Iran J Pediatr

Original Article Sep 2010; Vol 20 (No 3), Pp: 313-322

Validity and Reliability Determination of Denver Developmental

Screening Test-II in 0-6 Year-Olds in Tehran

Soheila Shahshahani1, MD; Roshanak Vameghi2, MD; Nadia Azari1, MD; Firoozeh Sajedi*2, MD;
and Anooshirvan Kazemnejad3, PhD
1. Pediatric Neurorehabilitation Research Center, University of Social Welfare & Rehabilitation Sciences,
Tehran, IR Iran
2. Clinical sciences department, Pediatric neurorehabilitation research center, USWR, Tehran, IR Iran
3. University of Tarbiat Modaress, Tehran, IR Iran

Received: Jun 13, 2009; Final Revision: Jan 07, 2010; Accepted: Feb 28, 2010

Abstract
Objective: T h i s r e s e a r c h w a s d e s i g n e d t o i d e n t i f y t h e ility
v a l iofd ithe
t y Persian
a nd reliab
version of Denver Developmental Screening Test II (DDST-II) in Iranian children, in order to
provide an appropriate developmental screening tool for Iranian child health workers.
Methods: At first a precise translation of test was done by three specia lists in English literature
and then it was revised by three pediatricians familiar with developmental domains. Then,
DDST-II was performed on 221 children ranging from 0 to 6 years, in four Child Health Clinics,
i n n o r t h , s o u t h , e a s t a n d w e s t r e g i o n s o f T e h rtoa ndetermine
c ity. I ntheoagreement
rder
coefficient, these children were also evaluated by ASQ test. Because ASQ is d esigned to u se f or
4-60 month- old children, children who were out of this rang we re evaluated by developmental
pediatricians. Available sampling was used. Obtained data was analyzed by SPSS software.
Findings: Developmental disorders were observed in 34% of children who were examined by
DDST-II, and in 12% of children who were examined by ASQ test. The estimated consistency
coefficient b etween D DST-II a nd A SQ w as 0 .21, w hich d between
i s w e a kDDST-II
, a n and the
physicians’ examination was 0.44. T h e c o n t e n t v a l i d i t y o fIIDwas DST verified
- by reviewing
books and journals, and by specialists’ opinions. All of the questions in DDST-II had appropriate
c o n t e n t v a l i d i t y , a n d t h e r eo need
w a s to
n change them. Test-ret e s t a n d I n t e r - r a t e r m e t h o d s
were used in order to determine reliability of the test, bynbach’s Cro α and Kauder-Richardson
coefficients. Kauder-Richardson coefficient for different developmental domains was between
6 1 % a n d 7 4 % , w h i c h i s g o o d . C r o n b a c h ’ s α c o e f f i c i emeasure
n t a n d ofK agreement
appa for
test-retest were 92% and 87% and for Inter-rater 90% and 76%, respectively.
Conclusion: This research showed that Persian version of DDST-II has a good validity and
reliability, and can be used as a screening tool for developmental screening of children in
Tehran city.

Iranian Journal of Pediatrics, Volume 20 (Number 3), September 2010, Pages: 313-322

Key Words: Development; Developmental screening; DDST-II

* Corresponding Author;
Address: Clinical sciences department, University of Social Welfare & Rehabilitation Sciences, Tehran, IR Iran
E-mail: fisajedi@ uswr.ac.ir

© 2010 by Pediatrics Center of Excellence, Children’s Medical Center, Tehran University of Medical Sciences, All rights reserved.
314 Denver Developmental Screening Test-II in 0-6 years old children; S Shahshahani, et al

Introduction Previous edition of Bayley infant scales[10].

DDST-II is a brief and validated screening tool
Developmental disabilities can be seen in 10- that many of pediatricians are familiar with it.
15% of children in different populations. Early Although there is doubt about its limited
detection and appropriate referral of children specificity (43%) and risks of over referral [5,11],
with developmental delays or disorders is it has high rate of sensitivity (83%) and
important in Pediatrics. This is only possible by identifies children with developmental
continuous developmental monitoring and delays[5,12]. DDST-II assesses child’s development
assessment. Developmental assessment is made in 4 general areas: 1) personal–social (25 items),
by early detection of problems through 2) fine motor- adaptive (29 items), 3) language
developmental surveillance and screening, (39 items), and 4) gross motor (32 items)[9,13].
precise evaluation by using standardized and Screening by it produces 3 scores: normal,
formal diagnostic tools as well as evaluation of suspect and untestable[9] (these children refused
the medical, social, family history and physical parti-cipating in some items that 95% of age
examination of the child[1,2]. Developmental matched children could pass them). Sometimes
screening must be repeated periodically and DDST results are interpreted as normal, suspect,
incorporated into pediatrics practice [3,4]. questionable (these children cannot pass some
Developmental screening test is a brief items that 75-95% of age matched children
standardized tool that is used for identifying could pass them) and untestable. A study found
children who need more detailed evaluation[5] sensitivity of 80% if "questionable scores" were
and if used appropriately is useful and cost included with abnormal scores but specificity of
benefit effective[6]. Because screening is used for 46%. Alternatively, if "questionable scores" were
identifying the children who will receive the included with normal scores, sensitivity was
benefits of more professional evaluation or 46% and specificity 80[11].
treatment, it is recommended that all children be By considering the importance of early
screened for developmental delays [5]. detection of developmental disabilities and
There are many developmental screening absence of an Iranian developmental screening
tools. The base of all of them is achieving test, this study was planned to determine the
developmental milestones at specific validity and reliability of Persian version of
chronological ages. Denver Developmental DDST-II (by translating to Persian and
Screening Test II (DDST-II) and Bayley are evaluating the cultural adaptation of the items)
examples for such formal tools. For having in Iranian children in order to provide an
ability to differentiate between abnormal appropriate developmental screening tool for
children from those normal children who have Iranian child health workers.
slower rate of achieving developmental skills,
these developmental screening tools must be
reliable and valid, have acceptable sensitivity
and specificity, be easy to perform and not
expensive[1,6,7]. Subjects and Methods
DDST-II is a formal developmental screening
tool that assesses children from birth to 6 years This research is an action research that was
of age. First it was standardized on 1036 performed from January to August 2008 in 4
children (543 boys and 493 girls) from 2 weeks Child Health Care centers located in north, south,
old to 6/4 years of age in Denver, Colorado as east and west regions of Tehran city.
DDST[8]. Then in 1992 it is revised and These are primary health care centers which
restandardized on 2096 children and is known provide mainly general health services for
as DDST-II. Test reliability on test-retest is 90% people including children from different socio-
and its inter-rater reliability is 80-95%[9]. The economical classes of general population.
test is valid and there is a strong relationship Usually normal children visit such centers and
between classification on the DDST and scores services for growth monitoring, vaccination,
on the Stanford-Binet intelligence scales and the vitamin supplements, etc). These centers are
Iran J Pediatr; Vol 20 (No 3); Sep 2010 315

under the supervision of Deputy of Health, or older children up to 2-3 days later) were re-
Shahid Beheshti Medical University. examined by the same examiners (test-retest).
At first test form and guiding sheet was Another 25% of children were retested by
translated precisely by 3 specialists familiar with another examiner (inter-rater reliability). In
English. Then the research team (4 order to determine agreement coefficient, these
pediatricians) read all 3 translated versions and children were also evaluated by ASQ (Ages and
for each item in form and sheet we chose the Stages Questionnaires) test. ASQ is not a
best translation (simple, short, easy to diagnostic gold standard test. It is a
understand and culturally compatible). Then we developmental screening tool. Because we had
sent them along with original version to 3 other no accessibility to any diagnostic tests we
pediatricians who were familiar with compared these two developmental screening
developmental domains. The research team tools to determine their agreement coefficient.
discussed their view points and implemented Anyway, by another research team, ASQ was
their opinions in the final form. Healthy translated into Persian and was standardized on
newborns, infants and children, 0-6 years old, in 11000 Iranian children. The results have not
Tehran city could participate in this study. The been published yet, but the general report exists
inclusion criteria were: 1) age between birth to 6 and we have used the translated forms. Because
years, 2) Iranian nationality, 3) living in Tehran ASQ is designed to use for 4-60 month-old
city, and 4) parental cooperation. Exclusion children and each questionnaire can be used for
criteria were: 1) having obvious developmental one month before or after the specific age,
delay or disability (because including children children who were out of this range (3-61
with gross developmental disorders would months) were evaluated by developmental
lower the cutoff point for each developmental pediatricians. Also 10% of children of other age
item in Iranian children), 2) parental refusal. groups, after examining by DDST-II and
The study was approved by the research completing the ASQ by parents, were evaluated
committee and thereafter by the ethical by developmental pediatricians.
committee of University of Social Welfare & As mentioned above, test-retest and inter-
Rehabilitation Sciences. Consent for rater methods were used in order to determine
participation was obtained from parents. The reliability of the test by Cronbach’s α and
parents whose children had developmental Kauder-Richardson coefficients. We use
problems were informed and guided. Cronbach’s α for reliability determining of each
Convenient sampling was used and 221 test item and Kauder-Richardson coefficient in 4
children (100 girls and 121 boys) in 13 age developmental domains. In test-retest and inter-
groups (0 to 2, 2.1 to 4, 4.1 to 6, 6.1 to 9, 9.1 to rater tests we measured Cronbach's α and kappa
12, 12.1 to 15, 15.1 to 18, 18.1 to 24, 24.1 to 30, measure of agreement for comparison of each
30.1 to 36, 36.1 to 48, 48.1 to 60 and 60.1 to 72 developmental domain and final results of each
months), each age group containing 17 children, test respectively. Content validity of the test was
were examined. Demographic items included verified by reviewing texts and related articles,
date of birth, sex, birth order, maternal and by specialists’ opinions. Data was analyzed
education level, gestational age at birth (preterm by SPSS software.
or term; for preterm children up to 2 years we
calculated corrected age), and history of
disability of the child.
Eight examiners were trained in a 1 day
workshop for performing the DDST-II. A Findings
demographic questionnaire was completed for
each child by parents and then DDST-II was done In this study 221 children were evaluated by
by the examiners. In order to determine the DDST-II (100 girls and 121 boys) in 13 age
reliability of DDST-II, 25% of children in each groups (Appendix). Birth order of children were
age group (small children after 30-60 minutes, 73% first, 22% second, 3% third and 2% fourth
316 Denver Developmental Screening Test-II in 0-6 years old children; S Shahshahani, et al

Table 1: Interclass Correlation Coefficients for test – retest examination by DDST- II

ICC interval Cronbach’s α
Developmental domain ICC*
(95% confidence interval) coefficient
Personal-social 0.95 0.92-0.97 0.96
Fine motor-adaptive 0.90 0.84 0.95
Language 0.93 0.89-0.96 0.96
Gross motor 0.91 0.86-0.95 0.95
ICC: Interclass Correlation Coefficients/ DDST-II: Denver Developmental Screening Test II

child of family. Maternal educations of 85% of Coefficients for test-retest and inter-rater
children were at high school or greater level. methods are shown in Tables 1 and 2.
95% of children were born at term and 5% of Table 3 shows comparison between the
them preterm (for preterm children up to 2 results of DDST-II with ASQ and results of
years we calculated and considered corrected pediatricians’ evaluation. Comparison of DDST-II
age). and ASQ results showed that 109 children
Children were selected from 4 different passed two tests and 21 children failed in both of
regions of Tehran city. Developmental screening them.
of children by DDST-II showed that 143(65%) of Consistency coefficient between DDST-II and
them developed normally, 75(34%) had ASQ was 0.21. Thus sensitivity and specificity of
developmental delay (suspect) and 3(1%) were DDST-II could be calculated as shown below:
untestable according to test scoring method. Sensitivity = 21: 35 ×100 = 60%
Cautions and delays number in each Specificity = 109:158 ×100 = 69%
developmental domains are 13 and 20 in Comparison of DDST-II and results of
Personal-social, 13 and 24 in Fine motor- pediatricians’ evaluation showed that 42
adaptive, 21 and 16 in language and finally 10 children passed and 4 children failed in both
and 23 in Gross motor areas. As it is seen evaluations. Consistency coefficient between
number of cautions and delays are greater in DDST-II and pediatricians’ evaluation was 0.44.
language and fine motor– adaptive domains Final translated version of DDST-II has been
respectively. Children with developmental shown in appendix.
delays differed in number of affected domains.36
children had delay in 1, 27 children in 2 and 9
children in 3 developmental domains.
In this study, reliability was evaluated by the
Kauder-Richardson coefficients determination. Discussion
The estimated coefficients were 0.74 for
personal-social, 0.63 for fine motor-adaptive, In our study the content validity of DDST-II was
0.63 for language and 0.61 for gross motor verified by reviewing books and journals, and by
domains. Test-retest and inter-rater methods specialists’ opinions. All of the questions in
were also used as other ways for reliability DDST-II had appropriate content validity, and
determination. Interclass Correlation there was no need to change them.

Table 2: Interclass Correlation Coefficients for inter-rater examination by DDST-II

ICC interval Cronbach’s
Developmental domain ICC*
(95% confidence interval) α coefficient
Personal-social 0.88 0.79-0.93 0.94
Fine motor-adaptive 0.89 0.82-0.94 0.94
Language 0.96 0.93-0.98 0.98
Gross motor 0.86 0.77-0.92 0.93
ICC: Interclass Correlation Coefficients/ DDST-II: Denver Developmental Screening Test II
Iran J Pediatr; Vol 20 (No 3); Sep 2010 317

Table 3: Comparison between the results of DDST-II with ASQ and pediatricians’ evaluation
DDST-II results (No. of children)
Test or clinical evaluation Result Total
Failed Passed
Failed 21 14 35
ASQ (No. of children) Passed 49 109 158
Total 70 123 193
Failed 4 0 4
Pediatricians’ evaluation
Passed 10 42 52
(No. of children)
Total 14 42 56
DDST-II: Denver Developmental Screening Test II / ASQ: Ages and Stages Questionnaires

We evaluated the reliability of the test by the and place of residence that are presented in
Kauder-Richardson coefficients determination. Denver-II technical manual[18].
Determined Kauder-Richardson coefficients for Some of our other findings revealed no
all of developmental domains were “good”. relationships between sex, maternal education
Test-retest and inter-rater methods were also and place of residence with children’s
used as other ways for reliability determination. developmental status in Tehran. In another
In test-retest examination the Cronbach’s α native study in Shiraz city, gross and fine motor
coefficients for all developmental domain is very performance of 1524 children aged 3-6 years
good and kappa measure of agreement is 87% was evaluated by DDST-II in 2005-2008. In this
(P<0.001). In Inter-rater examination the evaluation girls had better performance[16]. Yalaz
Cronbach’s α coefficients for all developmental and Epir tested 1176 Turkish children aged 2
domain were very good and kappa measure of weeks to 6 yr-4 mo by DDST in 1984. They found
agreement was 76% (P<0.001). Thus DDST-II that girls’ development is better than that of
has very good reliability in test-retest and Inter- boys’[17].
rater examination. Durmazlar and Anlar also evaluated 1091
Sensitivity of DDST-II in different references Turkish children aged 0-72 months by DDST-II
ranges from 40-83%[14,15] and its specificity is in 1998. In their study few and inconsistent
reported from 40-80%[16,17]. In this study differences were observed between boys and
sensitivity and specificity of DDST-II by girls[19]. Bryants and Stark. evaluated the
comparing the results of DDST-II and ASQ were achievement of test items in the first year of life
60% and 69% respectively. Of course this cannot of Cardiff infants by DDST in 1974. They
be considered as the actual validity of the test, concluded that in the first year of life, there are
because, as explained before, ASQ is not a no developmental differences between boys and
diagnostic gold standard test. We found that girls[20].
children passed the ASQ (88%) more than DDST- In this study maternal education had no effect
II (65%) and consistency coefficient of the two on children’s developmental status. In South
tests was poor (0.21). Therefore, either ASQ may Okanogan of Canada, Barnes and Stark evaluated
be undersensitive and/or DDST-II oversensitive. 206 children 2 weeks to 6 yr-4 mo old by DDST.
Which of these is true? It has to be investigated In their study, there was no relationship
by comparing the results of these tests with the between maternal education and child’s
results of a developmental diagnostic test. developmental level except in 10-12 month-old
It is possible that in comparison with the infants[21]. William’s study in Philippine showed
Denver sample, Iranian children have a slower that maternal education and her birth place
rate of development. One study conducted in (rural or urban) had relation to DDST results.
Shiraz (Iran) showed that 3-6 year-old Iranian Children of mothers with higher educational
children have slower rate of development by level and who were born in urban regions had
DDST-II in fine and gross motor domains[16]. It is better results[22]. Lejjaraga and co-workers
worthy to mention that DDST-II has subgroup studied 0-5 year-old children in Argentina in
standards based on sex, race, maternal education 2002. In their research, after first year of life, sex
318 Denver Developmental Screening Test-II in 0-6 years old children; S Shahshahani, et al

and maternal education were related to developmental domains. It is recommended to

children’s developmental status[23]. design another study on larger samples in order
Bryant et al examined 686 infants aged 2 to standardized DDST-II and determine the
weeks to 12 months in Cardiff by DDST in 1974. norms of Iranian children.
They found that children of Cardiff in fine and Early detection and intervention of children
gross motor domains had slower developmental with developmental delays or disorders is an
rate[20]. Later they standardized DDST on 1574 important issue in pediatrics medicine. Early
under 6 year-old children in Cardiff in 1976. detection and intervention in developmental
They showed that Cardiff children had slower problems can reduce their impacts on the well-
developmental rate, but under 18 months of age, being and functioning of child and his/her
they were better than Denver children in family. American Academy of Pediatrics
language domain. There was no difference recommended that pediatricians use
between the two groups in fine motor standardized developmental screening test
development and Cardiff children had better regularly at the 9, 18 and 30 (or 24) month
performance in personal-social domain [24]. Oeda visits[29].
in one DDST study on 1171 children showed that
children of Tokyo had better results in some
items of personal-social domain but in infancy
they had slower developmental rate in gross and Conclusion
fine motor domains[25]. Gross and fine motor
performance of 78 healthy Swedish children This research showed that Persian version of
aged 15 to18 months were examined with DDST DDST-II has a good validity and reliability, and
by Lundberg. He showed that Swedish children can be used as a screening tool for
had slower rate of fine and gross developmental screening of children in Tehran
development[26]. Shapiro and Harles in Israel city. For determining the sensitivity and
examined 2248 children 2 weeks to 6.5 years old specificity of the test, it is suggested that the
with DDST. They found that Israeli children in results of each of the two screening tests DDST-II
comparison to Denver children had slower rate and ASQ are compared with a standard
of development in gross and fine motor diagnostic test in future studies.
domains[27]. A review article showed that by
using DDST, children of Japan, Philippine, Tokyo,
Okinawa, Netherland and Bangkok had slower
rate of motor development [28].
Acknowledgment
This study has some limitations. First, some
parents that their children had to be re- This research was supported by a grant from
examined by DDST-II, did not return to clinic. So Pediatric Neurorehabilitation Research Center of
we chose other cases and there was wasting of University of Social Welfare and Rehabilitation,
time and resources. Second, developmental Tehran. We wish to thank Dr N Hatamizadeh, Dr
screening tools are not diagnostic and their H Karimi and Dr F Soleimani for their assistance.
results must be followed by a more intensive
evaluation. The sensitivity and specificity of Conflict of Interest: None
DDST-II must be determined by comparison of
the test results with a developmental diagnostic
test. Because there was no standardized
diagnostic test in Iran, we compared the DDST-II
with ASQ and pediatricians’ evaluation of
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