International Journal of Contemporary Pediatrics

Dewangan M et al. Int J Contemp Pediatr. 2020 Nov;7(11):2142-2145

http://www.ijpediatrics.com pISSN 2349-3283 | eISSN 2349-3291

DOI: http://dx.doi.org/10.18203/2349-3291.ijcp20204538
Original Research Article

Comparison of Trivandrum developmental screening charts

against the standard Denver development screening test
in children between 0-3 years
Mithlesh Dewangan*, Prateek Sharma

Department of Paediatrics, CCM Medical College, Durg, Chhattisgarh, India

Received: 01 September 2020

Revised: 10 October 2020
Accepted: 12 October 2020

*Correspondence:
Dr. Mithlesh Dewangan,
E-mail: dewangan.mithlesh@rediffmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: To compare of DDST II and TDSC in the age group of 0-3 years and to assess developmental delay at
various age groups using TDSC.
Methods: 400 children were tested in their performance in the two tests since birth till 3 year of and their results were
compared.
Results: TDSC has sensitivity of 66.66% and specificity of 98.93% in screening for developmental delays. Positive
predictive value for TDSC came out to be 100.00% and Negative predictive value for TDSC came out to be 97.20 %.
Prevalence rate of developmental delay was 11.25%.
Conclusions: Denver II test was concluded to be more sensitive test and TDSC as a more specific test.

Keywords: Development, TDSC, Delay

INTRODUCTION tests cover four general functions; personal social, fine

motor adaptive, language, and gross motor. DDST II is an
The term developmental delay in a child is used when update of the Denver developmental screening test use by
development lags behind established normal ranges for the physician, teacher and other childhood professional to
his or her age in areas of motor, cognitive, language, monitor the development of children between birth and
behavioural, emotional, or social development. Global six years of age.4 Trivandrum developmental screening
developmental delay is defined as a delay in two or more chart (TDSC) is a simple development screening test
developmental domains.1 In India, sources have found designed and validated at the child development centre,
prevalence of 1.5-2.5% of developmental delay in Thiruvananthapuram.5 This can be applied to children 0-
children less than 2 years of age.2,3 Early identification of 3 years of age. The objectives of our study are to
developmental delay is important to prevent onward compare of DDST II and TDSC in the age group of 0-3
progression to disability family problem, peer problem, years and to assess developmental delay at various age
and school failure. In order to improve the identification groups using TDSC.
of children with developmental delays early intervention
can be provided in a timely manner, and a significant METHODS
emphasis must be placed on the routine use of
developmental screening. The Denver developmental This is a cross sectional study of infants from birth to 3
screening test (DDST) is to help healthcare providers to years conducted in the department of pediatrics,
detect developmental problems in young children. The Chandulal Chandrakar memorial medical college, Durg,
with effect from September 2017 to July 2019.

International Journal of Contemporary Pediatrics | November 2020 | Vol 7 | Issue 11 Page 2142
 Dewangan M et al. Int J Contemp Pediatr. 2020 Nov;7(11):2142-2145

Inclusion criteria was all healthy babies up to one year of form has each of the items arranged within one of four
age, who visited Well baby clinic for immunization, sectors; personal-social, fine motor-adaptive, language,
feeding advice and for routine checkup were included. and gross motor. Age scales across the top and bottom of
Any child with congenital malformation, dysmorphic the test form depict ages in months and years from birth
child, history of perinatal asphyxia, sepsis, RDS, low to 6 years.
birth weight, preterm babies and baby of a diabetic
mother were excluded from the study. The neurodevelopmental assessment was done in all
children. It includes a detailed history with emphasis on
The total sample size N (number of positive cases for pregnancy, delivery, neonatal period and course of
developmental delay) was calculated using formula development. Each child was subjected to a complete
mentioned below: general and systemic examination including
anthropometry. A milestone of every child was assessed
N = (Z score)2SD × (1 − SD)/(margin of error)2 on TDSC and DDST II. All subjects were screened with
both TDSC and DDST II simultaneously by two separate
Where confidence level was 95%, Z score=1.96, SD persons to prevent observer bias. Data was analyzed
(standard deviation) was taken as 0.5 and a margin of using statistical functions available in Microsoft excel
error was taken as +5%.The sample size was calculated and SPSS (version 21.0 SPSS, USA). Sensitivity,
as approximately 400. specificity, positive predictive value, negative predictive
value and prevalence rate were calculated.
The study tools used in this study were the TDSC and
DDST II. In Trivandrum development screening chart, RESULTS
there are 27 test items in the chart, carefully chosen
after repeated trial and error. The age range of each test 400 cases were selected randomly from birth to 3 years of
item is taken from the norms given in the Bayley scales of age who attended the Well baby clinic, department of
infant development. The left hand side of each horizontal pediatrics and the observations were made. Distribution
dark line represented age at which 97% of the children of cases in the three age groups according to sex is shown
passed the item in the Baroda sample. A vertical line is in (Table 1). There is a predominance of male over
drawn or a pencil kept vertically, at the chronological age of female, with M: F of 1:0.92. In 0-12 months of 136
the child being tested. If the child failed to achieve any item children 53.67% were male and 46.32% are female. In
that falls on the left side of the vertical line, the child was 12-24 months of children 50.79% males and 49.2%
considered to have a developmental delay (any obvious females out of 126. In 25-36 months there were 51.44%
asymmetry is also considered abnormal).The Trivandrum males and 48.55% females out of 138 children.
developmental screening chart is a simple test which does
not require a developmental kit. A pen and a bunch of keys Table 1: Distribution of children in to three age
are the only objects required. It can be administered by groups according to sex.
Anganwadi workers or any person with minimal training.
The DDST II utilizes the materials are red yarn pom-pom Age group Males Females
Total
(approximately 4" diameter), raisins, rattle with narrow (months) N (%) N (%)
handle, 10.1-inch square colored wooden blocks, small, 0-12 73 (53.67) 63 (46.32) 136
clear glass bottle with a 5/8 inch opening, small bell, 12-24 64 (50.79) 62 (49.20) 126
tennis ball, red pencil, small plastic doll with feeding 25-36 71 (51.44) 67 (48.55) 138
bottle, plastic cup with handle and blank paper.The test Total 208 (52) 192 (48) 400

Table 2: Distribution of children detected normal and abnormal in the two developmental screening tests according
to three age groups.

Age group DSST II TDSC

Total
(months) N (%) N (%)
Normal Abnormal Normal Abnormal
0-12 120 (88.23) 16 (11.76) 123 (90.44) 13 (9.55) 136
12-24 112 (88.88) 14 (11.11) 115 (91.26) 11 (8.73) 126
25-36 123 (89.13) 15 (10.86) 127 (92.02) 11 (7.97) 138
Total 355 (88.75) 45 (11.25) 365 (91.25) 35 (8.75) 400

Normal and abnormal children according to age groups 13-24 months of age 88.88% were normal and 11.11%
with both test DDST II and TDSC are shown in (Table were abnormal with DDST II whereas with TDSC
2). In 0-12 months of age 88.33% were normal and 91.26% were normal and 8.73% were abnormal. In 25-36
11.76% were abnormal with DDST II whereas with months of age 89.13% were normal and 10.86% were
TDSC 90.44% were normal and 9.55% were abnormal. In abnormal with DDST II whereas with TDSC 92.02%

International Journal of Contemporary Pediatrics | November 2020 | Vol 7 | Issue 11 Page 2143
 Dewangan M et al. Int J Contemp Pediatr. 2020 Nov;7(11):2142-2145

were normal and 7.97% were abnormal. Overall 88.75% positive predictive value remains same but negative
were normal and 11.25% were abnormal with DDST II predictive value falls from 97.56% to 96.85%.
whereas with TDSC 91.25% were normal and 8.75%
were abnormal. There were increase in normality and Table 3: Cross tabulation of TDSC (0-3 years) against
decrease in abnormality as age advances. DDST II.

TDSC has sensitivity of 66.66% and specificity of TDSC Abnormal Normal Total TDSC
98.93% in screening for developmental delays. Positive Abnormal 35 (TP) 0 (FP) 35
predictive value for TDSC came out to be 100.00% and Normal 10 (FN) 355 (TN) 365
negative predictive value for TDSC came out to be
97.20%. Prevalence rate of developmental delay was Total DDST 45 355 400
11.25%. As the age advances the sensitivity falls from
81.25% to 73.33% and specificity remains same. The

Table 4: Results of cross tabulation of TDSC (0-3 years) against DDST II.

Test criteria Formula Calculations Result

Sensitivity TP/(TP+FN) (35/45)×100 77.77 %
Specificity TN/(TN+FP) (355/355)×100 100.00 %
Positive predictive value TP/(TP+FP) (35/35)×100 100.00 %
Negative predictive value TN/(TN+FN) (355/365)×100 97.26 %
Prevalence rate No. of cases/total sample (45/400)×100 11.25 %

Table 5: Results of cross tabulation of TDSC against DDST II according to three age groups.

Age groups
Criteria
0-12 months 13-24 months 25-36 months
Sensitivity (%) 81.25 78.57 73.33
Specificity (%) 100 100 100
Positive predictive value (%) 100 100 100
Negative predictive value (%) 97.56 97.39 96.85
Prevalence rate (%) 11.76 11.11 10.86

DISCUSSION II when compared to TDSC was observed even as the

child grew.
Ideally a screening test should be one with high
sensitivity and specificity. It must be cheap, simple and Presence study having overall sensitivity of 77.77% and
time saving. Some of the children screened as delay in specificity of 100% with positive predictive value of
test might not be delayed when screened with the 100% and negative predictive value of 97.26%.
standard test. This type of error is called false positive or Validation of TDSC against DDST, using sample
type 1 error. On other hand some are not delayed in populations from a Kerala coastal village and babies
screening test but are actually delayed with standard test. attending well baby clinic of SAT hospital showed a
This type of error is false negative or type 2 error. Early sensitivity of 66.7% and a specificity of 78.8% with
detection is effective in preventing or minimizing the positive predictive value of 100% and negative
effects of potentially handicapping disorders. predictive value 99.2-99.5%.9 Kannur et al shows
sensitivity of 83.33% and specificity of 91.4% with
DDST II and the TDSC were used as a screening tool to positive predictive value of 38.4% and negative
detect developmentally abnormal infants. The predictive value of 98.8%. The prevalence of
abnormality detection rate in Denver II was 11.76%, developmental delay in our study was found to be
11.11% and 10.86% in the age group of 0-12 months, 13- 11.25% in children from 0 to 3 years using TDSC.8
24 months, and 25-36 months respectively. While TDSC Prevalence of developmental delay ranges from 3.5% to
had detected 9.55%, 8.73% and 7.97% in the age group 10% of the general population in various studies.10-14
of 0-12 months, 13-24 months and 25-36 months
respectively. Hence, in each of four age groups Denver II Denver developmental screening test was the most widely
had declared higher number of children as abnormal used screening tool up to six years of age, because of its
when compared to the TDSC. A similar pattern of ease of administration. However this test underwent a
detecting higher number of abnormal children by Denver major revision and lead to development of modified

International Journal of Contemporary Pediatrics | November 2020 | Vol 7 | Issue 11 Page 2144
 Dewangan M et al. Int J Contemp Pediatr. 2020 Nov;7(11):2142-2145

Denver development test or DDST II. The need to revise disability among under-5 children in a rural ICDS
The DDST was felt because of difficulty in administering block. Indian Pediatr. 2009;46:S75-8.
and scoring some test items, certain test items were 4. Frankenburg WK, Dodds J, Archer P, Shapiro H,
inappropriate for various subgroups (such as ethnic Bresnick B. The Denver II: a major revision and
groups, sexes, maternal educational levels, and places of restandardization of the Denver developmental
residence). Hence, the modified Denver development test screening test. Pediatrics. 1992;89(1):91-7.
(DDST II) consisting of 125 items was devised, while the 5. Nair MKC. Early detection-need and developmental
original DDST consisted of only 105 items. tools. In: Chacko DS, George B, Kumar GS, eds.
Assessment and intervention in developmental
TDSC is a simple development screening test designed neurology. 1st ed. Venganoor: KM printers; 2007:11-
and validated at the child development centre, 56.
Thiruvananthapuram. It is being used in the at risk baby 6. Frankenburg WK, Dodds J, Archer P, Bresnick B,
clinic. It is a simple chart containing 27 items easily can Maschka P, Edelman N, et al. Denver II training
be used by Anganwadi worker, ANM, nurse and manual. Available at: https://denverii.com/. Accessed
paramedical staff in 10 min at low cost. It takes only 5-7 on 20 July 2020.
minutes to administer this test. 7. Nair M K, George B, Philip E, Lekshmi M A, Haran
J C, Sathy N. Trivandrum developmental screening
CONCLUSION chart. Indian Pediatr. 1991;28(8):869-72.
8. Kannur S, Rajshekhar SH, Bhatia S. The study to
The results of developmental screening of an infant in the compare Denver 1 and Trivandrum developmental
two different tests DDST II and TDSC are significantly screening charts in children between 0-3 years and to
different. Denver II test was a more sensitive test and assess developmental delay at various age. Int J
TDSC was more specific test (specificity=100%). DDST Physiol. 2017;5(1):5-9.
suffers from over screening and TDSC suffers from under 9. Nair MK, Nair GH, George B, Suma N, Neethu C,
screening. Results of Denver II might not be reproducible Leena ML, et al. Development and validation of
if repeated on the same infant after a period of time, Trivandrum development screening chart for
while results of TDSC are reproducible. Both of these test children aged 0-6 years. Indian J Pediatr.
after detecting a child as abnormal require further 2013;80(2):248-55.
detailed assessment. TDSC is a simple and convenient 10. Lewis RF, Judith SP. Infant or young child with
screening tool, for identifying children of developmental developmental delay. N Engl J Med. 1994;330(7):
delay in the community in the age group 0-3 years. This 478-83.
screening test helps grassroots level health worker to 11. William F. Well baby care in the first two year of
identify early developmental delay and necessary life. Available at: https://kidshealth.org/en/parents/
intervention. This test is not suitable to diagnose med12yr.html. Accessed on 20 July 2020.
developmental age and specific disability. 12. Nair MKC, Radhakrishnan S. Early childhood
development in deprived urban settlement. Indian
Funding: No funding sources Pediatr. 2004;41(3):227-37.
Conflict of interest: None declared 13. Louise H, Alison S, Jon D, Paul G. Evidence based
Ethical approval: The study was approved by the case reviews: invatigation of children with
Institutional Ethics Committee developmental delay. West J Med. 2002;176(1):29-
33.
REFERENCES 14. Rydz D, Shevell MI, Majnemer A, Oskoui M.
Topical review: developmental screening. J Child
1. Poon IK, Larosa AC, Pai GS. Developmental delay: Neurol. 2005;20(1):4-21.
timely identification and assessment. Indian Pediatr.
2010;47:415-22.
Cite this article as: Dewangan M, Sharma P.
2. Nair M, Radhakrishnan S. Early childhood
Comparison Trivandrum developmental screening
development in deprived urban settlements Indian
charts against the standard Denver development
Pediatr. 2004;41:227-237.
screening test in children between 0-3 years. Int J
3. Nair M, George B, Padmamohan J, Sunitha R, Resmi
Contemp Pediatr 2020;7:2142-5.
V, Prasanna G, et al. Developmental delay and

International Journal of Contemporary Pediatrics | November 2020 | Vol 7 | Issue 11 Page 2145