Content validity of the Harris Infant Neuromotor Test.

Background and Purpose. The purpose of this study was to assess the content validity of the Harris Infant Neuromotor Test (HINT), a new screening tool designed to detect early signs of cognitive and neuro-motor delays in infants with known risk factors. Subjects. A multidisciplinary panel of 26 international experts, including researchers and clinicians in physical therapy, occupational therapy, developmental pediatrics, child neurology, and psychology, was selected to assess, review, and suggest modifications to the HINT. Methods. A validity questionnaire that was keyed to the three parts of the HINT (background information, parent questionnaire, and infant assessment) and to individual items within each part was mailed to the selected content experts. Data were analyzed using descriptive statistics. Results. Twenty experts completed the validity questionnaires, and the remaining 6 experts provided written comments. The experts generally agreed that the items on the initial development edition of the HINT were clearly worded and free of cultural bias. Based on written feedback, additional background information items were added, a fifth question was added to the parent questionnaire portion, and 20 of the 22 infant assessment items were modified. Conclusion and Discussion. After receiving questionnaire responses and written comments from a panel of 26 experts, the original version of the HINT was modified and printed as development edition 2 in November 1993. This revised edition is currently being used to examine the reliability and validity of the HINT in assessing infants at risk. [Harris SR, Daniels LE. Content validity of the Harris Infant Neuromotor Test. Phys Ther. 1996;76:727-737.]

Early diagnosis of cerebral palsy, mental retardation, and some other neurodevelopment disabilities can be extremely difficult, particularly during the first year of an infant's life. Yet only through early identification of such elusive and difficult-to-diagnose disabilities is it possible to initiate early intervention strategies aimed at improving developmental outcomes and providing appropriate family support. Although research on the efficacy of early intervention for children with neurodevelopmental disabilities is both sparse and conflicting,[1-4] the greatest hope in effecting positive changes in developmental outcome appears to lie in the early treatment of those infants who are most difficult to reliably identify in early infancy.[5] Although infants with severe developmental disabilities and recognizable genetic defects are easily identifiable at birth or during the neonatal period, infants with subsequent mild to moderate disabilities and no obvious dysmorphic characteristics are much harder to diagnose. These, however, are the infants for whom early intervention may prove to be the most efficacious in that their central nervous system (CNS) defects or differences are probably less severe.[6]

Improved technology in the neonatal intensive care unit (NICU) during the 1970s and 1980s has led to increased survival of infants born very early and at very low birth weights. Concomitant with the decreased mortality of these tiny infants has been an increase in the absolute number of children with major neurodevelopmental handicaps, such as mental retardation and cerebral palsy.[7] A decade ago, Kiely and Paneth[8] stated that approximately one out of four infants weighing less than 1,000 g at birth would develop a major neurodevelopmental handicap. That estimate was corroborated by a recent longitudinal study of 156 infants with extremely low birth weights, 24.4% of whom showed "evidence of a neurosensory problem (cerebral palsy, visual impairment, hydrocephalus) and/or mental retardation (defined as an IQ of [less than or equal to] 70 or untestable)" at their 3-year-old follow-up visit.[9] (p579)

Although a number of infant neuromotor tests exist, none have been aimed at identifying movement disorders, such as cerebral palsy, as well as early cognitive delays in high-risk infants. In a recent review of infant tests,[10-16] Campbell and colleagues commented, "Each of these tests has one or more problems that limits its use in clinical practice, such as lack of summary or quantitative scores, excessive length, or questionable or inadequately demonstrated reliability or validity."[17] (p.586) In an attempt to counter some of these concerns, Campbell and colleagues have developed the Test of Infant Motor Performance (TIMP), a 534-item test designed for use by physical therapists and occupational therapists for assessing functional motor performance in high-risk infants ranging from 32 weeks' gestational age to 3.5 months postterm.[18] The TIMP has two scales, one that rates spontaneous movements and one that rates the infant's responses to handling and positioning. Average administration time is 36 minutes.

Another promising new motor test is the Alberta Infant Motor Scale (ALMS), a 58-item, norm-referenced observational assessment scale that can be administered in 20 to 30 minutes.[19] One of the primary goals of the ALMS is to discriminate infants (birth to 18 months of age) who exhibit immature or atypical motor development from those who are performing normally, whereas the TIMP was developed to identify infants with deficits in postural control. Both of these exciting new tools were designed to examine differences in motor behavior, with the goal of identifying infants with motor deficits. A secondary goal of the ALMS is to measure changes in motor performance over time or as a result of intervention, including small changes that are not easily detected by other standard motor assessment tools.[19]

Harris Infant Neuromotor Test

The Harris Infant Neuromotor Test (HINT)[20] is aimed not only at identifying early motor deficits in infants at risk but also at identifying early signs of cognitive delay. Spanning an age range of 3 to 12 months, administration of the HINT begins approximately at the end of the TIMP's age range (ie, 3.5 months) III addition to items assessing neuromotor milestones, active and passive muscle tone (as assessed by antigravity movements and resistance to quick, passive stretch, respectively), head circumference, stereotypical movement patterns, and behavioral interactions, the HINT has five questions asking the infant's parent or caregiver to assess how the infant feels while being carried, how the infant moves and plays, whether the infant's movement and play are on schedule, and whether the infant's parent or caregiver or any others (eg, spouse, grandparents, public health nurse) have concerns about the infant's movement, play, or interactions. These items were developed and included in the HINT based on the senior author's (SRH) clinical experience that parents were usually correct in determining whether their infant was showing developmental delays or differences.

Recent research on the first development edition of the HINT"t showed a high degree of parental or caregiver accuracy in determining an infant's developmental level (ahead of schedule, on schedule, slightly delayed, or very delayed) as compared with concurrent results on the Bayley Scales of Infant Development.[22] When compared with results on the Bayley Mental Scale, the specificity of the parents' developmental estimates was 85.9% and their sensitivity was 60%. Using the Bayley Motor Scale as the concurrent criterion, the specificity of parents' ratings reached 90.9% and the sensitivity was 80%.[23]

The HINT was developed to provide a reliable and valid neuromotor screening tool that can be used in clinical and research settings for the early identification of neurodevelopmental handicaps in high-risk infants. Although both the TIMP and the AIMS were designed to examine differences in motor behavior, specifically posture and antigravity control, with the goal of identifying infants with motor deficits, the purpose of the HINT differs somewhat in that it is aimed at identifying either motor deficits or cognitive deficits in infants at risk. Cognitive deficits are common both in infants with extremely low birth weights as well as in another group of high-risk infants, those with prenatal drug or alcohol exposure.[24,25]

The HINT, designed to be administered and scored in less than 30 minutes, is intended for use by occupational therapists, physical therapists, family physicians, pediatricians; and community health nurses involved in the early screening of high-risk infants. Initial development of the HINT was funded by a 1-year fellowship from the National Institute on Disability and Rehabilitation Research of the US Department of Education.[21]

Item development was based on research with the Movement Assessment of Infants (MAI),[26] including reliability,[27] validity? and item-analysis studies [29-30]; review of published research on early identification of neurodevelopmental problems, and the senior author's clinical experience in assessing high-risk infants and infants with developmental disabilities. The HINT consists of three parts: The first part is for recording background information on the child (eg, current age, birth weight, gender, prenatal and neonatal risk factors) and the caregiver (eg, age, occupation, highest grade completed, race); the second part is the five-item "Questions to Parent/Primary Caregiver" section; and the final part, entitled "Infant Assessment," consists of the 22 items that are either observed or assessed through physical handling (eg, muscle tone) and then scored by the test examiner. Following calculation of the infant's raw score, the examiner makes two summary decisions about the infant's overall neuromotor performance, one for developmental level and one for quality of performance. The content of development edition 2 of the HINT is provided in Table 1.

The content of the "Questions to Parent/Primary Caregiver" section is designed to assess the parents' level of concern and the specific areas of concern that they may have about their child.es In the "Infant Assessment" section, the content on motor behaviors in a supine-lying position, in transition to a prone-lying position, and in prone-lying and sitting positions includes both observation and physical-handling items that are ordered in a logical sequence by position. These items were selected from published research based on the item's reliability or importance as a predictor of later neurodevelopmental disability.[28-34]

The items assessing locomotion, posture, movements, and stereotypical behaviors; behavioral state; and the measurement of head circumference also were selected based on previous reliability and predictive validity studies.[28-34] These seven items can be observed or tested at any time during the assessment session.

The two-part developmental and qualitative judgment item was included to summarize the examiner's overall clinical impressions about the developmental appropriateness of the infant's neuromotor performance and the quality of the infant's movement behaviors. Based on research with the MAI[30] the MAI summary scores, which are intended to reflect the examiner's overall impression in each of four areas (tone [as assessed by extensibility, consistency, passivitity, and antigravity movements while positioned prone, supine, and in prone suspension], primitive reflexes, automatic reactions, volitional movement), were all important discriminators of later cerebral palsy. Therefore, it seemed both logical and important to include an item that would reflect the examiner's overall clinical impressions following administration of the HINT.

The first edition of the HINT was used to assess 31 high-risk infants, aged 3 to 9 months? In that study, raw scores decreased with increasing age, which was anticipated because higher scores are indicative of greater risk or less maturity. Concurrent validity was examined by comparing HINT raw scores with raw scores on the Bayley Scales of Infant Development[22] and the MAI with the following Pearson product-moment correlations, respectively: -.82, -.91, and .54. Infants who were identified as the most severely involved, based on clinical appraisal, had the highest scores on the HINT.

Content Validity

The purpose of this study was to examine the content validity of the first edition of the HINT.[20] Content validity has been defined as "the extent to which a measure is a complete representation of the concept of interest."35(pp158-159) A test need not cover all possible content characterizing the concept of interest but should include a representative sample of the content.[36] When designing a new test, one common method for examining its content validity is to have it assessed by a panel of expert judges.[37,38] Responses of the panel are then used to modify the items and the overall content of the test.

According to Dunn, "content validity is not indicated by a statistical measure but rather is inferred from these types of judgments."[38](p155) Determination of a test's content validity, is a requirement of the standards for tests and measurement of both the American Psychological Associations[9] and the American Physical Therapy Association.[40] In assessing the content validity of the HINT, some attempt also was made to assess its construct validity by virtue of the questions that were included in the questionnaire. Dunn has defined construct validity as "the underlying theoretical premises and concepts that are measured by test scores."[38](p160) Questions in the content validity questionnaire were aimed at addressing the measurement adequacy of the constructs "neuromotor function" and "cognitive delay" and the extent to which the neuromotor and developmental items included in the test are representative of neuromotor function and cognitive delay.

Method

Participants

A multidisciplinary panel of 26 international experts was selected by the research team (ie, the authors and the three therapists who participated in later reliability testing of the HINT) to assess and review the HINT items. Panel members included researchers and expert clinicians in physical therapy, occupational therapy, developmental pediatrics, child neurology, and psychology. Twenty of the respondents completed all questions on file questionnaire. The remaining 6 respondents chose to provide narrative feedback to the questions posed. The background and qualifications of the 20 content experts who completed the questionnaires are described in Table 2; we did not request demographic information from the 6 experts who provided narrative feedback only.

The content experts (17 women, 3 men) had an average of 22.3 years of experience in their respective disciplines (SD=5.30, range=15-35), of which 19.6 years was with the pediatric age group (SD=4.47, range=12-29). The group means were 16.6 years (SD=6.39, range=3-25) for clinical practice, 12.4 years (SD=7.48, range=0-24) for academic experience, 6.2 years (SD=5.44, range=0-15) for administration, and 11.9 years (SD=5.70, range=0-24) for research. All but one of the content experts was from North America and all were Caucasian, thus limiting the cultural heterogeneity and perspectives of this group.

Validity Questionnaire

The validity questionnaire was keyed to the three parts of the HINT (background information, parent questionnaire, and infant assessment) and to individual items within each part (as shown in Tab. 1). For file "Background Information" section, the experts were asked whether any items should be added, deleted, or modified, and if so, to make the changes directly on the HINT protocol sheet. The criteria used by the reviewers to assess each HINT item in the "Questions to Parent/Primary Caregiver" and "Infant Assessment" sections were based on those suggested by Bonder.[41] These criteria were (1) the item is clearly worded, (2) the item reflects content important to neuromotor development or diagnosis, (3) the item is likely to discriminate between infants who are developing normally and those who are not developing normally (ie, with and without neuromotor developmental problems), and (4) the item is not culturally biased. Using these four criteria, the content experts were asked to rate each HINT question and item on a five-point scale, where 1=no opinion, 2=strongly disagree, 3=disagree, 4=generally agree, and 5=fully agree.

The experts were then asked five questions dealing with the HINT's completeness and appropriateness, its capacity to screen for early neuromotor and cognitive delay, and its suitability for administration by the intended audience. The experts rated each question using a five-point rating scale (ranging from 1=poor to 5=excellent). These questions were modified from those used by Haley and colleagues[42] in examining the content validity of the Pediatric Evaluation of Disability Inventory (PEDI).

Data Analysis

Data were analyzed using descriptive statistics. The number of experts responding and the percentage of responses were calculated for each validity criterion category for the 27 HINT questions and test items as well as the global questions.

Results

The results of the validity questionnaire are shown in Table 3. Results are organized by question. For the "Questions to Parent/Primary Caregiver" section, the experts generally agreed (greater than or equal to) 80% rated the item 4 or 5) that the questions were clearly worded and that they were not culturally biased. They also agreed that parental opinion of how the baby feels when carried and how the baby moves and plays was important (greater than or equal to 80%). There was less agreement regarding the importance of asking the parents to compare their baby's movement and play with that of other babies the same age (75%) and to identify whether other people had concerns about the baby's development (60%). The ratings for the capacity of the parent questions to discriminate between normally developing children and those with neurodevelopmental delays were lower, ranging from 61.1% to 78.9%.

For the 22 items comprising the "Infant Assessment" portion of the HINT, the reviewers agreed (greater than or equal to) 80% that 16 items (72.7%) were clearly worded, 17 items (77.2%) evaluated an important aspect of neuromotor behavior, 12 items (54.4%) would discriminate between normally developing children and those with developmental delays, and 22 items (100%) were not culturally biased.

Clarity of wording was questioned (<80% of the reviewers were in general or full agreement) for the items "asymmetrical tonic neck reflex," "passive range of motion in supine," "head righting," "trunk mobility," "upper extremity position in prone," "head position in sitting," and "overall clinical impression." Neuromotor importance was questioned (<80% of the reviewers rated 4 or 5) for the items "asymmetrical tonic neck reflex," "trunk mobility," "passive range of motion in prone," "posture of feet," and "behavior and cooperation." Similarly, discriminative power was challenged for the items "asymmetrical tonic neck reflex," "reaching from supine," "passive range of motion in supine," "trunk mobility," "passive range of motion in prone," "posture of feet," "behavior and cooperation," "presence of stereotypical behaviors," "head circumference," and "overall clinical impression."

The responses of the content experts to the global questions about the HINT are summarized in Table 4. The experts rated the HINT as average or above average (greater than or equal to) 3 in the following areas: the completeness and appropriateness of the questions to the parent or primary caregiver, the ability of the HINT to screen for early neuromotor handicaps, and the completeness of the HINT for sampling early neuromotor disability or developmental delay. The HINT's appropriateness for administration by its intended audience was rated as average or above average (greater than or equal to 3 by 94.6% of the raters. The experts had concerns about the HINT's ability to screen for early cognitive delays in that 73.7% rated this item as <2. Considering file overall content of the HINT, 40% of the respondents indicated that they would add items, 25% indicated that they would delete items,: and 80% indicated that they would modify HINT items.

Of the remaining six experts who chose to provide narrative input rather than complete the questionnaire, most of the comments were positive, such as "All items are clearly worded, and all reflect important aspects of neuromotor behavior" and, with regard to the "Questions to Parent/Primary Caregiver" section, "Excellent." Concerns expressed included a need to add fine motor skills and language responses for the upper end of the HINT's age range in order to increase the test's discriminatory power. Based on the ratings and comments of the expert reviewers, revisions were made to the original edition of the HINT and the revised edition was subsequently printed in November 1993.*

Discussion

Results of the content validity study of the HINT compare favorably with those of other instruments recently developed by physical therapists and occupational therapists.[42,43] An interdisciplinary panel of experts generally agreed that items on the initial edition of the HINT were clearly worded and free of cultural bias. An important limitation of this study, however, was the fact that the cultural makeup of the content experts was predominantly white, female, upper middle class, and North American. The content experts' cultural makeup may limit their ability to adequately judge freedom from: cultural bias. At least one of the experts, however, has published a comprehensive literature review examining cultural variations in motor development in young children.[44]

Based on expert feedback concerning the "Questions to Parent/Primary Caregiver" section of the HINT, a fifth question was added: "Is anyone else (eg, spouse, grandparents, public health nurses) concerned about your baby?" In addition, the background information requested for both the child and the birth parents was expanded, and a two-page checklist of possible risk factors was added.

For the items that comprise the "Infant Assessment" portion of the HINT, scoring criteria were expanded for several of the 22 items based on suggestions provided by

* The revised edition score form is available from the senior author. the content experts. For the item "upper extremity position in prone," for example, the initial three behaviors were expanded to include a fourth behavior and the descriptor "with shoulders at 90 degrees of flexion" was added. In contrast, the scoring criteria for overall clinical impressions (item 22) were collapsed from four to three criteria by combining the two middle criteria ("immature" and "slightly delayed").

We were pleased that all of file experts who completed the content validity questionnaire rated the HINT as average or above average (greater than or equal to) 3 on three of the five global questions and that nearly all of the experts (94.3%) rated the appropriateness of the HINT for administration by its intended audience as average or above average (Tab. 4).

Almost three fourths of the judges, however, did not believe that the HINT would be able to screen for early cognitive delays. Preliminary follow-up data on 80 of the 45 high-risk infants in our predictive validity study suggest that the HINT was moderately successful in predicting cognitive outcomes at 18 to 20 months, as assessed on the Bayley-II.[45] Sensitivity of the HINT's overall rating of neuromotor performance as qualitatively suspect or abnormal, when compared with a Mental Developmental Index (MDI) of the Bayley-II of <85, was 64.7%; specificity of the HINT's overall rating of neuromotor performance as qualitatively normal was 61.5%, as compared with a Bayley-II MDI that was within normal limits at 18 to 20 months. These preliminary findings suggest that there is some relationship, albeit modest, between qualitative clinical judgments of an infant's neuromotor performance during the first year of life and the infant's cognitive performance as a toddler (18-20 months).

Based on input from the content experts who reviewed the initial edition of the HINT, additional information was added to the "Background Information" section, a fifth question was added to the "Questions to Parent/Primary Caregiver" section, and 20 of the 22 items were modified in the "Infant Assessment" section. Currently, we are assessing the reliability (interrater, intrarater, and test-retest) of this edition as well as its concurrent and predictive validity, using the Bayley-II as the outcome criterion.

Several limitations should be kept in mind when interpreting the results of our study. First, as already described, there was the narrow cultural makeup of the panel of judges and the limited degree to which they could interpret whether items were free of cultural bias. This shortcoming minimizes the generalizability of these opinions. A second limitation was the failure to include parents as content experts, particularly for the questions designed to be answered by the parent or caregiver.

Finally, the value of the experts opinions about the HINT would have been strengthened considerably had the experts been given the opportunity to actually administer the test rather than to merely review the written test form.

Conclusions and Future Research

Results of questionnaire feedback from 20 content experts and descriptive comments from 6 other experts suggest that the content of the HINT is representative of early neuromotor behaviors that can discriminate infants with neuromotor impairments from those who will develop typically. Less support was demonstrated for the HINT's ability to discriminate early cognitive delays. Written input from the experts was used to add new information and to modify many of the items from the first edition.

Because development edition 2 of the HINT is being used in our current research project to assess and follow infants with prenatal alcohol and drug exposure, as well as infants born at extremely low birth weights (<1,000 g), we will have both predictive and outcome data on groups that are at high risk for cognitive as well as neuromotor delays. Whether the HINT will be successful in discriminating early cognitive and neuromotor differences in infants less than 12 months of age and whether parental degree of concern adds to this ability to discriminate are questions that will be answered when this current project is completed.

Results of the reliability and validity studies will be used to make further modifications of the HINT and will be incorporated into the ongoing development of the HINT manual. On completion of the final version of the tool and the manual, normative data will be collected as the last phase in the test's development.

Acknowledgments

Our heartfelt thanks are extended to the 26 content experts who assisted us in revising the HINT through their thoughtful and constructive comments.

References

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2 Simeonsson RJ, Cooper DH. Schenier AP. A review and analysis of the effectiveness of early intervention programs. Pediatrics. 1982;69: 635-641.

3 Turnbull JD. Early intervention for children with or at risk for cerebral palsy. Am J Dis Child. 1993;147:54-59.

4 Harris SR. The effectiveness of early intervention for children with or at risk for cerebral palsy. In: Guralnick MJ, ed. The Effectiveness of Early Intervention: Second Generation Research. Baltimore, Md: Paul H Brookes Publishing Co. In press.

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12 Brazelton TB. Neonatal Behavioral Assessment Scale. 2nd ed. Philadelphia, Pa: JB Lippincott Co; 1984.

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15 Korner AF, Brown BW, Dimiceli S, et al. Stable individual differences in developmentally changing preterm infants: a replicated study. Child Dev. 1989:60:502-513.

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17 Campbell SK, Kolobe THA, Osten ET, et al. Construct validity of the Test of Infant Motor Performance. Phys Ther. 1995;75:585-596.

18 Campbell SK, Osten ET, Kolobe THA, Fisher AG. Development of the Test of Infant Motor Performance. Physical Medicine and Rehabilitation Clinics of North America. 1993;4:541-550.

19 Piper MC, Darrah J. Motor Assessment of the Developing Infant. Philadelphia, Pa: WB Saunders Co; 1994.

20 Harris SR. Harris Infant Neuromotor Test (Development Edition 2) [unpublished test]. 1993.

21 Harris SR. Development of an Infant Neuromotor Assessment Tool: Mar), E Switzer Research Fellowship Final Report. Washington, DC: National Institute on Disability and Rehabilitation Research; 1991.

22 Bayley N. Bayley Scales of Infant Development. New York, NY: The Psychological Corporation; 1969.

23 Harris SR. Parents' and caregivers' perceptions of their children's development. Dev Med Child Neurol. 1994;36:918-920.

24 van Baar A, de Graaff BMT. Cognitive development at preschoolage of infants of drug-dependent mothers. Dev Med Child Neurol. 1994; 86:1063-1075.

25 Osborn JA, Harris SR, Weinberg J. Fetal alcohol syndrome: review of the literature with implications for physical therapists. Phys Ther. 1993:73:599-607.

26 Chandler LS, Andrews MS, Swanson MW. Movement Assessment of Infants: A Manual. Rolling Bay, Wash: Chandler, Andrews, & Swanson; 1980.

27 Harris SR, Haley SM, Tada WL, Swanson MW. Reliability of observational measures of the Movement Assessment of Infants. Phys Ther. 1994;64:471-477.

28 Harris SR, Swanson MW, Andrews MS, et al. Predictive validity of the Movement Assessment of Infants. J Dev Behav Pediatr. 1984;5:336342.

29 Haley SM, Harris SR, Tada WL, Swanson MW. Item reliability of the Movement Assessment of Infants. Physical and Occupational Therapy in Pediatrics. 1984;6:21-39.

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31 Ellenberg J, Nelson K. Early recognition of infants at risk for cerebral palsy. Dev Med Child Neurol. 1981;23:705-716.

32 Amiel-Tison C, Korobkin R, Esquevauconloux M. Extensor hypertonia: a clinical sign of insult to the central nervous system of the newborn. Early Human Development. 1977;1/2:188-190.

33 Touwen BCL, Hadders-Algra M. Hyperextension of neck and trunk and shoulder retraction in infancy: a prognostic study. Neuropediatrics. 1983;14:202-205.

34 Harris SR. Movement analysis: an aid to early diagnosis of cerebral palsy. Phys Ther. 1991;71:215-221.

35 Domholdt E. Physical Therapy Research: Principles and Applications. Philadelphia, Pa: WB Saunders Co; 1993.

36 Borg WR, Gall MP. Educational Research: An Introduction. 5th ed. New York, NY: Longman; 1989.

37 Crocker L, Algina J. Introduction to Classical and Modern Test Theory. Orlando, Fla: Holt, Reinhart, & Winston; 1986.

38 Dunn WW. Validity. Physical and Occupational Therapy in Pediatrics. 1989;9:149-168.

39 Standards for Educational and Psychological Testing. Washington, DC: American Psychological Association; 1985.

40 Task Force on Standards for Measurement in Physical Therapy. Standards for Tests and Measurements in Physical Therapy Practice. Phys Ther. 1991;71:589-622.

41 Bonder BR. Planning the initial version. Physical and Occupational Therapy in Pediatrics. 1989;9:15-42.

42 Haley SM, Coster WJ, Faas RM. A content validity study of the Pediatric Evaluation of Disability Inventory. Pediatric Physical Therapy. 1991;3:177-184.

43 Renwick RM, Reid DT. Life satisfaction of parents of adolescents with Duchenne muscular dystrophy: validation of a new instrument. Occup Ther J. Res. 1992;12:297-311.

44 Cintas HL. Cross-cultural similarities and differences in development and the impact of parental expectations on motor behavior. Pediatric Physical Therapy. 1995;7:103-111.

45 Bayley N. Bayley Scales of Infant Development. 2nd ed. San Antonio, Tex: The Psychological Corporation; 1993.

Key Words: Cognitive development, Content validity, Infant assessment, Neuromotor development.

SR Harris, PhD, PT, FAPTA, is Professor, School of Rehabilitation Sciences, Faculty of Medicine, University oF British Columbia, T325-2211 Wesbrook Mall, Vancouver, British Columbia, Canada V6T 2B5 ([e-mail]), and Faculty Clinical Associate, Sunny Hill Health Centre for Children, 3644 Slocan St, Vancouver, British Columbia, Canada V5M 3E8. Address all correspondence to Dr Harris at the first address.

LE Daniels, OTR, OT(C), is Sole-Charge Occupational therapist, Outreach Therapy, Port Alberni, British Columbia, Canada V9Y IE5. Ms Daniels was project coordinator of the grant-funded research project that supported fills study.

This study was approved by the University, of British Columbia's Clinical Screening Committee for Research Involving Human Subjects.

This study was funded by a grant to Dr Harris from the British Columbia Health Research Foundation, Vancouver, British Columbia, Canada.

Table 1.

Content of Development Edition 2 of the Harris Infant Neuromotor Assessment"

Parent questionnaire domain contains five questions. Three of the questions are followed by lists of descriptors to identify the parents' views and possible concerns about the baby's muscle tone, play and general development. These question's are:

* When I pick up, carry, or play with my baby, she or he feels:

* Overall, my baby moves and plays:

* Compared to other babies the same age, my baby's movement and play is:

The last two questions are open-ended and request information about concerns held either by the primary caregiver or by others with whom the infant has contact.

Motor domain content includes items which are scored through observation of the infant's spontaneous motor behavior, items which may involve physical handling of the infant, items which require physical handling, and items which involve presentation of test materials to elicit motor behaviors. The categories of motor behavior and the items included are: Supine lying (seven items)

* Mobility in supine-lying

* Neck retraction

* Visual following

* Eye muscle control

* Asymmetrical tonic neck reflex

* Reaching from supine

* Passive range of motion in supine

Transition from supine lying to prone lying (two items) which can be observed during active or assisted rolling:

* Head righting

* Trunk mobility Prone lying (three items)

* Head position in prone

* Upper extremity position in prone

* Passive range of motion in prone Silting (two items)

* Head position in sitting

* Trunk position in silting Other (five items)

* Locomotion and transition skills

* Posture of hand

* Posture of feet

* Frequency and variety of movements

* Presence of stereotypical behaviors Behavioral domain consists of one item based on the infant's predominant behavioral state throughout the assessment session:

* Behavior and cooperation

Physical measurement consists of one item:

* Head circumference

Reproduced as printed in the Harris Infant Neuromotor Assessment (Development Edition 2), 1993.

  Table 2.
    Characteristics of Experts Who Completed Content Validity Questionnaire

Expert        Expert Characteristics
No.      Background      Education/Employment-Setting
                                                  Location

1    Physical therapist  MSc   University
                               hospital           Canada
2    Physical therapist  PhD   University         United States
3    Physical therapist  PhD   University         United States
4    Physical therapist  PhD   Rehabilitation
                               hospital           United States
5    Physical therapist  PhD   University         United States
6    Physical therapist  EdD   University         United States
7    Physical therapist   MS   University
                               hospital           United States
8    Psychologist        PhD   University         United States
9    Physical therapist  PhD   University         United States
10   Pediatrician         MD   University         Canada
11   Occupational thera  PhD   University         Canada
12   Special educator    PhD   University         United States
13   Physical therapist  PhD   University         United States
14   Physical therapist   MA   University
-                              affiliated
                               program            United States
15   Physical therapist   MS   Doctoral
                               candidate          United States
16   Physical therapist  ScD   University         United States
17   Occupational thera  EdD   University         United States
18   Occupational thera  PhD   Research
                               institute          United States
19   Occupational thera  PhD   University
                               hospital           United States
20   Physical therapist  PhD   University         Australia
  Table 3.
    Percentages of Responses to Validity Questionnaire[a]

    * The numbers below represents the following response:

1*- no response
2 - strongly disagree
3 - disagree
4 - generally agree
5 - fully agree
                               1*      2        3       4       5

PARENT QUESTIONNAIRE
1. When I pick up, carry or play
with my baby, she or he feels:
Clarity (n=20)                  0       0       20      20      60
Importance (n=20)               0       0       5       30      65
Discrimination (n=18}          10.0     5       10      50      25
Lack of Bias (n=20)             0       0       15      20      65

2. Overall, my baby moves and
plays:
Clarity (n=20)                  0       0       15      15      70
Importance (n=20)               5       10      5       50      30
Discrimination (n=19)          5.3     5.3     10.5    73.6    5.3
Lack oF Bias (n=20)             0       0       5       25      70

3. Compared to other babies the
same age, my baby's movement
and play is:
Clarity (n=20)                  0       0       15      20      65
Importance (n=20)               0       5       20      30      45
Discrimination (n=19)           0      5.3     15.8    57.9     21
Lack of Bias (n=20)             0       10      10      20      60

4. Please tell me any other
concerns you have about how
your baby moves, plays or
interacts with you and others:
Clarity (n=20)                  0       5       15      20      60
Importance (n=20)               20      5       15      25      35
Discrimination (n=18)          16.6    5.6     16.7     50     11.1
Lack of Bias (n=20)             0       0       10      20      70

INFANT ASSESSMENT

1. Mobility in Supine-Lying
Clarity (n=20)                  0       0       15      15      70
Importance (n=20)               0       0       0       20      80
Discrimination (n=19)          5.3      0      5.3      21     68.4
Lack oF Bias (n=20)             5       0       5       10      80

2. Neck Retraction
Clarity (n=20)                  0       5       15      50      30
Importance (n=20)               0       10      0       20      70
Discrimination (n=19)           0      10.5     0      36.7    52.6
Lack of Bias (n=20)             5       0       5       10      60

3. Visual Following
Clarity (n=20)                  0       5       15      50      30
Importance (n=20)               0       10      0       20      70
Discrimination (n=19)           0      10.5     0      36.8    52.6
Lack of Bias (n=20)             10      0       0       20      70

4. Eye Muscle Control
Clarity (n=20)                  0       5       15      50      30
Importance (n=20)               0       10      0       20      70
Discrimination (n=19)           0      10.5     0      36.8    52.6
Lack of Bias (n=20)             10      0       0       20      70

5. Asymmetrical Tonic Neck
   Reflex
Clarity (n=20)                  0       15      25      15      45
Importance (n=20)               0       10      15      20      55
Discrimination (n=18)           0      16.7    16.7    38.9    27.7
Lack of Bias (n=20)             5       0       0       10      85

6. Reaching from Supine
Clarity (n=19)                  0       0      5.3     31.5    63.2
Importance (n=20)               0       0       0       15      85
Discrimination (n=18)          5.6     5.6     11.1    33.3    44.4
Lack of Bias (n=19)            5.3      0      5.3     10.5    78.9

7. Passive Range of Motion
in Supine
Clarity (n=20)                  0       10      20      30      40
importance (n=20)               0       5       15      25      55
Discrimination (n=19)           0      15.8    10.5    47.4    26.3
Lack of Bias (n=20)             5       0       10      15      70

8. Head Righting
Clarity (n=20)                  0       15      30      20      35
Importance (n=18)               0       0      5.6     33.3    61.1
Discrimination (n=19)           0      10.5    5.3     42.1    42.1
Lack of Bias (n=20)             10      0       0       10      80

9. Trunk Mobility
Clarity (n=20)                  0       10      25      25      40
importance (n=20)               0       10      15      25      50
Discrimination (n=19)           0      5.3      21     52.7     21
Lack of Bias (n=20)             10      0       0       10      80

10. Head Position in Prone
Clarity (n=20)                  0       5       0       35      60
Importance (n=20)               0       0       5       20      75
Discrimination (n=19)           0       0      5.3     31.6    63.1
Lack al: Bias (n=20)            10      0       0       5       85

11. Upper Extremity Position
in Prone
Clarity (n=201                  0       5       20      35      40
Importance (n=20)               0       0       0       35      65
Discrimination (n=18)           0       0      11.1     50     38.9
Lack of Bias (n=20)             10      0       0       10      80

12. Passive Range of Motion
in Prone
Clarity (n=20)                  0       0       20      25      55
Importance [n=20)               0       5       35      35      25
Discrimination (n=19)           0      10.5    31.6    42.1    15.8
Lack of Bias (n=20)             5       0       5       10      80

13. Head Position in Sitting
Clarity (n=20)                  0       5       25      20      50
Importance (n=20)               0       0       5       25      70
Discrimination (n=19)           0       0      5.3     36.8    57.9
Lack of Bias (n=20)             5       0       0       10      85

14. Trunk Position in Sitting
Clarity (n=20)                  0       5       0       20      75
Importance (n=20)               0       0       0       20      80
Discrimination (n=19)           0       0      5.3     26.3    68.4
Lack of Bias (n=20)             5       0       5       15      75

15. Locomotion and
Transition Skills
Clarity (n=20)                  0       5       5       50      40
importance (n=20)               0       0       0       15      85
Discrimination (n=19)          5.3      0      5.3     5.3     84.1
Lack of Bias (n=20)             5       0       15      10      70

16. Posture of Hands
Clarity (n=20)                  0       0       10      20      70
Importance (n=20)               0       0       10      40      50
Discrimination (n=17)           0       0      11.8    35.3    52.9
Lack of Bias (n=20)             5       0       0       10      85

17. Posture of Feet
Clarity (n=20)                  0       0       15      30      55
Importance (n=20)               0       5       30      40      25
Discrimination (n=19)           0      5.3     31.6    36.8    26.3
Lack of Bias (n=20)             10      0       0       5       85

18. Frequency and Variety of
Movements
Clarity (n=20)                  0       5       15      35      45
Importance (n=20)               0       0       20      25      55
Discrimination (n=19)          5.3      0      10.5    31.6    52.6
Lack of Bias (n=20)             15      0       0       15      70

19. Behavior and Cooperation
Clarity (n=20)                  0       0       20      30      50
Importance (n=20)               5       5       30      35      25
Discrimination (n=19)          10.5    10.5    36.8    31.7    10.5
Lack of Bias (n=20)             5       10      15      15      55

20. Presence of Stereotypical
Behaviors
Clarity (n=20)                  0       0       15      35      50
Importance (n=20)               0       0       20      55      25
Discrimination (n=19)           0       0      31.6    42.1    26.3
Lack of Bias (n=20)             10      0       10      10      70

21. Head Circumference
Clarity (n=20)                  0       0       0       35      65
Importance (n=20)               0       5       5       55      35
Discrimination (n=19)          10.5     0      10.5    42.2    36.8
Lack of Bias (n=20)             10      0       0       10      80

22. Overall Clinical Impression
Clarity (n=20)                  5       5       30      35      25
Importance (n=20)               10      0       5       50      35
Discrimination (n=19)          5.3      0      15.8    52.6    26.3
Lack of Bias (n=20)             5       0       15      20      60

"Reproduced as printed in validity questionnaire distributed to study participants.

Table 4.

Percentages/Frequencies of Responses to Global Questions

[TABLE HAS BEEN OMITTED]