Health and Social Development, Faculty of (Okanagan)
Non UBC
Nursing, School of (Okanagan)
DSpace
Children 11 (6): 745 (2024)
Kurbatfinski, Stefan
Komanchuk, Jelena
Dosani, Aliyah
Letourneau, Nicole
Valid and reliable developmental screening and assessment tools allow professionals to identify disabilities/delays in children, enabling timely intervention to limit adverse lifelong impacts on health. However, differences in child development related to culture, genetics, and perinatal outcomes may impact tool applicability. This study evaluated the validity, reliability, and accessibility of multidomain developmental screening tools for young children, analyzed the applicability of tools across different contexts, and created a compendium of tools. Employing adapted realist review methods, we searched APA PsycInfo, MEDLINE, CINAHL, ERIC, and Google to identify relevant articles and information. We assessed accessibility, validity, reliability, and contextual applicability (N = 4110 evidence sources) to create tool ratings and make recommendations. Of 33 identified tools, 22 were screening and 11 were assessment tools. Fewer screening tools than assessment tools were rated highly overall. Evidence for use in different cultures was often lacking for both types of tools. The ASQ (screening) and BDI (assessment) tools were rated most favorably and are recommended for use, though other tools may be more applicable in different contexts (e.g., NEPSY among children with Asperger’s Syndrome). Future research should focus on assessing the validity and reliability of tools across different demographics to increase accessibility and ensure all children are properly supported.
Citation: Kurbatfinski, S.;Komanchuk, J.; Dosani, A.;Letourneau, N. Validity, Reliability,Accessibility, and Applicability ofYoung Children’s DevelopmentalScreening and Assessment Toolsacross Different Demographics: ARealist Review. Children 2024, 11, 745.https://doi.org/10.3390/children11060745Academic Editor: Pietro MuratoriReceived: 28 May 2024Revised: 9 June 2024Accepted: 16 June 2024Published: 18 June 2024Copyright: © 2024 by the authors.Licensee MDPI, Basel, Switzerland.This article is an open access articledistributed under the terms andconditions of the Creative CommonsAttribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).childrenReviewValidity, Reliability, Accessibility, and Applicability of YoungChildren’s Developmental Screening and Assessment Toolsacross Different Demographics: A Realist ReviewStefan Kurbatfinski 1 , Jelena Komanchuk 2 , Aliyah Dosani 3 and Nicole Letourneau 4,*1 Department of Community Health Sciences, Cumming School of Medicine, University of Calgary,Calgary, AB T2N 1N4, Canada; stefan.kurbatfinski@ucalgary.ca2 Faculty of Health and Social Development, School of Nursing, University of British Columbia Okanagan,Kelowna, BC V1V 1V7, Canada; jelena.komanchuk@ubc.ca3 Faculty of Health, Community and Education, School of Nursing and Midwifery, Mount Royal University,Calgary, AB T3E 6K6, Canada; adosani@mtroyal.ca4 Faculties of Nursing & Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada* Correspondence: nicole.letourneau@ucalgary.caAbstract: Valid and reliable developmental screening and assessment tools allow professionals to identifydisabilities/delays in children, enabling timely intervention to limit adverse lifelong impacts on health.However, differences in child development related to culture, genetics, and perinatal outcomes mayimpact tool applicability. This study evaluated the validity, reliability, and accessibility of multidomaindevelopmental screening tools for young children, analyzed the applicability of tools across differentcontexts, and created a compendium of tools. Employing adapted realist review methods, we searchedAPA PsycInfo, MEDLINE, CINAHL, ERIC, and Google to identify relevant articles and information.We assessed accessibility, validity, reliability, and contextual applicability (N = 4110 evidence sources) tocreate tool ratings and make recommendations. Of 33 identified tools, 22 were screening and 11 wereassessment tools. Fewer screening tools than assessment tools were rated highly overall. Evidencefor use in different cultures was often lacking for both types of tools. The ASQ (screening) and BDI(assessment) tools were rated most favorably and are recommended for use, though other tools may bemore applicable in different contexts (e.g., NEPSY among children with Asperger’s Syndrome). Futureresearch should focus on assessing the validity and reliability of tools across different demographics toincrease accessibility and ensure all children are properly supported.Keywords: child development; multidomain development tools; screening; assessment; validityand reliability1. IntroductionChild development is shaped significantly by caregiving environments [1,2], genet-ics [3], determinants of health [4], and other health outcomes (e.g., asthma; [5]), interactingconcomitantly to exert positive or negative impacts. Researchers and health profession-als specializing in child development often subdivide child development into four maindomains: physical (gross and fine motor), cognitive, social–emotional, and language(Table 1; [6]). Delays in certain domains can lead to health sequelae, such as behavioralconcerns, that may persist throughout the lifetime without intervention [7]. Early screeningor assessment of children’s developmental trajectories before school age permits the identi-fication of children’s diverse developmental needs, timely intervention if warranted, andprevention of poorer quality of health across the lifespan [8]. Therefore, valid (tools thataccurately measure what they are designed to measure) and reliable (tools that reproducesimilar results when used again) means of screening and assessing young children’s (new-borns to five-year-olds) development are critical to ensuring that early intervention andChildren 2024, 11, 745. https://doi.org/10.3390/children11060745 https://www.mdpi.com/journal/childrenChildren 2024, 11, 745 2 of 16resources are provided to caregivers in a timely manner to promote healthier developmentover the lifespan [7,9]. However, ascertainment of the validity and reliability of childdevelopment tools across various caregiving, genetic, and perinatal determinants of healthis required to increase applicability and accessibility and ensure child development is beingaccurately screened and assessed.Table 1. Definitions of commonly cited developmental domains [6].Developmental Domain DefinitionMultidomain tools Refers to three or more developmental domains.PhysicalRefers to children’s physical health and development (e.g., growth, muscle movement andcoordination, nutrition, and physiological functioning). Muscle movement and coordination are oftensubdivided into two categories: (1) gross motor (those pertaining to larger muscle movements) and(2) fine motor (those pertaining to smaller, more refined muscle movements).CognitiveRefers to the cognitive level and functioning of the child, including but not limited to executivefunctioning, impulse control, reasoning, learning competencies, and problem solving. The ability toadapt and self-regulate also falls under this developmental domain; however, it may be considered afifth developmental domain.Social–emotionalRefers to the ability of children to regulate their emotions, engage in social environments,build/maintain relationships, and have good overall social and emotional health. Behavioral concernsoften manifest when there are underlying social–emotional health issues (e.g., mental health).Language Refers to the ability to communicate, recognize and differentiate sounds, and have literacy skills.1.1. Caregiving Environments, Genetics, and Child DevelopmentEarly environments significantly impact child development, affecting how children behave,respond, and communicate in school, recreational, and other settings [1,2]. Children residingin secure and safe households with caregivers that engage in developmentally appropriateinteractions are more likely to acquire the stimulation they need for optimal developmentand longevity [3,10]. Conversely, children who experience adverse childhood experiences(e.g., physical abuse) are at risk for developmental challenges [2,3]. Studies support the positiveassociation between adverse childhood experiences and worsened child developmental out-comes, which can manifest as behavioral challenges, issues with learning and conduct, socialand communicative challenges, attachment insecurity, worsened motor movements, and othermental or physical health problems [11,12]. Tools that are sensitive to childhood adversity canhelp healthcare professionals identify potentially injurious interactions occurring within thehousehold and help predict future developmental milestones, allowing for the promotion ofhealthier familial functioning and better monitoring of children’s development.Children may also inherit genetic factors that promote or challenge their develop-ment trajectories (e.g., global developmental delay; [3]). For example, abnormalities incertain neurotransmitters or chromosomes that affect chemical signaling and genetic expres-sion can disrupt children’s appropriate physiological responses to environmental stimuli(e.g., caregiving; [3,13]). Further, certain genotypes may act advantageously in certain con-ditions while serving disadvantageously in others, reflecting the differential susceptibilityphenomenon [14]. On the other hand, children who inherit an irregular number of chromo-somes are at risk of developing certain health conditions (e.g., Down syndrome), alteringhow the developmental trajectory is expected to progress [15]. If healthcare professionalsare aware that children have certain genotypes or different chromosomal numbers than ex-pected, they can apply valid and reliable child development tools when available to monitorand predict development and provide adequate support [16]. Overall, the interplay betweennurture (caregiving environment) and nature (genetics) can result in positive (e.g., secureattachment) or negative (e.g., insecure attachment) developmental outcomes through epige-netic mechanisms [17–19]. High-quality screening and assessment tools, characterized byreliable and valid psychometric properties, are essential to ensure children’s development isbeing measured accurately in the context of various genotypes and epigenetic expressions.Children 2024, 11, 745 3 of 161.2. Perinatal Health FactorsPerinatal factors such as birthweight, gestational age, and the childbirth process cansignificantly impact children’s development [20–22]. Low birthweight in children andpreterm births are associated with complications in earlier years with attenuated ratesof growth [20,21], resulting in delayed attainment of developmental milestones and chal-lenges with behavior [22]. Complications during childbirth can also impact children’sdevelopment. For example, some studies have reported increased externalizing behav-iors (e.g., hyperactivity) among 11-year-old children born with birth complications suchas breech birth [23] or increased odds of behavioral problems among children born viacesarean section [24]. Another study team suggested similar outcomes among infants, evenin cases of mildly stressful birth deliveries [25]. Comprehensive screening and assessmenttools must also consider how children’s developmental trajectories may differ based ontheir perinatal outcomes and be sensitive to such differences. If tools are predictive ofhow child development is expected to progress in the context of these various perinataloutcomes, healthcare professionals can better intervene and attempt to minimize or evenprevent the impacts on developmental outcomes.1.3. Consideration of the Determinants of Health in Young Children’s Developmental ToolsDeterminants of health (e.g., race, sex, income, caregivers’ educational attainment) canadvantageously or disadvantageously influence a child’s positioning within society as wellas their developmental trajectories [4,26]. Marginalized children are less likely to acquire thecare they need in healthcare settings that are discriminatory [27]. Female children are morelikely to ascertain certain developmental milestones on average than male children, andvice versa [28]; female children are also more at risk of experiencing gender-based violenceand inequities within educational and employment settings [29]. Additionally, other factors,such as cultural expectations, can influence how children interact with others in their earlyyears and engage in different environments [30,31]. For example, cultures encouragingartistic expression may place significant emphasis on linguistic development, and thoseupholding gender stereotypes may observe differences in developmental domains due togender expectations [30,32]. Tools that measure child development without evidence of cross-cultural applicability may produce erroneous developmental scores, referred to as culturalbias [30], and while tools are often adapted to overcome language barriers and aid in culturalapplicability, adaptations may affect the reliability and validity of these measures [30].Therefore, translated tools must also be completed in such a way that the questions continueto measure the intended outcome, undergoing their own psychometric analysis to ensurethey are not only valid and reliable but also sensitive to cultural differences [33].1.4. Assessment versus Screening ToolsIt is important to note that tools can differ in their overall purpose. Screening tools(e.g., the Ages and Stages Questionnaire (ASQ)) may provide healthcare professionals witha preliminary understanding of whether children may be at risk of a certain developmentaldelay [8,34]. These tools often do not require any specialized training to be employed. Theyprovide insight on whether a more comprehensive assessment is necessary but are notdiagnostic [8,34]. On the other hand, assessment tools (e.g., Bayley Scales of Infant andToddler Development (BSID)) provide more detailed understandings of developmentaloutcomes, allowing for diagnoses and subsequent treatment recommendations [8]. Theyoften require specialized training prior to use and more time to complete, but they canprovide a diagnosis that enables subsequent healthcare support [8]. Understanding thedifferences between the two is important when considering their use in clinical and researchsettings, as the former may not truly capture the development of a child and lead to incorrectdiagnoses if used alone, while the application of the latter can be time-consuming andresource-intensive if unnecessary.Children 2024, 11, 745 4 of 161.5. Purpose of the StudyOther researchers have completed reviews on existing screening and assessment tools forchild development [35–37]; however, they do not provide a description of their use in differentcontexts (i.e., genetic, cultural, and perinatal factors) while also considering accessibility(e.g., cost). Because tools’ applicability in measuring child development can be impactedby cultural variability [38], genetic and inherited conditions [39], and other clinical/healthgroups [40], this comprehensive realist review aims to (1) provide a pragmatic compendium ofliterature evaluating the accessibility (i.e., cost, administration time, and training requirements),validity, and reliability of multidomain child development screening and assessment toolsand (2) highlight the literature discussing their use in different cultural and clinical groups(applicability). Findings from this review can guide healthcare professionals in choosing theoptimal tool when screening or assessing children’s development.2. Methods2.1. Review MethodologyThis study employed an adaptation of pragmatic realist review methods to identifymultidomain developmental child tools and to distinguish how, how well (e.g., psycho-metrics), for whom, and when these tools are used [41,42]. Searches were initiated inMay 2020 and updated from December 2022 to January 2023, reviewing a large body ofliterature. While realist review methods excel at producing explanations, only tentativerecommendations may be drawn [41]. Therefore, to enable more concise recommendations,tools were evaluated based on pre-specified rating criteria developed by our team after anexamination of existing literature.2.2. Search Strategy and Inclusion CriteriaTo be included, tools were (1) described as multiple developmental domains (more thantwo to increase applicability), (2) still in use, and (3) designed for young children (newbornsto five-year-olds). We first searched concepts including “early childhood development” AND“language”, “cognitive”, “mental”, “motor”, “communication”, AND “screening tool” or “psy-chometrics” on APA PsycInfo to identify child development tools, retrieving 496 evidencesources. Backward and forward searches helped identify other developmental tools. We thensearched APA PsycInfo, MEDLINE, CINAHL, and ERIC with the names of identified tools, re-sulting in 4110 evidence sources. Backward and forward searches also supported the saturationof data collection. After this, we searched through gray literature via Google to collect otherpertinent information about tools (e.g., costs and time to administer). We included evidencesources in English that provided general information about the included tools, examined theirvalidity and reliability, or described their use in different contexts. We provide definitions of thesubtypes of validity and reliability considered in this review (Table 2).Table 2. Definitions of different validities and reliabilities considered in this review.Psychometric Term DefinitionStructural, discriminant,and discriminative validitySubtypes of construct validity reflecting the ability of a tool to measure what it is actually designed tomeasure. Structural validity ensures that a tool is measuring its hypothesized construct. Discriminantvalidity measures whether constructs that are supposed to be unrelated are in fact unrelated.Discriminative validity measures whether a tool can differentiate between groups that are expectedto differ on the construct of interest [43].Concurrent andconvergent validityThough convergent validity is a subtype of construct validity and concurrent validity is a subtype ofcriterion validity, both provide a measure reflecting a tool’s performance relative to another tooldesigned to measure the same concept. Concurrent validity is assessed with a criterion (the goldstandard), and convergent validity is utilized in the absence of a gold standard [43]. Whileconducting this review, consensus appeared to be lacking on what tools comprise the gold standardfor evaluating child development. Therefore, we grouped these categories together.Children 2024, 11, 745 5 of 16Table 2. Cont.Psychometric Term DefinitionPredictive validity A subtype of criterion validity reflecting a tool’s performance relative to a criterion’s (the goldstandard) performance on an outcome that is in the future [43].Internal consistencyreliabilityA measure describing how consistently the items on a tool measure a variable or behavior of interestwithin a short time period, reflecting a ratio of variance of true versus observed scores [44].Intra-rater reliability A measure considering the scores retrieved from a measure completed by the same individual at twodifferent time points [45].Inter-rater reliability A measure comparing the scores retrieved from a measure by two different individuals, examiningtheir agreement [45].2.3. Data Collection and AnalysisAll studies captured by the search were entered into individualized Excel spreadsheetsdesigned for each tool. Three individuals (SK, JK, EP) independently participated inscreening, first reviewing the titles and abstracts for eligibility. Studies that includedvalidity and reliability analyses and described contextual applications were highlighted foreach tool, and the data were then extracted onto the same spreadsheet. Two authors (SK, JK)completed data extraction and saturation with high agreement based on a preliminary testof 50 articles (December 2022 to April 2023). We excluded some studies and test manualsdue to an inability to locate or access them despite our best efforts (an appropriate approachwithin realist review methods; [41]).Tools were divided and compared in terms of their use in screening or assessment.Saturation was achieved when identifying up to three papers (excluding the test manual)with evidence of high validity or reliability for each respective type, with the most recentpapers used first. We reviewed the cost, time, training, applicability, validity, and reliabilityof the included tools, initially rating them by their validity, reliability, and contextualapplication and then by their cost, time, and training; all the criteria led to an overallrating. However, validity, reliability, and contextual application largely contributed tothe overall rating given the need for psychometric evidence to ensure accurate screeningand assessment before considering accessibility. We developed rating ranges (i.e., low,moderate, and high) for costs, time to administer, and training to create a relatively fairdistribution of the tools while also ensuring that ranges were sensibly based on the type oftool being examined (screening versus assessment).For validity and reliability, a low rating indicated no evidence sources supporting highreliability and/or validity for each respective type beyond the test manual, a moderaterating indicated that there were two evidence sources supporting high reliability and/orvalidity for each respective type (along with the test manual, if available), and a highrating indicated that there was evidence from more than two publications (excluding thetest manual) supporting high reliability and/or validity for each respective type. With aslightly more liberal approach compared to other literature, we included any reliability orvalidity estimates with correlation coefficients above 0.40 (moderate to high correlation; [46])and estimates using other coefficients (e.g., Cronbach’s alpha, sensitivity, and specificity)above 0.70 (moderate to high estimates; [47,48]); we considered any values below thesecoefficients as a lack of evidence for validity or reliability and thus excluded these studies.Due to substantial similarity in versions of the same tool, we reported on tool validity andreliability based on more recent versions first. We also discussed the use of tools in differentcultural and clinical groups in terms of available sources, but more detailed informationcan be found in Table S1 of Supplementary Materials.3. ResultsThis review captured 41 tools that assessed multiple developmental domains. Of those,eight were removed due to being discontinued or no longer in use, including the ABILITIESIndex [49], Cognitive Ability Scale [50], Developing Skills Checklist [51], DevelopmentalChildren 2024, 11, 745 6 of 16Activities Screening Inventory [52], Developmental Observational Checklist System [53],Diagnostic Inventory for Screening Children [54], Gesell Developmental Schedules [55], andMiller Assessment for Preschoolers [56]. Therefore, we included 33 tools (Table 3). Despiteusing systematic methods in this realist review, applying important search concepts, andconducting backward and forward approaches in searches, we are aware and acknowledgethat the review did not capture all existing screening and assessment tools for youngchildren; nevertheless, we collected an impressively large body of literature on 33 youngchild development tools. Information including the domains assessed, age group, trainingand cost, administration, and use in different cultural and health groups for the includedtools is provided (see Supplementary Materials, Table S1). Validity and reliability resultsare also provided (see Supplementary Materials, Table S2).Table 3. Included tools (n = 33) and their abbreviations.Tool Name Abbreviation Tool Name AbbreviationScreening Tools (n = 22) Screening Tools Continued (n = 22)Ages and Stages Questionnaire ASQ Parents’ Evaluation of DevelopmentalStatus Developmental Milestones PEDS DMAustralian Developmental Screening Test ADST Preschool Developmental Assessment Scale PDASBayley Infant Neurodevelopmental Screener BINS Revised Denver PrescreeningDevelopmental Questionnaire R-PDQ/PDQ-IIBRIGANCE Screens III BRIGANCE Shoklo Developmental Test SDTChild Development Inventory CDI Toddler Language and Motor Questionnaire TLMQChild Development Review CDR Assessment Tools (n = 11)Copenhagen Infant Mental Health Screening CIMHS Assessment, Evaluation, and ProgrammingSystem for Infants and Children AEPSDevelopmental Assessment of Young Children DAYC Battelle Developmental Inventory BDIDenver Developmental Screening Test DDST Bayley Scales of Infant and ToddlerDevelopment BSIDDevelopmental Indicators for theAssessment of Learning DIALCapute Scales (Cognitive AdaptiveTest/Clinical Linguistic and AuditoryMilestone Scale)CAT/CLAMSDevelopmental Profile DP Child Observation Record (COR) Advantage COREarly Screening Inventory—Revised ESI-R Comprehensive Developmental Inventoryfor Infants and Toddler CDIITEarly Screening Profiles ESP Gesell Developmental Observation Revised GDO-RInfant Development Inventory IDI Griffiths Mental Development Scales GMDSInfant–Toddler Checklist ITC Mullen Scales of Early Learning MSELNipissing District Development Screen(Looksee Checklist) NDDSNEPSY: A DevelopmentalNeuropsychological Assessment NEPSYParents’ Evaluation of Developmental Status PEDS Vineland Adaptive Behavior Scales VABS3.1. Comparing Screening Tools3.1.1. Comparing the Validity, Reliability, and Contextual Application of Screening ToolsFor each respective form of reliability and validity, many screening tools were rated“low” (Table 4), implying that no evidence sources of validity or reliability were available.However, the ASQ consistently rated highly across all three forms of reliability and validity,providing strong psychometric evidence for the developmental screening of young children.Except for inter-rater reliability, the DIAL also rated highly on all other psychometric forms,reflecting its potential as another valid and modestly reliable screening tool. The DDSTrated highly on all forms of reliability, suggesting that it is a reliable screening tool butChildren 2024, 11, 745 7 of 16less valid due to a lack of high evidence for structural, discriminant, or discriminative andpredictive validity. All three tools also demonstrated use in a variety of clinical groups.The ASQ had studies completed among children with epilepsy, complex congenital heartdisease, low birthweight, early gestational age, and cancer, whereas the DDST was usedamong children with sickle cell anemia and the DIAL among children with autism spectrumdisorder. Other tools with lower validity and reliability also demonstrated evidence foruse among highly specific clinical groups (e.g., the DAYC in conjunction with magneticresonance detects cerebral palsy). Of the three tools, the ASQ and DDST demonstratedcompelling evidence for use across several different cultures, whereas the DIAL lackedevidence for use in cultural groups outside the United States. All three tools (alongsideother screening tools) demonstrated limited evidence for use in Central and South America,Africa, and Australia. While other screening tools showed use across different clinical andcultural groups, a lack of affordability, validity, and reliability limited further discussion oftheir use in healthcare settings.Table 4. Screening tool (n = 22) comparison of cost, administration time, training, and psychometrics.Cost (Low = Costs Higher than USD 400,Moderate = Costs between USD 100 and400, High = Costs Lower than USD 100)Administration Time (Low = Time to Complete IsMore than 30 min; Moderate = Time to Complete Is10 to 30 min; High = Time to Complete Is Less than10 min)Training Required (Low = Professional withFormal Education and Training (e.g., SpecificDegrees); Moderate = Some Training(e.g., Working with Children) and aProfessional or Supervised Caregiver;High = Little to No Training to Administer)Low ADST, BRIGANCE, DAYC, DDST, DIAL,DP, ESP DDST, DIAL, DP, ESP DAYC, DDST, DIAL, DP, ESI-R, ESP, SDTModerate ASQ, BINS, CDI, ESI-R, ITC ASQ, ADST, BINS, BRIGANCE, CDI, CDR, DAYC,ESI-R, R-PDQ, SDT ADST, IDI, ITC, R-PDQHigh CDR, IDI, NDDS, PEDS, PEDS DM, R-PDQ ITC, NDDS, PEDS, PEDS DM ASQ, BINS, BRIGANCE, CDI, CDR, CIMHS,NDDS, PEDS, PEDS DM, TLMQInternalConsistencyReliabilityIntra-RaterReliability Inter-Rater ReliabilityStructural and Discrimi-nant/DiscriminativeValidityConcurrent/ConvergentValidity Predictive ValidityLowADST, BRIGANCE,CDR, CIMHS, DP,ESI-R, ESP, IDI,NDDS, PEDS, PDAS,R-PDQ, SDT, TLMQADST, BRIGANCE,CDI, CDR, CIMHS,DP, ESI-R, IDI,NDDS, PDAS,R-PDQ, SDT, TLMQADST, BINS,BRIGANCE, CDI,CDR, CIMHS, DAYC,DP, ESI-R, ESP, IDI,NDDS, PEDS DM,PDAS, SDT, TLMQADST, BRIGANCE, CDR,CIMHS, DDST, DP, ESI-R,ESP, IDI, NDDS, PEDS,PEDS DM, PDAS,R-PDQ, SDT, TLMQCIMHS, DAYC, DP,ESI-R, IDI, NDDS,PDAS, SDT,TLMQADST, BRIGANCE,CDI, CDR, CIMHS,DAYC, DP, ESI-R, ESP,IDI, NDDS, PEDS DM,PDAS, R-PDQ, SDT,TLMQModerate BINS, CDI, DAYC,PEDS DMBINS, DAYC, ESP,ITC, PEDS, PEDSDMDIAL, ITC, PEDS,R-PDQ BINS, CDI, DAYCADST, BINS,BRIGANCE, CDR, ITC,PEDS, PEDS DMDDST, ITCHigh ASQ, DDST, DIAL,ITC ASQ, DDST, DIAL ASQ, DDST ASQ, DIAL, ITCASQ, CDI, DDST,DIAL, ESP, R-PDQASQ, BINS, DIAL,PEDS3.1.2. Screening Tool Cost, Time, and TrainingCosts, administration times, and training required for screening tools are compared inTable 4. Screening tool costs ranged from free (R-PDQ) or a few cents (PEDS) to USD 877(DIAL, although it can be used to screen multiple children at once). The time to administerscreening tools ranged from less than five minutes (NDDS, PEDS, and PEDS DM) to onehour (DDST). Most screening tools required little to no training to administer and wereusable among young children (i.e., ASQ, ADST, BRIGANCE, CDI, DAYC, DP, NDDS, PEDS,PEDS DM, and R-PDQ), indicating increased accessibility and applicability. The NDDS,PEDS, and PEDS DM rated highly on all three criteria, suggesting that they are affordable,quick to administer, and require little to no training.3.1.3. Combining the ResultsWhen considering only cost, time to administer, and training, the NDDS, PEDS, andPEDS DM consistently rated highest; however, they achieved moderate to low scores acrossforms of reliability and validity. Conversely, because the ASQ rated consistently moderateon the former criteria and consistently high across the latter, it was rated as the mostfavorable screening tool based on this review. However, for use specifically in the UnitedChildren 2024, 11, 745 8 of 16States and in larger child centers (e.g., classrooms), the DIAL was rated as a favorable toolbecause it can be used to screen several children at once, thus negating its higher cost.For organizations or centers prioritizing cheaper, quicker, and easily trainable screeningtools over validity and reliability, the PEDS and PEDS DM were rated highly, with manytranslated versions.3.2. Comparing Assessment Tools3.2.1. Comparing the Validity, Reliability, and Contextual Application of Assessment ToolsCompared to validity measurements, many assessment tools lacked high reliability(Table 5). However, the BSID consistently rated highly across all three forms of reliabilityand validity, providing strong psychometric evidence for assessing young children’s devel-opment. Except for structural, discriminant, or discriminative validity, the BDI rated highlyon all psychometric forms, reflecting its potential use as another reliable and modestlyvalid assessment tool. The MSEL appeared to have moderate reliability to high validity,suggesting its close follow-up as an assessment tool in terms of validity and reliability.The use of all three tools in various clinical groups increased their applicability. BSIDstudies examined its use among children with congenital heart disease, early gestationalage, infants exposed to HIV, and neurodiverse children, whereas the BDI and MSEL weremore applicable for children with neurodiverse diagnoses and developmental delays. Someassessment tools demonstrated use among other clinical groups (e.g., CAT/CLAMS differ-entiates between global developmental delay and language problems). Of the three tools,the BSID demonstrated compelling evidence for use across numerous cultures, followedby the MSEL. NEPSY had many studies on validity and reliability; however, these studiesincluded populations of children above five years of age. Central and South America,Africa, and Australia had limited studies on tool use.Table 5. Assessment tool (n = 11) comparison of cost, administration time, training, and psychometrics.Cost (Low = Costs Higher than USD1000, Moderate = Costs between USD400 and 1000, High = Costs Lower thanUSD 400)Administration Time (Low = Time toComplete Is More than 60 min;Moderate = Time to Complete Is Morethan 45 to 60 min; High = Time toComplete Is around 45 min or Less)Training Required (High = RequiresPost-Graduate Degree and SpecificCourses; Moderate = Requires anUndergraduate Degree and SpecificTraining; Low = Requires Either anUndergraduate Degree or SpecificTraining to Administer)Low BSID, GMDS, MSEL, NEPSY AEPS, BDI, BSID, COR, GMDS BDIModerate AEPS, BDI CDIIT, MSEL CORHigh CAT/CLAMS, COR, GDO-R, VABS CAT/CLAMS, GDO-R, NEPSY, VABS AEPS, BSID, CAT/CLAMS, MSELInternalConsistencyReliabilityIntra-RaterReliabilityInter-RaterReliabilityStructural andDiscriminant/DiscriminativeValidityConcurrent/ConvergentValidityPredictiveValidityLowAEPS,CAT/CLAMS,CDIIT, GDO-R,GMDS, NEPSYAEPS,CAT/CLAMS,COR, CDIIT,GDO-R, GMDS,NEPSYCAT/CLAMS,COR, CDIIT,GDO-R, NEPSY,VABSCAT/CLAMS, CDIIT,GDO-R, GMDS CDIIT, GDO-RAEPS, COR,CDIIT, GDO-R,VABSModerate COR, MSEL VABS, MSEL GMDS BDI AEPS NEPSYHigh BDI, BSID, VABS BDI, BSID AEPS, BDI, BSID,MSELAEPS, BSID, COR,MSEL, NEPSY, VABSBDI, BSID,CAT/CLAMS, COR,GMDS, MSEL,NEPSY, VABSBDI, BSID,CAT/CLAMS,GMDS, MSEL3.2.2. Assessment Tool Cost, Time, and TrainingCosts, administration times, and training required for assessment tools are compared inTable 5. Assessment tool costs ranged from USD 70 (COR) to 1999 (GMDS). Administrationtimes ranged from approximately 15 min (MSEL) to 2–3 months (COR). All assessment toolsChildren 2024, 11, 745 9 of 16require trained professionals to administer them (e.g., clinicians and teachers); however,some only require an undergraduate degree/diploma (e.g., AEPS), whereas others requirea post-graduate degree (e.g., BDI). Of all the assessment tools, only the CAT/CLAMS ratedhighly across all criteria; however, the GDO-R and the VABS also rated highly on cost andadministration (information regarding training for these tools was unlocatable).3.2.3. Combining the ResultsWhen considering only cost, time to administer, and training, the CAT/CLAMS, GDO-R, and VABS rated highest; however, these tools rated inconsistently across reliability andvalidity forms. While the BSID rated highly on the latter, low ratings on the former suggesta lack of accessibility for users. On the other hand, the MSEL rated relatively well acrossvalidity and reliability values, was used in some different cultural and clinical groups, andrated better than the BSID in terms of administration time, suggesting similar potentialuse. The BDI also showed high psychometric evidence (except moderate in structural,discriminant, or discriminative validity) and use in various clinical and cultural groups,and although rated similarly in administration time and training as the BSID and MSEL, itwas less than half the cost of either tool. Therefore, based on this review, the BDI appearsto be the most favorable assessment tool. However, for use specifically in the United Statesin Head Start programs, the COR may be a more suitable tool given evidence for its usein such programs. For organizations or centers prioritizing cheaper, quicker, and easilytrainable assessment tools over validity and reliability, the CAT/CLAMS, GDO-R, andVABS are the most suitable tools.4. DiscussionThis adapted realist review aimed to provide a compendium of validity and reliabilitydata on various multidomain developmental screening and assessment tools for youngchildren, along with contextual information on their accessibility and applicability acrossdifferent groups (i.e., cultural and clinical groups). Almost all tools had at least one studydemonstrating one type of validity and reliability. Screening tools that cost the least andwere the fastest to administer were the NDDS, PEDS, and PEDS DM, whereas the DIALcost the most and the DDST required the most time to administer. Training requirementsvaried between screening tools, providing individuals in clinical, community, and researchsettings with options that fit their qualifications, resources, and employment settings.However, the DAYC, DDST, DIAL, DP, ESI-R, ESP, IDI, ITC, R-PDQ, and SDT had specifictraining and educational requirements, requiring more resources to be attained prior toconducting screening evaluations. The ASQ and DDST (along with BINS) demonstratedcompelling evidence for use in different countries, and the ASQ, DDST, and DIAL wereused in several clinical groups. The ASQ was identified as the most favorable screeningtool; however, the DIAL may be preferred when screening larger groups of children in theUnited States. However, we do acknowledge that other tools may be preferred in differentcontexts (e.g TLMQ in Iceland).The CAT/CLAMS, GDO-R, and VABS were consistently the most affordable, leasttime-consuming, and least training-intensive of the assessment tools; however, these toolsscored lower on validity and reliability, and only the VABS showed some cultural andclinical diversity group application. The BSID was the only assessment tool that scoredhighly across all forms of validity. However, the BDI scored high on all forms except forstructural, discriminant, or discriminative validity, was applicable across diverse culturaland clinical groups, and was more accessible in terms of cost (34.6% of the cost of the BSID),suggesting the BDI as the most generally effective assessment tool. However, the COR maybe preferred in the United States in Head Start programs due to evidence for its use in suchsettings, reflecting how other tools may be more effective in different contexts.Children 2024, 11, 745 10 of 164.1. Validity across Screening and Assessment ToolsIn general, screening tools lacked high validity, whereas assessment tools rated rela-tively highly across all examined forms. Only the ASQ and DIAL screening tools and theBSID assessment tool rated highly across all three types of validity; however, the BDI alsorated highly except when scoring moderate on structural, discriminant, and/or discrimina-tive validity. These findings suggest that these tools have been the most studied relative tothe performance of other tools, in addition to the examination of their internal constructs.Evidence of structural, discriminative, and discriminant validity can provide assuranceto professionals (e.g., in healthcare or early childhood development settings) that thedevelopmental tools they are using accurately screen/assess the intended outcomes orconstructs [45]; however, based on this review, only 3/16 screening tools (i.e., ASQ, DIAL,ITC) had high structural, discriminant, and/or discriminative validity. Lack of such validityreveals an important gap in research and clinical knowledge, which threatens the accuracyof screening children [57]. Tools lacking this form of validity may not measure the intendedconstruct, leading to false positives (or negatives) and erroneous referrals, preventingaccurate diagnosis and treatment [57]. Most assessment tools (i.e., AEPS, BSID, COR, MSEL,NEPSY, VABS; 6/11), however, had high validity of this type, suggesting that if childrenare correctly screened for the developmental outcome of interest, several assessment toolsexist with the ability to measure the outcome of interest and to compare clinically similar(or different) child groups. However, assessments require accurate screening; therefore,it is recommended that researchers further examine the structural, discriminant, and/ordiscriminative validity of screening tools to optimize the overall developmental evaluationprocess of children.Concurrent and/or convergent validity correlatively examines outcomes with anothertool (the gold standard in the case of concurrent validity; [57]). Most screening toolsfell within the moderate to low category (16/22); therefore, more research is needed ontheir capacity to screen for children’s development relative to a more studied tool. Whenconsidering the implementation of child screening and assessments in different regions,evidence of concurrent and convergent validity of cheaper and less timely tools may providean opportunity to overcome health disparities in impoverished areas [58], exemplifying theimportance of such validity. Almost all assessment tools (8/11) captured in this review hadhigh concurrent and/or convergent validity, potentially providing healthcare professionalswith more options when assessing certain developmental outcomes (e.g., using the BDIinstead of the BSID in Colombia or among children with neurodiverse diagnoses, savingUSD 779 per child).Predictive validity is particularly important in child development tools. Identificationof plausible developmental milestones that should be attained given a child’s health and ageallows healthcare professionals to track how a child might progress developmentally andmay allow for a more integrative approach to developmental screening and assessment [59].Only 4/22 screening (i.e., ASQ, BINS, DIAL, PEDS) and 4/11 assessment (i.e., BDI, BSID,CAT/CLAMS, GMDS) tools demonstrated high predictive validity, suggesting profoundimplications for the ability of healthcare professionals to predict children’s developmentover time. Because screening tools are cheaper, less timely, and less arduous to complete,predictive validity is particularly important in their application, as it can permit practi-tioners and clinicians to initially predict how children are developing and identify anyunderlying conditions sooner to prevent health sequalae from occurring [60]. This impliesnot only positive implications for public healthcare (e.g., lower healthcare costs and fewerresources toward assessments) but also for children and families, revealing the significantbenefit of a primary preventive approach to child health.4.2. Reliability across Screening and Assessment ToolsIn general, both screening and assessment tools lacked high reliability. Only theASQ and DDST screening tools and the BSID and BDI assessment tools rated highlyacross all three types of reliability forms, suggesting that these tools have well-developedChildren 2024, 11, 745 11 of 16internal constructs in addition to their reproducibility between two individuals (inter-raterreliability) or by the same person over time (intra-rater reliability).To ensure that all the items of a child developmental screening tool are assessing aspecific outcome (i.e., a developmental domain), studies on internal consistency reliabilityare required [57]. This is exemplified through assessments of adult mental health, whereissues have arisen in differentiating between anxiety and depression items [61]. Only 4/22screening (i.e., ASQ, DDST, DIAL, ITC) and 3/11 assessment (i.e., BDI, BSID, VABS) toolsin this review had high internal consistency reliability; therefore, the items on tools ratedmoderate to low may not be reliably inferred as measuring the outcome of interest in itsentirety [57]. Additional evaluations of internal consistency reliability are needed for toolsclassified as low to moderate.Intra-rater (i.e., test–retest) and inter-rater reliability measurements provide informa-tion on the reproducibility of screening and assessment by the same individual or betweenindividuals, respectively [57]. If a tool is difficult to administer (e.g., requires significanttraining), the accuracy of developmental assessments may differ between administrators,which in turn reduces the assessment’s accuracy [62]. Only 2/22 screening (i.e., ASQ,DDST) and 4/11 assessment tools (i.e., AEPS, BDI, BSID, MSEL) rated highly on inter-raterreliability in this review; the limited evidence for similar use between different individualssuggests the potential for differential classification as a function of the user [57]. It is also im-portant that a professional can apply the same tool over time with similar results. Similarly,only 3/22 screening (i.e., ASQ, DDST, DIAL) and 2/11 assessment (i.e., BDI, BSID) toolsrated highly on intra-rater reliability, which implies that other tools may not be understoodor applied correctly when evaluating a child, leading to erroneous diagnoses. The busyenvironments and lack of resources in healthcare centers may explain the limited evidenceof these two types of reliability [63]; however, their significance in ensuring appropriatechild development evaluation cannot be overlooked and should be further investigated.4.3. Contextualization across Different GroupsMost multidomain child development tools, whether screening or assessment, wereutilized in North America, Europe, and Asia, requiring more evaluations in Central andSouth America, Africa, and Australia. Given this gap in use and evaluation, it is notsurprising that some screening and assessment tools were specifically developed andtested for certain continents, such as the ADST in Australia, which reflects a solution (ifpsychometrically researched) to the lack of tools for certain cultural contexts. Culturallysensitive tools provide a means to overcome differences in cultural expectations, values, andlanguages, preventing cultural bias from affecting outcomes [64]. The ASQ and DDST wereused as screening tools across many different cultural groups, which implies more culturallysensitive approaches to child development screening and subsequent referral for follow-up.The BSID and the DDST (although the DDST was not evaluated in Australia) had studiesperformed in at least one country on every continent, suggesting preliminary evidencefor their use globally in assessing child development. Few tools have translated versionsavailable in more than two languages, which eliminates their application within any otherlanguage groups. For tools that had translated versions, few had psychometric analysisto support their use among the specific languages they were translated to, potentiallyoverlooking cultural differences, altering the meaning and descriptions of items derivingfrom the original instrumentation, and triggering feelings of stigma, blame, or shameamong families through misinterpretations of translated questions and items [33,38]. Forexample, the PEDS had over 60 translations available; however, no psychometric evidencewas available for a large majority of the translated versions. Children being screened orassessed with a tool unsuitable for their culture or language may result in an inaccuraterepresentation of their developmental trajectories [64]. The development of revised versionsfor different cultures that are psychometrically assessed may allow healthcare professionalsto overcome such challenges and ensure all children are receiving proper screening andassessments within professional settings despite cultural differences.Children 2024, 11, 745 12 of 16Children born preterm or at lower birthweights, along with those experiencing adverseantenatal conditions, are at risk of worsened developmental outcomes that may persistthroughout their lifetime [20,40]. Similarly, children with certain genetic disorders or healthconditions are likely to experience delays in achieving developmental milestones [65].Some screening tools, such as the ADST and CDR, had no studies completed among thesedifferent contexts based on those captured by this review, suggesting that they are notapplicable for screening or assessing children presenting with disabilities or health con-ditions. Conversely, the ASQ and DDST were used in several different clinical groups,suggesting sensitivity to the diverse developmental milestones of children with differentdisabilities. Many assessment tools were used among highly specific clinical child groups,such as the BSID for infants exposed to HIV, the CAT/CLAMS for differentiating betweenglobal development delay and language problems, the DDST for children with sickle cellanemia, the DAYC-2 to identify cerebral palsy (in conjunction with magnetic resonance),and the NEPSY among children with Asperger’s disorder. Nevertheless, it is imperativethat more studies be conducted on specific developmental disabilities to provide healthcareprofessionals with diverse options (e.g., cost). Further, more studies are required to exam-ine how different cultural and clinical contexts may intersect and affect developmentaltrajectories concomitantly.4.4. Future ResearchIntra-rater and inter-rater reliability studies comprise an area in which future re-searchers could focus in order to ensure reproducibility between the same individual orbetween two different individuals, respectively. Most of the studies provided evidencefor tool use in North America, Europe, and Asia, but more studies are needed on theirperformance in Africa, Australia, and Central and South America to provide professionalswith more options and comfort in applying tools among different cultural groups. Thoughsome tools may be designed specifically for certain countries (e.g., TLMQ in Iceland), thesetools require much more psychometric analysis to ensure that they are measuring theintended developmental domain. Not all tools will be designed for every purpose or group;however, ensuring that several valid and reliable tools exist that consider the diversity ofchildren (i.e., culture and health) can encourage more accessibility, equity, and optimaldevelopmental screening and assessment by healthcare professionals to improve lifelongoutcomes in children. In relation to this, researchers should focus on collecting availableevidence and conducting assessments of measurement invariance (which ensures that aconstruct has the same meaning across different sociodemographic groups [66]) and itemresponse theory (which helps to identify interindividual variation and reduce scales toshorter versions when possible [67]) to ensure tools are adequate across different identitygroups and to limit response burden.4.5. Strengths and LimitationsAlthough the search was comprehensive, the test manuals for certain tools wereunidentifiable or inaccessible, and it is possible that some tools had validity and reliabilitydata not found in the search. However, this may not necessarily be a limitation of the studyitself but rather a reflection of the difficulty in accessing important data and informationthat researchers need to adequately conduct child development research. Though realistreview methods allow for saturation to be achieved and permit exploration to identifywhat tools are best and for whom, under various circumstances (e.g., culturally diversepopulations; [41]), employing adapted realist review methods may hinder the possibilityof reproducibility. We did nevertheless attempt to be as clear as possible in our methodsto allow for transparency and for other researchers to understand how this study wascompleted. Included studies were also not critically appraised as this was beyond thescope of this paper, but this review provides researchers, healthcare professionals, andpolicymakers with a compendium of data on each tool, facilitating access to validity,reliability, and contextualized analyses and the identification of the most appropriate toolChildren 2024, 11, 745 13 of 16for a healthcare professional under a certain circumstance. Further, a compelling body ofliterature was reviewed, providing important information and data on over 30 screeningand assessment tools for young children’s development.5. ConclusionsThis adapted realist review developed a compendium of multidomain developmentalscreening and assessment tools for young children to describe their validity, reliability,accessibility, and applicability in various contexts. Almost all tools had studies on atleast one form of validity and reliability. Often, researchers cite evidence for reliability orvalidity from other studies, which may not be fully reflective of the tool’s psychometriccapacity in their study population. The ASQ appeared to be the most valid, reliable, andcontextually applicable screening tool, with moderate to high ratings across affordabilityand accessibility; however, evidence from this review may favor the use of the DIAL inlarger child groups (e.g., preschool daycares) in the United States. On the other hand,findings from this review highlight the use of the BDI as an assessment tool, as it performedalmost as well as the BSID at 36% of the cost. However, some tools may complementeach other in certain contexts; more specifically, when considering specific clinical groups,one could consider using the ASQ or the BDI with other tools that have psychometricevidence among specific clinical groups. For example, the ASQ could be used alongsidethe DAYC when screening development among children with cerebral palsy, while the BDIcould be used alongside the GMDS when assessing development among children withDown syndrome. In terms of culture, some tools do demonstrate potential for uniqueuse in specific regions (e.g., ADST in Australia), warranting further consideration. Itis imperative to examine the intersections between the determinants of health, genetics,and the caregiving environment in the context of multidomain developmental screeningand assessment so that healthcare professionals are properly equipped to evaluate youngchildren’s development and optimize child and family health.Supplementary Materials: The following supporting information can be downloaded at https://www.mdpi.com/article/10.3390/children11060745/s1, Table S1: Information about screening andassessment tools; Table S2: Reliability and validity of screening and assessment tools.Author Contributions: S.K. was involved in study conceptualization, data curation, formal anal-ysis, investigation, methodology, project administration, supervision, writing—original draft, andwriting—review and editing. J.K. was involved in study conceptualization, project administra-tion, supervision, data curation, formal analysis, investigation, methodology, and writing—reviewand editing. A.D. was involved in methodology and writing—review and editing. N.L. was in-volved in conceptualization, investigation, methodology, project administration, supervision, andwriting—review and editing. All authors have read and agreed to the published version of the manuscript.Funding: This research received no external funding.Institutional Review Board Statement: As a narrative review, this study did not require ethical approval.Informed Consent Statement: Not applicable.Data Availability Statement: No new data were created or analyzed in this study. Data sharing isnot applicable to this article.Acknowledgments: We thank Era Patidgas (EP) for their support in study screening and organizationand all the authors and research teams of the included studies for their contributions to this area of study.Conflicts of Interest: The authors declare no conflicts of interest.References1. Gee, D.G.; Cohodes, E.M. 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eng
Reviewed
Vancouver : University of British Columbia Library
Multidisciplinary Digital Publishing Institute
CC BY 4.0
Faculty
child development
multidomain development tools
screening
assessment
validity and reliability
Validity, Reliability, Accessibility, and Applicability of Young Children’s Developmental Screening and Assessment Tools across Different Demographics: A Realist Review
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