Clinical Assessment of Infants and Toddlers
Walter S. Gilliam
Linda C. Mayes
Why perform infant assessments? It is perhaps easier to state definitively what infant assessments cannot provide. They do not provide a measure of fixed or immutable intelligence, a trajectory for future development, or a window on future adjustment, nor can they typically partial out the various potential causal factors. Results are descriptive, with only limited application for etiological understanding or detailed prognosticating. Questions such as “How much of this infant’s delay comes from his environment, versus how much from his prematurity?” or “What will be the eventual extent of this child’s developmental disability?” are not definitively answerable by a developmental assessment. Developmental assessments, however complete and skillfully done, cannot provide sure predictions of long-term outcome or parcel out the complex contributions of endowment, experience, and maturational forces.
Despite the above caveats, assessment of infant development can be highly useful, and in many cases essential to proper clinical treatment. Skillfully done, these assessments can help create a picture of the child’s current developmental level and environmental context that can be invaluable to sound clinical decisionmaking and treatment planning. Essentially, developmental assessment results help provide a lens through which we might be better able to perceive the world from the child’s perspective. Indeed, Bagnato and Neisworth (1) have pointed out that the word assidere (the Greek origin of assessment) literally means “to sit beside,” and hence to get to know someone.
Clinical assessment of infants and toddlers is a subspecialty area of clinical practice. Not all psychiatrists, psychologists, pediatricians, and other professionals will possess the training and degree of closely supervised practice necessary to competently and independently conduct such evaluations. Those professionals who do possess these specialized skills typically have acquired them through formal subspecialization near the end of their professional training.
A Brief History of Infant Developmental Assessment
A brief discussion of the history of infant assessment may provide an illustration of the evolving aims and technological advances in this field. (A more complete history is provided by Gilliam & Mayes (2), and the more ambitious readers are referred to Brooks & Weinraub (3) and Wyly (4).
The Late 1800s: Enlightenment and Curiosity
In the late nineteenth century, the European scientific community was consumed with a fervor and creativity best characterized by the studies of evolution, theories about the unconscious mind, and a growing concern for the mentally deficient and insane. The field of experimental psychology was largely concerned with the measurement of various perceptual abilities, and the science of child development was dominated by single-child case studies— often the children of the scientists. Although these “baby biographies” were insufficient for benchmarking normal child development, they provided the basis for the creation of development tests during the twentieth century.
1900–1920: The Birth of Intelligence Testing
The concept of measuring infant capacities grew out of the concern of scientists of the time to find a metric for human intelligence that would permit the creation of criteria for schools for children with intellectual deficiencies (5). In 1904 the minister of public education in Paris appointed Binet and Simon to be members of a commission studying the question of special education. In response to their charge, Binet and Simon developed the concept of mental age and a test, published in 1905, for measuring it (3). Terman (6) created an adaptation of the Binet-Simon test for use in the United States and revised the concept of mental age by creating the intelligence quotient (IQ), a ratio between mental age and chronological age multiplied by 100.
1920–1940: “Infant IQ” versus “Developmental” Models
In the decades that followed the development of Terman’s IQ test, two basic approaches were used in exploring intellectual development in infants. One approach, the infant IQ model, sought to extend downward the IQ assessment model to children younger than school age, eventually including infants. A second approach, the Gesellian model, sought to create a new model of assessment that began with the newborn and extended upward. In contrast to the “baby biographers” of the previous century, the more behaviorally empirical scientists of the 1920s and ’30s relied on direct observation of child behavior across several children under highly structured conditions.
The best example of an infant IQ or infant cognition test is the Cattell Infant Intelligence Scale (7). Cattell’s test was conceptualized as a downward extension of the 1937 Stanford-Binet Intelligence Scale, the much-revised American version of the Binet-Simon test. Although some initial studies were encouraging, the ability of the Cattell and other infant IQ tests to predict an infant’s later IQ was weak (8). Overall, “infant IQ tests” were found to be inadequate at meaningfully extending the IQ assessment model into infancy and are now all but extinct in use.
At about the same time that first “infant IQ tests” were being developed, Arnold Gesell began his groundbreaking work at Yale University on systematically documenting normal maturational development in infants and toddlers, leading to the creation of the Gesell Developmental Schedules (GDS), first published in 1925. Several aspects of Gesell’s work distinguish it from those of his predecessors and contemporaries. First, whereas the infant IQ tradition grew from an interest in identifying deviant patterns of development, Gesell’s interest was mostly in documenting normal developmental trends. Second, Gesell’s model supported the conceptualization of development occurring simultaneously in many distinct but interrelated domains (9), as opposed to a singular factor of intellectual ability. Third, Gesell’s model of developmental maturation supported an understanding of the effects of the child’s environment in altering the course of development, as opposed to viewing IQ as a stable and static trait, opening the way for the more transactional and dynamic understanding of developmental processes that would later prevail.
Gesell’s work was farreaching, and subsequent researchers relied heavily on the developmental tasks and techniques he pioneered. Most notable was Nancy Bayley of the Berkley Institute of Child Welfare. Bayley applied testing concepts more familiar to the infant IQ model to the assessment techniques developed by Gesell. The result was the development of two scales of infant development that would later revolutionize and dominate the field of infant assessment: the California First-Year Mental Scale10,11 and the California Infant Scale of Motor Development 12,13.
1940–1960: The Fall of the “Infant IQ” Model
In the 1940s and 1950s, the science of infant developmental assessment gained greater international attention, through the publishing of the Griffiths Mental Development Scale(14) in London. At that time, infant assessment techniques were used primarily for diagnosis and categorization purposes, e.g., preadoptive screening, testing for admission to special schools, or evaluating physical handicaps (15). The assessments for diagnosis and categorization were predicated on clinicians’ continuing adherence to the belief that intelligence is fixed from infancy. This belief in a fixed IQ still was so well rooted that evidence to the contrary (findings documenting an increase in IQ in high-risk infants after nursery school attendance) was being dismissed and attributed to poor standardization of the scales (3). In the context of this debate, American developmentalists first began to consider seriously the stage theory of Jean Piaget, which clearly favored the view of qualitative, rather than simply quantitative, differences in the abilities of children of various ages. It was largely on the basis of Bayley’s longitudinal work with her developmental instruments (16) that the concept of an immutable IQ that was fixed at birth was discredited. The use of infant IQ tests continued for a while, but are now all but extinct in use.
The 1960s and 70s: Breakthroughs in Infant Test Development
The 1960s and 1970s brought a new wave of infant development tests, more rigorously standardized on larger numbers of infants, with careful testing of interobserver agreement and test-retest reliability. The Bayley Scales of Infant Development (BSID)(17) consolidated Bayley’s original two scales into one assessment instrument with norms based on a nationally representative sample of infants. The BSID set a new and enduring standard of sophistication for the development and standardization of infant developmental assessment tools. Thoughtful research led to far more caution about the predictive validity of early assessment and to important conceptual revisions. Concomitant interest in newborn capacities and the rapidly emerging field of newborn sensory perception also led to the development of a number of scales to measure competency in newborns.
1980–Present: New Directions in Infant Developmental Assessment
The 1980s and 1990s were dominated by increasing psychometric improvements; a renewed interest in diagnostic functionality, again primarily driven by the needs of public education; and the application of information-processing theory to the study of infant development. Federal mandates for the special education of young children created the need for an arsenal of assessment tools that encompassed all of the qualifying areas of delay, utilized information from both direct assessment of the child and parent report, and facilitated early intervention treatment planning and program accountability. Also, a plethora of brief developmental screening instruments
also were developed for use by professionals with relatively little training in formal assessment.
also were developed for use by professionals with relatively little training in formal assessment.
The advent of information-processing theories of human intelligence led to more elaborate models of infant cognition. Several studies have shown measures of infant information-processing (e.g., attention, recognition, stimulus habituation, and memory) to be significantly related to later IQ scores (several excellent reviews are available 18,19). However, these measures can be difficult to administer under usual clinical assessment conditions, and the model has not been translated to clinical assessment tools. Regardless, measures of information-processing may play an important role in the next generations of developmental assessment instruments.
Sources of Information in an Infant Assessment
The developmental assessment of infants involves more than the simple administration of a set of developmental test protocols. Assessments performed in the first three years of life require the clinician to function simultaneously as a generalist and a specialist, to blend quiet observation with active probing, to synthesize information from caregivers with that gathered through direct observation of the child, and to be involved in a curious blend of searching for specifically defined responses from a child with inferences based on behavior. This set of skills is indeed important for adequate clinical assessment of children of all ages. However, the need is even greatest for those providing clinical services to these youngest of patients, since development during the early years is the most rapid, context-dependent, and intersystemic.
Next we discuss general sources of information and three techniques that are central for the clinician doing infant assessments: interviewing skills, observation of children and of caregiver-child interactions (apart from formal structured testing), and synthesis of the information gathered during the evaluation. (See Table 4.2.1.1 for a summary of some of the information obtained during an infant assessment.) While interviewing, observation, and synthesis are the skills of medical diagnosis in general, there are unique aspects to each in the process of assessing infants.
Interviewing
It is axiomatic that skillful interviewing is central to a complete developmental assessment, since much of the data about infants’ daily functioning and their relationships with others come from interviews with the caregivers. Skillful interviewing techniques include letting caregivers begin their story wherever they choose; using directed, information-gathering questions in such a way as to clarify but not disrupt the parents’ account; and listening for affect as much as content. Importantly, nearly every step of the assessment process requires an alliance between clinician and caregiver, since infants usually perform better when they are in the company of familiar adults, and the initial interview between clinician and family is crucial in setting the tone for such an alliance. Moreover, establishing an alliance is central to evaluating infants’ interactions with the adults in their world. Indeed, infant assessments are quite compromised when there are no familiar adults available to meet with the clinician and be with the infant. Parenthetically, it is often in cases involving the most severe environmental disturbance that clinicians do not have access to caregivers that are able to describe the infant’s history.
Addressing Caregiver Fears Regarding the Assessment
When parents, foster parents, or other caregivers are available, skillful interviewing is also critical in helping parents follow through with the assessment process. Coming for a developmental evaluation or participating in one while their infant is hospitalized is enormously stressful and often frightening for caregivers. Clinicians working with infants and their families need to understand that, regardless of what caregivers have been told about the assessment, caregivers’ fears and fantasies about the process are as potent as the facts of the presenting problem. Not uncommonly, caregivers have begun to see the infant as damaged or defective in some way and are afraid and
guilty about the effect of their own behavior on the infant. Their fears of what the infant’s problems signify may be expressed in many ways. They may anticipate that their infant has a serious developmental disability, such as autism or mental retardation, or that the infant will have serious emotional difficulties in school, or that they themselves will be, or already are, inadequate caregivers. It is always a vulnerable time for caregivers, and clinicians should keep in mind that what seem inconsequential moments and statements to them may be memorable and powerful for many caregivers. Furthermore, the stress of coming for an assessment affects the caregivers’ abilities to report about the infant’s development. Often, the “facts” start to change as the alliance between caregivers and clinician develops.
guilty about the effect of their own behavior on the infant. Their fears of what the infant’s problems signify may be expressed in many ways. They may anticipate that their infant has a serious developmental disability, such as autism or mental retardation, or that the infant will have serious emotional difficulties in school, or that they themselves will be, or already are, inadequate caregivers. It is always a vulnerable time for caregivers, and clinicians should keep in mind that what seem inconsequential moments and statements to them may be memorable and powerful for many caregivers. Furthermore, the stress of coming for an assessment affects the caregivers’ abilities to report about the infant’s development. Often, the “facts” start to change as the alliance between caregivers and clinician develops.
TABLE 4.2.1.1 SOME OF THE INFORMATION OBTAINED DURING AN INFANT ASSESSMENT | ||||
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