doi:10.1111/j.1440-1754.2009.01492.

ORIGINAL ARTICLE

Can parents accurately screen children at risk of

developmental delay?
Glenys Dixon,1 Nadia Badawi,1,2 Davina French3 and Jennifer J Kurinczuk1,4
1
Telethon Institute for Child Health Research, Centre for Child Health Research, The University of Western Australia, Subiaco, Western Australia, 2Grace Centre
for Newborn Care, The Childrens Hospital at Westmead, University of Sydney, Sydney, New South Wales, 3School of Psychology, The University of Western
Australia, Nedlands, Western Australia, Australia and 4National Perinatal Epidemiology Unit, University of Oxford Old Road Campus, Oxford, United Kingdom

Aim: To evaluate the validity and potential value of the parent-completed Infant/Child Monitoring Questionnaire (IMQ) as a screening measure
for developmental delay in high-risk infants.
Methods: One hundred and forty-one term infants born with moderate or severe newborn encephalopathy (NE) and 374 randomly selected
comparison infants were administered a Grifths Mental Development Scales (GMDS) assessment and an IMQ concurrently. Concordance of
classications between measures was compared for agreement, sensitivity, specicity, positive predictive value, negative predictive value, false
positives and false negatives.
Results: Overall, sensitivity and specicity of the IMQ for infants with NE averaged across all age groups was 87%, positive predictive value 57%
and negative predictive value 97%. The IMQ did not perform as well for comparison infants with a sensitivity of 50%, specicity 94%, positive
predictive value 15% and negative predictive value 99% averaged across all age groups. Overall under-referral for infants with NE was 13%,
compared with 50% for comparison infants.
Conclusions: Use of the IMQ as an accurate screening measure in infants at risk of developmental delay is supported. The low sensitivity of
the IMQ for the comparison infants indicates a need for caution when considering its application for general population screening.
Key words: developmental delay; parent; questionnaire; screening.

Approximately one-third of children with developmental or

behavioural disorders remain undetected before entering the
education system,1 and although we have no specific Australian
Key Points
data at this point in time, it is probable the numbers would be
1 Children with developmental delay can be difcult to identify
similar. One explanation for the low detection rates of develop-
before school entry. The delay in identication of problems may
mental delay is that identifying children with developmental
be due to the subtlety of symptoms or the costly and time-
and/or behavioural problems is often challenging, particularly
consuming nature of professional assessments. An alternative
when children have more subtle symptoms rather than present-
to professionally administered tests is a parent-completed
ing with clear signs of delay. Developmental problems may also
questionnaire.
remain undetected because of the costly and time-consuming
2 The present study evaluated a parent-completed question-
nature of developmental assessments, which are typically not
naire, the Infant/Child Monitoring Questionnaire (IMQ), com-
readily available to families located in rural and remote com-
pared with a gold standard professionally administered
munities. One alternative to expensive and time-consuming
developmental assessment widely used by Australian paedia-
professionally administered developmental assessments is
tricians, the Grifths Mental Development Scales, in two rela-
screening with parent-completed questionnaires designed to
tively large groups of children with and without risk of delay.
identify children at risk of developmental delay and in need of
3 The ndings from this study support the use of the IMQ for
further evaluation.
screening populations at high risk of developmental delay. Use
Although a number of parent-completed screening instru-
of the IMQ as a screening instrument in the general population
ments have been developed, there are very few that meet the
should be introduced with caution. Further evaluations need to
psychometric properties recommended by National Health and
be undertaken in larger groups of older children.
Medical Research Council (NHMRC) of 70% for specificity
and sensitivity.2 Sensitivity levels of 70% are considered
Correspondence: Ms Glenys Dixon, Telethon Institute for Child Health acceptable3 and specificity levels of 7080% realistic in devel-
Research, Centre for Child Health Research, The University of Western Aus- opmental screening.4,5 These standards are recommended for
tralia, PO Box 855, West Perth, WA 6872, Australia. Fax: +61 8 9489 7700; concurrent outcomes with a developmental test or gold stan-
email: glenysd@ichr.uwa.edu.au
dard as a criterion measure. The Infant/Child Monitoring
Accepted for publication 16 November 2008. Questionnaire (IMQ) was developed as a parent-completed

268 Journal of Paediatrics and Child Health 45 (2009) 268273

2009 The Authors
Journal compilation 2009 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
G Dixon et al. Screening children at risk for delay

questionnaire6 and was later renamed the Ages and Stages
Questionnaire (ASQ) in 1995 with minimal revision to content.
The change of content was so minimal that the data collected
from the IMQ and the revised ASQ were combined to report
psychometric properties for the revised ASQ, which is essen-
tially the same tool with a new name.7
Although there have been a number of comparisons of the
IMQ and/or ASQ with popular developmental assessments
used overseas, the concurrent validity of the IMQ/ASQ with
criterion measures used in Australia through a population-
based study has not, as far as we are aware, been evaluated. A
study of 167 infants born prematurely8 and considered at risk
of developmental disability reported the concurrent validity
and test characteristics of the IMQ with the Griffiths Mental
Development Scales (GMDS).9 Based on their results of high
negative predictive values, Skellern et al. supported the use of
the ASQ as a screening tool for cognitive and motor delays in
the follow-up of ex-premature infants but suggest combining
the screening instrument with other strategies for comprehen-
sive follow-up.8
However, another study examining the test characteristics
of the IMQ with high-risk infants from a neonatal intensive care
unit reported that the IMQ had a high under-referral rate of
33% and was therefore considered to have limited value as a
screening instrument of high-risk populations.10 In the absence
of consistent research findings about the utility of this screening
tool in Australian populations other than ex-premature or very
high-risk infants, the immediate and long-term implications of
introducing the ASQ (formerly IMQ) into clinical and non-
clinical populations for comprehensive follow-up programmes
remain unclear.
The primary aim of this study was to compare the IMQ with
a concurrently administered gold standard measure, the
GMDS, to examine the test characteristics and concurrent valid-
ity in two groups of children, one of which is high-risk.
Methods
Participants
Participants were members of a longitudinal cohort study in
Perth, Western Australia, who were originally recruited in a case
control study established to investigate the antecedents of
newborn encephalopathy (NE) and subsequently followed to
determine their outcomes. The methods for the Western Aus-
tralian NE Study have been described in detail previously11 and
are outlined briefly here.
Eligibility criteria of children diagnosed with NE
Infants with NE were all live infants born at term (37 weeks)
in Western Australia between 1 June 1993 and 31 December
1996 who fulfilled the criteria in Figure 1. Deaths in the first
week of life were reviewed to ensure that no baby who fulfilled
the eligibility criteria died before inclusion in the study.
The severity of NE was graded by a neonatologist as moderate
or severe according to the criteria modified from Sarnat and
Sarnat.11,12 In the total sample there were 177 infants with
moderate NE and 99 with severe NE. The incidence of moderate
or severe NE was 3.80 per 1000 term live births (95% confi-
dence interval 3.244.43).11
Comparison cohort
There were 564 infants in the comparison cohort who were
randomly selected from the population of term live births
without NE delivered in metropolitan Perth during the same
time period as the infants with NE.
Follow-up procedures
The follow-up protocol requested parents to complete the IMQ
when their children were aged 4, 8, 12, 18, 24, 36 and

Fig. 1 Inclusion criteria for cases with moder-

ate or severe newborn encephalopathy.

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Screening children at risk for delay
48 months. When infants were aged 12 months, the parents
were contacted to have their child assessed by a trained assessor
(blind to the case control status of the child) using the GMDS. If
families were unavailable for a Griffiths assessment when their
child was 12 months of age, the assessment was arranged for
a later date which resulted in some children being older than
12 months when the GMDS was completed.
Measures
Screening measure (IMQ)
The IMQ is a parent-completed questionnaire designed to
screen infants aged from 4 to 48 months with questionnaire
items developed to reflect developmental milestones.7 Each
questionnaire has 30 items equally distributed over five sub-
scales, including gross motor skills, fine motor skills, adaptive
skills, communication and personal-social skills. The question-
naires also include open-ended questions to elicit parental con-
cerns about their childs development.
Criterion measure
The GMDS was designed to assess the development of babies to
children from birth to 2 years with an extended version from 2
to 8 years.9 The GMDS assesses developmental milestones in
gross motor, personal social, speech and hearing (communica-
tion), eye and hand co-ordination (fine motor) and perfor-
mance (adaptive) (for 02 years) and also practical reasoning
(for 28 years version). The GMDS is widely used by Australian
paediatricians.13,14
Traditionally, the use of a General Quotient (GQ) of 100 and
standard deviation (SD) of 12.2 has been used to determine
levels of impairment. However, these scores were based on the
original sample standardised in 1950 (02 years) and 1960
(08 years extended version). Results from the GMDS for the
Western Australian NE Study comparison cohort without NE
revealed a mean GQ of 113 (SD: 9.3), which was in agreement
with more recent study results that have utilised the older
version of the Griffiths scales.1518 We therefore used this mean
and SD to define clinically significant developmental delay (>2
SDs below the mean) for this study population.
Statistical analyses
Statistical analysis was undertaken using SPSS version 13 for
Windows (SPSS Inc., Chicago, IL, USA). Concurrent validity of
Table 1 Age of infants with concurrent IMQ and GMDS (N = 515)
Age at concurrent assessments
12 months
(n = 200)
Comparison infants (n = 374; 202 male, 172 female) 146
Infants with NE (n = 141; 81 male, 60 female) 54
GMDS, Grifths Mental Development Scales; IMQ, Infant/Child Monitoring Questionnaire; NE, newborn encephalopathy.
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G Dixon et al.
the IMQ and GMDS was determined by the concordance
between classifications on the screening measure (IMQ) and
criterion measure (GMDS) and was calculated as percentage
agreement using the binary prediction model.19 Measures of
association adjusted for chance agreement (Kappa coefficient)
were used to measure classification accuracy. Sensitivity, speci-
ficity, positive and negative predictive values, over-referrals and
under-referrals were calculated in each age group, across all age
groups and for each area of development.
Ethical approval
The protocol for this study was approved by the Ethics Com-
mittees of The University of Western Australia, King Edward
Memorial and Princess Margaret Hospitals which conforms with
the provision of the Declaration of Helsinki in 1995 (as revised
in Edinburgh 2000). Informed consent was obtained from the
parents of all children who participated.
Results
Of the original cohort of 840 infants, 36 infants with NE and one
comparison infant died before any assessment. One infant with
NE died after the ASQ and GMDS were completed and was
included in these results.
There were 240 surviving infants with NE and 563 surviving
comparison infants eligible for an IMQ and a GMDS. Of the NE
group, 203 (84%) returned at least one IMQ, 195 (81%) had a
GMDS and 141 (59%) had concurrent IMQ and GMDS assess-
ments within a 3-month period, of which 32 (13%) were aged
more than 24 months. There were 108 infants with moderate
NE and 33 with severe NE that had a concurrent IMQ and a
GMDS completed. Of the surviving comparison infants, 488
(87%) returned at least one IMQ, 456 (81%) had a GMDS and
374 (66%) had a concurrent IMQ and GMDS within a 3-month
period, 53 (9%) of which were over the age of 24 months.
Overall, there were 515 infants assessed concurrently by the
screening measure (IMQ) and the gold standard criterion
measure (GMDS) at varying age intervals (Table 1). The mean
age of GMDS completion was 18 months for comparison infants
and 19 months for infants with NE.
Overall, 31 infants were classified with delayed development
on the GMDS, of which 24 (sensitivity 77%) were classified as
being delayed by the concurrent IMQ and seven (23%) were
false negatives (under-referrals). Among the seven false nega-
tives on the IMQ, three were infants with moderate NE and four
18 months 24 months 36 months 48 months
(n = 230) (n = 47) (n = 30) (n = 8)
175 29 22 2
55 18 8 6
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G Dixon et al. Screening children at risk for delay

Table 2 Classication indices of concurrent IMQ and GMDS by age at assessment

IMQ age N Sensitivity Specicity Positive Negative Over-referrals Under-referrals Kappa P-value
(%) (%) predictive predictive (false positives) (false negatives)
value (%) value (%) (%) (%)

All ages 515

Comparison infants 374 50 94 15 99 6 50 0.202 <0.001
Infants with NE 141 87 87 57 97 13 13 0.614 <0.001
12-month IMQ 200
Comparison infants 146 100 90 6 100 10 0 0.106 <0.004
Infants with NE 54 100 78 27 100 22 0 0.340 <0.001
18-month IMQ 230
Comparison infants 175 100 97 17 100 3 0 0.279 <0.001
Infants with NE 55 85 98 92 95 6 15 0.845 <0.001
24-month IMQ 47
Comparison infants 29 25 88 25 88 12 75 0.130 0.484
Infants with NE 18 67 87 50 93 13 33 0.471 0.043

GMDS, Grifths Mental Development Scales; IMQ, Infant/Child Monitoring Questionnaire; NE, newborn encephalopathy.

Table 3 Concordance classication indices of concurrent IMQ and GMDS according to area of development

Development Sample (N) Sensitivity Specicity Positive Negative Over-referrals Under-referrals Kappa P-value
(%) (%) predictive predictive (false (false negatives)
value (%) value (%) positives) (%) (%)

Communication Total (515) 44 97 52 96 3 56 0.443 <0.001

Comparison infants (374) 11 98 11 98 2 89 0.089 0.085
Infants with NE (141) 57 96 72 92 4 4 0.573 <0.001
Gross motor Total (515) 83 98 61 99 2 17 0.688 <0.001
Comparison infants (374) 50 99 38 99 1 50 0.418 <0.001
Infants with NE (141) 94 94 70 99 6 6 0.768 <0.001
Fine motor Total (515) 15 99 92 95 0 68 0.449 <0.001
Comparison infants (374) 15 99 67 97 0 85 0.240 <0.001
Infants with NE (141) 41 100 100 90 0 59 0.539 <0.001
Adaptive Total (515) 55 97 39 98 3 45 0.433 <0.001
Comparison infants (374) 17 98 12 99 2 83 0.127 0.013
Infants with NE (141) 71 92 50 97 8 28 0.579 <0.001
Personal social Total (515) 48 99 69 98 1 52 0.548 <0.001
Comparison infants (374) 25 99 33 99 0.5 75 0.279 <0.001
Infants with NE (141) 53 97 77 93 2 47 0.534 <0.001

GMDS, Grifths Mental Development Scales; IMQ, Infant/Child Monitoring Questionnaire; NE, newborn encephalopathy.

were comparison infants. The characteristics of the validity
measures according to age are given in Table 2. Because of the
small numbers, validity measures are not provided beyond age
24 months.
For infants with NE, across all ages, the sensitivity and speci-
ficity of the IMQ was 87%, positive predictive value 57% and
negative predictive value 97%. For comparison infants across
all ages, the sensitivity of the IMQ was 50%, specificity 94%,
positive predictive value 15% and negative predictive value
99%. Overall under-referral for infants with NE was 13%, com-
pared with 50% for comparison infants.
For infants with NE the agreement between the IMQ and
GMDS measured by Kappa was fair at 12 months (Kappa = 0.340,
P = 0.001, n = 54), almost perfect at 18 months (Kappa = 0.845,
P < 0.001, n = 55) and moderate at 24 months (Kappa = 0.471,
P = 0.043, n = 18). The association of agreement for the
comparison group showed slight agreement at 12 months
(Kappa = 0.106, P = 0.004, n = 146), was fair at 18 months (Kappa
= 0.279, P < 0.001, n = 175) and slight at 24 months (Kappa =
0.130, P < 0.484, n = 29).
Classifications of at-risk of delay on the IMQ and being
delayed on the GMDS were also compared according to cor-
responding areas of development to determine if parents and
professionals had parallel agreement in detecting delay in spe-
cific areas of development (Table 3). Overall, the sensitivity was
lower for corresponding areas of development compared with

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Screening children at risk for delay
agreement for overall failure by age groups. Sensitivity for
infants with NE ranged from 41% (fine motor) to 94% (gross
motor) and only met the acceptable level in gross motor devel-
opment, whereas sensitivity for comparison infants was lower
in all developmental areas.
Parent comments
Parent comments to the open-ended unscored questions on
the IMQ were also examined. Overall, 182 (35%) had parental
comments on the IMQ with infants with NE (53%) having more
parental comments than comparison infants (29%). When
further examined according to infants who passed or failed the
concurrent GMDS, there were more comments on the IMQ of
failed infants (96% of infants with NE and 50% of comparison
infants) compared with infants who passed (45% of infants with
NE and 28% of comparison infants). Of the seven false nega-
tives on the IMQ, all infants with NE (3) had parental concerns
noted and none of the four comparison infants had parental
concerns noted.
Discussion
We examined the screening characteristics of the IMQ in two
relatively large groups of children, the encephalopathy survi-
vors born at term who represent a group at high risk of devel-
opmental delay and the comparison cohort who represent the
general population of children born at term in Western Austra-
lia. We compared the IMQ results with the professionally
administered Griffiths test and our findings support the use of
the IMQ as an accurate and potentially cost-effective alternative
to professional screening of infants at risk of developmental
delay aged 018 months. These results for the high-risk group
were similar to those reported by Skellern et al.8 However,
agreement between parents of comparison infants and profes-
sionals is only slight or fair which may be a function of the
general population being at low risk for developmental delay.
The results from this sample of infants indicate exercising
caution before any widespread introduction of the IMQ as a
single method to monitor or screen the general population.
Overall, the IMQ performed better for infants with NE com-
pared with the comparison infants when individual areas of
development were examined for agreement with the gold stan-
dard assessment. These results could indicate that the IMQ is
sensitive to developmentally at-risk populations whereby
the most obvious and severe problems are detected more easily
than the more subtle problems or it could also reflect that the
parents of infants with NE were more anxious and therefore
more vigilant about signs of delay in their children compared
with parents of comparison infants. The heightened anxiety of
parents of infants who have experienced a serious illness or
accident early in life resulting in perceived child vulnerability
has been well researched and supported in previous studies20
and it is thus plausible that parents of children with NE could
have a perceived child vulnerability resulting in the differences
in parent responses in the two groups.
When the sensitivity of an instrument is low and specificity is
high, there will be fewer false positives (over-referrals), but
there will be more false negatives (under-referrals) as is seen in
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G Dixon et al.
the 12-month age group for both the infants with NE and the
comparison infants. The question is whether fewer false posi-
tives are more optimal in terms of costs than higher rates of false
negatives. The initial financial costs of further professional
testing could be high and would seem to defeat the purpose
of screening; however, the longer-term cost of under-referral
could be significant when a child potentially misses out on early
intervention for a problem harder to habilitate at a later age.
However, it should be acknowledged that over-inclusion (over-
referral) could provoke unnecessary anxiety in parents of chil-
dren referred for further diagnostic testing yet subsequently not
shown to have a problem, which in itself is not without cost.
Among the failures on the IMQ for both groups, parents made
comments at almost twice the rate they did when the child
passed their IMQ. The parents comments on the open-ended
questions in the overall section of the questionnaires may offer
a way to augment quantitative data and increase early detection
of more subtle problems. The true value of parent comments to
the open-ended questions should be more thoroughly exam-
ined to facilitate ways to quantitatively process these concerns
and accurately assess their value. Previous research has shown
that screening measures which accurately elicit parental con-
cerns are as predictive as other screening measures.21 Such
screening measures also serve to actively involve parents in
their childs health care which could facilitate advice and infor-
mation in response to parental concerns to be delivered within
the broader historical and family context.22
Parent-completed screening measures which meet criteria for
adequate psychometric properties (sensitivity and specificity
>70%) may be appropriate for follow-up programmes designed
to detect certain conditions and as such, should be confined to
these conditions. However, even with evidence of the effective-
ness of such screening, it is recommended that the quality of the
test be just part of an overall process which will include the test,
the interpretation, and training of testers, tracking, referral,
reporting, support and overall management (NHMRC Report).
The notion of one-off screening in itself should not be the
central focus for a pass/fail result as these tests are not diag-
nostic22 but alternatively could provide reinforcement for a
surveillance system which is family-centred in practice to effec-
tively monitor the health of the whole community of children
over time.23
In summary, our findings support the potential value of using
the parent-completed IMQ (now ASQ) for infants at risk of
developmental delay in Australian populations. The test char-
acteristics of the IMQ make it useful for the follow-up surveil-
lance of infants up to the age of 18 months with wider coverage
of rural and remote locations at potentially less cost compared
with a professional assessment. On the basis of the results from
this study, the widespread use of the IMQ as a screening instru-
ment in the general population where the risk of developmental
delay was perceived to be minimal is not recommended in
isolation or without caution when interpreting results, and
further research is needed with larger numbers of children aged
more than 18 months to examine the efficacy of such measures.
Finally, the value of parents comments on the IMQ in closing
the gap on the under-referrals in all groups needs to be further
evaluated. Initial examination appears to suggest that parents
have a valuable contribution to make in detecting the early signs
Journal of Paediatrics and Child Health 45 (2009) 268273
2009 The Authors
G Dixon et al.
of more subtle and complex problems before they are apparent
to professionals or rate as failures on screening measures.
Acknowledgements
The Western Australian Newborn Encephalopathy Study was
funded by the Public Health Research and Development Com-
mittee of the National Health and Medical Research Council
of Australia (94/3368) and the National Health and Medical
Research Council of Australia (96/0560, 96/3209, 98/7062,
00/3209).
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