Background
Methods
Study setting
Adaptation process of the Denver II
Classifying test items under ‘cross-cultural’ and ‘culture-specific’ categories
Pilot studies and draft versions
Large sample study and standardization
Sampling, inclusion and exclusion criteria
Assessment of feasibility and reliability
Test item administration and scoring system
Standardization
Data management and statistical analysis
Results
Outcome of the adaptation
Denver II test items adapted | Item code | Description of adaptation of the item |
---|---|---|
Work for toy
a
|
PS5
|
Rattle or culturally used tools such as small pebbles “ calle” or “ elela” were selected.
|
Feed self | PS6 | The items "cracker", "cookie" or “any finger food” were replaced by locally used food such a piece of "bread", "cake", "biscuit", "injera" or a piece of sugar-cane. |
Play pat-a-cake | PS7 | Replaced by "play a clapping game": a culturally equivalent game played by clapping hands. |
Wave bye-bye | PS9 | Modified Cultural difference in expressing goodbye: "saying" or "waving" goodbye |
Imitate (household) activities | PS11 | Activities such as "vacuuming", or "talking on the phone" were replaced by activities such as ...."cooking" or "washing clothes". |
Drink from cup | PS12 | ….child can hold a regular cup or glass and drink from it without help replaced by a regular "cup or glass" or any suitable container used in the family. |
Use spoon/fork | PS14 | Modified as "eat using hand or sppon/fork. The child uses a spoon or fork to eat. is modified as “the child is able to eat independently by using his/her fingers or a spoon or fork” |
Remove garment | PS15 | … items such as…."jackets", "pants", are modified as… items such as "blouse", "dress" or "trousers" |
Feed doll | PS16 | The criterion to pass the test item “ if the child places the bottle to the doll's mouth, or tries to put it to the mouth"… is modified as “if the child imitates putting food into the doll’s mouth or if the child imitates breast feeding”. The use of bottle feeding is being discouraged and many mothers do not practice. Since toy bottle was found strange for many children, performing the task is not expected to pass the test item . |
Put on clothing | PS17 | ….clothing, such as "underpants", "socks" are modified as … clothing, such as "blouse", "trousers", "dress", "skirt" |
Brush teeth with help | PS18 | Replaced by "wash mouth with help"… if the child "brushes his/her teeth with some help"…is modified as if the child "washes his/her mouth with some help" |
Wash and dry hands | PS19 | Criteria for passing the test item is modified as … child can "wash both sides of hands properly" (because hands are culturally dried by dripping water off the hands). Use of soap and towels are not required to pass the item. |
Name friend | PS20 | Replaced by "name playmate" |
Put on T-shirt | PS21 | "pullover" …is replaced by "T-shirt" or "blouse" … |
Dress, no help | PS22 | First: "at least play-clothes" …is modified as …"his/her own clothes", because children may not have many alternative clothing. Finally: adaptation dropped |
Play board/card games | PS23 | Modified as "play social games" …. "board" or "card" games, … “Candy Land” or “Old Maid”… is modified as “joins in simple "group games", like "hide and seek" |
Brush teeth, no help | PS24 | "brush teeth, no help" replaced by "clean face, no help". … if the child "washes his/her own teeth" …is replaced by… if the child "washes and dries" his/her face (eyes, nose, mouth and teeth) …. this is usually done by using water and fingers) |
Prepare Cereal | PS25 | First: … if the child can prepare a bowl of cereal …… is modified as …if the child can prepare his/her own breakfast, including taking bread (or injera,…) from the shelf, taking a cup and pouring a liquid (water, milk, juice) in it.. Finally: modified as "serve oneself 'injera'" (cultural food served with stew) |
Toilet going
b
| PS26 | First: Toilet going (new item): Ask the caregiver if the child can independently use latrine or other facilities available for the family. PASS if they report the child can independently use toilet or latrine or available facility Finally: item dropped |
Regard raisin | FM6 | Is replaced by "Regard coffee bean". |
Rake raisin | FM9 | Is replaced by "Rake coffee bean" |
Thumb-finger grasp | FM12 | … "raisin" which is used as an object for child to grasp is replaced by "coffee bean" |
Scribbles | FM15 | The instruction …”do not show him/her how to scribble”… is modified as.… you may write your name using the pencil to let the child who have never ever seen a pencil before that it is something to write with |
Dump raisin, demonstrated | FM16 | Replaced by "dump coffee bean, demonstrated" |
Copy 0 | FM23 | The instruction “ you may show how to hold the pencil” is added to familiarize a child who has never seen a pencil before |
Draw person – 3 parts, 6 parts | FM24 & FM 28 | The instruction… “You may show how to hold the pencil”… is added to familiarize a child who has never seen a pencil before |
Copy + | FM25 | The instruction… “You may show how to hold the pencil”… is added familiarize a child who has never seen a pencil before |
Copy □ | FM29 | The instruction… “You may show how to hold the pencil”… is added to familiarize a child who has never seen a pencil before |
Body parts – 6 | LA21 | A testing object "white doll" replaced by a black or chocolate colour doll. The use of either a white doll or a chocolate colour doll based on need of child was suggested based on repeated observation. |
Name colours – 1,4 | LA27 & LA34 | First: Criterion for passing test item modified as, “ Child could pass the test if he/she refers to an object with the same colour: sky/water for blue, grass/tree for green, sun for yellow and blood for red. Finally: The "blue" and "green" colour cubes are replaced by "black" and "white" colour cubes. |
Use of objects – 2, 3 | LA28 & LA 30 | ....“What is a 'pencil' used for?”…. is replaced by ….“What is a 'bed' used for?”…. |
Define words – 5, 7 | LA35 & LA39 | The words "desk", "curtain", "lake", are replaced by the words "knife", "firewood", "river" |
Opposites – 2 | LA37 | “If 'fire' is 'hot', 'ice' is..." was replaced by "if a stone is heavy, a feather/leaf is …..” |
Walk up stepc | GM20 | Walk up steps where there are steps in homes, and/or walk up-ward on steep location/ climbs and passes over an elevated door-step |
Outcome of the standardization
Characteristics of the standardization sample
Characteristics | No. (%) | Characteristics | No. (%) |
---|---|---|---|
Children’s (n = 1682) | Mother’s (n = 1588) | ||
Sex | Ethnicity | ||
Male | 833 (49.5) | Oromo | 716 (45.1) |
Female | 849 (50.5) | Amhara | 363 (22.9) |
Nutritional status | Tigre | 46 (2.9) | |
Normal rangea | Gurage | 140 (8.8) | |
Male | 789 (46.9) | Dawuro | 148 (9.3) |
Female | 808 (48) | Keficho | 72 (4.5) |
Malnourishedb | Wolaita | 30 (1.9) | |
Male | 43 (2.6) | Others | 62 (3.9) |
Female | 40 (2.4) | Missing/Unknown | 11 (0.7) |
Unknown status | Perceived socio-economic status | ||
Male | 1 (0.06) | High | 58 (3.7) |
Female | 1 (0.06) | Middle | 1443 (90.9) |
Low | 65 (4.1) | ||
Mother’s (n = 1588) | Very low | 0 | |
Education level | Missing/unknown | 22 (1.4) | |
Illiterate | 147 (9.3) | ||
Grades 1–8 | 546 (34.4) | Religion | |
Grades 9–12 | 485 (30.5) | Islam | 558 (35.1) |
Certificate after grade 12 | 98 (6.2) | Orthodox Christian | 725 (45.7) |
Diploma | 247 (15.6) | Protestant | 271 (17.1) |
Degree and above | 55 (3.5) | Catholic | 23 (1.4) |
Missing/unknown | 10 (0.6) | Others | 6 (0.4) |
Missing | 5 (0.3) |
The Denver II-Jimma Age Milestones
Item code | Item label | 25 % | 50 % | 75 % | 90 % | Item code | Item label | 25 % | 50 % | 75 % | 90 % |
---|---|---|---|---|---|---|---|---|---|---|---|
Personal social domain | Fine motor domain | ||||||||||
PS1 | Regard face | birthb | birthb,d | birthb,d | birthb,d | FM1 | Follow to midline | birthb | 0.1f | 0.1e | 0.2e |
PS2 | Smile responsively | 0.8 | 1.1f | 1.3d | 1.6d | FM2 | Follow past midline | 1.3 | 1.5f | 2.2e | 2.7d |
PS3 | Smile spontaneously | 1.1 | 1.4e | 1.6f | 1.9e | FM3 | Grasp rattle | 2.4 | 3.0d | 3.6d | 4.1d |
PS4 | Regard own hand | 1.6 | 1.,8e | 3.2e | 4.1d | FM4 | Hands together | 2.5 | 3.1f | 3.7f | 4.3d |
PS5 | Work for toy | 3.1 | 4.5d | 6.0f | 7.6f | FM5 | Follow 180° | 3.1 | 3.7f | 4.3f | 4.9d |
PS6 |
Feed self
a
| 4.0 | 5.9d | 8.2f | 10.5f | FM6 |
Regard coffee bean
a
| 4.1 | 4.5f | 5.0f | 5.4d |
PS7 |
Play clapping game
a
| 6.9 | 8.1e | 9.4d | 10.6d | FM7 | Reaches | 4.2 | 4.7d | 5.2d | 5.6d |
PS8 | Indicate wants | 6.1 | 8.1e | 10.1d | 12.2d | FM8 | Look for yarn | 4.9 | 5.4d | 6.0d | 6.6d |
PS9 |
Wave bye-bye/Say good-bye
a
| 8.2 | 10.0f | 11.8f | 13.6d | FM9 |
Rake coffee bean
a
| 5.3 | 5.9d | 6.4d | 6.9d |
PS10 | Play ball with examiner | 10.4 | 12.,2f | 14.0f | 15.8d | FM10 | Pass cube | 6.2 | 7.4f | 8.5f | 9.7f |
PS11 |
Imitate activities
a
| 9.7 | 11.6d | 13.4d | 15.2d | FM11 | Take 2 cubes | 5.8 | 6.9f | 8.2f | 9.5d |
PS12 |
Drink from cup or glass
a
| 9.7 | 11.8d | 13.9d | 16.0d | FM12 |
Thumb-finger grasp
a
| 6.5 | 7.5d | 8.7d | 9.9 |
PS13 | Help in house | 12.9 | 15.9f | 18.4f | 20.9f | FM13 | Bang 2 cubes held in hands | 7.4 | 9.3f | 11.3f | 13.3f |
PS14 |
Eats using spoon/fork/fingers
a
| 11.7 | 14.5d | 17.2d | 20.0 | FM14 | Put block in cup | 8.7 | 10.2d | 11.7d | 13.1d |
PS15 |
Remove garment
a
| 15.5 | 20.4f | 24.5f | 28.6f | FM15 |
Scribbles
a
| 10.7 | 13.4d | 16.0d | 18.6f |
PS16 |
Feed doll
a
| 14.4 | 19.5f | 24.5f | 29.7f | FM16 |
Dump coffee bean, demonstrated
a
| 10.9 | 13.5d | 16.0d | 18.5d |
PS17 |
Put on clothing
a
| 25.3 | 31.8f | 38.1f | 44.5f | FM17 | Tower of 2 cubes | 12.6 | 15.6d | 18.3d | 21.0d |
PS18 |
Wash mouth with help
a
| 20.4 | 24.8f | 29.1d | 33.4d | FM18 | Tower of 4 cubes | 16.4 | 19.3d | 22.2d | 25.1d |
PS19 |
Wash and dry hands
a
| 22.9 | 27.4f | 32.4f | 37.4d | FM19 | Tower of 6 cubes | 19.7 | 23.1d | 26.6d | 30.1d |
PS20 |
Name playmate
a
| 22.8 | 28,3d | 33.4d | 38.6d | FM20 | Imitate vertical line | 25.9 | 32.4f | 37.7f | 43.0f |
PS21 |
Put on t-shirt
a
| 34.2 | 40.8f | 47.3f | 53.8f | FM21 | Tower of 8 cubes | 22.1 | 29.4f | 35.0d | 40.6d |
PS22 |
Dress, no help
a
| 43.9 | 50.5f | 57.0f | 63.5f | FM22 | Thumb wiggle | 27.0 | 32.8d | 38.4d | 44.2d |
PS23 |
Play social games
a
| 31.8 | 41.6f | 51.2d | 60.9d | FM23 |
Copy
a
O
| 38.7 | 43.1d | 47.3d | 51.6d |
PS24 |
Clean face, no help
a
| 37.9 | 46.8f | 55.5d | 64.4d | FM24 |
Draw person—3 parts
a
| 44.0 | 48.2d | 52.3d | 56.4d |
PS25 |
Serve oneself
injera
a
| 31.7 | 46.5d | 61.2f | 76.0d | FM25 | Copya + | 33.8 | 40.4d | 46.9d | 53.4d |
PS26 | Toilet-goingc | 60.1 | 70.4d | 80.6d | 90.8d | FM26 | Pick longer line | 33.8 | 40.4d | 46.9d | 53.4e |
FM27 | Copy □ demonstrated | 45.7 | 51.8d | 57.7d | 63.6d | ||||||
FM28 | Draw person—6 partsa | 52.4 | 57.5d | 62.4d | 67.4d | ||||||
FM29 | Copya□ | 52.3 | 58.2d | 64.0d | 69.8d | ||||||
Language domain | Gross motor domain | ||||||||||
LA1 | Respond to bell | birthb | birthb,d | birthb,d | birthb,d | GM1 | Equal movement | birthb | birthb,d | birthb,d | birthb,d |
LA2 | Vocalizes | birthb | birthb,d | 0.3f | 1.0f | GM2 | Lift head | birthb | 0.1f | 0.4f | 0.7f |
LA3 | “Ooo”/ Aah | 1.4 | 1.5f | 1.6d | 1.6e | GM3 | Head up 45° | 1.6 | 2.4f | 2.3f | 2.6d |
LA4 | Laugh | 2.0 | 2.2f | 2.5d | 2.7e | GM4 | Head up 90° | 2.9 | 3.2f | 3.6f | 3.9d |
LA5 | Squeals | 2.2 | 2.5f | 2.8d | 3.2e | GM5 | Sit head steady | 3.0 | 3.3f | 3.6f | 3.9d |
LA6 | Turn to rattling sound | 3.7 | 4.3f | 4.8d | 5.4d | GM6 | Bear weight on legs | 3.1 | 3.4f | 3.6d | 3.8e |
LA7 | Turn to voice | 4.5 | 5.2f | 5.8d | 6.5d | GM7 | Chest up-arm support | 3.9 | 4.3f | 4.6f | 4.9d |
LA8 | Single syllables | 4.6 | 5.5d | 6.3d | 7.1d | GM8 | Roll over | 3.8 | 4.4f | 4.9f | 5.4d |
LA9 | Imitate speech sounds | 5.2 | 6.5f | 7.8f | 9.1d | GM9 | Pull to sit, no head lag | 4,4 | 4.9f | 5.5f | 6.0d |
LA10 | Dada/Baba/Mama, non-specific | 5.7 | 6.7d | 7.8d | 8.8d | GM10 | Sit, no support | 5,4 | 6.0d | 6.6d | 7.3d |
LA11 | Combine syllables | 6.2 | 7.5f | 8.8f | 10.1d | GM11 | Stand, holding on | 6,5 | 7.3d | 8.3d | 9.3d |
LA12 | Jabbers | 7.0 | 8.5f | 10.0f | 11.5d | GM12 | Pull to stand | 7,2 | 8.0d | 8.9d | 9.9d |
LA13 | Dada/Mama/baba, specific | 8.8 | 10.2f | 11.6d | 12.9d | GM13 | Get to sitting | 7,4 | 8.3d | 9.2d | 10.1d |
LA14 | One word | 10.1 | 11.9d | 13.6d | 15.3d | GM14 | Stand 2 s | 8,6 | 9.7d | 10.7d | 11.6d |
LA15 | 2 words | 11.5 | 13.8f | 15.9d | 18.0d | GM15 | Stand alone | 9,8 | 11.3d | 12.3d | 13.4d |
LA16 | 3 words | 13,5 | 15.6f | 17.7f | 19.8d | GM16 | Stoop and recover | 11,6 | 13.2d | 14.8f | 16.4f |
LA17 | 6 words | 16,5 | 19.1f | 21.8f | 24.4f | GM17 | Walk well | 11,3 | 13.1d | 14.9f | 16.7f |
LA18 | Point 2 pictures | 20,8 | 24.0f | 27.2f | 30.3f | GM18 | Walk backwards | 11,9 | 14.9d | 17.4f | 19.9f |
LA19 | Combine words | 18,7 | 21.3d | 23.9d | 26.4d | GM19 | Runs | 14,4 | 16.6d | 18.9d | 21.2d |
LA20 | Name 1 picture | 20,1 | 23.2f | 26.2f | 29.3d | GM20 |
Walk up steps
a
| 13,9 | 16.9d | 19.6d | 22.3d |
LA21 |
Body parts 6
a
| 20,3 | 23.0f | 25.6f | 28.2d | GM21 | Kick ball forward | 14,2 | 17.6d | 21.0d | 24.4d |
LA22 | Point 4 pictures | 25,9 | 31.0f | 35.9f | 40.9f | GM22 | Jump up | 24.0 | 27.0f | 31.0f | 35.0f |
LA23 | Speech, half understandable | 20,5 | 24.2f | 27.8d | 31.5e | GM23 | Throw ball overhand | 16.9 | 22.1d | 27.2f | 32.4d |
LA24 | Name 4 pictures | 27,6 | 32.5f | 37.3f | 42.1f | GM24 | Broad jump | 31.7 | 35.6d | 39.3f | 43.1f |
LA25 | Know 2 actions | 24,5 | 29.5d | 34.4d | 39.4d | GM25 | Balance each foot 1 s | 23.4 | 28.9d | 33.0d | 37.1d |
LA26 | Know 2 adjectives | 30,9 | 35.1d | 39.1d | 43.3d | GM26 | Balance each foot 2 s | 23.9 | 31.2e | 36.4e | 41.6e |
LA27 |
Name 1 color
a
| 40,3 | 45.1d | 49.8f | 54.6f | GM27 | Hops | 31.9 | 38.5d | 45.0d | 51.5d |
LA28 |
Use of 2 objects
a
| 30,4 | 35.6f | 40.7d | 45.8d | GM28 | Balance each foot 3 s | 29.8 | 36.1d | 42.2e | 48.4e |
LA29 | Count 1 block | 36,6 | 41.9d | 47.0f | 52.2f | GM29 | Balance each foot 4 s | 33.8 | 40.0e | 46.0e | 52.1e |
LA30 |
Use of 3 objects
a
| 32,3 | 37.5d | 42.7d | 47.8d | GM30 | Balance each foot 5 s | 39.2 | 44.8e | 50.2e | 55.8e |
LA31 | Know 4 actions | 32,4 | 38.5e | 44.4f | 50.4d | GM31 | Heel-to-toe walk | 49.1 | 55.5d | 61.8d | 68.1d |
LA32 | Speech all understandable | 28,4 | 36.3f | 44.0f | 51.8d | GM32 | Balance each foot 6 s | 41.8 | 47.9e | 53.8e | 59.7e |
LA33 | Understand 4 prepositions | 30,8 | 37.5d | 44.0d | 50.7e | ||||||
LA34 |
Name 4 colors
a
| 51,9 | 56.8f | 61.5f | 66.3f | ||||||
LA35 |
Define 5 words
a
| 47,4 | 54.3f | 61.0d | 67.8d | ||||||
LA36 | Know 3 adjectives | 34,5 | 40.6d | 46.5d | 52.5e | ||||||
LA37 |
Count 5 blocks
a
| 49,0 | 54.3d | 59.4d | 64.6d | ||||||
LA38 | Opposites-2 | 48,5 | 54.0d | 59.2d | 64.5d | ||||||
LA39 |
Define 7 words
a
| 59,1 | 66.8f | 74.2f | 81.8f |
Reliability of the Denver II-Jimma
Reliability Measures | PS (26 items) | FM (29 items) | LA (39 items) | GM (32 items) | Total (126 items) |
---|---|---|---|---|---|
Inter-rater (kappa values) | |||||
Excellent (0.81–1.00) | 21 (80.8 %) | 24 (82.8 %) | 34 (87.2 %) | 27 (84.4 %) | 124 (98.4 %) |
4 (15.4 %)*** | 4(13.8 %)*** | 5(12.8 %)*** | 5(15.6 %)*** | ||
Substantial (0.61–0.80) | 1(3.8 %) | 1 (3.4 %) | - | - | 2 (1.6 %) |
Acceptable (0.41–0.60) | - | - | - | - | - |
Poor (<0.41) | - | - | - | - | - |
Inter-rater (ICC)C, [95 % CI] | 0.983, [0.979-0.986] | 0.982, [0.978-0.985] | 0.951, [0.940-0.959] | 0.967, [0.961-0.973] | |
Test retest (kappa values) | |||||
Excellent (0.81–1.00) | 15 (57.7 %) | 4(13.8 %) | 14 (35.9 %) | 14 (43.8 %) | 69 (54.8 %) |
4 (15.4 %)*** | 5 (17.24 %)*** | 6 (15.4 %)*** | 5 (15.6 %)*** | ||
1(3.45)* | 1(2.6 %)** | ||||
Substantial (0.61–0.80) | 5 (19.2 %) | 13 (44.8 %) | 16 (41 %) | 11 (34.4 %) | 45 (35.7 %) |
Acceptable (0.41–0.60) | 2 (7.7 %) | 5 (17.24 %) | 2 (5.1 %) | 2 (6.3 %) | 11 (8.7 %) |
Poor (<0.41) | 1 (3.45 %) | - | - | 1 (0.8 %) | |
Test-retest (ICC)d, [95 % CI] | 0.802, [0.721–0.859] | 0.831, [0.736–0.888] | 0.840, [0.773–0.887] | 0.793, [0.711–0.852] |