When to Watch, When to Refer, When to Reassure
Case Authors:
Emily Jean Davidson MD
Carolyn Frazer, MD
Harvard Medical School
Children’s Hospital, Boston
Case Advisor:
William Frankenburg, MD
University of Colorado School of Medicine
Topic: Using the Denver Developmental Screening Test II (DENVER II)
Abstract:
Developmental delay is one of the most common childhood problems with a prevalence of 10%.
Effective treatments including Early Intervention and special education are available for children with
developmental delays. Therefore, clinicians need to be able to identify developmental delays early on
and make appropriate referrals for further evaluation and treatment. The Denver Developmental
Screening Test II (DENVER II) has been widely used in clinical practice, is easy to learn to administer
and score, and provides a structured approach to developmental assessment in the office setting. This
educational exercise includes eight brief case descriptions that provide an introduction to using the
DENVER II to screen children for developmental delay. Discussion includes initial management and
indications for further evaluation of children with delay.
Goal: To improve clinical skills in administering and interpreting the DENVER II.
Objectives:
As a result of this training, clinicians will learn:
1. To monitor and record developmental observations using the DENVER II.
2. To score and interpret results of the DENVER II.
3. To recognize normal and abnormal patterns of development in children under age 6 years through use
of this standardized tool.
4. To develop an initial management plan for children with suspected developmental delay.
Pre-requisite Cases: N/A
Related Cases:
"Will David Catch Up?" (Global Delay)
"The Tongue Tied Toddler" (Language Delay)
"Jose's New Family" (Atypical Behaviors, Developmental Delay)
Themes: Child Development and Behavior
Key Words:
Child development, Denver II, developmental screening, language delay, early intervention, special
education
Supported by a grant from The Genentech Foundation for Growth and Development. These
materials may be freely reproduced, but may not be modified without written consent of the
authors.
Bright Futures Core Concepts:
While all of the Core Concepts are included in each case, this particular case can be used to highlight
communication, partnership, advocacy, and prevention/health promotion.
Materials Provided:
• Facilitator's Guide (including answer key and discussion for each case and teaching tips)
• 8 Case vignettes with DENVER II results
• Handout #1: How to perform the DENVER II
• Handout #2: Early Intervention and School Referral
• Bibliography
Preparation for the Session:
Facilitators should thoroughly review this guide and the other materials provided. The DENVER II Test
forms and DENVER II Test Kit, as well as training materials including The DENVER II Training
Videotape (Introduction), The DENVER II Item Administration Videotape, The DENVER II
Training Manual, and The DENVER II Technical Manual, may be purchased directly from:
Denver Developmental Materials, Inc.
PO Box 6919
Denver, CO 80206-0919
Tel. 1-800-419-4729
The training materials should be reviewed by the teacher and may be given to students before or
between teaching sessions.
Overview of Format for Two 1-Hour Sessions (or a single 2-hour session):
We anticipate that case facilitators will modify implementation of the case sessions to best fit
their educational setting and learners. For detailed recommendations on case facilitation,
please see the chapter entitled, “A Brief Guide to Facilitating Case-Discussion,” found in The
Case Teaching Method; and Growth in Children and Adolescents (book 1 of this series).
First hour:
1. Discussion of DENVER II basics. (30 minutes)
2. Live/video demonstration of DENVER II with a child. The demonstration of the DENVER II with
a live child or children has been very popular with residents and medical students. Volunteer
children can often be found by asking seminar participants who are parents to bring one of their
children along to the session. Using an older (4-6 year old) child to demonstrate items may get
better cooperation in front of the group. (15-30 minutes)
3. Practice item administration not covered during child’s demonstration. (0-15 minutes)
Between sessions:
1. Participants should read the DENVER II manual and/or watch the training video on item
administration.
2. Participants should be asked to practice administering the DENVER II. If possible, this should be
done under the supervision of an experienced clinician.
Second hour:
1. Begin by asking participants about their experiences practicing the DENVER II and any questions
remaining about administering it. (5 min)
2. Review key concepts that have not already been covered during the discussion. (5 min)
3. Lead the group in scoring the DENVER II for each case using an overhead projector. A brief
discussion on interpreting the results should follow. More cases may be covered if time permits,
however, mini-cases 1-4 should be covered with each group.
Detailed Teaching Tips
Session 1:
1) Session format:
a) Didactic teaching session on performing DENVER II (30 minutes)
b) Demonstration with child (15-30 minutes)
c) Continued demonstration of items for remainder of session
2) Materials needed:
a) Session 1: Denver Basics
b) Handout #1: How to perform the Denver II
c) Blank DENVER II forms for all students
d) Overhead transparencies of pages 14, 15, 16 from DENVER II training manual
e) Copy of blank DENVER II on an overhead transparency
f) Denver kit (preferably a few kits)
3) Preparation for session:
a) Review “Session 1: Denver Basics” and Handout #1.
b) Review DENVER II training manual and DENVER II item administration video.
c) Read through teaching materials and read selected references.
d) Invite child for demonstration (preferably 2 children of different ages).
4) Running the session:
a) Introduction: Begin the session by asking learners what they know about the DENVER II
and what they would like to learn. Then present background information on the DENVER
II in question-and-answer format to help elicit learner participation. The background portion
of the talk needs to be completed efficiently and should not take more than 10 minutes.
b) Basic Instruction: The section on the basics of performing the DENVER II should take at
least 20 minutes.
• Begin this part by distributing Handout #1.
• Pass around the items in the kit as they are discussed.
• Show the age calculations on the board or an overhead.
• Demonstrate drawing the age line on an overhead transparency of a DENVER II.
• Refer to the overhead transparencies of pages 14-16 of the DENVER II to explain
interpretation.
c) Demonstration: The demonstration with a live child draws students in very effectively. It
is helpful to invite two children of different ages. It is especially nice to have an older child
with whom you can demonstrate not only the age-appropriate items but items appropriate
for a younger child as well. Letting the child play quietly in a corner of the room during the
didactic session can help the child relax and be comfortable with the people in the room
before the demonstration begins. If the child refuses at the last minute, a video
demonstration can be substituted or the facilitator can ask a learner to role-play as a child.
Once the child has done as much as possible, the facilitator can continue to demonstrate
item administration with learners. Have an observer time the administration of the
DENVER II. Learners are often surprised at how little time it takes to complete.
d) Practice: At the end of the session, ask learners to practice performing the DENVER II at
least once or twice on their own patients (or other children) before the next session. Ideally,
this practice should take place under the supervision of a clinician experienced in the
administration of the DENVER II who can provide individualized instruction and feedback.
In addition, learners should read the DENVER II manual and watch the item administration
video.
Session 2:
1) Session format:
a) Review of student experiences with practice DENVER II (5 minutes)
b) Review of key concepts not covered in above discussion (5 minutes)
c) Use of cases to demonstrate interpretation of findings (30-50 minutes)
2) Materials needed:
a) Handout #1: How to Perform the DENVER II (extra copies for learners)
b) DENVER II manual for reference
c) Handout #2: Early Intervention and School Referral (extra copies for learners)
d) Create 4 overhead transparencies of blank DENVER II sheets (and overhead projector).
e) Create overhead transparencies of cases 1-4 and 5-8 (optional)
f) Denver kit
3) Preparation for session: Review DENVER II materials as for session 1.
4) Running the session: There are several ways to use the 8 case vignettes to teach learners about
interpreting the DENVER II.
a) The facilitator may ask a student to administer the test while he/she acts as the child in the
vignette. Have the group participate in making the age line and score each item demonstrated on
the blank DENVER II overhead. Once the DENVER II is complete, discuss interpretation and
further evaluation.
b) Show the overhead of the completed DENVER II with case vignette and discuss the
interpretation and appropriate further management.
c) Hand out the cases with completed DENVER II. Learners can spend 10-15 minutes reading
and interpreting them independently before discussing them as a group.
Guiding Questions for Discussion:
For each brief case description and accompanying DENVER II record form, the following two
questions should be discussed by the group:
1. What is your interpretation of the DENVER II for this case?
2. What is your next step?
This facilitator’s guide contains the answers to the above questions and a brief discussion guide for each
DENVER II case vignette. Facilitators may wish to copy some of these and distribute to the learners
after the case is discussed.
Session 1: Denver Basics
Overview:
This information should be presented during the first hour of a two-hour unit on using the Denver
Developmental Screening Test-II in clinical practice. The first hour will include a presentation of basic
information about administering and scoring the DENVER II, followed by a demonstration with a
volunteer child. Whenever possible, facilitators should encourage group discussion. The second hour
will utilize mini-cases to focus on scoring and interpretation of DENVER II results, recognition of
developmental problems, and making appropriate referrals.
I: Background
Primary care visits provide a unique opportunity for ongoing developmental surveillance. However,
without a structured format for developmental screening, identifying children with delays is difficult for
even the most experienced clinician. The Denver Developmental Screening Test was first published in
1967. It has since been used on more than 50 million children worldwide.4 In 1990, it was revised to
include more language items, two new articulation items, a new age scale, a new category of item
interpretation to identify milder delays, a behavioral rating scale, and new training materials. The revised
DENVER II was re-normed using a more diverse population of 2,000 children.3
What functional areas does the DENVER II assess?
The DENVER II consists of 125 items assessing four areas of functioning:
1. Personal-Social (relating to people and caring for personal needs)
2. Fine Motor-Adaptive (eye-hand coordination, manipulation of small objects and problem solving)
3. Language (hearing, understanding and using language)
4. Gross Motor (sitting, walking, jumping and overall large muscle coordination)
For what age child is the DENVER II designed?
The DENVER II is designed for children from birth to 6 years of age. The Committee on Children
with Disabilities of the American Academy of Pediatrics recommends administering it at every well
child check.5
How should the DENVER II be used?
The DENVER II is a screening test and as such, should be used as part of routine developmental
surveillance to identify children with areas of concern. Children with potential concerns should undergo
further evaluation. The DENVER II is not an intelligence or IQ test, a predictor of future ability or a
diagnostic tool. Although the results may suggest certain problems or diagnoses, the DENVER II alone
should never be used to make a diagnosis.
Is the DENVER II the only developmental screening test available?
No. There are several other developmental screening tests including the Clinical Adaptive Test/Clinical
Linguistic and Auditory Milestone Scale (CAT/CLAMS),6 Early Language Milestones (ELMS), the
Battelle Developmental Inventory Screening test, and The Screening Children for Related Early
Educational Needs (SCREEN).7
Is the DENVER II alone sufficient for screening child behavior and development?
The DENVER II alone is not enough. Other strategies for obtaining developmental information:
1. Elicit parental concerns. There is a very high correlation between parental concern and
presence of developmental delay. This is especially true of language delay.10
2. Ask open-ended questions. Good examples of these questions, specific to the age of the
child, can be found in the Bright Futures Guidelines for Health Supervision.
3. Observe and interact with the child throughout the interview and exam process.
4. Consider asking parents to keep records of behavior at home.
5. Obtain reports from daycare providers, teachers and other professionals working with the
child.
Why is developmental screening important? What is the value of identifying children at risk
for developmental delay?
Knowing how to assess a child at risk for developmental delay allows the clinicians to intervene and
enhance the care they provide. Amendments to the Individuals with Disabilities Education Act,
enacted in 1992, require that children age 3 and over who have disabilities receive services through the
public school system. For children under 3 years, each state runs Early Intervention services, often
through the Department of Public Health. These services are funded through private insurance and
public funds. There is no direct cost to the family. Early Intervention has explicit criteria for entry but
any child can be referred by physician, teacher, or parent for evaluation (See Handout #2: Early
Intervention and School Referral) . By understanding these criteria and how to screen for them,
clinicians become better equipped to offer their patients these available resources.
Session 2: Discussion Guide
Case 1
Josephina is an 18-month old former 27-week premature girl whom you have followed since her discharge
from the neonatal intensive care unit. Her NICU course was notable for a Grade III intraventricular
hemorrhage, respiratory distress syndrome, intubation for 3 weeks, and mild residual bronchopulmonary
dysplasia. She was receiving services from Early Intervention, but these were discontinued at her first
birthday because “She was doing so well.”
Question 1: What is your interpretation of the DENVER II for this case?
Answer: (b) suspect
Key Teaching Points: Josephina has two cautions (scribbles, and walk well) and one delay (thumb finger
grasp) on her testing.
Question 2: What is your next step?
Answer: (c) Refer to Early Intervention
Discussion: Ongoing developmental surveillance of at-risk children is crucial. Your background
information tells you that Josephina was premature and had an intraventricular hemorrhage, this puts her at
risk for cerebral palsy. The most common type of cerebral palsy in premature infants is spastic diplegia.
Although the lower extremities are most involved, fine motor control can be problematic as well.
Josephina’s fine and gross motor delays merit further evaluation. A referral to Early Intervention can lead
to a more in depth evaluation of fine motor, gross motor and cognitive skills and appropriate treatment can
be instituted. In addition, referrals to neurology and orthopedics should be considered. (See Handout #2:
Early Intervention and School Referral).
Case 2
Jimmy is a 12-month old boy who is new to your practice. His clinic record indicates that he has not been
seen for a well child visit since he was 6 months old. The last immunizations he received were his “4
month shots.” His mother, Isabel reports that his 10 year old brother provides much of Jimmy’s care.
During his physical exam, you observe that he has not been washed recently. During the Denver II, Isabel
reports “I never gave him a cup - he loves the bottle.” When asked if Jimmy imitates, she asks, “What do
you mean?” Jimmy looks confused when you try to play ball with him, although he does reach up to be
held.
Question 1: What is your interpretation of the DENVER II for this case?
Answer: (a) normal
Key Teaching Points: Jimmy has only one caution (wave bye-bye) and no delays.
Question 2: What is your next step?
Answer:
(b) Referral to social services
(c) A referral to EI is also an acceptable plan.
Discussion: While the results of the Denver II per se do not suggest developmental delay, you make some
observations that raise concerns about Jimmy’s home situation. Missing several primary care visits,
having care provided by a 10 year old, and poor hygiene all raise concerns about the resources available to
Jimmy’s mother and the safety of the home situation. The types of tasks Jimmy is unable to perform raise
concerns about whether he has adequate opportunity for developmental stimulation. This family should
have further evaluation and support provided by a social services consultation. Where social services are
not available, the clinician will need to undertake this investigation himself or herself. Questions to consider
include the following. What is the housing situation? Does Isabel have sufficient money to buy food,
clothing and diapers? Is an alternative child care arrangement possible? Does Isabel need help with
parenting skills? A referral to Early Intervention services may provide access to parent support groups,
parent training, etc. (Teachers should include information on resources provided by their home state. For
example, the Massachusetts Society for the Prevention of Cruelty to Children has parenting classes and
can provide support. Women and Infants with Children (WIC) can provide funding for groceries if Isabel
meets the financial criteria.)
Case 3
Daniel is a 2-year old boy who has been in your office at least 5 times this winter for otitis media.
Otherwise, he has been quite well. His mother, Sandra, reports that “he is a delightful, friendly kid who
gets along great with his brother and sisters and Brandy, our Golden Retriever.” She notes, “Daniel is my
quiet one, he talks less than the others but of course they always talk for him.” You ask Daniel some
questions and he smiles at you but his speech is very difficult to understand. You rely on Sandra to
translate for him.
Question 1: What is your interpretation of the DENVER II for this case?
Answer: (b) Suspect. Daniel has 2 cautions (body parts, point 2 pictures).
Question 2: What is your next step?
Answer: (a) Further medical evaluation
Discussion: Language delay is the most common form of developmental delay, occurring in up to 5-10% of
preschoolers. Daniel’s current language skills are significantly delayed based on your brief history and
observation. By two years of age, a child should have a large expressive vocabulary (over 200 words), use
two or three word combinations to communicate, point to several body parts, use “no” and express a
question through rising intonation. Despite parental reports that a child “understands everything,” many
children with language delay may rely on visual or situational cues to understand. Parents may
unknowingly simplify language by breaking commands into single steps or repeating directions frequently.
Clinical impressions of hearing status are often inaccurate. Children with more mild hearing loss may use
visual cues to aid comprehension and thus not appear hearing impaired. Hearing loss, particularly before
age 5 years, impacts significantly on language development. Even fluctuating, mild to moderate conductive
hearing loss related to serous otitis media may affect acquisition of language in the younger child. All
children with suspected language delay should have a formal hearing evaluation to rule out any hearing
loss contributing to the language delay. There are several types of tests available:
Tympanometry: assesses ear drum mobility and middle ear pressure; helpful in diagnosing middle ear
effusion; does not assess hearing.
Behavioral audiometry: may be used in children 6 months and older; visual reinforcement technique
where sound presented in sound room, reinforcement (often a toy or puppet) appears if infant or
child correctly turns to sound source.
Pure tone audiometry: evaluates hearing over the range of frequencies most critical for speech (250 8000 Hz); headphones used to assess hearing in each ear separately.
Brainstem evoked auditory response: electrophysiological test used to assess sensorineural hearing
loss; examines hearing over all components of the neural pathway.
After, or concomitant with, the audiologic evaluation, Daniel should have a speech and language
assessment. This may be performed through Early Intervention or through the speech/language
department at the local medical center. Speech and language therapy, which Daniel is likely to need, is
usually provided as well by the Early Intervention Program.
Although this presentation suggests isolated language delay secondary to hearing loss, it is also important
to obtain a comprehensive developmental evaluation to be sure that other areas of development are not
affected. Language development is a better predictor of cognitive development than is motor
development, and “speech delay” is the most common presenting complaint for global developmental
disorders. In addition to isolated delay in language development, the differential diagnosis for speech
delay includes global developmental delay, mental retardation, pervasive developmental disorder/autism,
and impoverished environment or neglect.
Case 4
Eleanor is a 3-year-old girl who is new to your clinic. Her mother, Susan, reports that she is healthy but
that “She is still not interested in potty training.” Eleanor has been in a playgroup but seems to prefer
playing by herself. She is unable to name a friend other than “Mommy.” She does not point to the pictures
but smiles and repeats “meow” when you asks “which one says meow.” Despite multiple demonstrations,
Eleanor cannot stand on one foot. After completing a tower of 5 blocks, she looks at both you and her
mother, claps and laughs.
Question 1: What is your interpretation of the DENVER II for this case?
Answer: (b) Suspect
Key Teaching Points: Eleanor has 3 delays (tower of 6 cubes, point 4 pictures, body parts) and 9 cautions
(name friend, tower of 8 cubes, imitate vertical line, know 2 adjectives, know 2 actions, name 4 pictures,
speech ½ understandable, balance each foot 1-second, broad jump).
Question 2: What is your next step?
Answer: (a) Refer for a school-based evaluation
Discussion: This profile is concerning with delays in fine motor adaptive and language skills and cautions in
all domains. There has been no loss of milestones, and Eleanor is sociable and interactive (only cautions in
the personal-social domain). This profile is more consistent with a global developmental delay and less
consistent with Pervasive Developmental Disorder or Autism. Eleanor should be referred for a schoolbased evaluation. The evaluation should include cognitive, speech and language, and occupational therapy
assessments. (See Handout #2: Early Intervention and School Referral). If a thorough medical and
developmental history, family history, and physical examination indicate concerns for other medical
problems, these should be pursued as well. Hearing and vision tests should be performed and other
diagnostic testing (such as electroencephalogram or chromosomes) may be indicated. Mental retardation
cannot reliably be diagnosed before age 3. After age 3, intelligence tests such as the Wechsler
Intelligence Scale for Children—Revised (WPPSI-R, 1989, The Psychological Corporation, San
Antonio, TX) can be used to assess cognitive functioning. Although cognitive testing in pre-school children
can be helpful, testing performed in school age (5-7 years) children is more predictive of long term
functioning. To be diagnosed with mental retardation, a child must have impairment in adaptive or
functional skills in addition to impairment in cognitive skills. Adaptive skills can be quantified using the
Vineland Adaptive Behavior Scales (Sara S. Sparrow, David A. Balla, and Domenic V. Cicchetti, 1984,
American Guidance Service, Inc. Circle Pines, MN) (Please see the case: “Will David Catch Up?” for a
more extensive discussion of global developmental delay).
Case 5
Shenika is a 4 year old girl who presents for her preschool screening visit. Her older sister Sharde was
followed by you in the past for lead poisoning. Shenika comes right into the exam room, sits down in the
chair next to you and asks, “Are you my doctor? Are you going to check my heart?” Shenika’s mother
Jackie laughs and states that Shenika “is always talking!” She reports that Shenika loves to fix her own
breakfast, dresses herself and loves to play “Chutes and Ladders” with Sharde. While you are taking the
history, Shenika stacks the blocks and sings her ABCs. She tells you her favorite color is purple and she
begins pointing at different colors around the room and tells you that the tiles in your office are “salmon.”
You attempt to administer a Denver II, but Shenika refuses activities or laughs and says, “I’m not gonna
tell you!” You are able to observe her during the visit, and gather some information by history from Jackie.
Question 1: What is your interpretation of the DENVER II for this case?
Answer: Untestable
Question 2: What is your next step?
Answer: (e) Reassure parent, rescreen on next visit.
Discussion: The DENVER-II manual indicates that Shenika should be retested in 1- 2 weeks. However,
several features of her presentation suggest that this would be unnecessary. She passes all items in the
personal-social domain and she can do an advanced item in the fine motor domain (drawing a person with
6 parts). Although she refuses to wiggle her thumb, her success with the advanced drawing items makes
this less concerning. Although she refuses several language items, she was able to name one color before
beginning the Denver II. She refused many items in the gross motor section but her mother reports that
she does these at home. Thus, it would be reasonable to wait for her next visit to retest.
Case 6
Jacob comes for his 2-year visit. His mother Anna’s biggest concern is that “Jacob has terrible temper
tantrums and doesn’t talk as much as his sister did at his age.” Anna’s parents have told her not to worry
because the temper tantrums are part of “the terrible twos” and “because you spoil him.” Jacob makes
screeching noises but does not use any words in the office. Anna reports that he struggles when she
brushes his hair or tries to dress him. He does not throw the ball you offer, however he does nearly hit you
in the head when he throws a toy overhand. He jumps up and down and flaps his hands.
Question 1: What is your interpretation of the DENVER II for this case?
Answer: (b) Suspect
Key Teaching Points: Jacob has 10 delays (feed doll, help in house, tower of 4 cubes, tower of 2 cubes,
dump raisin demonstrated, put block in cup, body parts, name 1 picture, combine words, point 2 pictures, 6
words) and 5 cautions (brush teeth with help, put on clothing, tower of 6 cubes, speech ½ understandable,
point 4 pictures).
Question 2: What is your next step?
Answer: (c) Referral to Early Intervention
(a) Further medical evaluation is also an acceptable plan.
Discussion: Jacob manifests delays in personal-social, fine motor, and language skills. Beyond the delays
noted on the DENVER II, there are several features to Jacob’s presentation that suggest a significant
problem. He shows difficulty with socially oriented skills, including dressing and tooth brushing. He does
not follow commands well and he has stereotyped or atypical behaviors such as hand flapping. This
profile is suggestive of a child with Pervasive Developmental Disorder (PDD) or Autism. PDD is used to
describe a spectrum of disorders characterized by language delay, impairment in social interaction, and
stereotyped or atypical behaviors. The diagnosis of PDD requires further developmental assessment
including speech and language and cognitive testing. In addition, further medical work-up may be
indicated such as metabolic testing, Fragile X testing, or EEG to rule out Landau-Kleffner syndrome
(acquired epileptic aphasia). Early Intervention services can perform the developmental testing and so a
referral to EI would be a good first step. (See Handout #2: Early Intervention and School Referral for
more information). However, referral to a medically based developmental team may be necessary. In
addition, a thorough physical examination and past medical and family history should be obtained. A child
who is diagnosed with PDD/autism will need intensive educational services. The program should include
speech/language therapy, and general development and behavioral training for home and school. Jacob
will need a referral to the school system when he turns 3 years old. Children with developmental
disabilities who are over age 3 are eligible to receive services in the public school system.
Case 7
Heather is 18 months old. Her mother Kathleen brings her to clinic quite worried that Heather is no longer
doing the things she could previously do. Kathleen’s pregnancy, labor and delivery were uncomplicated.
Looking through her chart you note that Heather’s Denver II screening tests were interpreted as normal
during her first year. At her one-year visit, Heather was just beginning to walk independently, able to put a
block in a cup and said “baba” and “doggie” in addition to “mama” and “papa.”
Question 1: What is your interpretation of the DENVER II for this case?
Answer: (b) Suspect
Key Teaching Points: Heather has 8 delays (help in house, drink from cup, imitate activities, play ball with
examiner, scribbles, 2 words, 1 word, stoop and recover) and at least 5 cautions (use spoon/fork, tower of
2 cubes, dump raisin-demonstrated, 3 words, runs).
Question 2: What is your next step?
Answer: (a) Further medical evaluation (EI is also correct, but priority should be given to further medical
evaluation).
Discussion: Loss of developmental milestones is very concerning. Although there is a fair amount of
normal variation in the acquisition of milestones, losing milestones is never a variant of normal. In
Heather’s case, she has lost motor and language milestones and failed to gain personal-social milestones.
Developmental regression can be caused by a variety of conditions, such as significant medical illness with
prolonged hospitalization. Other causes of developmental regression include: Pervasive Developmental
Disorders including Autism, Rett’s syndrome and childhood disintegrative disorder; metabolic disorders;
and neuromuscular disorders. These would all require further medical evaluation starting with a detailed
medical and family history and thorough physical examination. Whatever the underlying cause and
prognosis, a referral to Early Intervention services would be appropriate concomitantly with further
medical evaluation. Referral to social services for family support may also be needed.
Case 8
Manuel is a 9-month-old boy who has been coming to your practice since birth for his well child care.
Pregnancy, labor, and delivery were all normal. His mother, Maria, is concerned that “Manuel still doesn’t
sleep through the night and won’t share his toys with his big brother.”
Question 1: What is your interpretation of the DENVER II for this case?
Answer: Normal
Key Teaching Points: No cautions or delays
Question 2: What is the next step?
Answer: (e) Reassure parent, retest next visit.
Discussion: Manuel’s profile does not raise suspicion of developmental delay. It is appropriate to reassure
Maria about his development. It is also important to address her concerns about sleep and sharing toys.
At nine months, Manuel is not developmentally capable of understanding sharing. His brother should be
taught to use trading (get Manuel really interested in a different toy and then exchange that toy). By age
four months, when nighttime feeding is no longer needed, it is possible for a child to sleep through the
night. However, many things can interfere with sleep. The clinician should ask, “Where does Manuel
sleep? How is he put to sleep each night? Is he taking bottles during the night? When does he wake
during the night and what happens when he does?” Helpful suggestions include setting a consistent bed
time and bedtime routine, eliminating bottles in bed, putting Manuel down in his crib drowsy but awake, and
using brief periods of reassurance if Manuel awakes during the night. For more information on this topic
please see bibliography.
Case 1
Josephina is an 18-month old former 27-week premature girl whom you have followed
since her discharge from the neonatal intensive care unit. Her NICU course was notable
for a Grade III intraventricular hemorrhage, respiratory distress syndrome, intubation for
3 weeks, and mild residual bronchopulmonary dysplasia. She was receiving services from
Early Intervention, but these were discontinued at her first birthday because “She was
doing so well.”
1. Interpretation of Denver II:
a) Normal
b) Suspect
c) Untestable
2. Your next step:
a) Further medical evaluation
b) Refer to Social Services
c) Refer to Early Intervention
d) Refer for School Evaluation
e) Reassure parent, rescreen next visit
When to Watch, When to Refer, When to Reassure
Case #1: “Josephina”
DA FORM 5694, MAY 1988
Denver II
MONTHS
2
Name: Josephina
Birthdate: Case #1
ID No.:
Examiner:
Date:
YEARS
4
6
9
12
15
18
24
3
4
5
6
R PREPARE CEREAL
Percent of children passing
25
50
75
R BRUSH TEETH, NO HELP
Corrected
age
90
R PLAY BOARD/CARD GAMES
R
4 DRESS, NO HELP
R
1 TEST ITEM
86%
NAME FRIEND
15 COPY
R WASH & DRY HANDS
16 DRAW PERSON 6 PARTS
R
3 BRUSH TEETH WITH HELP
"She tries but
she drops it a lot."
13 COPY
R PUT ON CLOTHING
FEED DOLL
14 COPY
R REMOVE GARMENT
16 DRAW PERSON 3 PTS
R USE SPOON FORK
12 COPY
R HELP IN HOUSE
F
DEFINE 7 WORDS
TOWER OF 8 CUBES
PERSONAL - SOCIAL
P
F
1 SMILE
RESPONSIVELY
25 DEFINE 5 WORDS
NAME 4 COLORS
F DUMP RAISIN, DEMONSTRATED
F SCRIBBLES
C
24 UNDERSTAND 4 PREPOSITIONS
SPEECH ALL UNDERSTANDABLE
PUT BLOCK IN CUP
20 KNOW 4 ACTIONS
R BANG 2 CUBES
HELD IN HANDS
P SMILE
SPONTANEOUSLY
22 USE OF 3 OBJECTS
23 COUNT 1 BLOCK
9 THUMB-FINGER
GRASP
22 USE OF 2 OBJECTS
P TAKE 2 CUBES
P 8 PASS CUBE
P RAKE RAISIN
REGARD
FACE
NAME 1 COLOR
KNOW 2
ADJECTIVES
7LOOK FOR YARN
20 KNOW 2 ACTIONS
"mama" "doggy"
"dada" "kitty"
"bottle" "truck"
"juice" "baby"
5 FOLLOW 180º
FINE MOTOR - ADAPTIVE
30 HEEL-TO-TOE WALK
SPEECH HALF UNDERSTANDABLE
REGARD RAISIN
HANDS
TOGETHER
6 GRASP
RATTLE
5 FOLLOW PAST
MIDLINE
P
P
P
P
19 BODY PARTS-6
BALANCE EACH
FOOT 1 SECOND
29 BROAD JUMP
R 2 WORDS
28 THROW BALL OVERHAND
R ONE WORD
JUMP UP
KICK BALL FORWARD
F R27 WALK UP STEPS
F RUNS
TEST BEHAVIOR
(Check boxes for 1st, 2nd, or 3rd test)
R WALK BACKWARDS
P STAND ALONE
P STAND-2 SECS.
TURN TO VOICE
17 TURN TO
RATTLING SOUND
R GET TO
SITTING
R SQUEALS
PULL TO
STAND
R LAUGHS
R "OOO/AAH"
STAND
HOLDING ON
R VOCALIZES
HOPS
BALANCE EACH
FOOT 2 SECONDS
18 POINT 2 PICTURES
F WALK WELL
C
P STOOP AND RECOVER
R SINGLE SYLLABLES
BALANCE EACH FOOT 3 SECONDS
R COMBINE WORDS
R 3 WORDS
F
R IMITATE SPEECH SOUNDS
BALANCE EACH FOOT 4 SECS.
18 NAME 1 PICTURE
R DADA/MAMA SPECIFIC
R DADA/MAMA
NON-SPECIFIC
BALANCE EACH FOOT 5 SECS.
18 POINT 4 PICTURES
P R 6 WORDS
FOLLOW
5 TO
MIDLINE
P R JABBERS
P R COMBINE SYLLABLES
LANGUAGE
BALANCE EACH FOOT 6 SECONDS
18 NAME 4 PICTURES
REACHES
SIT-NO
SUPPORT
RESPOND TO BELL
23 COUNT 5 BLOCKS
TOWER OF 4 CUBES
F TOWER OF 2 CUBES
R FEED SELF
P
26 OPPOSITES-2
10IMITATE VERTICAL LINE
TOWER OF 6 CUBES
21 KNOW 3 ADJECTIVES
P R WAVE BYE-BYE
P R INDICATE WANTS
P R PLAY PAT-A-CAKE
WORK FOR TOY
88%
11 THUMB WIGGLE
R DRINK FROM CUP
P R IMITATE ACTIVITIES
P PLAY BALL WITH EXAMINER
R
2 REGARD OWN HAND
DEMONSTR.
13 PICK LONGER LINE
Typical
Yes
No
1
2
3
Compliance (See Note 31)
Always Complies
Usually Complies
Rarely Complies
1
2
3
Interest in Surroundings
1
2
3
1
2
3
1
2
3
Alert
Somewhat Disinterested
Seriously Disinterested
PULL TO SIT - NO HEAD-LAG
R ROLL OVER
Fearfulness
CHEST UP-ARM
SUPPORT
None
Mild
Extreme
BEAR WEIGHT ON LEGS
SIT-HEAD STEADY
HEAD UP 90º
Attention Span
HEAD UP 45º
Appropriate
Somewhat Distractible
Very Distractible
RLIFT
HEAD
EQUAL
MOVEMENTS
MONTHS
2
4
6
FOR USE OF THIS FORM, SEE AR 600-75
RPUT ON T-SHIRT
©1969, 1989, 1990 W. K. Frankenburg and J. B. Dodds©
May pass by report
Footnote no.
(see back of form)
9
12
15
18
24
3
YEARS
4
5
6
Case 2
Jimmy is a 12-month old boy who is new to your practice. His clinic record indicates that
he has not been seen for a well child visit since he was 6 months old. The last
immunizations he received were his “4 month shots.” His mother, Isabel reports that his
10 year old brother provides much of Jimmy’s care. During his physical exam, you
observe that he has not been washed recently. During the Denver II, Isabel reports “I
never gave him a cup - he loves the bottle.” When asked if Jimmy imitates, she asks,
“What do you mean?” Jimmy looks confused when you try to play ball with him,
although he does reach up to be held.
1. Interpretation of Denver II:
a) Normal
b) Suspect
c) Untestable
2. Your next step:
a) Further medical evaluation
b) Refer to Social Services
c) Refer to Early Intervention
d) Refer for School Evaluation
e) Reassure parent, rescreen next visit
When to Watch, When to Refer, When to Reassure
Case #2: “Jimmy”
DA FORM 5694, MAY 1988
Denver II
MONTHS
2
Name: Jimmy
Birthdate: Case
ID No.:
Examiner:
Date:
#2
YEARS
4
6
9
12
15
18
24
3
4
5
6
R PREPARE CEREAL
R BRUSH TEETH, NO HELP
R PLAY BOARD/CARD GAMES
Percent of children passing
25
50
75
R
4 DRESS, NO HELP
90
R
1 TEST ITEM
RPUT ON T-SHIRT
86%
NAME FRIEND
15 COPY
R WASH & DRY HANDS
16 DRAW PERSON 6 PARTS
R
3 BRUSH TEETH WITH HELP
13 COPY
R PUT ON CLOTHING
"He's on the
bottle"
14 COPY
R REMOVE GARMENT
16 DRAW PERSON 3 PTS
R USE SPOON FORK
12 COPY
R HELP IN HOUSE
No.
"What do you mean?"
P
P
DEFINE 7 WORDS
TOWER OF 8 CUBES
R IMITATE ACTIVITIES
P R INDICATE WANTS
P R PLAY PAT-A-CAKE
25 DEFINE 5 WORDS
NAME 4 COLORS
DUMP RAISIN, DEMONSTRATED
24 UNDERSTAND 4 PREPOSITIONS
SCRIBBLES
SPEECH ALL UNDERSTANDABLE
F PUT BLOCK IN CUP
WORK FOR TOY
P
20 KNOW 4 ACTIONS
R BANG 2 CUBES
HELD IN HANDS
P SMILE
SPONTANEOUSLY
P
1 SMILE
RESPONSIVELY
21 KNOW 3 ADJECTIVES
TOWER OF 4 CUBES
TOWER OF 2 CUBES
R FEED SELF
R
2 REGARD OWN HAND
22 USE OF 3 OBJECTS
23 COUNT 1 BLOCK
9 THUMB-FINGER
GRASP
22 USE OF 2 OBJECTS
P TAKE 2 CUBES
REGARD
FACE
NAME 1 COLOR
8 PASS CUBE
KNOW 2
ADJECTIVES
RAKE RAISIN
7LOOK FOR YARN
20 KNOW 2 ACTIONS
REACHES
REGARD RAISIN
FINE MOTOR - ADAPTIVE
HANDS
TOGETHER
6 GRASP
RATTLE
5 FOLLOW PAST
MIDLINE
P
P
BALANCE EACH
FOOT 1 SECOND
29 BROAD JUMP
28 THROW BALL OVERHAND
JUMP UP
KICK BALL FORWARD
R
27 WALK UP STEPS
TEST BEHAVIOR
RUNS
(Check boxes for 1st, 2nd, or 3rd test)
R WALK BACKWARDS
P STAND ALONE
P STAND-2 SECS.
P
R SQUEALS
P
R LAUGHS
R "OOO/AAH"
R GET TO
SITTING
PULL TO
STAND
STAND
HOLDING ON
R VOCALIZES
SIT-NO
SUPPORT
RESPOND TO BELL
HOPS
BALANCE EACH
FOOT 2 SECONDS
18 POINT 2 PICTURES
F WALK WELL
F STOOP AND RECOVER
TURN TO VOICE
17 TURN TO
RATTLING SOUND
BALANCE EACH FOOT 3 SECONDS
R COMBINE WORDS
R 2 WORDS
P R JABBERS
P R COMBINE SYLLABLES
P R DADA/MAMA
NON-SPECIFIC
R SINGLE SYLLABLES
BALANCE EACH FOOT 4 SECS.
18 NAME 1 PICTURE
R 3 WORDS
R DADA/MAMA SPECIFIC
R IMITATE SPEECH SOUNDS
BALANCE EACH FOOT 5 SECS.
18 POINT 4 PICTURES
19 BODY PARTS-6
P R ONE WORD
P
30 HEEL-TO-TOE WALK
SPEECH HALF UNDERSTANDABLE
R 6 WORDS
FOLLOW
5 TO
MIDLINE
BALANCE EACH FOOT 6 SECONDS
18 NAME 4 PICTURES
"bye"
"birdie"
"milk"
"mama"
"babo"
[bobby]
5 FOLLOW 180º
LANGUAGE
23 COUNT 5 BLOCKS
TOWER OF 6 CUBES
C
R WAVE BYE-BYE
26 OPPOSITES-2
10IMITATE VERTICAL LINE
PLAY BALL WITH EXAMINER
Typical
Yes
No
1
2
3
Compliance (See Note 31)
Always Complies
Usually Complies
Rarely Complies
1
2
3
Interest in Surroundings
1
2
3
1
2
3
1
2
3
©1969, 1989, 1990 W. K. Frankenburg and J. B. Dodds©
PERSONAL - SOCIAL
F
F
88%
11 THUMB WIGGLE
R DRINK FROM CUP
F
DEMONSTR.
13 PICK LONGER LINE
FEED DOLL
FOR USE OF THIS FORM, SEE AR 600-75
May pass by report
Footnote no.
(see back of form)
Alert
Somewhat Disinterested
Seriously Disinterested
PULL TO SIT - NO HEAD-LAG
R ROLL OVER
Fearfulness
CHEST UP-ARM
SUPPORT
None
Mild
Extreme
BEAR WEIGHT ON LEGS
SIT-HEAD STEADY
HEAD UP 90º
Attention Span
HEAD UP 45º
Appropriate
Somewhat Distractible
Very Distractible
RLIFT
HEAD
EQUAL
MOVEMENTS
MONTHS
2
4
6
9
12
15
18
24
3
YEARS
4
5
6
Case 3
Daniel is a 2-year old boy who has been in your office at least 5 times this winter for
otitis media. Otherwise, he has been quite well. His mother, Sandra, reports that “he is a
delightful, friendly kid who gets along great with his brother and sisters and Brandy, our
Golden Retriever.” She notes, “Daniel is my quiet one, he talks less than the others but of
course they always talk for him.” You ask Daniel some questions and he smiles at you
but his speech is very difficult to understand. You rely on Sandra to translate for him.
1. Interpretation of Denver II:
a) Normal
b) Suspect
c) Untestable
2. Your next step:
a) Further medical evaluation
b) Refer to Social Services
c) Refer to Early Intervention
d) Refer for School Evaluation
e) Reassure parent, rescreen next visit
When to Watch, When to Refer, When to Reassure
Case #3: “Daniel”
DA FORM 5694, MAY 1988
Denver II
MONTHS
2
Name: Daniel
Birthdate: Case
ID No.:
Examiner:
Date:
#3
YEARS
4
6
9
12
15
18
24
3
4
5
6
R PREPARE CEREAL
R BRUSH TEETH, NO HELP
R PLAY BOARD/CARD GAMES
Percent of children passing
25
50
75
R
4 DRESS, NO HELP
90
R
1 TEST ITEM
RPUT ON T-SHIRT
P
P
P
P
P
13 COPY
R PUT ON CLOTHING
FEED DOLL
14 COPY
16 DRAW PERSON 3 PTS
12 COPY
DEFINE 7 WORDS
F
TOWER OF 8 CUBES
25 DEFINE 5 WORDS
NAME 4 COLORS
24 UNDERSTAND 4 PREPOSITIONS
SCRIBBLES
SPEECH ALL UNDERSTANDABLE
PUT BLOCK IN CUP
20 KNOW 4 ACTIONS
R
2 REGARD OWN HAND
R BANG 2 CUBES
HELD IN HANDS
P SMILE
SPONTANEOUSLY
22 USE OF 3 OBJECTS
23 COUNT 1 BLOCK
9 THUMB-FINGER
GRASP
1 SMILE
RESPONSIVELY
22 USE OF 2 OBJECTS
TAKE 2 CUBES
NAME 1 COLOR
REGARD
FACE
8 PASS CUBE
KNOW 2
ADJECTIVES
RAKE RAISIN
7LOOK FOR YARN
20 KNOW 2 ACTIONS
F
REACHES
(points to
eyes & nose)
HANDS
TOGETHER
6 GRASP
RATTLE
5 FOLLOW PAST
MIDLINE
FOLLOW
5 TO
MIDLINE
P
P
F SPEECH HALF UNDERSTANDABLE
F 18 POINT 4 PICTURES
F 19 BODY PARTS-6
C
F 18 NAME 1 PICTURE
P R COMBINE WORDS
F 18 POINT 2 PICTURES C
P
R DADA/MAMA SPECIFIC
TEST BEHAVIOR
(Check boxes for 1st, 2nd, or 3rd test)
WALK WELL
STOOP AND RECOVER
R SINGLE SYLLABLES
STAND ALONE
TURN TO VOICE
STAND-2 SECS.
17 TURN TO
RATTLING SOUND
R GET TO
SITTING
R SQUEALS
PULL TO
STAND
R LAUGHS
R "OOO/AAH"
STAND
HOLDING ON
R VOCALIZES
SIT-NO
SUPPORT
RESPOND TO BELL
HOPS
BALANCE EACH
FOOT 2 SECONDS
P JUMP UP
P R27 WALK UP STEPS
P RUNS
R WALK BACKWARDS
R IMITATE SPEECH SOUNDS
BALANCE EACH FOOT 3 SECONDS
28 THROW BALL OVERHAND
P KICK BALL FORWARD
R DADA/MAMA
NON-SPECIFIC
BALANCE EACH FOOT 5 SECS.
BALANCE EACH FOOT 4 SECS.
29 BROAD JUMP
P R 2 WORDS
P R ONE WORD
R COMBINE SYLLABLES
30 HEEL-TO-TOE WALK
BALANCE EACH
FOOT 1 SECOND
R 6 WORDS
R 3 WORDS
R JABBERS
BALANCE EACH FOOT 6 SECONDS
18 NAME 4 PICTURES
Typical
Yes
No
1
2
3
Compliance (See Note 31)
Always Complies
Usually Complies
Rarely Complies
1
2
3
Interest in Surroundings
1
2
3
1
2
3
1
2
3
©1969, 1989, 1990 W. K. Frankenburg and J. B. Dodds©
REGARD RAISIN
5 FOLLOW 180º
FINE MOTOR - ADAPTIVE
23 COUNT 5 BLOCKS
21 KNOW 3 ADJECTIVES
P TOWER OF 2 CUBES
P DUMP RAISIN, DEMONSTRATED
P
R FEED SELF
WORK FOR TOY
26 OPPOSITES-2
10IMITATE VERTICAL LINE
P TOWER OF 6 CUBES
P TOWER OF 4 CUBES
R INDICATE WANTS
88%
11 THUMB WIGGLE
R DRINK FROM CUP
R WAVE BYE-BYE
DEMONSTR.
13 PICK LONGER LINE
R REMOVE GARMENT
PLAY BALL WITH EXAMINER
PERSONAL - SOCIAL
16 DRAW PERSON 6 PARTS
R
3 BRUSH TEETH WITH HELP
P R USE SPOON FORK
P R HELP IN HOUSE
R PLAY PAT-A-CAKE
15 COPY
R WASH & DRY HANDS
R IMITATE ACTIVITIES
LANGUAGE
86%
NAME FRIEND
P
FOR USE OF THIS FORM, SEE AR 600-75
May pass by report
Footnote no.
(see back of form)
Alert
Somewhat Disinterested
Seriously Disinterested
PULL TO SIT - NO HEAD-LAG
R ROLL OVER
Fearfulness
CHEST UP-ARM
SUPPORT
None
Mild
Extreme
BEAR WEIGHT ON LEGS
SIT-HEAD STEADY
HEAD UP 90º
Attention Span
HEAD UP 45º
Appropriate
Somewhat Distractible
Very Distractible
RLIFT
HEAD
EQUAL
MOVEMENTS
MONTHS
2
4
6
9
12
15
18
24
3
YEARS
4
5
6
Case 4
Eleanor is a 3-year-old girl who is new to your clinic. Her mother, Susan, reports that she
is healthy but that “She is still not interested in potty training.” Eleanor has been in a
playgroup but seems to prefer playing by herself. She is unable to name a friend other
than “Mommy.” She does not point to the pictures but smiles and repeats “meow” when
you asks “which one says meow.” Despite multiple demonstrations, Eleanor cannot stand
on one foot. After completing a tower of 5 blocks, she looks at both you and her mother,
claps and laughs.
1. Interpretation of Denver II:
a) Normal
b) Suspect
c) Untestable
2. Your next step:
a) Further medical evaluation
b) Refer to Social Services
c) Refer to Early Intervention
d) Refer for School Evaluation
e) Reassure parent, rescreen next visit
When to Watch, When to Refer, When to Reassure
Case #4: “Eleanor”
DA FORM 5694, MAY 1988
Denver II
MONTHS
2
Name: Eleanor
Birthdate: Case
ID No.:
Examiner:
Date:
#4
YEARS
4
6
9
12
15
18
24
3
4
5
6
R PREPARE CEREAL
R BRUSH TEETH, NO HELP
R PLAY BOARD/CARD GAMES
R
4 DRESS, NO HELP
90
R
1 TEST ITEM
May pass by report
Footnote no.
(see back of form)
P
P
P
F RPUT ON T-SHIRT
F NAME FRIEND C
16 DRAW PERSON 6 PARTS
R
3 BRUSH TEETH WITH HELP
P
13 COPY
R PUT ON CLOTHING
14 COPY
16 DRAW PERSON 3 PTS
R USE SPOON FORK
12 COPY
R HELP IN HOUSE
F 11 THUMB WIGGLE
F TOWER OF 8 CUBES
C
F 10IMITATE VERTICAL LINE C
R DRINK FROM CUP
R IMITATE ACTIVITIES
F TOWER OF 6 CUBES
PLAY BALL WITH EXAMINER
25 DEFINE 5 WORDS
24 UNDERSTAND 4 PREPOSITIONS
SCRIBBLES
F SPEECH ALL UNDERSTANDABLE
WORK FOR TOY
PUT BLOCK IN CUP
R
F 20 KNOW 4 ACTIONS
R BANG 2 CUBES
2 REGARD OWN HAND
HELD IN HANDS
F 22 USE OF 3 OBJECTS
P SMILE
SPONTANEOUSLY
9 THUMB-FINGER
F 23 COUNT 1 BLOCK
GRASP
1 SMILE
F 22 USE OF 2 OBJECTS
RESPONTAKE 2 CUBES
SIVELY
F NAME 1 COLOR
REGARD
8 PASS CUBE
FACE
2
F KNOW
ADJECTIVES
RAKE RAISIN
(speech 1/3
7LOOK FOR YARN
F 20 KNOW 2 ACTIONS C
understandable)
BALANCE EACH FOOT 6 SECONDS
REACHES
F 18NAME 4 PICTURES C
30 HEEL-TO-TOE WALK
SPEECH
HALF
UNDERSTANDABLE
REGARD RAISIN
F
C
(points to
BALANCE EACH FOOT 5 SECS.
5 FOLLOW 180º
tummy)
F 18 POINT 4 PICTURES
BALANCE EACH FOOT 4 SECS.
HANDS
F 19 BODY PARTS-6
BALANCE EACH FOOT 3 SECONDS
TOGETHER
P 18 NAME 1 PICTURE
ice"
ju
t
HOPS
an
"w
GRASP
6
R
COMBINE
WORDS
RATTLE
P
BALANCE EACH
F
FOOT
2
SECONDS
P 18 POINT 2 PICTURES
5 FOLLOW PAST
MIDLINE
BALANCE EACH
R 6 WORDS
F FOOT
C
FOLLOW
1 SECOND
5 TO
R 3 WORDS
MIDLINE
F 29 BROAD JUMP C
R 2 WORDS
P 28 THROW BALL OVERHAND
R ONE WORD
P JUMP UP
R DADA/MAMA SPECIFIC
P KICK BALL FORWARD
R JABBERS
P R27 WALK UP STEPS
R COMBINE SYLLABLES
TEST BEHAVIOR
RUNS
R DADA/MAMA
NON-SPECIFIC
(Check boxes for 1st, 2nd, or 3rd test)
R WALK BACKWARDS
WALK WELL
R IMITATE SPEECH SOUNDS
STOOP AND RECOVER
R SINGLE SYLLABLES
STAND ALONE
TURN TO VOICE
STAND-2 SECS.
17 TURN TO
RATTLING SOUND
LANGUAGE
23 COUNT 5 BLOCKS
R GET TO
SITTING
R SQUEALS
PULL TO
STAND
R LAUGHS
R "OOO/AAH"
STAND
HOLDING ON
R VOCALIZES
SIT-NO
SUPPORT
RESPOND TO BELL
Typical
Yes
No
1
2
3
Compliance (See Note 31)
Always Complies
Usually Complies
Rarely Complies
1
2
3
Interest in Surroundings
1
2
3
1
2
3
1
2
3
©1969, 1989, 1990 W. K. Frankenburg and J. B. Dodds©
PERSONAL - SOCIAL
FINE MOTOR - ADAPTIVE
R FEED SELF
26 OPPOSITES-2
NAME 4 COLORS
P DUMP RAISIN, DEMONSTRATED
R PLAY PAT-A-CAKE
88%
DEFINE 7 WORDS
21 KNOW 3 ADJECTIVES
P TOWER OF 4 CUBES
P TOWER OF 2 CUBES
R INDICATE WANTS
DEMONSTR.
13 PICK LONGER LINE
FEED DOLL
R REMOVE GARMENT
R WAVE BYE-BYE
86%
15 COPY
R WASH & DRY HANDS
Alert
Somewhat Disinterested
Seriously Disinterested
PULL TO SIT - NO HEAD-LAG
R ROLL OVER
Fearfulness
CHEST UP-ARM
SUPPORT
None
Mild
Extreme
BEAR WEIGHT ON LEGS
SIT-HEAD STEADY
HEAD UP 90º
Attention Span
HEAD UP 45º
Appropriate
Somewhat Distractible
Very Distractible
RLIFT
HEAD
EQUAL
MOVEMENTS
MONTHS
2
4
6
9
12
15
FOR USE OF THIS FORM, SEE AR 600-75
Percent of children passing
25
50
75
18
24
3
YEARS
4
5
6
Case 5
Shenika is a 4 year old girl who presents for her preschool screening visit. Her older
sister Sharde was followed by you in the past for lead poisoning. Shenika comes right
into the exam room, sits down in the chair next to you and asks, “Are you my doctor? Are
you going to check my heart?” Shenika’s mother Jackie laughs and states that Shenika
“is always talking!” She reports that Shenika loves to fix her own breakfast, dresses
herself and loves to play “Chutes and Ladders” with Sharde. While you are taking the
history, Shenika stacks the blocks and sings her ABCs. She tells you her favorite color is
purple and she begins pointing at different colors around the room and tells you that the
tiles in your office are “salmon.” You attempt to administer a Denver II, but Shenika
refuses activities or laughs and says, “I’m not gonna tell you!” You are able to observe
her during the visit, and gather some information by history from Jackie.
1. Interpretation of Denver II:
a) Normal
b) Suspect
c) Untestable
2. Your next step:
a) Further medical evaluation
b) Refer to Social Services
c) Refer to Early Intervention
d) Refer for School Evaluation
e) Reassure parent, rescreen next visit
When to Watch, When to Refer, When to Reassure
Case #5: “Shenika”
DA FORM 5694, MAY 1988
Denver II
YEARS
4
6
9
Percent of children passing
25
50
75
12
15
18
"she won't
let me
help her"
90
R
1 TEST ITEM
May pass by report
Footnote no.
(see back of form)
24
P
P
P
R
3 BRUSH TEETH WITH HELP
R IMITATE ACTIVITIES
P TOWER OF 6 CUBES
P TOWER OF 4 CUBES
PLAY BALL WITH EXAMINER
R WAVE BYE-BYE
PERSONAL - SOCIAL
PUT BLOCK IN CUP
9 THUMB-FINGER
GRASP
TAKE 2 CUBES
REGARD
FACE
8 PASS CUBE
RAKE RAISIN
7LOOK FOR YARN
"she does
these at
home"
REACHES
REGARD RAISIN
FINE MOTOR - ADAPTIVE
5 FOLLOW 180º
HANDS
TOGETHER
6 GRASP
RATTLE
5 FOLLOW PAST
MIDLINE
R 6 WORDS
FOLLOW
5 TO
MIDLINE
R 3 WORDS
R 2 WORDS
R ONE WORD
R DADA/MAMA SPECIFIC
R JABBERS
P
R COMBINE SYLLABLES
P
TEST BEHAVIOR
(Check boxes for 1st, 2nd, or 3rd test)
R WALK BACKWARDS
STOOP AND RECOVER
R SINGLE SYLLABLES
STAND ALONE
TURN TO VOICE
STAND-2 SECS.
17 TURN TO
RATTLING SOUND
LANGUAGE
R KICK BALL FORWARD
R
27 WALK UP STEPS
WALK WELL
R IMITATE SPEECH SOUNDS
R GET TO
SITTING
R SQUEALS
PULL TO
STAND
R LAUGHS
R "OOO/AAH"
STAND
HOLDING ON
R VOCALIZES
SIT-NO
SUPPORT
RESPOND TO BELL
21 KNOW 3 ADJECTIVES
P 24 UNDERSTAND 4 PREPOSITIONS
P SPEECH ALL UNDERSTANDABLE
P 20 KNOW 4 ACTIONS
P 22 USE OF 3 OBJECTS
P 23 COUNT 1 BLOCK
P 22 USE OF 2 OBJECTS
R NAME 1 COLOR
2
P KNOW
ADJECTIVES
P 20 KNOW 2 ACTIONS
BALANCE EACH FOOT 6 SECONDS
18 NAME 4 PICTURES
R 30 HEEL-TO-TOE WALK
P SPEECH HALF UNDERSTANDABLE
F BALANCE EACH FOOT 5 SECS.
18 POINT 4 PICTURES
R BALANCE EACH FOOT 4 SECS.
19 BODY PARTS-6
R BALANCE EACH FOOT 3 SECONDS
18 NAME 1 PICTURE
R HOPS
"I'm
R COMBINE WORDS
BALANCE EACH
R FOOT
not gonna
2 SECONDS
18 POINT 2 PICTURES
hop!"
BALANCE EACH
R FOOT
1 SECOND
R 29 BROAD JUMP
R 28 THROW BALL OVERHAND
P JUMP UP
RUNS
R DADA/MAMA
NON-SPECIFIC
88%
R 25 DEFINE 5 WORDS
R NAME 4 COLORS
TOWER OF 2 CUBES
R BANG 2 CUBES
HELD IN HANDS
1 SMILE
RESPONSIVELY
P
DUMP RAISIN, DEMONSTRATED
SCRIBBLES
P SMILE
SPONTANEOUSLY
86%
15 COPY
R 11 THUMB WIGGLE
DEFINE 7 WORDS
P TOWER OF 8 CUBES
R 26 OPPOSITES-2
P 10IMITATE VERTICAL LINE
R 23 COUNT 5 BLOCKS
R HELP IN HOUSE
R DRINK FROM CUP
R
2 REGARD OWN HAND
6
P16 DRAW PERSON 6 PARTS
P13 COPY DEMONSTR.
R 13 PICK LONGER LINE
"Can't
make me"
R 14 COPY
P 16 DRAW PERSON 3 PTS
P 12 COPY
R WASH & DRY HANDS
R REMOVE GARMENT
R FEED SELF
5
P RPUT ON T-SHIRT
P NAME FRIEND
R USE SPOON FORK
WORK FOR TOY
R PREPARE CEREAL
R BRUSH TEETH, NO HELP
R PUT ON CLOTHING
R PLAY PAT-A-CAKE
4
P
P R PLAY BOARD/CARD GAMES
P R4 DRESS, NO HELP
FEED DOLL
R INDICATE WANTS
3
Typical
Yes
No
1
2
3
Compliance (See Note 31)
Always Complies
Usually Complies
Rarely Complies
1
2
3
Interest in Surroundings
1
2
3
1
2
3
1
2
3
Alert
Somewhat Disinterested
Seriously Disinterested
PULL TO SIT - NO HEAD-LAG
R ROLL OVER
Fearfulness
CHEST UP-ARM
SUPPORT
None
Mild
Extreme
BEAR WEIGHT ON LEGS
SIT-HEAD STEADY
HEAD UP 90º
Attention Span
HEAD UP 45º
Appropriate
Somewhat Distractible
Very Distractible
RLIFT
HEAD
EQUAL
MOVEMENTS
MONTHS
2
4
6
9
12
FOR USE OF THIS FORM, SEE AR 600-75
2
©1969, 1989, 1990 W. K. Frankenburg and J. B. Dodds©
MONTHS
Name: Shenika
Birthdate: Case #5
ID No.:
Examiner:
Date:
15
18
24
3
YEARS
4
5
6
Case 6
Jacob comes for his 2-year visit. His mother Anna’s biggest concern is that “Jacob has
terrible temper tantrums and doesn’t talk as much as his sister did at his age.” Anna’s
parents have told her not to worry because the temper tantrums are part of “the terrible
twos” and “because you spoil him.” Jacob makes screeching noises but does not use any
words in the office. Anna reports that he struggles when she brushes his hair or tries to
dress him. He does not throw the ball you offer, however he does nearly hit you in the
head when he throws a toy overhand. He jumps up and down and flaps his hands.
1. Interpretation of Denver II:
a) Normal
b) Suspect
c) Untestable
2. Your next step:
a) Further medical evaluation
b) Refer to Social Services
c) Refer to Early Intervention
d) Refer for School Evaluation
e) Reassure parent, rescreen next visit
When to Watch, When to Refer, When to Reassure
Case #6: “Jacob”
DA FORM 5694, MAY 1988
Denver II
MONTHS
2
Name: Jacob
Birthdate: Case
ID No.:
Examiner:
Date:
#6
YEARS
4
6
9
12
15
18
24
3
4
5
6
R PREPARE CEREAL
Percent of children passing
25
50
75
"dressing & brushing
teeth are a
big struggle"
90
R PLAY BOARD/CARD GAMES
R
4 DRESS, NO HELP
R
1 TEST ITEM
RPUT ON T-SHIRT
P
F
F
P
P
F
14 COPY
16 DRAW PERSON 3 PTS
12 COPY
1 SMILE
RESPONSIVELY
F TOWER OF 8 CUBES
26 OPPOSITES-2
F 10IMITATE VERTICAL LINE
23 COUNT 5 BLOCKS
F TOWER OF 6 CUBES C 21
KNOW 3 ADJECTIVES
25 DEFINE 5 WORDS
NAME 4 COLORS
F DUMP RAISIN, DEMONSTRATED
24 UNDERSTAND 4 PREPOSITIONS
P SCRIBBLES
F PUT BLOCK IN CUP
2 CUBES
P RBANG
HELD IN HANDS
repeatedly
lines cubes
up in a
straight
line
9 THUMB-FINGER
GRASP
TAKE 2 CUBES
REGARD
FACE
SPEECH ALL UNDERSTANDABLE
20 KNOW 4 ACTIONS
22 USE OF 3 OBJECTS
23 COUNT 1 BLOCK
22 USE OF 2 OBJECTS
NAME 1 COLOR
8 PASS CUBE
KNOW 2
ADJECTIVES
RAKE RAISIN
F
F 18NAME 4 PICTURES
7LOOK FOR YARN
20 KNOW 2 ACTIONS
REACHES
6 GRASP
RATTLE
"mamma"
F R 6 WORDS
"cookie"
P R 3 WORDS
"train"
"juice" P R 2 WORDS
R 28 THROW BALL OVERHAND
P R ONE WORD
P JUMP UP
R DADA/MAMA SPECIFIC
P KICK BALL FORWARD
R JABBERS
P R27 WALK UP STEPS
R COMBINE SYLLABLES
P RUNS
5 FOLLOW PAST
MIDLINE
FOLLOW
5 TO
MIDLINE
R DADA/MAMA
NON-SPECIFIC
WALK WELL
STOOP AND RECOVER
R SINGLE SYLLABLES
STAND ALONE
TURN TO VOICE
STAND-2 SECS.
17 TURN TO
RATTLING SOUND
R GET TO
SITTING
R SQUEALS
Refuses to
throw ball
but throws
doll overhand.
PULL TO
STAND
R LAUGHS
R "OOO/AAH"
STAND
HOLDING ON
R VOCALIZES
SIT-NO
SUPPORT
29 BROAD JUMP
TEST BEHAVIOR
(Check boxes for 1st, 2nd, or 3rd test)
R WALK BACKWARDS
R IMITATE SPEECH SOUNDS
BALANCE EACH
FOOT 1 SECOND
PULL TO SIT - NO HEAD-LAG
Typical
Yes
No
1
2
3
Compliance (See Note 31)
Always Complies
Usually Complies
Rarely Complies
1
2
3
Interest in Surroundings
1
2
3
1
2
3
1
2
3
©1969, 1989, 1990 W. K. Frankenburg and J. B. Dodds©
FINE MOTOR - ADAPTIVE
HANDS
TOGETHER
RESPOND TO BELL
BALANCE EACH FOOT 6 SECONDS
30 HEEL-TO-TOE WALK
F SPEECH HALF UNDERSTANDABLE
C
BALANCE EACH FOOT 5 SECS.
F 18 POINT 4 PICTURES C
BALANCE EACH FOOT 4 SECS.
19
F BODY PARTS-6
BALANCE EACH FOOT 3 SECONDS
F 18 NAME 1 PICTURE
HOPS
F R COMBINE WORDS
BALANCE EACH
FOOT 2 SECONDS
18
POINT
2
PICTURES
F
REGARD RAISIN
5 FOLLOW 180º
LANGUAGE
88%
11 THUMB WIGGLE
F TOWER OF 4 CUBES
F TOWER OF 2 CUBES
R INDICATE WANTS
P
DEMONSTR.
13 PICK LONGER LINE
FEED DOLL
PLAY BALL WITH EXAMINER
P SMILE
SPONTANEOUSLY
13 COPY
DEFINE 7 WORDS
R WAVE BYE-BYE
R
2 REGARD OWN HAND
16 DRAW PERSON 6 PARTS
C
R REMOVE GARMENT
R DRINK FROM CUP
R PLAY PAT-A-CAKE
15 COPY
C
R PUT ON CLOTHING
P R USE SPOON FORK
F R HELP IN HOUSE
R FEED SELF
86%
NAME FRIEND
R
3 BRUSH TEETH WITH HELP
R IMITATE ACTIVITIES
WORK FOR TOY
F
R WASH & DRY HANDS
FOR USE OF THIS FORM, SEE AR 600-75
May pass by report
Footnote no.
(see back of form)
PERSONAL - SOCIAL
R BRUSH TEETH, NO HELP
Alert
Somewhat Disinterested
Seriously Disinterested
R ROLL OVER
Fearfulness
CHEST UP-ARM
SUPPORT
None
Mild
Extreme
BEAR WEIGHT ON LEGS
SIT-HEAD STEADY
HEAD UP 90º
Attention Span
HEAD UP 45º
Appropriate
Somewhat Distractible
Very Distractible
RLIFT
HEAD
EQUAL
MOVEMENTS
MONTHS
2
4
6
9
12
15
18
24
3
YEARS
4
5
6
Case 7
Heather is 18 months old. Her mother Kathleen brings her to clinic quite worried that
Heather is no longer doing the things she could previously do. Kathleen’s pregnancy,
labor and delivery were uncomplicated. Looking through her chart you note that
Heather’s Denver II screening tests were interpreted as normal during her first year. At
her one-year visit, Heather was just beginning to walk independently, able to put a block
in a cup and said “baba” and “doggie” in addition to “mama” and “papa.”
1. Interpretation of Denver II:
a) Normal
b) Suspect
c) Untestable
2. Your next step:
a) Further medical evaluation
b) Refer to Social Services
c) Refer to Early Intervention
d) Refer for School Evaluation
e) Reassure parent, rescreen next visit
When to Watch, When to Refer, When to Reassure
Case #7: “Heather”
DA FORM 5694, MAY 1988
Denver II
MONTHS
2
Name: Heather
Birthdate: Case #7
ID No.:
Examiner:
Date:
YEARS
4
6
9
12
15
18
24
3
4
5
6
R PREPARE CEREAL
R BRUSH TEETH, NO HELP
R PLAY BOARD/CARD GAMES
Percent of children passing
25
50
75
R
4 DRESS, NO HELP
90
R
1 TEST ITEM
RPUT ON T-SHIRT
86%
NAME FRIEND
15 COPY
R WASH & DRY HANDS
16 DRAW PERSON 6 PARTS
R
3 BRUSH TEETH WITH HELP
13 COPY
R PUT ON CLOTHING
FEED DOLL
14 COPY
F R REMOVE GARMENT
F R USE SPOON FORK
F R HELP IN HOUSE
F
P
P
P
TAKE 2 CUBES
25 DEFINE 5 WORDS
NAME 4 COLORS
24 UNDERSTAND 4 PREPOSITIONS
SPEECH ALL UNDERSTANDABLE
20 KNOW 4 ACTIONS
22 USE OF 3 OBJECTS
23 COUNT 1 BLOCK
22 USE OF 2 OBJECTS
NAME 1 COLOR
REGARD
FACE
8 PASS CUBE
KNOW 2
ADJECTIVES
RAKE RAISIN
7LOOK FOR YARN
20 KNOW 2 ACTIONS
FINE MOTOR - ADAPTIVE
no longer
says any
of these
ma"
"mama"
d
"da a"
"bab gy"
"dog e"
"mor
6 GRASP
RATTLE
R SQUEALS
BALANCE EACH FOOT 5 SECS.
18 POINT 4 PICTURES
HANDS
TOGETHER
5 FOLLOW PAST
MIDLINE
30 HEEL-TO-TOE WALK
SPEECH HALF UNDERSTANDABLE
REGARD RAISIN
5 FOLLOW 180º
FOLLOW
5 TO
MIDLINE
BALANCE EACH FOOT 6 SECONDS
18 NAME 4 PICTURES
REACHES
LANGUAGE
23 COUNT 5 BLOCKS
21 KNOW 3 ADJECTIVES
"she used to
scribble but
can't anymore"
9 THUMB-FINGER
GRASP
26 OPPOSITES-2
10IMITATE VERTICAL LINE
TOWER OF 6 CUBES
F TOWER OF 4 CUBES
F TOWER OF 2 CUBES
C
F DUMP RAISIN, DEMONSTRATED
C
2 CUBES
P RBANG
HELD IN HANDS
1 SMILE
RESPONSIVELY
TOWER OF 8 CUBES
F SCRIBBLES
P PUT BLOCK IN CUP
R FEED SELF
WORK FOR TOY
P SMILE
SPONTANEOUSLY
DEFINE 7 WORDS
PLAY BALL WITH EXAMINER
R WAVE BYE-BYE
88%
11 THUMB WIGGLE
F R IMITATE ACTIVITIES
P R INDICATE WANTS
P R PLAY PAT-A-CAKE
R
2 REGARD OWN HAND
12 COPY
BALANCE EACH FOOT 4 SECS.
19 BODY PARTS-6
BALANCE EACH FOOT 3 SECONDS
18 NAME 1 PICTURE
R COMBINE WORDS
HOPS
BALANCE EACH
FOOT 2 SECONDS
18 POINT 2 PICTURES
BALANCE EACH
F R 6 WORDS
FOOT 1 SECOND
P R 3 WORDS
F
C
29 BROAD JUMP
P R 2 WORDS
F
F28 THROW BALL OVERHAND
P R ONE WORD
F
JUMP UP
P R DADA/MAMA SPECIFIC
F KICK BALL FORWARD
P R JABBERS
F R27 WALK UP STEPS
TEST BEHAVIOR
P R COMBINE SYLLABLES
F RUNS
C
(Check boxes for 1st, 2nd, or 3rd test)
P R WALK BACKWARDS
P R DADA/MAMA
NON-SPECIFIC
P WALK WELL
R IMITATE SPEECH SOUNDS
2
1
Typical
F STOOP AND RECOVER
R SINGLE SYLLABLES
Yes
P STAND ALONE
No
TURN TO VOICE
P STAND-2 SECS.
Compliance
(See Note 31)
17 TURN TO
2
1
RATTLING SOUND
GET TO
P RSITTING
Always Complies
STAND
HOLDING ON
R VOCALIZES
Interest in Surroundings
SIT-NO
SUPPORT
RESPOND TO BELL
3
Usually Complies
Rarely Complies
TO
P PULL
STAND
R LAUGHS
R "OOO/AAH"
3
©1969, 1989, 1990 W. K. Frankenburg and J. B. Dodds©
PERSONAL - SOCIAL
P
16 DRAW PERSON 3 PTS
C
R DRINK FROM CUP
F
DEMONSTR.
13 PICK LONGER LINE
FOR USE OF THIS FORM, SEE AR 600-75
May pass by report
Footnote no.
(see back of form)
1
2
3
1
2
3
1
2
3
Alert
Somewhat Disinterested
Seriously Disinterested
PULL TO SIT - NO HEAD-LAG
R ROLL OVER
Fearfulness
CHEST UP-ARM
SUPPORT
None
Mild
Extreme
BEAR WEIGHT ON LEGS
SIT-HEAD STEADY
HEAD UP 90º
Attention Span
HEAD UP 45º
Appropriate
Somewhat Distractible
Very Distractible
RLIFT
HEAD
EQUAL
MOVEMENTS
MONTHS
2
4
6
9
12
15
18
24
3
YEARS
4
5
6
Case 8
Manuel is a 9-month-old boy who has been coming to your practice since birth for his
well child care. Pregnancy, labor, and delivery were all normal. His mother, Maria, is
concerned that “Manuel still doesn’t sleep through the night and won’t share his toys with
his big brother.”
1. Interpretation of Denver II:
a) Normal
b) Suspect
c) Untestable
2. Your next step:
a) Further medical evaluation
b) Refer to Social Services
c) Refer to Early Intervention
d) Refer for School Evaluation
e) Reassure parent, rescreen next visit
When to Watch, When to Refer, When to Reassure
Case #8: “Manuel”
DA FORM 5694, MAY 1988
Denver II
MONTHS
2
Name: Manuel
Birthdate: Case
ID No.:
Examiner:
Date:
#8
YEARS
4
6
9
12
15
18
24
3
4
5
6
R PREPARE CEREAL
R BRUSH TEETH, NO HELP
R PLAY BOARD/CARD GAMES
Percent of children passing
25
50
75
R
4 DRESS, NO HELP
90
R
1 TEST ITEM
RPUT ON T-SHIRT
86%
NAME FRIEND
15 COPY
R WASH & DRY HANDS
16 DRAW PERSON 6 PARTS
R
3 BRUSH TEETH WITH HELP
13 COPY
R PUT ON CLOTHING
FEED DOLL
14 COPY
R REMOVE GARMENT
16 DRAW PERSON 3 PTS
R USE SPOON FORK
12 COPY
R HELP IN HOUSE
DEFINE 7 WORDS
TOWER OF 8 CUBES
R IMITATE ACTIVITIES
P
P
TOWER OF 4 CUBES
25 DEFINE 5 WORDS
TOWER OF 2 CUBES
NAME 4 COLORS
DUMP RAISIN, DEMONSTRATED
24 UNDERSTAND 4 PREPOSITIONS
R FEED SELF
SCRIBBLES
SPEECH ALL UNDERSTANDABLE
PUT BLOCK IN CUP
20 KNOW 4 ACTIONS
R
2 REGARD OWN HAND
P
P SMILE
SPONTANEOUSLY
R BANG 2 CUBES
HELD IN HANDS
F
1 SMILE
RESPONSIVELY
22 USE OF 3 OBJECTS
23 COUNT 1 BLOCK
9 THUMB-FINGER
GRASP
22 USE OF 2 OBJECTS
P TAKE 2 CUBES
P
P
NAME 1 COLOR
8 PASS CUBE
P
KNOW 2
ADJECTIVES
RAKE RAISIN
7LOOK FOR YARN
20 KNOW 2 ACTIONS
BALANCE EACH FOOT 6 SECONDS
18 NAME 4 PICTURES
REACHES
30 HEEL-TO-TOE WALK
SPEECH HALF UNDERSTANDABLE
REGARD RAISIN
5 FOLLOW 180º
FINE MOTOR - ADAPTIVE
23 COUNT 5 BLOCKS
TOWER OF 6 CUBES
21 KNOW 3 ADJECTIVES
P R WAVE BYE-BYE
F R INDICATE WANTS
P R PLAY PAT-A-CAKE
WORK FOR TOY
REGARD
FACE
BALANCE EACH FOOT 5 SECS.
18 POINT 4 PICTURES
BALANCE EACH FOOT 4 SECS.
19 BODY PARTS-6
HANDS
TOGETHER
BALANCE EACH FOOT 3 SECONDS
18 NAME 1 PICTURE
6 GRASP
RATTLE
R COMBINE WORDS
HOPS
BALANCE EACH
FOOT 2 SECONDS
18 POINT 2 PICTURES
5 FOLLOW PAST
MIDLINE
BALANCE EACH
R 6 WORDS
FOOT 1 SECOND
"he says mama to me
R 3 WORDS
29 BROAD JUMP
but sometimes
R 2 WORDS
28 THROW BALL OVERHAND
calls his
R ONE WORD
JUMP UP
brother
F R DADA/MAMA SPECIFIC
KICK BALL FORWARD
dada"
P R JABBERS
R
27 WALK UP STEPS
TEST BEHAVIOR
P R COMBINE SYLLABLES
RUNS
R DADA/MAMA
(Check boxes for 1st, 2nd, or 3rd test)
R WALK BACKWARDS
P NON-SPECIFIC
FOLLOW
5 TO
MIDLINE
PR
WALK WELL
IMITATE SPEECH SOUNDS
P RSINGLE SYLLABLES
STOOP AND RECOVER
P TURN TO VOICE
STAND ALONE
STAND-2 SECS.
17 TURN TO
RATTLING SOUND
LANGUAGE
26 OPPOSITES-2
10IMITATE VERTICAL LINE
PLAY BALL WITH EXAMINER
F
R SQUEALS
P
R LAUGHS
R "OOO/AAH"
P
R VOCALIZES
P
RESPOND TO BELL
P
R GET TO
SITTING
PULL TO
STAND
STAND
HOLDING ON
SIT-NO
SUPPORT
Typical
Yes
No
1
2
3
Compliance (See Note 31)
Always Complies
Usually Complies
Rarely Complies
1
2
3
Interest in Surroundings
1
2
3
1
2
3
1
2
3
©1969, 1989, 1990 W. K. Frankenburg and J. B. Dodds©
PERSONAL - SOCIAL
P
88%
11 THUMB WIGGLE
R DRINK FROM CUP
"sometimes"
DEMONSTR.
13 PICK LONGER LINE
FOR USE OF THIS FORM, SEE AR 600-75
May pass by report
Footnote no.
(see back of form)
Alert
Somewhat Disinterested
Seriously Disinterested
PULL TO SIT - NO HEAD-LAG
R ROLL OVER
Fearfulness
CHEST UP-ARM
SUPPORT
None
Mild
Extreme
BEAR WEIGHT ON LEGS
SIT-HEAD STEADY
HEAD UP 90º
Attention Span
HEAD UP 45º
Appropriate
Somewhat Distractible
Very Distractible
RLIFT
HEAD
EQUAL
MOVEMENTS
MONTHS
2
4
6
9
12
15
18
24
3
YEARS
4
5
6
When to Watch, When to Refer, When to Reassure
Handout #1: How to Perform the DENVER II
What you need:
The items needed to perform the DENVER II can be purchased from Denver Developmental
Materials, Inc. as a complete set in a carrying case. These include:
•
•
•
•
•
•
red yarn pom-pom
raisins or O shaped cereal
rattle with narrow handle
ten 1-inch square colored wooden blocks
small, clear plastic bottle with 5/8"opening
small bell
•
•
•
•
•
•
small plastic doll
small plastic feeding bottle for doll
red pencil
plastic cup with handle
blank paper
tennis ball
1. Calculate the child’s chronological age.
a) Subtract the child’s date of birth from the date of the examination using 12 months to a year
and 30 days to a month if you need to borrow. For example, if today is 10/18/97 and the
baby’s date of birth is 11/20/95, calculations are performed as follows.
1) months = [(10-1 )+12] - 11 = 10
2) days = (18+30) - 20 =28
3) years = 96-95 = 1
(12) (30)
97 10 18
- 95 11 20
96 21 48
à - 95 11 20
01 10 28
Age = 1 year 10 months 28 days.
b) Adjust for prematurity (if more than 2 weeks early): divide the number of weeks premature
into months and days and subtract from the calculated age. Once a child is over 2 years it
is no longer necessary to correct for prematurity.
2. Using a straight edge, draw a line down the DENVER II Record Form at the appropriate
age line, and write the date of testing at the top of the line.
3. Make the exam as efficient and enjoyable as possible.
a) The best time to perform the DENVER II may be at the beginning of the office visit, before
the child has had a chance to get upset by other procedures. Keep the child fully clothed,
be playful, help the child to relax.
b) Make sure that parents understand that the DENVER II is not an IQ test and that the child
is not expected to pass every item.
c) Ask about “report” items first (these items are identified by an “R”).
d) Perform gross motor items last (after you have gained the child’s confidence and when you
are less likely to lose the child’s attention).
e) Perform items requiring the test kit all at once. Try to keep kit in your lap, and the table
free from distractions as much as possible.
f) In babies, administer all of the items for which the child is supine at one time.
4. Start with easier items (those completely to the left of the line). Proceed next towards the
right. The only exception is when an easier item reveals the answer to a harder item. For
example, a child who has shown that he can copy a square following a demonstration can no
longer be tested to see if he can copy a square without a demonstration.
5. Administer only as many items as you need for your purposes:
a) To see if a child is at risk (a minimum); do three items that are completely to the left of
the line and every item that intersects the age line in each sector. If the child cannot do
any of these items (fails, refuses, has had no opportunity on reported items), keep going
with items to the left of the line until child passes three items in each sector.
b) To test strengths , proceed as above but also administer every item intersected by the line
and continue towards the right until three failures are recorded in each sector.
6. Be strategic to minimize time needed to complete the DENVER II:
a) Allow the child to play with the toys in the kit during the parent interview. The child may
complete numerous tasks even before the testing starts.
b) Give the child paper and pencil and allow him/her to draw.
7. The child may attempt (and be shown) each item 3 times. After that, item should be
marked “fail.” You may document the ability to pass on subsequent trials in your notes.
8. Fill in the “Test Behavior” box in the lower right hand corner. This describes features of
the child’s performance that may help you better interpret test results. If a toddler is having a
temper tantrum during the session, results of the testing are unlikely to reflect the child’s best
performance. Ask the parent if the child’s behavior is typical. Fill in the other observations
yourself.
9. Scoring: every item should be marked with one of the following:
P = pass
F = fail
N.O. = no opportunity (e.g., for reported items—it would not be accurate to “fail” a child on
tooth brushing when she has never been allowed to brush her teeth).
R = refusal (Child refuses to do test item). Minimize these by telling the child to do the item.
Say, “Feed the baby?” rather than asking “Do you want to feed the baby?” Enlist the
care-giver as your ally.
10. Interpreting individual items:
Advanced = passing an item completely to the right of the age line (advanced items are not
used in interpreting the examination).
Normal = failing or refusing an item completely to the right of the age line; passing, failing or
refusing an item in which the age line intersects the white (<75%) portion of the item bar
(normal items are not used in interpreting the examination).
Caution = failing an item in which the age line intersects the dark (75-90%) portion of the
item bar
Delayed = failing or refusing an item completely to the left of the age line
No Opportunity = reported items the child has not had a chance to try
11. Interpreting the test as a whole:
Normal = no delays, and maximum of one caution
Suspect = two or more cautions, or one or more delays
Untestable = refusal on one or more items completely to the left of the age line or on more
than one item intersected by the age line in the 75-90% (dark) area.
12. What to do next: The DENVER II manual suggests that you should retest a child in 1-2
weeks if the interpretation is suspect or untestable. If the Denver II profile is very suspicious, you
should refer the child right away.
When to Watch, When to Refer, When to Reassure
Handout #2: Early Intervention and School Referral
I. Early Intervention:
What are Early Intervention Programs (EIP)?
Early Intervention programs are designed to provide integrated developmental services for eligible children
ages birth to three years. Early Intervention is administered by the Department of Public Health. Early
Intervention programs have teams of professionals including: occupational and physical therapists, speech
therapists, developmental educators, social workers, nurses and psychologists. The teams rely on an
interdisciplinary (multiple disciplines working together) and transdisciplinary (members of the team cross
discipline boundaries incorporating information from other team members into their work) models and
strive to provide family focused care.
What are eligibility criteria?
1.The child has a known disabling physical or mental condition including but not limited to diagnosed
chromosomal, neurological, metabolic disorders; visual or hearing impairment not corrected by medical
intervention or prosthesis; or the presence of a delay in one or more areas of development, including
cognitive development, physical development, vision, hearing, communication development, adaptive
development, or psychosocial development.
OR
2. Any four or more risk factors from either of the two following lists are present:
Child Characteristics
Family Characteristics
*Birthweight <1200 grams
*Gestational age <32 weeks
*NICU admission more than 5 days
*Diagnosis of intrauterine growth retardation
(IUGR) or small for gestational age (SGA)
*Weight or height <5% for age; weight for height
<5%; weight for age dropped >2 major centiles in 3
mo for children <12 mo of age (or in 6 mo. for
children 12-24 mo. of age)
*Chronic feeding difficulties
*Insecure attachment/interactional difficulties
*Blood lead levels > 15 mg/dl
*Suspected central nervous system abnormality
*Multiple trauma or losses
*Maternal age at child’s birth <17 or maternal
history of 3 or more births before age 20
*Parental chronic illness or disability affecting
care giving ability
*Family lacking social supports
*Inadequate food, shelter, clothing
*Open or confirmed protective service case
*Substance abuse in the home
*Domestic violence in the home
Guideline:
Developmental delay by age and number of months delayed
AGE
DELAY BY
6 months
1.5 months
12 months
3 months
18 months
4 months
24 months, 30 months
6 months
Who can refer to EIPs?
Physicians, nurses, social workers, teachers, parents can all refer to Early Intervention.
How does one make a referral?
A referral should be make directly to the Early Intervention Program located near the family. A book listing
the programs in your area should be available in every primary care setting. Referral should include the
following information: names of child and parent(s), address, phone number (home and work), child’s date
of birth, primary care provider, other involved services, physicians, reason for referral, and insurance
coverage.
What happens after a referral to an EIP?
Within 45 working days an assessment will take place and an Individualized Family Service Plan will be
developed by the Early Intervention team along with family members. The IFSP documents the goals and
resources of the family and the services that will be provided by Early Intervention.
How is Early Intervention funded?
EI evaluation and services are funded through the Department of Public Health, private insurance, and
Medicaid.
II. School Services
Children with special needs are eligible for special services in the public school system. There are several
relevant pieces of legislation:
Federal:
The Individuals with Disabilities Education Act (IDEA, formerly entitled the Education of the
Handicapped Act, often referred to as P.L. 94-142) calls for a free public education for all children in the
least restrictive environment which meets their learning needs.
Section 504 of the Rehabilitation Act of 1973 is the federal civil rights law that prohibits recipients of
federal funds from discriminating against otherwise qualified disabled persons.
State:
State laws vary from state to state. As an example, in Massachusetts, Chapter 766 is the state version of the
Federal law.
Who can refer to School Services?
Physicians, nurses, social workers, teachers, parents can make direct referrals.
How does one make a referral?
There is a formal process whereby any child may be referred to their local public school system for an
evaluation to determine if there are any special learning needs. Parents must specifically request such an
evaluation before the process can begin.
What happens after a referral to School Services?
Following the evaluation, the school staff meets with the parents to present the results and drafts an
Individualized Educational Plan (IEP) if such needs are identified. The IEP includes an individual student
learning profile, a list of objectives, and documentation of the specific services to be provided. Parents
may then sign the plan, indicating their agreement and the services will start. Parents also have a right to
dispute the results and request an outside opinion.
There are a number of models or prototypes for providing special education and the “least restrictive”
environment which meets the child’s needs is used. These prototypes range from services provided within
a regular classroom, to some services given in a resource room, to all academics taught in a resource room
or separate small classroom.
When to Watch, When to Refer, When to Reassure
Bibliography:
1. First L, Palfrey J. The infant or young child with developmental delay. New England Journal of Medicine 1994;
330:478-483.
2. Dworkin PH. Developmental screening: (still) expecting the impossible? [comment]. Pediatrics 1992; 89:1253-5.
3. Frankenburg W, Dodds J, Archer P, Shapiro H, Bresnick B. The DENVER II: A major revision and
restandardization of the Denver Developmental Screening Test. Pediatrics 1992; 89:91-97.
4. Frankenburg W, Dodds J, Archer P, et al. DENVER II: Training Manual. Denver: Denver Developmental
Materials, Inc.; 1992
5. American Academy of Pediatrics Committee on Children with Disabilities. Screening infants and young children
for developmental disabilities. Pediatrics 1994;93:863-5.
6. Wachtel RC, Shapiro BK, Palmer FB, Allen MC, Capute AJ. CAT/CLAMS. A tool for the pediatric evaluation of
infants and young children with developmental delay. Clinical Adaptive Test/Clinical Linguistic and Auditory
Milestone Scale. Clinical Pediatrics 1994; 33:410-5.
7. Glascoe FP, Martin ED, Humphrey S. A comparative review of developmental screening tests. Pediatrics 1990;
86:547-54.
8. Dworkin PH. Detection of behavioral, developmental, and psychosocial problems in pediatric primary care
practice. Current Opinion in Pediatrics 1993; 5:531-6.
9. Glascoe FP, Dworkin PH. Obstacles to effective developmental surveillance: errors in clinical reasoning. Journal
of Developmental & Behavioral Pediatrics 1993; 14:344-9.
10. Glascoe FP, Dworkin PH. The role of parents in the detection of developmental and behavioral problems.
Pediatrics 1995; 95:829-36.
11. Green M, editor. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents.
Arlington: National Center for Education in Maternal and Child Health; 1994.
12. Green M, Palfrey, JS, editors. Bright Futures: Guidelines for Health Supervision of Infants, Children, and
Adolescents, Second edition. Arlington, VA : National Center for Education in Maternal and Child Health; 2000.
Suggested Readings (Annotated)
First LR and Palfrey JS. The Infant or Young Child with Developmental Delay. The New England Journal of
Medicine 1994;330:478-483. This review article reinforces the importance of early identification of developmental
delay and provides a step by step approach in developmental assessment appropriate for the primary care clinician.
Gilbride, KE. Developmental Testing. Pediatrics in Review 1995;16(8):338-45. This review article outlines the
battery of developmental screening and testing measures most commonly used. It delineates the role of each measure
in a child’s overall assessment based on the validity, sensitivity, specificity, and population for which the tests were
designed.
McInerny TK. Children who have difficulty in school: A primary pediatrician’s approach. Pediatrics in Review
1995;16(9):325-32. This article presents a comprehensive overview of management of school failure in primary care
office practice. It includes a discussion of the etiologies, a guide to diagnosis, a list of commonly used tests, and
clinician’s guide to management strategies.
Resources:
The DENVER II Test forms and DENVER II Test Kit, as well as training materials including The DENVER II Training
Videotape (Introduction), The DENVER II Item Administration Videotape, The DENVER II Training Manual, and
The DENVER II Technical Manual, may be purchased directly from:
Denver Developmental Materials, Inc.
PO Box 6919
Denver, CO 80206-0919
Tel. 1-800-419-4729