OF DEVELOPMENTAL EXAMINATION AS A METHOD OF …jech.bmj.com/content/jech/26/2/94.full.pdf · AS A METHOD OF DETECTING NEUROLOGICAL, VISUAL, AND AUDITORY HANDICAPS IN ... universal

Brit. J. prev. soc. Med. (1972), 26, 94-100

AN EVALUATION OF DEVELOPMENTAL EXAMINATIONAS A METHOD OF DETECTING NEUROLOGICAL,

VISUAL, AND AUDITORY HANDICAPS IN INFANCY

C. J. ROBERTS AND T. KHOSLADepartmenit of Social and Occupational Medicine, The Welsh National School of Medicinte, Cardiff

A recent editorial (British Medical Journal, 1971)discussed the value of universal neurologicalscreening of the newborn in the light of criteriaaccepted as generally applicable to all screeningprocedures: firstly, that a reliable screening testshould not give many false negative or positiveresults; secondly, that early detection is worth-while because early treatment has proved advant-ageous; and finally, that the use of medical andother resources is a reasonable priority in terms oftotal supply of these resources and the demandsmade on them. (It was estimated that a 15-minuteneonatal neurological examination on every new-born would take up 470 hours per year of allpractising paediatricians and senior paediatricregistrars.)The editorial noted that none of the requirements

had been fulfilled for neonatal neurological screen-ing but went on to say that 'It is now widely acceptedthat all children should have periodic developmentalscreening tests beginning at, say, 6 weeks, 6 months,and 10 months'. Clear and practicable schemes havebeen devised for doing these tests (Sheridan,1968; Egan, Illingworth, and MacKeith, 1969).We can find no published evidence showing how

effective developmental screening (or even fulldevelopmental examination) is in detecting abnor-malities. The screening schemes in current use(Frankenberg and Dodds, 1967; Sheridan, 1968;Egan et al., 1969) presume a degree of effectivenessbased on the admittedly reasonable assumption thata proportion of infants with neurological, auditory,and visual defects will present as developmentaldelay (Gesell and Amatruda, 1941). Frankenbergand Dodds claim to have undertaken both reli-ability and validity studies on the Denver scale.Estimates of the former were based on the results oftwo tests separated by an interval of one week andundertaken by the same examiner on 20 childrenwhose ages ranged from 2i months to 51 years (test-retest reliability) and the percentage agreementbetween different examiners of the same subject

(examiner reliability); estimates of the validitywere based on correlations between results ofexamination with the Denver scale and examinationwith the Yale developmental schedule (itself adevelopmental examination based on Gesell, withthe additional items from various IQ tests). Im-portant as these parameters are they clearly give noindication of the ability of developmental screeningto detect clinical handicap in infancy. Assessmentof reliability (or effectiveness) in this context canbe determined only from concordance studiesbetween the results of developmental screening anddefinitive clinical examination of the same popu-lation.

Similarly, there is no published evidence tosupport the criterion of advantageous early therapyin respect of infant developmental screening be-cause of the considerable ethical and practicaldifficulties of undertaking controlled trials of earlytreatment. In this situation one must therefore beguided by the opinion of experts and accept thatearly treatment is of value.

Finally, it would seem plausible to argue that thereasonableness of developmental screening as apriority can only be approached when evidence ofthe reliability and efficacy of the procedure has beenmeasured. Thus, in view of the current absence ofevidence to support any of the above criteria for de-velopmental screening, we felt that the one aspectwhich needed to be looked at urgently was that ofthe reliability and effectiveness of developmentalexamination. Such a study forms the basis of thispaper.A full developmental examination procedure is

time consuming and requires considerable trainingand expertise for its application and interpretation.These qualifications make it unsuitable for routineuse on large populations of apparently healthychildren. An attempt has been made to overcomethis problem by devising simplified developmentaltests of items abstracted (somewhat arbitrarily) fromthe battery of observations in the full diagnostic

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AN EVALUATION OF DEVELOPMENTAL SCREENING TESTS

developmental examination. It is claimed that thesesimplified (screening) tests are suitable for use byparamedical workers (e.g., health visitors) or evenby members of the lay public who satisfy certainminimal education requirements and have under-gone a short period of training (Frankenberg, 1970).Although evidence supporting the effectiveness ofthis approach has not yet been published and thesensitivity and specificity of the procedure areunknown, considerable resources (in terms of man-power and finance) have already been mobilised topromote this policy.

This paper is concerned with two aspects ofdevelopmental examination in relation to screeningfor handicaps in infancy:

(1) the extent to which full developmentalexamination can detect neurological, auditory,and visual defects in infants-this we havecalled its effectiveness (which is closelyassociated with reliability requirements-seeabove);

(2) the extent to which the number of observa-tions made in the full developmental exami-nation can be reduced (i.e., to make a screen-ing test) without seriously affecting the degreeof effectiveness as estimated above-this wehave called redundancy.

MATERIAL AND METHODSData used in this study are derived from a sample

originally taken to examine the influence of toxaemiaand antepartum haemorrhage on infant develop-ment (Roberts, 1971). The sample consisted of193 infants aged 11 to 13 months whose mothersexperienced toxaemia and/or antepartum haemor-rhage during the related pregnancy, and 193 con-trols matched for sex, parity, maternal age, place ofbirth, and social class whose mothers did notexperience toxaemia or antepartum haemorrhage.One of us (C.J.R.) carried out a four-part examina-

tion on each subject:(1) a developmental examination using the Gesell

developmental test (Gesell and Amatruda,1941), which consists of items divided intofive subgroups: gross motor (x1), fine motor(x2); adaptive (X3); language (X4); and per-sonal social (x5). In each subject the develop-mental age score is the ratio of the numberof items completed successfully comparedwith those required by Gesell at the same age.The aggregate developmental score is basedon the mean of the five subgroups:

Iy (Xi ± X2 -F x3 ± x4 + xN);

(2) a neurological examination using a batteryof 64 observations covering muscle tone, re-flex activity, and neuromotor patterning(Gesell and Amatruda, 1941; Knobloch andPasamanick, 1962);

(3) an examination of auditory responses to freefield pure tones (Roberts, 1968). A history ofprevious ill health (to include upper respiratorytract and ear infections) was taken. Otoscopywas done on all subjects whose auditory re-sponses were abnormal;

(4) an examination of binocular visual com-petence using a in diameter white ball rollinghorizontally across the infant's line of vision(Sheridan, 1960) together with an examinationof the eyes for nystagmus, failure of fixation,use of peripheral vision, and strabismus.

Data thus collected were analysed:(1) for evidence of redundant tests in the full

developmental examination (by use of amultiple regression technique); this analysiswas undertaken on the 193 control subjectsin the original sample (subsample 1);

(2) to consider the degree of concordance be-tween the clinical classification of abnormalitybased on independent neurological criteriaand the developmental classification (inpercentiles) based on the full developmentalexamination. This analysis was undertakenon all infants from the original sample whowere classified as abnormal on the basis ofthe neurological examination (the groupcomprised 12 infants and will be referred to assubsample 2);

(3) to study the concordance between the resultsof auditory assessment and language develop-ment (subsample 3);

(4) to study the concordance between visualexamination and fine motor development(subsample 4). Both subsamples 3 and 4included every infant in the original sample(i.e., cases and controls, n = 386).

Support for the inclusion of all subgroups (xl to x5)in both the full and the simplified (screening) de-velopmental examination derives from the belief thatwhile some children (e.g., those with mental handi-cap) will show delay in all subgroups, others (e.g.,those with motor, visual, or hearing handicap) willappear abnormal on one subgroup only; but it couldequally be argued that a defect in one field largeenough to be detected by these relatively crudetechniques is likely to have an effect in other fieldsas well.

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C. J. ROBERTS AND T. KHOSLA

RESULTSMULTIPLE REGRESSION ANALYSIS (SUBSAMPLE 1)Table I shows the subgroup and aggregate de-

velopmental scores for subsample 1, and Table II

TABLE IMEANS AND STANDARD DEVIATIONS OF AGGREGATE

AND SUBGROUP DEVELOPMENTAL SCORES OF 193SUBJECTS

Developmental Subgroup Developmental ScoreMean (S.D.)

Aggregate (y) 91-4 (9*9)Gross motor (xi) 97.5 (15-4)Fine motor (x2) 95 5 (9-3)Adaptive (x,) 90.1 (12-1)Language (x4) 855 (13 4)Social maturity (xs) 88 5 (13-3)

TABLE IICORRELATION MATRIX OF AGGREGATE AND

SUBGROUP SCORES OF 193 SUBJECTS

Developmental SubgroupDevelopmental

Subgroupy X1 X2 X3 X4 XS

y 1 00 0-82 081 079 051 067XIL 1-00 052 040 035 045

XS 1 00 0 59 0'39 0-51X3 -100 056 0*71X4 100 0-74xs 1-00

shows the intercorrelation between all of these.The size of some of these correlations (viz., x4 andx5; Xs and x5) suggests that certain subgroups couldbe deleted from the full developmental examinationwithout any appreciable loss of information.

Table III considers how much information islost from the aggregate developmental score as

TABLE IIISTEPWISE MULTIPLE REGRESSION ANALYSIS ON FIVE

DEVELOPMENTAL TESTS ON 193 SUBJECTS

No. of Variables inSet Independent Multiple Regression Rs CommentNo. Variables %I 5 xI xS xS x4 xs 98-12*II 4 x1 x. x3 x4 98-08 No loss ofIII 3 x1 x2 xa 98-03 1 informationIV 2 xI x, 87-32 Some lossV I x1 67 60 Great lossVI 4 x, X3 X4 X5 80 99 < Set IVVII 4 xI X3 X4 X, 92-61 < Set IIIVIII 3 xI x, x4 88-93 < Set IIIIX 3 xI x, X5 90-4 < Set II

* Deviation from 100% is attributable to rounding errors.x1 Gross motor; x2 Fine motor; x3 Adaptive; x4 Language; x5 Social

maturity.

various subgroups are omitted using the method ofstepwise regression. The square of the multiplecorrelation coefficient (R2) accounts for the per-centage variation in 'y' (the aggregate score)

accounted for by the set of 'independent' variables.Thus, if all the five subgroups are included in theexamination, R2 should be 100%-the observedR2 (98-12) is attributable to errors due to rounding.

Deletion of x4 and xs shows a negligible loss ofinformation; deletion of x3 results in a 10% loss ofinformation in 'y'; and deletion of x2 causes afurther 20% loss of information in 'y'. Subgroups xland x2 together give more information than thefour subgroups x2, X3, X4, and x5-this finding againemphasizes the importance of xl. Other combina-tions of subgroups were examined (xl, X3, X4, X5;X1, X2, X4; X1, X2, X5) but all yielded appreciably lessinformation than xl, x2, and x3. Thus, three develop-mental subgroups, xl, x2, and x3, gave as muchinformation as all five subgroups, suggesting thattests x4 and x5 may be superfluous in the routineexamination of the year-old infant.

ANALYSIS OF DATA FROM SUBSAMPLE 2The results described so far refer to the routine

examination of predominantly normal children(only two subjects in subsample 1 had a neuro-logical defect). It could be argued that subgroupsconsidered redundant (x4 and X5) or of minimal use(X3) in respect of normal children may well be ofvalue for screening abnormal children. In order tostudy this, the concordance between neurologicalclassification and developmental classification wasexamined. The scores of the 12 subjects in sub-sample 2 (A to L) in each of the five developmentalsubgroups are shown in Table IV.

TABLE IVDEVELOPMENT SCORES OF 12 INFANTS

CLASSIFIED ABNORMAL BY INDEPENDENTNEUROLOGICAL EXAMINATION

Developmental SubgroupSubject

X1 XS Xa X4 Xg

A 94 94 94 94 94B 72 88 96 88 88C 60 92 72 80 72D 31 31 24 20 20E 68 68 79 85 79F 65 73 46 73 65G 68 72 60 64 64H 70 67 74 59 59I 80 88 96 96 88J 65 77 92 69 77K 67 82 78 78 78L 86 90 90 87 85

Table V shows the distribution of subsample 2by their percentiles. To illustrate, subject C scored60 on xl (Table IV) and thus fell below the firstpercentile. Seven of the 12 subjects were classifiedabnormal (i.e., below the 20th percentile) by x5;five by x,; seven by x3; in certain of these the classi-fication was borderline (i.e., between the 10th and

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TABLE VDEVELOPMENTAL SCORES IN PERCENTILES OF 12

INFANTS CLASSIFIED AS ABNORMAL BY INDEPENDENTNEUROLOGICAL CRITERIA

Developmental SubgroupSubject

X1 x2 X3 X& Xs

A N N N N NB 5 20 N N NC I N 10 N 20D 1 1 1 1 1E 1 1 20 N NF 1 I 1 20 5G 1 1 5 5 5H 1 1 10 1 5I 10 20 N N NJ 1 5 N 10 20K 1 10 20 N 20L 20 N N N N

Percentile code I = below 1st percentile5 = below 5th percentile10 = below 10th percentile20 = below 20th percentileN = above 20

20th percentile)-three in x5, one in x4, and two inX3. In every case where subjects were classifiedabnormal by x3, X4, and x5 they were also classifiedabnormal by xl. Two (B and I) who were notabnormal in x3, X4, and x5 were abnormal in xl;and two (C and L) were normal in x2 but abnormalin x1.

Subject A was classified normal by developmentalexamination but abnormal by neurological examina-tion; he was found to have abnormal neuromotorpatterns confined to the legs which were not severeenough to delay motor development below the 20thpercentile.Thus the 12 infants classified as clinically abnormal

on the basis of independent neurological criteriawere classified as follows on the basis of the de-velopmental examination:

Classification based on Developmental PercentilesTest

Abnormal Borderline Normal(below 10th) (l0th-20th) (above 20th)

XI 10 1 1x2 7 2 3x, 5 2 5x4 4 1 7x6t,4 3 5

These results suggest that test xl is of over-whelming importance in screening for neurologicalabnormality by developmental examination. TestsX3, x4, and x5 are not specific for neurologicalabnormality and thus tend to misclassify manyinfants as normal or of only borderline significance.Test x2 did not provide any information that was

not already available from test xl.

ANALYSIS OF DATA FROM SUBSAMPLE 3Twenty-one subjects had abnormal responses to

sound. Of these(a) eleven (28y% of total sample) were considered

to have conductive deafness due to middle eardisease, a diagnosis based on the triad ofabnormal hearing test result, otoscopic evidence,and a past history ofmiddle ear disease;

(b) four (1-0%) had high frequency deafness diag-nosed on the basis of consistent differet-ntialresponses to high (2 and 4 kHz) compared withlow and middle (0-25, 05, and 1 kHz) puretones;

(c) four (1-0%) had abnormal responses not con-sidered to be caused by hearing loss but bygeneral developmental or specific motor re-tardation.

Thus in this study 5-4% of the sample failed thedefinitive hearing test, of whom one quarter wereconsidered to be false positives (group c above). Nocases of severe congenital deafness were encountered(expected frequency 0 01 %; Fraser (1964)).The two remaining subjects with abnormal

responses to sound showed no distinctive clinical,neurological, or developmental features.The concordance between the results of definitive

auditory assessment on the one hand and languageand motor development on the other is shown inTable VI. Fifty-seven per cent of subjects who failed

TABLE VIDISTRIBUTION OF 21 INFANTS WITH ABNORMAL RE-SPONSES TO SOUND BY RESULTS ON TEST xl (MOTOR

DEVELOPMENT) AND TEST x, (LANGUAGEDEVELOPMENT)

Test xl Test x,

Below 20th Above 20thPercentile Percentile

Below 20th percentile 4 3Above 20th percentile 5 9

Total 9 12

the hearing test had normal language development(i.e., above the 20th percentile); four out of the re-maining nine subjects with delayed language de-velopment also had delayed motor development (allcategory c above) and would, therefore, have beenscreened as abnormal using test xl above.

ANALYSIS OF DATA FROM SUBSAMPLE 4Three hundred and eighty-three subjects (9922%)

had normal visual competence; of the three subjectswho failed the rolling ball test, one could not situpright at all and two had severe head drop whensupported in the sitting position; but when testedin the supine position with a lin diameter dangling

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ring moved across the line of vision, all three fol-lowed the test object which suggested that theirvisual competence was normal for their level ofmotor development. No gross abnormalities of theeyes (i.e., nystagmus, cataract, limitation of peri-pheral vision, or ocular malformation) were ob-served in any subject but 10 (2 6%) had strabismus.None of those with strabismus had abnormalvisual competence; their mean fine motor develop-mental score (test x2) was 96-4 compared with 95 5for the remainder of the sample. The difference isnot statistically significant.

In this study there was no concordance betweenvisual examination (i.e., inspection of the eyes forcataract, nystagmus, squint, etc.) and fine motor(coordinative) development. (It is accepted thatgross visual defects are likely to delay development(Gardiner, MacKeith, and Smith, 1969) but thiscould not be studied in this project since no suchgross defects were observed.)

DiscUSSIONEstimates of effectiveness can be made by com-

paring the results of the exposure of a populationfirst to the developmental testing procedure andthen to an examination using clinical criteria ofneurological, auditory, and visual abnormality. Sofar as we can determine, neither the full develop-mental examination procedures (Gesell and Ama-truda, 1941; Griffiths, 1954) nor currently useddevelopmental screening tests consisting of itemsabstracted from the battery of observations listedin the full developmental examination (Sheridan,1968; Egan et al., 1969; Frankenberg, 1970) haveyet been validated in this way, and consequentlytheir true value remains in some doubt. In parti-cular, the notion that the screening procedureshould include observations from each of thesubgroups in the full developmental examination inorder to detect subjects with a single motor, visualor hearing handicap has never been proven experi-mentally.

EFFECTIVENESS OF DEVELOPMENTAL EXAMINATIONIn the present study this has been estimated by

observing the number of children with neurological,auditory, and visual defects discovered by clinicalexamination who would also have been classifiedas abnormal on the basis of developmental testsalone:

(l) Ninety-two per cent of infants with clinicalneurological defects were classified as abnormal onthe basis of developmental examination alone, thesebeing subjects who showed retardation in gross andfine motor subgroups (x1 and x2). This is perhaps not

altogether surprising since, clinically, abnormalsigns are essentially observations of motor functionand thus developmental examination is likely toprove to be a highly effective method of elicitingabnormal neurological signs in infancy (Gesell andAmatruda, 1941; Knobloch and Pasamanick, 1962).

(2) Only 43% of subjects with independentlydetermined hearing loss (i.e., by definitive free-fieldhearing tests) were classified as abnormal on thebasis of a developmental examination, i.e., languagedevelopment (test X4). Possible explanations fornormal language development in the presence ofabnormal htaring are-deafness not severe enoughto delay early linguistic development (at 1 year);deafness of recent origin; and deafness of an inter-mittent nature (e.g., due to middle ear effusion).However, hearing disorders such as these may wellgo on to cause speech, behaviour, and educationalproblems, and there is little doubt that these de-fects (rather than the more severe and much rarerforms of congenital neurosensory deafness) formthe bulk of the work of the school and peripateticservices for the deaf (Robinson et al., 1967). Theresults of this study, therefore, suggest that develop-mental testing is not an effective method of detect-ing this important category of hearing disorders ininfancy.

(3) No subjects with visual defects were recordedas having abnormal development. No cases ofsevere defects were observed in this study, but if,as Gardiner et al. (1969) suggest, gross disordersof eyesight manifest themselves in infancy in termsof slow development, it can be reasonably assumedthat it would be in errors of fine and gross motorfunction (tests x1 and x2). In a paper on visualscreening in very young children, Sheridan (1960)stated that there was general agreement (presumablyamong paediatricians) that the earlier all visualdefects were diagnosed and treated the more favour-able is their prognosis; more recently, Gardiner etal. (1969) referred to children with squints, ambly-opia, and myopia as neglected 'because tests ofvision are generally omitted from screening pro-cedures in infants and young children'. Acceptingthe view of these authorities that early diagnosisof all visual defects is of value since it will lead to asubstantial improvement in prognosis, the resultsof this study suggest that developmental testing isnot an effective method of detecting this categoryof defects.

Thus, in summarizing the effectiveness of thisform of examination it would seem that develop-mental testing at 1 year is effective in detectingneurological defects but not in discovering abnor-malities of vision and hearing.

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REDUNDANCYHaving determined which categories of defect the

developmental examination can effectively detect,it remains to determine the smallest number ofobservations required before the degree of effective-ness is significantly reduced.The results of analysis of subsample 1 show that

two time-scaled behavioural observations (i.e.,gross and fine motor function) would predict 87%of the total variance of the full developmental scorecalculated as an aggregate of the five subgroupscores, and would also detect 92% of infantsclassified abnormal by independent neurologicalexamination. One reason for this is that many testitems merely repeat, or are minimal variations of,observations made in other subgroups with theresult that the information they provide is notadditive.

Joint consideration of effectiveness and re-dundancy of developmental examination suggeststhat the information effectively provided by fulldevelopmental examination could be equally wellprovided by a much simplified developmental testconsisting of observations of gross and fine motorfunction (see above). This procedure may havecertain advantages-it utilizes observations whichare easily defined and do not depend on maternalrecall and so are thus likely to have low observererror. For these reasons it may well be suited foruse by paramedical or even lay personnel. Also theprocedure time would be reduced to approximatelyone minute compared with 20 to 30 minutes forexisting developmental screening tests, thus allow-ing more time to be spent (if considered necessary)on specific tests of auditory and visual function.The number and complexity of the observations

which make up a screening procedure will deter-mine the number and professional status of thestaff required. This will influence the cost of theprocedure and this in turn will determine whetherit is adopted nationally or locally, and, if adopted,whether it reaches all those who may benefit fromit or only certain selected groups (e.g., at riskcategories). At present most developmental testing(and hence screening) procedures are rather com-plicated and time consuming and thus usually haveto be applied by medical or paramedical personnelwith the result that they reach only a small pro-portion of the infant population. In view of theapparent specific range of effectiveness of develop-mental testing (and hence developmental screening)in the detection ofhandicaps in infancy (i.e., develop-mental and neurological but not auditory or visual),there may have been an over investment (in termsof the number and professional status of personnel

employed, and the time spent in testing individualsubjects) on this aspect of paediatric screening. Theevidence collected in this study suggests that timespent in developmental screening might be usefullyreallocated-much less to be spent on the examina-tion of development (which could be accomplishedwith a simple screening test such as that proposedin this paper undertaken by trained but non-medical observers) and more on a detailed clinicalexamination of auditory and visual function.Some handicaps of infancy are uncommon (e.g.,

congenital neurosensory deafness and severe visualdefects) and it might be reasonably argued that inview of the relatively small size of the samplestudied in the project it cannot necessarily be con-cluded that developmental screening is ineffectivein detecting such disorders. We accept this criticismbut believe that, in view of the considerable andgrowing deployment of medical resources into de-velopmental screening, the onus lies with the pro-ponents of this approach to show by concordancestudies (on necessarily large populations) that therecommended procedures are effective and reliable.

SUMMARYThe simplicity (measured in terms of number

and nature of observations required, proceduretime and professional status of tester) of develop-mental screening tests will largely determine theextent to which they can be applied to every mem-ber of the infant community. In the search forsimplicity the present study looks at two aspects ofdevelopmental examination in relation to handicapat 1 year. One is the extent of redundancy amongcomponent observations ot the developmental test(i.e., can the same amount of information be ob-tained from fewer observations?). The other isthe effectiveness of developmental testing estimatedfrom the concordance between the results of fulldevelopmental examination and examination usingclinical criteria of neurological, visual, and auditoryabnormality.The results of the analysis, based on a sample of

386 infants aged 11 to 13 months, show that de-velopmental examination has only limited effective-ness when applied during infancy (i.e., in the study92% of all subjects with neurological defect, butonly 40% of subjects with abnormal hearing, andno infants with visual defects were classified asabnormal on the basis of a full developmentalexamination). Furthermore, there was clear evidenceof considerable redundancy among componentobservations of the full developmental examination-a multiple regression analysis showed that 87%of the total variance of the aggregate developmental

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score derived from the five components of the fullexamination could be predicted from two com-ponent observations (gross and fine motor function)without reducing the levels of effectiveness for theindividual categories of handicap quoted above.The findings of the small study reported in thispaper lead us to conclude that medical and para-medical personnel currently engaged in the routineapplication of developmental tests during infancymay not be effectively deployed (and therefore inrelation to the scarcity of health service manpowermay possibly be inefficiently deployed) since theyspend considerable time making many observationswhich contribute nothing to the case-findingeffectiveness of the procedure, and the small numberof observations that are effective are of such anature that they could probably be made equallywell by lay personnel. In view of the importanceof establishing that the use of medical and para-medical resources in infant screening is a reason-able priority (in terms of total supply of resourcesand demands made upon them), there would appearto be an urgent need for a large-scale study of theeffectiveness of developmental screening as a methodof detecting handicaps in infancy.

The research was sponsored by a generous grant fromthe Association for the Aid of Crippled Children, NewYork.We are indebted to Dr. W. E. Thomas, Medical

Officer of Health for Glamorgan, for allowing us bothaccess to the medical records and the opportunity toliaise with the health visitor staff working in the areawhere the research was undertaken.

REFERENCESBRITISH MMICAL JOURNAL (1971). Editorial-Screening

for spastics, 4, 381.EGAN, D. F., ILLINGWORTH, R. S., and MAcKEITH, R. C.

(1969). Developmental Screening 0-5 years, Spastics.Heinemann, London.

FRANKENBERG, W. K. (1970). Personal communication., and DODDS, J. B. (1967). The Denver develop-

mental screening test. J. Pediatrics, 71, 181.FRASER, G. R. (1964). Profound childhood deafness. J.

med. Genet., 1, 118.GARDINER, P., MACKEITH, R., and SMITH, V. (1969).

Aspects of Developmental and Paediatric Ophthal-mology. Heinemann, London.

GESELL, A., and AMATRUDA, C. S. (1941). DevelopmentalDiagnosis. Hoeber, New York.

GRIFFITHS, R. (1954). The Abilities ofBabies. Universityof London Press, London.

KNOBLOCH, H., and PASAMANICK, B. (1962). The de-velopmental behavioural approach to the neurologicexamination in infancy. Child Develop., 33, 181.

ROBERTS, C. J. (1968). Screening for defective hearing ininfancy. Publ. Hlth (Lond.), 82, 173.

(1971). Manifestations of cerebral dysfunction ininfancy and their association with toxaemia and ante-partum haemorrhage. A cohort study. Brit. J. prev. soc.Med., 25, 135.

ROBINSON, G. C., ANDERSON, D. O., MOGHADAM, H. K.,CAMBON, K. G., and MURRAY, A. B. (1967). Asurvey of hearing loss in Vancouver schoolchildren.Part 1. Methodology and prevalence. Canad. med.Ass. J., 97, 1199.

SHERIDAN, M. D. (1960). Vision screening of very youngor handicapped children. Brit. med. J., 2, 453.

(1968) . The Developmental Progress of Infants andYoung Children, 2nd ed. Reports on Public Health andMedical Subjects No. 102. H.M.S.O., London.

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