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Responses of urban preschool children to a developmental screening test
November, 1970 T h e Journal o[ P E D I A T R I C S
775
Responses of urban preschool children to a developmental screening test Developmental examinations o[ 4- to 6-year-old children using the Denver Developmental Screening Test were carried out by medical students in an urban lower class neighborhood. Results o[ the testing o[ 104 children are presented and compared with previously published norms. The children studied had considerable delay in acquisition of language and specific aspects o[ conceptual functioning. It is suggested that in the pediatric setting, a descriptive evaluation o[ behavioral [unetioning provides very limited data in screening procedures, unless in[ormation regarding the [amily background is considered.
Louise Sandier, Ph.D., Jack VanCampen, Gerald Ratner, Calvin Stafford, and Richard Weismar P H I L A D E L P H I A ~ PA.
I N R E C E N T years, attempts have been made to devise brief developmental screening instruments for the benefit of busy pediatricians, medical students, and pediatric nurses. The screening tests present significant behavioral items selected from such well-known tests as the Gesell Schedules, ~ Buehler and Hetzer, 2 and Griffiths 3 and require little time and equipment for administration. As the primary purpose of such examinations is the earliest possible identification of developmental abnormalities, it is essential that the normative data employed be applicable to the children studied. Unfortunately, clinical experience has demonstrated repeatedly that comparisons of reFrom the Departments o[ Pediatrics and Psychiatry, Hahnemann Medical College and Hospital. Reprint address: Louise Sandler, 1417 Race St., PhzTadelphia, Pa. 19102.
sponses of lower class children to norms based on middle class sample populations are of limited value. ~ Indeed, when the young child from the slum fails to respond or responds incorrectly to a task, the examiner can well maintain that "he probably never held a pencil" or "he never saw or heard of a cow." In the pediatric setting, one finds a growing disenchantment with the total developmental examination. There is a tendency to confine the developmental examination to an assessment of motor functioning with the addition of a few questions related to "milestones" of development. It is commonly taken for granted that environmental deprivation sets severe limits on cognitive and perceptual learning and that low test performances may be viewed as a function of limitation of acquired abilities rather than capacity. Even if one agrees with this asVol. 77, No. 5, pp. 775-781
776
Sandler et aI.
sunrption, it is obvious that the need to devetop norms defining the process of development of culturally disadvantaged preschool children is no less urgent. In other words, we must be able to compare one disadvantaged child with another disadvantaged child of similar age. In outpatient clinics serving the poverty areas, the thorough developmental examination of the infant and preschool child patients of these health centers should be emphasized in practice. It would be hoped that such concern would lead to increased services for young patients and their families as an integral part of total pediatric care. PURPOSE AND SETTING OF T H E S T U D Y
This investigation was undertaken in order to provide additional information concerning the responses of urban lower class Puerto Rican and Negro preschool children to the Denver Developmental Screening Test (DDST) .s The present study is concerned with a comparison of responses of the study population with normative data reported by the developers of the test. The children forming the sample population belong to the sociocultural group generally described as "the culture of poverty. ''6 Demographic study of the community reveals that it is a neighborhood of predominately Puerto Rican newcomers, largely living in isolation from the surrounding city. Family disorganization and unernployment are prevalent throughout the community. During the winter preceding the investl9 gation, the Department of Community Medicine established a facility within this neighborhood for the purposes of providing services which answer to a variety of health, community, recreational, and educational needs. A suite of rooms was equipped within the center for the purposes of the study. THE DENVER DEVELOPMENTAL SCREENING TEST
The D D S T was designed as a method for evaluating a child's functioning in four basic areas: gross motor, fine motor adaptive,
The Journal o/ Pediatrics November 1970
language, and personal-social. The authors of the assessment technique emphasize the purpose of the test as a screening method for the identification of developmental delays so that more thorough diagnostic studies could be initiated as indicated. The D D S T does not yield either a developmental or intelligence quotient and is not intended to be employed as a diagnostic instrument, All examinations were carried out by the 4 medical students following 2 weeks of intensive training in the methods of administration and scoring of the tests. Each student tested 10 children of varying ages while being observed by the 3 other trainees and the preceptor. Independent judgments were made for each of the test responses. Percentages of interrater agreement for each category of items ranged from 62 to 79. Much of the variability in judgments was due to the uncertainty of whether a child's nonresponse to a request was "failure" or "refusal." It is important to note that this dilemma remained throughout the study. SUBJECTS
The D D S T was administered to 250 children ranging in age from 1 month to 6 years. The limitations of available babies and toddlers up to 4 years of age prevent meaningful presentation and discussion of the findings in this age group. The findings and discussion will be limited to the data from the study of 104 children who were 4 to 6 years of age. The sample included 65 Puerto Rican and 39 Negro children. The distribution of the sample is presented in Table I. ~ FAMILY AND SOCIAL CHARACTERISTICS OF THE CHILDREN
Infom~afion concerning family organization and socioeconomic status was gathered by the researchers in an interview with each mother. The data show that a "typical" family was one with 5 children ranging in age from infancy through 8 years. In general, the mothers had more years of formal education than
Volume 77 Number 5
Responses o/ children to developmental test
did the fathers. However, only 48 per cent of the mothers completed at least eleventh grade; 32 per cent of the fathers h a d a comparable education. U n e m p l o y m e n t was high a m o n g the fathers. Over one third of the families were receiving support from the D e p a r t m e n t of Public Assistance. Approximately 20 per cent of the mothers of the children studied were working full time outside of the home. RESULTS
T h e test results are presented for the following 3 areas: gross motor, language, a n d fine motor adaptive. ~ T h e items i n the D D S T for assessment of personal-social f u n c tioning are primarily useful for infancy a n d eAttempts were m a d e to test significance of differences in percentages where the average ages of the children of a specified age group corresponds to normative ages. T h e sample could not be considered adequate to m a k e a sound inference.
T a b l e I. N u m b e r of subjects in age range
Age range (too.)
No.
Negro
Puerto Rican
49 to 54 55 to 60 61 to 72 Total
36 35 33 104
21 20 19 60
15 15 14 44
777
toddler age groups. A l t h o u g h i n f o r m a t i o n concerning the child's ability to perform such behavior actions as " b u t t o n i n g clothes, .... separates from mother," a n d "dressing without supervision" was given by the mothers, the n u m b e r of items i n the screening test which are relevant to the age g r o u p studied are too few for a m e a n i n g f u l presentation. I n addition, the investigators generally could not accept the mother's account of the child's behavior. For example, mothers would report that the child could b u t t o n his shirt; spot checking revealed that the child was not able to do this a n d was u n f a m i l i a r with the action. Gross m o t o r f u n c t i o n i n g . I n general, the children required little e n c o u r a g e m e n t from the examiners in responding to the requests. Refusals to cooperate with a n "invitation" to play ball, j u m p , hop, etc., were few. As T a b l e I I shows, comparisons with the D D S T norms for gross m o t o r f u n c t i o n i n g show similarity in results for the age groups studied. Both in terms of relative ease in eliciting the looked-for behavioral response a n d in reliability of published norms for preschool children 4.1 to 6 years of age, the D D S T items are very useful in the developm e n t a l screening test.
T a b l e II. Percentage passing gross motor items a n d comparison with D e n v e r n o r m s
I
Age group (yr.)
% passing
Balance on 1 foot 5 seconds
4.1-4.5 4.6- 5.0 5.1 - 6.0
82.9 97.0' 100.0
75 at 4.0 90 at 4.5
Balance on 1 foot I0 seconds
4.1- 4.5 4.6 - 5.0 5.1- 6.0
68.6 87.9 97.1
50 at 4.4 75 at 5.2 90 at 5.7
Hops on 1 foot
4.1-4.5 4.6-5.0 5.1 - 6.0
89.1 97.1 97.1
75 at 4.3 90 at 5.0
Catches bounced ball
4.1 - 4.5 4.6 - 5.0 5.1- 6.0
68.6 81.8 97.1
50 at 4.2 75 at 4.8 90 at 5.5
Heel-to-toe walk
4.1- 4.5 4.6- 5.0 5.1 - 6.0
65.7 93.9 97.1
75 at 4.4 90 at 5.0
Backward heel-toe
4.1-4.5 4.6 - 5.0 5.1-6.0
28.6 64.1 .74.1
25 at 4.2 50 at 4.9 75 at 6.0
Items
Denver % passing at age (yr.)
778
Sandler et al.
The ]ournal o[ Pediatrics November 1970
T a b l e I I I . Percentage passing language items a n d comparisons with Denver norms Age group (yr.)
% passing
Denver % passing at age (yr.)
Uses plurals
4.1- 4.5 4.6 -5.0 5.1 - 6.0
72.2 61.1 71.9
90 at 3.4 ---
Gives first and last name
4.1 - 4.5 4.6 - 5.0 5.1 - 6.0
50.1 58.3 71.9
90 at 3.9 ---
Comprehends cold, tired, and hungry
4.1 - 4.5 4.6- 5.0 5.1 ~ 6.0
61.1 52.8 87.5
75 at 3.6 90 at 4.6 --
Comprehends 3 prepositions
4.1 -4.5 4.6- 5.0 5.1 - 6.0
66.7 63.9 81.3
75 at 3.6 90 at 4.4 --
Recognizes 3 colors
4.1- 4.5 4.6-5.0 5.1- 6.0
27.8 30.6 50.0
50 at 3.2 75 at 4.8 90 at 5.0
Opposite analogies
4.1- 4.5 4.6- 5.0 5.1- 6.0
58.3 38.9 68.8
50 at 3.8 73 at 5.0 90 at 6.0
Defines 6 words
4.1 - 4.5 4.6- 5.0 5.1- 6.0
11.1 25.0 43.8
25 at 4.2 50 at 5.2 75 at 6.2
Composition of materials
4.1 - 4.5 4.6- 5.0 5.1- 6.0
0.0 2.8 18.8
25 at 4.5 50 at 5.5 60 at 6.3
Items
Language. W i t h o u t doubt, the most difficult category to assess in our child population was language functioning. Although the testing was done in the child's p r i m a r y language (English or Spanish) a n d refusals to respond were not prevalent a m o n g the children, the examiners were struck by what seemed to be a n absence of investment in verbal c o m m u n i c a t i o n . This, more t h a n "failure to give a correct response," was the significant feature in the language testing situation. Whereas there was some noticeable degree of active participation with the examiners i n the predominately n o n v e r b a l areas of testing, the children appeared to be confused by verbal requests a n d u n a w a r e of word meanings a n d usage. As T a b l e I I I shows, comparisons of our results with D D S T n o r m s for language functioning show considerable differences. T h e results strongly suggest that the Denver norms for language f u n c t i o n i n g are not applicable to the present study population.
If the purpose of the screening test is to alert the e x a m i n e r "to the possibility of developmental delays so that appropriate diagnostic studies m a y be pursued," then it is obvious that a large n u m b e r of children in our study could be judged as " a b n o r m a l " in acquisition of verbal skills a n d properly referred for speech a n d h e a r i n g e x a m i n a tions. However, if the gross i m m a t u r i t y of the children's verbal development is "norm a l " for children of our p o p u l a t i o n a n d similar disadvantaged groups, then the "referral requests" must be of a different kind, requiring remedial a n d interventive efforts in the sociocultural lives of the children. F i n e m o t o r adaptive. T h e results of fine m o t o r adaptive testing reveal some import a n t response differences a m o n g the children studied, compared to the normative population. As T a b l e I V shows, the children performed as well as the Denver sample in rep r o d u c t i o n of the "square." They were con-
Volume 77 Number 5
Responses of children to d e v e l o p m e n t a l test
7 79
T a b l e IV. Percentage passing fine m o t o r adaptive items and comparisons with D e n v e r norms
Age group (yr.) 4.1 - 4.5 4.6 - 5.0 5.1 - 6.0
% passing 78.1 86.5 90.1
Copies square, not demonstrated
4.1 - 4.5 4.6 - 5.0 5.1 - 6.0
43.2 53.1 81.1
25 50 75 90
at at at at
4.1 4.7 5.5 6.0
Imitates a square, demonstrated
4.1 - 4.5 4.6-5.0 5.1 - 6.0
78.4 90.6 90.9
25 50 75 90
at at at at
4.2 4.6 5.5 6.0
Draws a man, 3 parts
4.1 - 4.5 4.6- 5.0 5.1 - 6.0
45.9 63.6 71.9
50 at 3.8 75 at 4.5 90 at 4.8
Draws
4.1 - 4.5 4.6 - 5.0 5.1 - 6.0
0 0 60.6
--50 at 5.3 75 at 5.9 90' at 6.3
4.1- 4.5 4.6 - 5.0 5.1 - 6.0
25.0 45.5 54.5
90 at 4.2 ---
1terns Copies a cross, not demonstrated
a man,
6 parts
Picks longer line
siderably superior to the normative sample in imitating the examiner's drawing of the square. O n l y the younger group of children (4.1 to 4.5 years) appeared to be below the D e n v e r sample i n reproducing a "cross." As this item is considered a less m a t u r e task, a n a t t e m p t to explain the poorer p e r f o r m a n c e of the younger group is pure conjecture. T h e " d r a w i n g of a cross" is the first item given a m o n g these pencil a n d paper tasks. T h e younger children, i n general, were slower to w a r m u p a n d r e s p o n d to all the test items. I t m a y be that the inconsistency in performance between the results in the two tasks reflects sensitivity of the inexperienced y o u n g child to a n u n f a m i l i a r situation. I n general, the study children show ageappropriate f u n c t i o n i n g o n tests calling for visual-motor perceptual functioning, utilizing a model to copy or imitate. However, the study children were considerably below n o r m expectancies i n tasks requiring i n d e p e n d e n t cognitive operations. As T a b l e I V shows,
Denver % passing at age (yr.) 90 at 4.4 ---
the study p o p u l a t i o n did not achieve n o r m a five expectancies of the D D S T in the task requiring the child to " d r a w a m a n . " T h e specific instructions to the child in this task were to "draw a person." F o r children who m i g h t not u n d e r s t a n d the m e a n i n g of "a person," the examiner added, " D r a w a boy or girl, or a m a n or w o m a n . " T h e results suggest that the relative inability to draw the h u m a n figure reflects a slower rate of m a t u r a t i o n . Investigations by Koppitz 7 indicate that kindergarten experience does not appreciably affect the d r a w i n g of a h u m a n figure when children come from middle class s u b u r b a n homes. However, the hypothesis that the young child's d r a w i n g is determined by his age a n d level of m a t u r a t i o n s m u s t be cautiously accepted in studies of disadvantaged children. W h e n children have h a d m i n i m a l experiences in the h o m e with drawing, it is likely that the early school programs would effect i m p r o v e m e n t in the ability to draw the h u m a n figure. T h e social
7 80
Sandler et al.
The Journal o[ Pediatrics November 1970
and cultural influences on young children's art productions cannot be ignored in the attempt to understand the failures within the study population2, a0 Turning to the children's faiIure to point out the "longer line" of two lines, there is little doubt that the failures are related to the lack of understanding of the word "longer" as well as the child's lack of ability to take two things (lines) together and recognize the conflict between them. In administering the test, the examiners presented the instructions "show me the bigger line" when the child did not appear to recognize the word "longer." However, confusions persisted, particularly when the positions of the lines were reversed from left to right. The children in our study seem to be overly dependent upon the perceptual cues of position of the object and have not learned the verbal labels or their significance in act ion.l~ The task as presented was, in general, beyond the conceptual level of the children studied. CHILDREN'S BEHAVIOR TEST RESULTS
AND
The predominant behavior styles of the children were noted and considered in terms of their effects upon test results. In the testing situation, the children continued to be suspicious of the examiner. Even with mother present and with optimal encouragement, the children were slow to respond. There appeared to be little interest in doing the "right thing." Rather, the children responded to their own interests rather than to requests. It was often difficult to hold the attention of the children long enough for completion of the task without continuous support. The test results reflect the personality deficits in the study population. The children, as a group, showed poor motivation for performing successfully. These children suffer from emotional inadequacies which decrease their test scores. As Ziegler and Butterfield ~2 have pointed out in their study of deprived preschool children, these tests should not be equated with the child's cognitive ability.
DISCUSSION
AND IMPLICATIONS
The findings of this study underline the need for caution in applying published norms to children living in urban poverty areas. As the primary purpose of the screening assessment is to provide a useful method for the early identification of developmental delays and retardation, the implications of these findings as they relate to practice within outpatient pediatric settings require serious consideration. There is little doubt that an alarmingly large number of the study children would be considered "at risk" if they had been assessed in the pediatric clinic. The examining pediatrician, medical student, or nurse using existing guidelines could well say that " X shows severe delays in language and perceptual functioning." General physical and neurologic studies may reveal that X is a "well child," leading to the judgment that child X has suffered deprivation of living experiences which may have contributed to the observed deficiencies. The patient is a disadvantaged child. It is possible that if norms are "adjusted" in accord with findings as presented in this report and in similar studies of the lower class child, the examiner can well maintain that " X is performing within age group expectancies." The child would be doing as well as may be expected under lower class (disorganized, broken home, overcrowded, and substandard housing) living conditions. Thus, the behavioral responses and personality characteristics observed in the evaluation could be viewed as "normal" adaptive responses to living experiences rather than indicative of idiosyncratic developmental deviatiQn. One certainly can agree that a child's level of performance as well as his manner of relating to the examiner and test materials are influenced significantly by his living experiences.9,~0, a2 However, tile assumption that a child has experienced deprivation in his living experiences because he belongs to a low socioeconomic group impedes and frustrates efforts to identify the child "at risk" in regard to present and future development. The assumption of similarity of experi-
Volume 77 Number 5
Responses o/ children to developmental test
ences on the basis of social and economic status surely represents a naive approach to the developmental assessment. Factors such as a parent's educational aspirations for his child, housing conditions, number of children in a family, and types of interaction and activities with parents are a m o n g the family background factors which m a y act as independent contributors to children's performances. J u d g m e n t and interpretations of a child's deficiencies in functioning require a knowledge of the living experiences of the child and their significant relationship to observed performance. Thus, if one is seriously concerned with the prevention of cumulative deficits in a child's development, the developmental screening technique together with an evaluation of the child's family background can provide essential data for the identification and amelioration of developmental deficiencies. I n the pediatric setting, a descriptive evaluation of the behavioral functioning of the preschool child can serve but limited usefulness without the development of appropriate remedial programs. T h e findings point to the crucial need for environmental enrichment to counteract the cumulative effects of cultural deprivation. Such programs in day care settings could be devised, staffed, and supervised by the pediatric and child psychiatry departments of our hospitals. T h e crippIing effects of deprivation u p o n cognitive and emotional development are generally recognized by the professional community. I n the light of this recognition, the need for rehabilitation programs utilizing
78 1
the professional expertise of pediatricians, child development specialists, and mental health workers is urgent. REFERENCES
1. Gesell, A., and Amatruda, C. S.: Developmental diagnosis, ed. 2, New York, 1954, Paul B. Hoeber, Inc., Medical Book Division of Harper and Row, Publishers. 2. Buhler, C., and Hetzer, H.: Testing children's development from birth to school age, New York, 1935, Holt, Rinehart, & Winston, Inc. 3. Griffiths, R.: The abilities of babies, New York, 1954, McGraw-Hill Book Company, Inc. 4. Fishman, J., et al.: Guidelines for testing minority group children, J. Soc. Issues, 20: 129, 1964. 5. Frankenburg, W., and Dodds, J. B.: The Denver Developmental Screening Test, J. PEDIAT. 71: 2, 1967. 6. Lewis, O.: The culture of poverty, Sci. Amer. 215: 19, 1966. 7. Koppitz, E.: Psychological evaluation of children's human figure drawings, New York, 1968, Grune & Stratton, Inc. 8. Kellogg, R.: What children scribble and why, Palo Alto, Calif., 1959, National Press. 9. Whiteman, M., Brown, B., and Deutsch, M.: Some effects of social class and race on children's language and intellectual abilities, in Disadvant. Child. Basic Books, New York, 1967, pp. 319-335. 10. Hunt, J. M.: Intelligence and experience, New York, 1961, The Ronald Press Co. 11. Gibson, E. J., and Olum, V.: Experimental methods of studying perception in children, in Mussen, P. H., editor: Handbook of research methods in child development, New York, 1960, John Wiley & Sons, Inc. 12. Ziegler, E., and Butterfield, E. C.: Malnutritional aspects of changes in IQ test performance of culturally deprived Negro school children, in Chess, S., and Thomas A., editors: Annals of Progress in Child Psychiatry and Child Development, New York, 1969, Brunner-Mazel.
775
Responses of urban preschool children to a developmental screening test Developmental examinations o[ 4- to 6-year-old children using the Denver Developmental Screening Test were carried out by medical students in an urban lower class neighborhood. Results o[ the testing o[ 104 children are presented and compared with previously published norms. The children studied had considerable delay in acquisition of language and specific aspects o[ conceptual functioning. It is suggested that in the pediatric setting, a descriptive evaluation o[ behavioral [unetioning provides very limited data in screening procedures, unless in[ormation regarding the [amily background is considered.
Louise Sandier, Ph.D., Jack VanCampen, Gerald Ratner, Calvin Stafford, and Richard Weismar P H I L A D E L P H I A ~ PA.
I N R E C E N T years, attempts have been made to devise brief developmental screening instruments for the benefit of busy pediatricians, medical students, and pediatric nurses. The screening tests present significant behavioral items selected from such well-known tests as the Gesell Schedules, ~ Buehler and Hetzer, 2 and Griffiths 3 and require little time and equipment for administration. As the primary purpose of such examinations is the earliest possible identification of developmental abnormalities, it is essential that the normative data employed be applicable to the children studied. Unfortunately, clinical experience has demonstrated repeatedly that comparisons of reFrom the Departments o[ Pediatrics and Psychiatry, Hahnemann Medical College and Hospital. Reprint address: Louise Sandler, 1417 Race St., PhzTadelphia, Pa. 19102.
sponses of lower class children to norms based on middle class sample populations are of limited value. ~ Indeed, when the young child from the slum fails to respond or responds incorrectly to a task, the examiner can well maintain that "he probably never held a pencil" or "he never saw or heard of a cow." In the pediatric setting, one finds a growing disenchantment with the total developmental examination. There is a tendency to confine the developmental examination to an assessment of motor functioning with the addition of a few questions related to "milestones" of development. It is commonly taken for granted that environmental deprivation sets severe limits on cognitive and perceptual learning and that low test performances may be viewed as a function of limitation of acquired abilities rather than capacity. Even if one agrees with this asVol. 77, No. 5, pp. 775-781
776
Sandler et aI.
sunrption, it is obvious that the need to devetop norms defining the process of development of culturally disadvantaged preschool children is no less urgent. In other words, we must be able to compare one disadvantaged child with another disadvantaged child of similar age. In outpatient clinics serving the poverty areas, the thorough developmental examination of the infant and preschool child patients of these health centers should be emphasized in practice. It would be hoped that such concern would lead to increased services for young patients and their families as an integral part of total pediatric care. PURPOSE AND SETTING OF T H E S T U D Y
This investigation was undertaken in order to provide additional information concerning the responses of urban lower class Puerto Rican and Negro preschool children to the Denver Developmental Screening Test (DDST) .s The present study is concerned with a comparison of responses of the study population with normative data reported by the developers of the test. The children forming the sample population belong to the sociocultural group generally described as "the culture of poverty. ''6 Demographic study of the community reveals that it is a neighborhood of predominately Puerto Rican newcomers, largely living in isolation from the surrounding city. Family disorganization and unernployment are prevalent throughout the community. During the winter preceding the investl9 gation, the Department of Community Medicine established a facility within this neighborhood for the purposes of providing services which answer to a variety of health, community, recreational, and educational needs. A suite of rooms was equipped within the center for the purposes of the study. THE DENVER DEVELOPMENTAL SCREENING TEST
The D D S T was designed as a method for evaluating a child's functioning in four basic areas: gross motor, fine motor adaptive,
The Journal o/ Pediatrics November 1970
language, and personal-social. The authors of the assessment technique emphasize the purpose of the test as a screening method for the identification of developmental delays so that more thorough diagnostic studies could be initiated as indicated. The D D S T does not yield either a developmental or intelligence quotient and is not intended to be employed as a diagnostic instrument, All examinations were carried out by the 4 medical students following 2 weeks of intensive training in the methods of administration and scoring of the tests. Each student tested 10 children of varying ages while being observed by the 3 other trainees and the preceptor. Independent judgments were made for each of the test responses. Percentages of interrater agreement for each category of items ranged from 62 to 79. Much of the variability in judgments was due to the uncertainty of whether a child's nonresponse to a request was "failure" or "refusal." It is important to note that this dilemma remained throughout the study. SUBJECTS
The D D S T was administered to 250 children ranging in age from 1 month to 6 years. The limitations of available babies and toddlers up to 4 years of age prevent meaningful presentation and discussion of the findings in this age group. The findings and discussion will be limited to the data from the study of 104 children who were 4 to 6 years of age. The sample included 65 Puerto Rican and 39 Negro children. The distribution of the sample is presented in Table I. ~ FAMILY AND SOCIAL CHARACTERISTICS OF THE CHILDREN
Infom~afion concerning family organization and socioeconomic status was gathered by the researchers in an interview with each mother. The data show that a "typical" family was one with 5 children ranging in age from infancy through 8 years. In general, the mothers had more years of formal education than
Volume 77 Number 5
Responses o/ children to developmental test
did the fathers. However, only 48 per cent of the mothers completed at least eleventh grade; 32 per cent of the fathers h a d a comparable education. U n e m p l o y m e n t was high a m o n g the fathers. Over one third of the families were receiving support from the D e p a r t m e n t of Public Assistance. Approximately 20 per cent of the mothers of the children studied were working full time outside of the home. RESULTS
T h e test results are presented for the following 3 areas: gross motor, language, a n d fine motor adaptive. ~ T h e items i n the D D S T for assessment of personal-social f u n c tioning are primarily useful for infancy a n d eAttempts were m a d e to test significance of differences in percentages where the average ages of the children of a specified age group corresponds to normative ages. T h e sample could not be considered adequate to m a k e a sound inference.
T a b l e I. N u m b e r of subjects in age range
Age range (too.)
No.
Negro
Puerto Rican
49 to 54 55 to 60 61 to 72 Total
36 35 33 104
21 20 19 60
15 15 14 44
777
toddler age groups. A l t h o u g h i n f o r m a t i o n concerning the child's ability to perform such behavior actions as " b u t t o n i n g clothes, .... separates from mother," a n d "dressing without supervision" was given by the mothers, the n u m b e r of items i n the screening test which are relevant to the age g r o u p studied are too few for a m e a n i n g f u l presentation. I n addition, the investigators generally could not accept the mother's account of the child's behavior. For example, mothers would report that the child could b u t t o n his shirt; spot checking revealed that the child was not able to do this a n d was u n f a m i l i a r with the action. Gross m o t o r f u n c t i o n i n g . I n general, the children required little e n c o u r a g e m e n t from the examiners in responding to the requests. Refusals to cooperate with a n "invitation" to play ball, j u m p , hop, etc., were few. As T a b l e I I shows, comparisons with the D D S T norms for gross m o t o r f u n c t i o n i n g show similarity in results for the age groups studied. Both in terms of relative ease in eliciting the looked-for behavioral response a n d in reliability of published norms for preschool children 4.1 to 6 years of age, the D D S T items are very useful in the developm e n t a l screening test.
T a b l e II. Percentage passing gross motor items a n d comparison with D e n v e r n o r m s
I
Age group (yr.)
% passing
Balance on 1 foot 5 seconds
4.1-4.5 4.6- 5.0 5.1 - 6.0
82.9 97.0' 100.0
75 at 4.0 90 at 4.5
Balance on 1 foot I0 seconds
4.1- 4.5 4.6 - 5.0 5.1- 6.0
68.6 87.9 97.1
50 at 4.4 75 at 5.2 90 at 5.7
Hops on 1 foot
4.1-4.5 4.6-5.0 5.1 - 6.0
89.1 97.1 97.1
75 at 4.3 90 at 5.0
Catches bounced ball
4.1 - 4.5 4.6 - 5.0 5.1- 6.0
68.6 81.8 97.1
50 at 4.2 75 at 4.8 90 at 5.5
Heel-to-toe walk
4.1- 4.5 4.6- 5.0 5.1 - 6.0
65.7 93.9 97.1
75 at 4.4 90 at 5.0
Backward heel-toe
4.1-4.5 4.6 - 5.0 5.1-6.0
28.6 64.1 .74.1
25 at 4.2 50 at 4.9 75 at 6.0
Items
Denver % passing at age (yr.)
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The ]ournal o[ Pediatrics November 1970
T a b l e I I I . Percentage passing language items a n d comparisons with Denver norms Age group (yr.)
% passing
Denver % passing at age (yr.)
Uses plurals
4.1- 4.5 4.6 -5.0 5.1 - 6.0
72.2 61.1 71.9
90 at 3.4 ---
Gives first and last name
4.1 - 4.5 4.6 - 5.0 5.1 - 6.0
50.1 58.3 71.9
90 at 3.9 ---
Comprehends cold, tired, and hungry
4.1 - 4.5 4.6- 5.0 5.1 ~ 6.0
61.1 52.8 87.5
75 at 3.6 90 at 4.6 --
Comprehends 3 prepositions
4.1 -4.5 4.6- 5.0 5.1 - 6.0
66.7 63.9 81.3
75 at 3.6 90 at 4.4 --
Recognizes 3 colors
4.1- 4.5 4.6-5.0 5.1- 6.0
27.8 30.6 50.0
50 at 3.2 75 at 4.8 90 at 5.0
Opposite analogies
4.1- 4.5 4.6- 5.0 5.1- 6.0
58.3 38.9 68.8
50 at 3.8 73 at 5.0 90 at 6.0
Defines 6 words
4.1 - 4.5 4.6- 5.0 5.1- 6.0
11.1 25.0 43.8
25 at 4.2 50 at 5.2 75 at 6.2
Composition of materials
4.1 - 4.5 4.6- 5.0 5.1- 6.0
0.0 2.8 18.8
25 at 4.5 50 at 5.5 60 at 6.3
Items
Language. W i t h o u t doubt, the most difficult category to assess in our child population was language functioning. Although the testing was done in the child's p r i m a r y language (English or Spanish) a n d refusals to respond were not prevalent a m o n g the children, the examiners were struck by what seemed to be a n absence of investment in verbal c o m m u n i c a t i o n . This, more t h a n "failure to give a correct response," was the significant feature in the language testing situation. Whereas there was some noticeable degree of active participation with the examiners i n the predominately n o n v e r b a l areas of testing, the children appeared to be confused by verbal requests a n d u n a w a r e of word meanings a n d usage. As T a b l e I I I shows, comparisons of our results with D D S T n o r m s for language functioning show considerable differences. T h e results strongly suggest that the Denver norms for language f u n c t i o n i n g are not applicable to the present study population.
If the purpose of the screening test is to alert the e x a m i n e r "to the possibility of developmental delays so that appropriate diagnostic studies m a y be pursued," then it is obvious that a large n u m b e r of children in our study could be judged as " a b n o r m a l " in acquisition of verbal skills a n d properly referred for speech a n d h e a r i n g e x a m i n a tions. However, if the gross i m m a t u r i t y of the children's verbal development is "norm a l " for children of our p o p u l a t i o n a n d similar disadvantaged groups, then the "referral requests" must be of a different kind, requiring remedial a n d interventive efforts in the sociocultural lives of the children. F i n e m o t o r adaptive. T h e results of fine m o t o r adaptive testing reveal some import a n t response differences a m o n g the children studied, compared to the normative population. As T a b l e I V shows, the children performed as well as the Denver sample in rep r o d u c t i o n of the "square." They were con-
Volume 77 Number 5
Responses of children to d e v e l o p m e n t a l test
7 79
T a b l e IV. Percentage passing fine m o t o r adaptive items and comparisons with D e n v e r norms
Age group (yr.) 4.1 - 4.5 4.6 - 5.0 5.1 - 6.0
% passing 78.1 86.5 90.1
Copies square, not demonstrated
4.1 - 4.5 4.6 - 5.0 5.1 - 6.0
43.2 53.1 81.1
25 50 75 90
at at at at
4.1 4.7 5.5 6.0
Imitates a square, demonstrated
4.1 - 4.5 4.6-5.0 5.1 - 6.0
78.4 90.6 90.9
25 50 75 90
at at at at
4.2 4.6 5.5 6.0
Draws a man, 3 parts
4.1 - 4.5 4.6- 5.0 5.1 - 6.0
45.9 63.6 71.9
50 at 3.8 75 at 4.5 90 at 4.8
Draws
4.1 - 4.5 4.6 - 5.0 5.1 - 6.0
0 0 60.6
--50 at 5.3 75 at 5.9 90' at 6.3
4.1- 4.5 4.6 - 5.0 5.1 - 6.0
25.0 45.5 54.5
90 at 4.2 ---
1terns Copies a cross, not demonstrated
a man,
6 parts
Picks longer line
siderably superior to the normative sample in imitating the examiner's drawing of the square. O n l y the younger group of children (4.1 to 4.5 years) appeared to be below the D e n v e r sample i n reproducing a "cross." As this item is considered a less m a t u r e task, a n a t t e m p t to explain the poorer p e r f o r m a n c e of the younger group is pure conjecture. T h e " d r a w i n g of a cross" is the first item given a m o n g these pencil a n d paper tasks. T h e younger children, i n general, were slower to w a r m u p a n d r e s p o n d to all the test items. I t m a y be that the inconsistency in performance between the results in the two tasks reflects sensitivity of the inexperienced y o u n g child to a n u n f a m i l i a r situation. I n general, the study children show ageappropriate f u n c t i o n i n g o n tests calling for visual-motor perceptual functioning, utilizing a model to copy or imitate. However, the study children were considerably below n o r m expectancies i n tasks requiring i n d e p e n d e n t cognitive operations. As T a b l e I V shows,
Denver % passing at age (yr.) 90 at 4.4 ---
the study p o p u l a t i o n did not achieve n o r m a five expectancies of the D D S T in the task requiring the child to " d r a w a m a n . " T h e specific instructions to the child in this task were to "draw a person." F o r children who m i g h t not u n d e r s t a n d the m e a n i n g of "a person," the examiner added, " D r a w a boy or girl, or a m a n or w o m a n . " T h e results suggest that the relative inability to draw the h u m a n figure reflects a slower rate of m a t u r a t i o n . Investigations by Koppitz 7 indicate that kindergarten experience does not appreciably affect the d r a w i n g of a h u m a n figure when children come from middle class s u b u r b a n homes. However, the hypothesis that the young child's d r a w i n g is determined by his age a n d level of m a t u r a t i o n s m u s t be cautiously accepted in studies of disadvantaged children. W h e n children have h a d m i n i m a l experiences in the h o m e with drawing, it is likely that the early school programs would effect i m p r o v e m e n t in the ability to draw the h u m a n figure. T h e social
7 80
Sandler et al.
The Journal o[ Pediatrics November 1970
and cultural influences on young children's art productions cannot be ignored in the attempt to understand the failures within the study population2, a0 Turning to the children's faiIure to point out the "longer line" of two lines, there is little doubt that the failures are related to the lack of understanding of the word "longer" as well as the child's lack of ability to take two things (lines) together and recognize the conflict between them. In administering the test, the examiners presented the instructions "show me the bigger line" when the child did not appear to recognize the word "longer." However, confusions persisted, particularly when the positions of the lines were reversed from left to right. The children in our study seem to be overly dependent upon the perceptual cues of position of the object and have not learned the verbal labels or their significance in act ion.l~ The task as presented was, in general, beyond the conceptual level of the children studied. CHILDREN'S BEHAVIOR TEST RESULTS
AND
The predominant behavior styles of the children were noted and considered in terms of their effects upon test results. In the testing situation, the children continued to be suspicious of the examiner. Even with mother present and with optimal encouragement, the children were slow to respond. There appeared to be little interest in doing the "right thing." Rather, the children responded to their own interests rather than to requests. It was often difficult to hold the attention of the children long enough for completion of the task without continuous support. The test results reflect the personality deficits in the study population. The children, as a group, showed poor motivation for performing successfully. These children suffer from emotional inadequacies which decrease their test scores. As Ziegler and Butterfield ~2 have pointed out in their study of deprived preschool children, these tests should not be equated with the child's cognitive ability.
DISCUSSION
AND IMPLICATIONS
The findings of this study underline the need for caution in applying published norms to children living in urban poverty areas. As the primary purpose of the screening assessment is to provide a useful method for the early identification of developmental delays and retardation, the implications of these findings as they relate to practice within outpatient pediatric settings require serious consideration. There is little doubt that an alarmingly large number of the study children would be considered "at risk" if they had been assessed in the pediatric clinic. The examining pediatrician, medical student, or nurse using existing guidelines could well say that " X shows severe delays in language and perceptual functioning." General physical and neurologic studies may reveal that X is a "well child," leading to the judgment that child X has suffered deprivation of living experiences which may have contributed to the observed deficiencies. The patient is a disadvantaged child. It is possible that if norms are "adjusted" in accord with findings as presented in this report and in similar studies of the lower class child, the examiner can well maintain that " X is performing within age group expectancies." The child would be doing as well as may be expected under lower class (disorganized, broken home, overcrowded, and substandard housing) living conditions. Thus, the behavioral responses and personality characteristics observed in the evaluation could be viewed as "normal" adaptive responses to living experiences rather than indicative of idiosyncratic developmental deviatiQn. One certainly can agree that a child's level of performance as well as his manner of relating to the examiner and test materials are influenced significantly by his living experiences.9,~0, a2 However, tile assumption that a child has experienced deprivation in his living experiences because he belongs to a low socioeconomic group impedes and frustrates efforts to identify the child "at risk" in regard to present and future development. The assumption of similarity of experi-
Volume 77 Number 5
Responses o/ children to developmental test
ences on the basis of social and economic status surely represents a naive approach to the developmental assessment. Factors such as a parent's educational aspirations for his child, housing conditions, number of children in a family, and types of interaction and activities with parents are a m o n g the family background factors which m a y act as independent contributors to children's performances. J u d g m e n t and interpretations of a child's deficiencies in functioning require a knowledge of the living experiences of the child and their significant relationship to observed performance. Thus, if one is seriously concerned with the prevention of cumulative deficits in a child's development, the developmental screening technique together with an evaluation of the child's family background can provide essential data for the identification and amelioration of developmental deficiencies. I n the pediatric setting, a descriptive evaluation of the behavioral functioning of the preschool child can serve but limited usefulness without the development of appropriate remedial programs. T h e findings point to the crucial need for environmental enrichment to counteract the cumulative effects of cultural deprivation. Such programs in day care settings could be devised, staffed, and supervised by the pediatric and child psychiatry departments of our hospitals. T h e crippIing effects of deprivation u p o n cognitive and emotional development are generally recognized by the professional community. I n the light of this recognition, the need for rehabilitation programs utilizing
78 1
the professional expertise of pediatricians, child development specialists, and mental health workers is urgent. REFERENCES
1. Gesell, A., and Amatruda, C. S.: Developmental diagnosis, ed. 2, New York, 1954, Paul B. Hoeber, Inc., Medical Book Division of Harper and Row, Publishers. 2. Buhler, C., and Hetzer, H.: Testing children's development from birth to school age, New York, 1935, Holt, Rinehart, & Winston, Inc. 3. Griffiths, R.: The abilities of babies, New York, 1954, McGraw-Hill Book Company, Inc. 4. Fishman, J., et al.: Guidelines for testing minority group children, J. Soc. Issues, 20: 129, 1964. 5. Frankenburg, W., and Dodds, J. B.: The Denver Developmental Screening Test, J. PEDIAT. 71: 2, 1967. 6. Lewis, O.: The culture of poverty, Sci. Amer. 215: 19, 1966. 7. Koppitz, E.: Psychological evaluation of children's human figure drawings, New York, 1968, Grune & Stratton, Inc. 8. Kellogg, R.: What children scribble and why, Palo Alto, Calif., 1959, National Press. 9. Whiteman, M., Brown, B., and Deutsch, M.: Some effects of social class and race on children's language and intellectual abilities, in Disadvant. Child. Basic Books, New York, 1967, pp. 319-335. 10. Hunt, J. M.: Intelligence and experience, New York, 1961, The Ronald Press Co. 11. Gibson, E. J., and Olum, V.: Experimental methods of studying perception in children, in Mussen, P. H., editor: Handbook of research methods in child development, New York, 1960, John Wiley & Sons, Inc. 12. Ziegler, E., and Butterfield, E. C.: Malnutritional aspects of changes in IQ test performance of culturally deprived Negro school children, in Chess, S., and Thomas A., editors: Annals of Progress in Child Psychiatry and Child Development, New York, 1969, Brunner-Mazel.