physiatrist, speech pathologist
and ophthalmologist are made available in the clinic. The objective of
this paper is to describe our experience of conducting developmental
evaluation clinic at CDC, assess the prevalence of developmental delay
document the possible prenatal, natal and postnatal risk factors for
developmental delay, and to identify the patterns of delay, deviation or
disorder identified by DDST II and clinical examination results together.
Over a period of 5 years, 2111 children below the age
of 6 years were referred to the clinic for detailed developmental
assessment. Developmental screen-ing was done in all the children using
Denver Developmental Screening Test (DDST II)(6) by a developmental
therapist, with at least five years experience in developmental
assessment. An experienced pediatrician examined all children initially,
recorded the clinical findings and the same was reviewed by a consultant
pediatric neurologist and physiatrist. After the clinical diagnosis was
confirmed, the children were referred to the appropriate speciality clinic
at CDC for more specific tests and for therapy services by a
physiotherapist and developmental therapist specialized in speech
stimulation. A standard performa was used to record known prenatal, natal
and postnatal risk factors. For the purpose of this study, an abnormal
DDST was taken as delay in any two of the four areas of development-gross
motor, fine motor, personal social and language.
The data was coded and checked for accuracy.
Statistical Package for Social Sciences (SPSS) 13.0 was used to analyse
the data. Bivariate analysis was done taking abnormal DDST as the
dependant variable and family history of mental retardation and other
study variables as independent variables. The study variables, which were
significant at 20% level at the bivariate analysis were included in the
logistic regression analysis to control the effect of confounders.
Out of the 2111 children below 6 years referred to
developmental evaluation clinic, DDST II results were abnormal for 953
(45.1%) children and normal (no delay in all the four areas) in 1130
children. The mean age of the group with abnormal DDST II was 18.1 (12.5)
months and that of normal DDST II was 15.93 (11.54) months. There were
1286 (60.9%) children with gross motor delay, 773 (36.6%) with fine motor
delay, 719 (34.1%) with personal social delay and 940 (44.5%) with
Table I shows the results of the bivariate
analysis of prenatal, natal and postnatal risk factors against DDST II
results (normal or abnormal). Table II shows the
results of the multivariate analysis. Delayed cry at birth, increasing age
of the child, presence of feeding problems, assisted delivery and birth
injury were found to be associated with increasingly abnormal DDST.
History of antenatal bleeding was identified as a probable protective
factor with RR 0.67. This may be due to better antenatal and natal care
received by the mothers with a history of antenatal bleeding. Table
III shows that nearly 50% of babies referred for
developmental evaluation had developmental delay without a specific
clinical diagnosis and nearly 17% were normal on DDST II evaluation.
Bivariate Analysis of Risk Factors for Abnormal DDST II Results
Presence of variable
|Family history of MR
|Family history of Epilepsy
|Mother’s weight gain <10 kg
|Low birth weight
|Delayed cry at birth
DDST: Denver Developmental Screening
Test, MR: Mental retardation
Logistic Regression Analysis to Identify Risk Factors for Abnormal DDST
Presence of variable
(95 % CI)
Family history of MR
Family history of epilepsy
Pregnancy weight gain <10 kg
Low birthweight (<2500g)
Delayed birth cry
Age of the child (mo)
MR: Mental retardation
Diagnosis Using DDST and Clinical Examination Together (n=2111)
|Developmental delay (fine motor, gross motor delays)
|Speech and language delay
|Neurological problems (cerebral palsy, mental
retardation, attention deficit hyperactivity disorder)
|Chromosomal anomalies (Downs syndrome, Turner
|Visual abnormalities (cataract, ptosis, blindness)
|Pervasive Developmental Disorders (autism, Retts
|Deformities (congenital talipes equino varus,limb
DDST II is a developmental screening test with good
track record and can be used across the age group of 0 -6 years. The real
advantage of DDST II is that the area or areas of delay in a particular
child being tested can be made out easily and this helps the pediatrician
to plan further management. In routine clinical practice, some known risk
factors may be identified in the majority of cases of developmental delay.
The results of this study showing that delayed cry at birth, assisted
delivery, birth injury and presence of feeding problems are associated
with increasingly abnormal DDST II, highlight the strong association of
birth related events to developmental delay. However, the report of the
National Institutes of Health Task Force on "Joint Assessment of Prenatal
and Perinatal Factors Associated with Brain Disorders" found that,
although it was simple to say that a specific event such as birth trauma
or asphyxia caused brain disorders, it is not usually possible to pinpoint
a single cause and its effect. The normal brain’s ability to repair or
compensate for even major developmental disruptions, combined with the
gross and subtle interactions of biologic, social and environmental
factors, confounds the task of assigning etiologies to brain disorders.
The causes of severe mental retardation are primarily genetic,
biochemical, viral, and developmental and not related to birth events(7).
The observation that as the age of presentation of the
child increases there is 1.02 times chance to be abnormal on DDST II
suggest that developmental delay should be detected earlier. Paramleen,
et al.(8) showed that among the utilizers of their early intervention
program clinic, 88% were mentally retarded, 50% were children with
cerebral palsy, 24% with learning disorder, 12% with ADHD and 4% with
autism. Among these children, 66% were unable to communicate verbally, 25%
suffered from epilepsy and 21% had strong evidence of genetic disorders.
However, the mean age of these children was 4.0 ± 1.4 years as against
18.1 and 15.9 months in children with abnormal and normal DDST,
respectively in our study. This suggests a high referral of suspected
cases at early years at our center.
The presented study had some limitations. The focus was
on biological risk factors and all the known and unknown family and
environmental risk factors were not studied. Moreover, as the children are
referred from far away places, it was not possible to give sustained early
intervention therapy for developmental delay. Hence in the Indian context,
to reach out to all babies, a more appropriate strategy would be to do
simple developmental screening using TDSC by trained anganwadi workers and
follow it up with DDST II by trained pediatricians.
Lakshmi MA, Latha S, Jyothi R, Sunitha RM, Prasanna GL,
Resmi VR, Rajee K, Preetha VS, Aanandam R, Indira MS, Jayakrishnan M, and
Asokan N, Child Development Centre, Medical College, Thiruvananthapuram.
Contributors: MKCN was involved in designing the
study and preparation of the manuscript and will act as guarantor. BG, KP,
NP were involved in the data collection and KEE in manuscript writing. The
data were analysed by LT.
Competing interest: None stated. The findings and
conclusions of this study are those of the authors and do not necessarily
represent the views of the funding agency.
What This Study Adds?
• Nearly 50% of babies referred to developmental
evaluation clinic had developmental delay without a specific
• Delivery type other than normal delivery,
delayed cry at birth, birth injury, and feeding problems were
identified as significant risk factors for abnormal DDST II.
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