Search Menu Abstract Objective To determine predictive validity of the Bayley Infant Neurodevelopmental Screener BINS during the first 2 years of life with a group of children at risk for developmental delay due to environmental risk factors. Method The setting consisted of home visits to participants. Three risk groups were identified: low, moderate, and high. A cut score of 85 1.

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Search Menu Abstract Objective To determine predictive validity of the Bayley Infant Neurodevelopmental Screener BINS during the first 2 years of life with a group of children at risk for developmental delay due to environmental risk factors. Method The setting consisted of home visits to participants. Three risk groups were identified: low, moderate, and high. A cut score of 85 1.

Positive predictive value was higher when the cut score was set below 90 than when it was set below Conclusions Low predictive validity of the BINS with an environmental risk group highlights the difficulties inherent in developmental screening among infants who have environmental, but not biological, risk factors.

Because infants at environmental risk tend to experience developmental declines after infancy, it may be beneficial for primary care providers to use psychosocial screening tools to identify which children need closer monitoring and referral to enrichment programs to prevent developmental declines during toddlerhood.

To have the best chance of preventing developmental delays, intervention should begin during the first 3 years of life when children are experiencing rapid growth and development Committee on Children with Disabilities, Children with biological risk factors e.

In Maryland, for example, EPSDT guidelines specify that children receive routine developmental screening at every well-child visit from 6 months to 4 years of age Maryland Medicaid Program, The EPSDT program is based on a model of preventive care for early detection of illnesses and developmental problems so that services can be put in place to treat existing problems and prevent further delays.

Although the Denver II has been helpful in identifying children at risk for developmental delays, it may overidentify children as delayed when they are actually typically developing, causing a high overreferral rate Glascoe et al. There is a need to examine alternative screening tools that may have better predictive utility and are brief and cost-effective for routine screening.

Cut scores are used to classify children as high, moderate, or low risk for developmental delays. It is administered by a trained professional in about 10 minutes, making it cost-effective for routine screening. The BSID-II requires a highly trained examiner and takes 30—60 minutes, depending on the age of the child, making it an expensive and lengthy exam. PPV is defined as the proportion of children with a positive screening test result who are truly developmentally delayed.

We have used a brief example to illustrate how sensitivity, specificity, and PPV can be applied to developmental delays. If we have a population of children, of whom 10 have a developmental delay and the other 90 do not, we may use a screening test to identify the children who have a developmental delay. Assume that the screening test has identified 18 children as delayed: 8 who are truly delayed and 10 who are not see Table I.

The PPV is the probability that a child is truly developmentally delayed when results of the screening test are positive. Unlike the sensitivity and specificity of a screening test, which can be thought of as characteristics of the test itself, the PPV is dependent upon the prevalence of the disorder in the population tested Gordis, When the prevalence of developmental delay within the study population is thought to be low, the PPV will necessarily be low.

Therefore, the sensitivity of the test may be a better measure to evaluate a screening tool for developmental delay than its PPV. When used with low birth weight children, the BINS showed moderate stability in classification of children over the first 2 years of life, although sensitivity, specificity, and PPVs varied according to the cutoffs used to define risk and delay Aylward et al. Across studies of the BINS with low birth weight children, there was no clear consensus about which BINS risk grouping yielded the best predictive validity.

This investigation was undertaken to examine the predictive validity of the BINS among a group of socially disadvantaged infants, specifically African American infants from low-income, urban environments whose primary caregivers were adolescent mothers.

Aylward and Verhulst have suggested that the BINS can be used reliably with children from diverse populations, including those from low socioeconomic backgrounds. This is the first study to evaluate how effective the BINS is with an environmental risk group of children who are not at biological risk. This is considered to be clinically meaningful because it identifies children who are mildly delayed in developmental skills. Use of this cutoff score allows practitioners to identify which children require closer monitoring to help prevent further declines.

Two other cutoff scores were used to determine whether greater sensitivity, specificity, and PPV would be achieved by raising or lowering the cutoff score on the BSID-II criterion. Because national policies require that eligibility for public services be restricted to adolescent mothers who are in the guardianship of an adult U.

House of Representatives, , many adolescent mothers live with their mother. We limited our sample to adolescent mothers who were living with their mother grandmother of the baby.

None of the infants experienced complications following delivery that required neonatal intensive care services. There were no differences in maternal age or education between those who completed the baseline evaluation and those who did not.

Follow-up evaluations were conducted when infants were 6, 13, and 24 months. Two children were untestable at the month evaluation due to behavioral difficulties.

The remaining families were not compliant with the follow-up visits. There were no differences in maternal age, maternal education, infant birth weight, infant gender, or intervention status between families included in the evaluation of the study and families who were not.

Each item is scored as optimal or nonoptimal, and the optimal responses are totaled to yield a summary score. The internal reliability of the BINS has been reported to be high, ranging from. The BSID-II is a standardized assessment tool that measures mental and motor development of children from 1 to 42 months of age Bayley, It is often considered to be the gold standard for identification of developmental delays for children from 0 to 3 years.

Items on the mental developmental index MDI and the psychomotor developmental index PDI are administered individually to the child. Raw scores are converted to index scores with a mean of and a standard deviation of 15, based on age-specific norms. Procedures Infants and mothers were recruited from three hospitals in Baltimore, Maryland. The study was approved by the institutional review boards at all three hospitals. Mothers were approached shortly after delivery and given a brochure explaining the study.

Those who expressed interest in enrolling in the study signed consent forms and were scheduled to receive a baseline home evaluation within 3 weeks. When infants were 6 and 13 months old, the BINS Aylward, was administered by research assistants who had been trained by a psychologist in administration and scoring.

The research assistants were unaware of intervention-group assignment. When the children were 24 months old, the BSID-II Bayley, was administered by a graduate student in psychology who had been trained in administration and scoring by a psychologist and was unaware of group assignment. Data Analysis The BINS scores at 6 and 13 months were classified using three different risk cutoffs as established in the scoring manual: low, moderate, and high.

The primary binary variable was created using a cutoff of 1. Children scoring below 85 were classified as mildly delayed in mental skills per the BSID-II scoring manual; therefore, this represents a clinically meaningful criterion cutoff.

In addition, two other criterion cutoffs were evaluated: 0. The same three criteria were used to dichotomize the composite score. Sensitivity, specificity, and PPVs were calculated separately for children receiving the intervention versus those who were not. The receiver operator characteristic ROC curve was used to examine the predictive power of the BINS for identifying a child with developmental delay Harrell, This procedure plots the true positives sensitivity against the false positives 1.

The area under the ROC curve approaches 1. Areas under the ROC curve were computed using a cross-validation technique that provides unbiased estimates of prediction error Harrell, Since none of the results differed by intervention status, the data were combined for all analyses. Results When children were 6 months of age, the mean age of the mothers was Mean ages for children at the 6-, , and month evaluations were 6. None of the children classified on the BINS as high risk at 6 months was also classified as high risk at 13 months.

Forty-three percent of children scored at least 1. Few children scored less than 1. Therefore, this criterion cutoff was eliminated from analyses. Specificity was only marginally higher for the below cutoff versus the below cutoff. In this case, the BINS screening test at both 6 and 13 months did a good job of classifying children as not delayed who did not experience a developmental delay on the BSID-II at 24 months.

This finding held for both the 6-month and the month BINS, regardless of the classification used. Results for sensitivity and specificity were similar regardless of whether delayed development was defined as BSID-II scores below 85 1. Sensitivity and PPV were better when BINS risk groups were defined as low no delay versus moderate and high delay than when BINS risk groups were defined as low and moderate no delay versus high delay.

Specificity was better when BINS risk groups were defined as low and moderate no delay versus high delay. Although PDI scores were within normal limits, the mean MDI scores were approximately one standard deviation below the mean score expected within a normal sample. The high specificity values in our study indicated that most children who were not delayed on the BSID-II at 24 months were accurately identified as not delayed on the screening tool at 6 and 13 months. However, the low sensitivity values indicated that infants who were delayed on the BSID-II at 24 months were not identified as delayed on the screening tool at 6 or 13 months.

Despite the relatively high base rate of delayed cognitive development in our sample i. In this investigation, the low predictive validity of the BINS when using a clinically meaningful cutoff below 85 to identify those children with mild developmental delays suggests that the BINS alone is not an ideal measure for use with an environmental risk group of infants who have no biological risks.

The BINS may be a better measure of risk for biological risk samples than for infants with environmental risks, because it includes items that capture skills and competencies in infancy that continue to be problematic for that group over time Aylward et al. Preterm and low birth weight infants who score low on neurological and motor items in infancy may continue to score low on these items in toddlerhood. Traditionally, measures of sensitivity and specificity have been used as one means of assessing the validity of screening tools.

Frankenburg suggests that validity assessments of screening tools should focus on the way in which developmental norms were established, that is, the method of standardization for the screener.

One possible explanation for the poor predictive validity of the BINS found for this low-income, urban risk group is that items on the BINS administered at the 6- or month evaluations may not predict later developmental delays for environmental risk groups. Compared with low birth weight and premature infants, infants from low-income families are less likely to have neurological and motor difficulties, and thus are unlikely to score low on these items at early ages.

Children from environmental risk groups tend to have more difficulty with language and problem-solving tasks than with neurological or motor tasks Aylward, It is likely that other screening tools that assess sensorimotor and neurological skills would also lack predictive utility from infancy to toddlerhood for environmental risk groups.

When routine screening is conducted during the first year of life with infants in environmental risk groups, screening tools should include more items to assess verbal and cognitive abilities so that they are more sensitive to detecting delays that children in environmental risk groups are likely to experience. In addition, it may be useful for screening tools to have domain subscales. We cannot rule out the possibility that gains in motor skills may have masked delays in language and cognitive areas, yielding lower overall sensitivity of the BINS for this environmental risk group.

Another possible explanation for low predictive validity from the first to the second year of life for environmental risk groups is that risk for delayed development is low during the first year of life but increases over time.

The canalization theory of development helps support this explanation. According to canalization theory, there is a species-specific process that helps ensure that development unfolds similarly for all children during early life McCall, Variability in development becomes more apparent after infancy, as environmental influences exert themselves Aylward, Low predictive validity of the BINS may therefore be a result of increased risk for delayed development during the second year of life as protection from self-righting processes decrease.

Empirical evidence to support this explanation comes from several cross-sectional and longitudinal studies that have indicated that children from low-income, urban households are more vulnerable to delayed development during toddlerhood than during infancy Black et al.


Bayley Infant Neurodevelopmental Screener™ (BINS™)

Physician inter-rater agreement with training tapes was Infants were classified into being at low, moderate, or high risk for developmental delay or neurological impairment based on their total BINS score. Results Female infants performed higher than male at 16 to 20 months and 21 to 24 months; male infant scores were more variable at 5 to 6 months. Scores on only two items were significantly different between Spanish and Portuguese speaking participants. South American scores were typically significantly higher than the US sample, and a lower proportion of infants were classified as being at high risk in the South American sample than in the US standardization sample. Conclusion Overall, the results of this study indicate that the BINS is feasible and appropriate for neurodevelopmental screening in South America.


Bayley Infant Neurodevelopmental Screener




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