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CLINICAL RATING SCALE FOR HEAD CONTROL-A PILOT STUDY

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The Indian Journal of Occupational Therapy : Vol. XXXIX : No. 3 (December 2007 - March 2008)
† CLINICAL RATING SCALE FOR HEAD CONTROL
– A PILOT STUDY
*Shashidhar Rao Chavan, M.Sc. (OT)
Abstract :
In this study, a clinical scale to evaluate head control was designed. It included the components of integrity of muscle strength,
postural control against gravity, body movement and dynamic stability. Three testing positions: Prone, supine and supported/
recline sitting were analyzed for their influence on the head control on an ordinal scale.
From the convenient sample of 36 patients, 28 children with delayed development were included in the study. Three occupational
therapists with varied experience served as independent rater to establish the interrater reliability for the scale. Kappa statistic
was employed to compute the data. The analysis of the result revealed varied picture. Among the three positions, prone items had
low agreement. However, the other two positions revealed moderate to good agreement. Also, kappa values with the examiner
having least experience was found to be low indicating that with experience, the scale can be administered reliably. This tool is
recommended for the clinical purpose.
Key words: Head control, Cerebral palsy, delayed motor milestone, severity, measurement, reliability

INTRODUCTION of posture, movement in three positions: prone, supine, and

Developmental milestones reflect the growth and integration
of the central nervous system in the child. Head control is
the first motor milestone to be achieved. Good head control
lays the foundation for the development and refinement of
other milestones. It also enables the child to explore the
environment effectively in play and to develop more
advanced skills.
Brenneman (1999) defined head control as the ability to keep
the head aligned with respect to gravity1. Bobath (1980)
describes head control as the ability to maintain head in space-
face vertical and mouth horizontal 2. Scherzer (1990)
recognize that lack of head control is often the first sign of
abnormality in children with atypical development3. Thus,
attaining head control is frequently used as the starting point
in therapeutic intervention for the children with cerebral palsy
or other developmental disabilities by the pediatric
occupational therapist (Kramer, 1992)4.
Pratt & Coley (1989), Halpern (1990) & Colangelo (1983)
described assessment of head control by the pediatric
occupational therapist that includes examining the quality
* Assistant Professor
Place of Study : Manipal College of Allied Health Sciences, Manipal
Period of Study : August 2000 - April 2002
Correspondence :
Chavan Shashidhar Rao
Department of Occupational Therapy, Manipal College of Allied Health
Sciences (MCOAHS), Manipal - 576119, Karnataka (India)
Tel. : 0820-2922938,
E-mail: chavanshashidhar@yahoo.com
† Presented at 3rd South Asia Pacific Occupational Therapy
Congress, Sep. 2003, Singapore.
supported sitting 5,6,7. Bobath (1980) describe the degree to
which a child has acquired head control as: poor, fair, stable,
and better2. However, interpretation of these rating depends
on individual judgment of the therapist due to lack of proper
description of the grades.
REVIEW OF LITERATURE
Electronic database (MEDLINE, PubMed) search was made
using the keywords cerebral palsy, developmental delay, in
combination with head control, gross motor, grade, and scale.
The titles and abstracts of articles identified by the initial
search strategy were scanned and the related articles link on
PubMed was used to identify the relevant articles, which
measured the degree of head control. The review revealed
that commonly used standardized scales for the clinical and
research purposes were Peabody Developmental Motor Scale
II (PDMS-GM), and Gross Motor Functional Measure
(GMFS) and Alberta Infant Motor Scale (AIMS).
Hinderer et al. (1989) observed that the three point scoring
scale of (0, 1, and 2) of the PDMS has been a great concern
due to the vague and subjective criteria for assigning score
of for assigning grade 18. Moreover, specific scoring criteria
for a value of 1 are not provided for each test item (Gebhard
et al. 1994)9. Thereby, leaving the raters to decide whether
there is a resemblance to the criteria needed for a successful
performance. Palisano (1995), while examining the validity
of the PDMS-GM as an evaluative measure of infants found
that the PDMS-GM was not responsive to change particularly
in infants with cerebral palsy10. For the clinical use of a scale,
it is desired that the scale be reliable and sensitive (or
responsive) to changes.

IJOT : Vol. XXXIX : No. 3 59 December, 2007 - March, 2008

Piper and Darrah (2002), observed that Alberta Infant Motor
Scale (AIMS), primarily a norm referenced screening test to
have limitations with children above fifteen months of age.11
GMFM-88 (a criterion-referenced scale comprising five
dimensions) originally developed and validated by Russell
and colleagues (1994), as an evaluative assessment of gross
motor function in children with cerebral palsy is recently
modified to a shorter version of GMFM-6612. Russel et.al
(2002), recognized one of the limitation related to the clinical
applicability of GMFM is the requirement of the computer
software program (GMAE) and one-day training workshop
by the users of the scale13.
These standardized scales evaluate head control as a part of
larger gross motor assessment and does not provide the degree
or severity of impairment of the head control.
Therefore, a need was felt in the clinical practice to
objectively grade impaired/lack of head control in children
with motor disability and to monitor the progress of treatment
administered by the occupational therapist. Thus, in the
proposed scale, an attempt was made to develop a measure
for head control, which would be sensitive to changes
occurring in children with neurological impairment or
cerebral palsy with respect to head control.
Aim of The Study
The aim of this study was to:
1) Develop a criterion-referenced scale to measure head
control, using familiar procedures of clinical
observation.
2) Examine the interrater agreement of the three examiners
on the scale.
3) Determine if experience of the examiners has any effect
on the interpretation and scoring of the responses on the
scale.
METHODOLOGY
Development of The Scale
Preliminary Scale
A list of common problems and abnormalities of head control
in three developmental stages: prone, supine and supported
sitting was compiled. The selection of items in each test
position was based on literature review (Halpern, 1990;
Colangelo, 1983; Pratt & Coley, 1989; Scherzer, 1990; &
Bobath, 1980) and clinical experience6,7,5,3, & 2. Four-point
ordinal scale (0, 1, 2, & 3) was designed to grade the quality
of responses are defined as follows:
Grade 0 no response.
IJOT : Vol. XXXIX : No. 3
Grade 1 (immature response): unable to lift and hold
(sustain) the head upright.
Grade 2 (partial response): lacks in either lifting or holding
(sustaining) the head upright.
Grade 3 (mature response): ability to lift and hold (sustain)
the head upright.
The responses in each position tend to progress from
immature responses towards mature responses. Grade zero
specifies the immature responses and grade three specifies
the mature responses in each of the three positions.
One pediatric physician with more than 15 years of
experience and two senior occupational therapists each with
about 10 years of experience in pediatric occupational therapy
was asked to judge for the content validity.
Subsequently, a preliminary study on thirteen children with
cerebral palsy was carried out. Following which, the
administration of the scale, scoring criteria and certain items
were modified. The main reason for the modification of the
scale was that some children with cerebral palsy could not
satisfy all the criteria of a particular grade and also
demonstrated partial responses from the adjacent grades.
Thus, the scoring procedure could not enable the examiners
to award discrete grade for some children with cerebral palsy
in the preliminary study. It also seemed that the scale would
not be sensitive to detect changes on retest. Furthermore, it
was observed that inclusion of an item to reflect upon the
dynamic head stability (Colangelo, 1983, p. 263) in all the
three test positions would indicate higher degree of head
control than the operational mature response as stated above7.
Accordingly, the items on the scale and scoring pattern were
rearranged to meet the objectives of the study. The operational
definition of head control was stated as the ability to lift and
hold (sustain) head upright with respect to gravity during
static and dynamic tasks in three dimensions namely prone,
supine, and supported sitting. The static task signifies keeping
the head aligned with the trunk in the above-mentioned
dimensions. Dynamic task signifies ability to keep the head
aligned, when moving or engaged in play. (e.g. during play
or reach activities).
The items on the revised scale (see appendix-A) were grouped
into 3 dimensions: (a) prone, (b) supine and (c) supported
sitting. The items in prone and supported sitting dimensions
were ranked on a 5-point ordinal scale (0, 1, 2, 3, & 4) and
in supine dimension it was ranked on a 4-point ordinal scale
(0, 1, 2, & 3). Thus, a child with poor head control will obtain
low grades on each of the three dimensions; alternatively, a
child with improved head control will obtain high grades on
each dimension. The highest score on each of the dimension
reflected absolute dynamic stability of the head. Although
60 December, 2007 - March, 2008
the items within a dimension, tend to reflect improved Table 1
postural control and alignment their ordering was based on Sample Characteristics
clinical judgment, and the order had not been substantiated Number of children Diagnosis
with data-based evidence. The test required to be carried out 17 Cerebral palsy
on a plinth.
09 Motor delay
Scoring was by observation of the child in each dimension.
01 Down’s syndrome
Accompanying instructions, and tools required were detailed
to standardize the test procedures. Tools used were a rattler 01 Hydrocephalus
or a toy. With the child who was uncooperative, parent’s
Table 2
report on the motor response of the child was considered. A
Tonal Abnormality of the Sample
maximum of 05 minutes were given for each examiner to
observe the motor response in each dimension. Number of children Classification
10 Hypotonic
Design Of The Interrater Reliability Study
17 Hypotonic
Participants
01 Athetoid
All successive pediatric patients with developmental delay,
referred for occupational therapy intervention from the and methodology of the study was explained to the examiners
pediatric unit of a general hospital, were included in this with minimal instructions. They were asked to read the scale
study. The only selection criteria used was that the child had and clarify doubts if any. Detailed instructions were avoided.
impaired head control as determined by the referral physician The three examiners performed evaluation independently
beyond the expected age of acquisition of head control. In within thirty to forty five minutes of one another.
some cases, parents’ opinion on the stutus of head control
was considered. Parents consent to cooperate with the study DATA ANALYSIS
was also obtained. As an ordinal scale was used in this study, non-parametric
Out of thirty-six children with impaired head control, referred statistics were chosen to compare the scores between the
for occupational therapy intervention, eight of them were examiners. Altman (1990) advocated the use of kappa
excluded because one or the other examiners could not statistics to assess the reliability of the raters with the ordinal
evaluate them. Twenty-eight (sixteen male and twelve female) scale14. The kappa provides a measure of the degree to which
children were included in the study. two judges concur in their respective judgment. The kappa
statistics is a measure of how much agreement exists beyond
Apart from patient’s personal data, information was obtained the amount expected by chance alone. The scores of each
on the nature of impairment participant for each of the dimensions were compared with
(e.g. presence of seizure disorder, cerebral palsy, the corresponding dimension score of the other two
developmental delay or Down’s Syndrome/ mental examiners. Thus, the kappa values for each dimension was
retardation). The diagnosis and the tonal abnormality of the obtained between: Examiner 1 with Examiner 2 (E1 X E2);
sample is shown in (Table -1 and Table - 2). Seventeen Examiner 2 with Examiner 3 (E2 X E3); and Examiner 3
children were diagnosed as cerebral palsy of which nine had with Examiner 1 (E3 X E1). Coefficient (k) was calculated
seizure disorders. Moreover, ten of the total participants for the test items in the three dimensions. The significance
included in the study (35.5%) were observed to be inattentive of kappa values was obtained by p-value at 0.05 level (Fleiss,
to the environment around, with inability to establish eye 1981)15.
contact or recognize mother and stereotyped random
movements of body and limbs.
RESULTS
The mean age of the participants in the study was 17.6 months Reliability Study
(range: 4 months to 48 months; S.D.: 12.63 months). The kappa (k) values for the three test dimensions are
presented in (Table 3, 4, & 5). Computation of the data was
PROCEDURE made through, VassarStats at http://faculty.vassar.edu/lowry/
Three examiners (E1, E2 and E3) evaluated all the kappa.html
participants (N=28). E1 and E2 each had more than 5 years To describe the relative strength of agreement associated with
of experience in pediatric occupational therapy and E3 was the various kappa values, guidelines are described in Table
a recently graduated occupational therapist. General aim 6 are applied.

IJOT : Vol. XXXIX : No. 3 61 December, 2007 - March, 2008

With reference to the Tables (3, 4, and 5), the kappa values
obtained with the supported sitting dimension were the
highest between the examiners. The least kappa value (<0.20)
was obtained for the prone position (E2 X E3), which
indicated slight agreement. In general, the reliability with
the third examiner had low kappa values in all the test
positions. For the remaining items, a moderate to good
agreement was found. The corresponding p-values indicate
good degree of agreement beyond chance.
DISCUSSION
In this study, an attempt was made to design a criterion-
referenced clinical rating scale, which measure head control
for children with motor disability. After preliminary test, the
items on the scale were modified and the scoring criteria
altered. The influence of head control in three test dimensions
namely prone, supine and supported sitting were observed.
An interrater reliability study was undertaken to examine
whether three different examiners could apply this scale
consistently in clinical practice. The examiners were chosen
with a range of experience. The analysis of the data for
different test dimensions, using kappa statistics revealed a
varied picture.
Reliability was slight to moderate for prone dimension, as
seen in table 3 (E1 X E2), table 4 (E1 X E3) and table 5 (E2
X E3). By and large, the kappa values (k) obtained for the
prone dimension are less than the values obtained for the
supine and supported sitting dimensions. Possible
explanations could be attributed to the dislike of prone
position and the resultant emotional stress by some children
(ten of the participants who were observed to have
stereotyped continuous movement of limbs) may have
resulted in variation of motor responses in the prone
dimension. As the three examiners performed evaluation
independently within thirty to forty five minutes of one
another.

Table 3
Kappa (K) For The Scale Items Between (E1 X E2)
Testing position k p-value. 0.95 Confidence Interval Std. E. z-test
Lower limit. Upper limit.
Prone 0.51 0.001 0.25 0.77 0.13 3.82
Supine 0.61 0.001 0.39 0.84 0.11 5.32
Supported Sitting. 0.67 0.001 0.46 0.88 0.11 6.29
N=28; Std. E.: standard Error.
Table 4
Kappa (K) For The Scale Items Between (E1 X E3)
Testing position k p-value. 0.95 Confidence Interval Std. E. z-test
Lower limit. Upper limit.
Prone 0.35 0.002 0.06 0.65 0.15 2.35
Supine 0.43 0.001 0.19 0.68 0.12 3.52
Supported Sitting. 0.59 0.001 0.37 0.81 0.11 5.33
N=28; Std. E.: standard Error.
Table 5
Kappa (K) For The Scale Items Between (E2 X E3)
Testing position k p-value. 0.95 Confidence Interval Std. E. z-test.
Lower limit. Upper limit.
Prone 0.16 0.03 -0.13 0.44 0.15 1.06
Supine 0.49 0.001 0.26 0.73 0.12 3.82
Supported Sitting. 0.58 0.001 0.36 0.81 0.11 5.12
N=28; Std. E.: Standard Error.

IJOT : Vol. XXXIX : No. 3 62 December, 2007 - March, 2008

 Table 6
Strength Of Agreement Of Kappa (K) Values
Kappa (k) Strength of agreement.
<0.20 Poor.
0.21-0.40 Fair.
0.41-0.60 Moderate.
0.61-0.80 Good.
0.81-1.00 Very Good.
The variability of the motor responses because of independent
test administration by the therapists on three occasions might
have influenced the supine and supported sitting dimensions.
However, it may be reasonable assumed that with experience
the motor responses would be easier to identify in supine
and supported sitting dimensions. Experience of the examiner
seemed to have an influence, on administration of this scale
clinically, as the values of kappa, when related with the third
examiner (E3), is found to be less. In general, kappa values
(of reliability) should be interpreted and compared with the
number of grades used in the ordinal scale. Two-point grade
scale would give a higher reliability than the three or four
point grade scale for the same test (Altman, 1990, p. 409)14.
Thus, the use of four- point (supine dimension) and five-
point (prone and supported sitting dimension) scale in this
study might have resulted to obtain values of kappa on the
lower side and influenced the reliability. However, the kappa
calculations proved to be significant at p<0.05. Small size
of the sample has reflected in the larger confidence interval
obtained for each dimension.
The development of this scale was intended to be a pilot
study and it would be too early at this stage to consider the
scale ready for clinical use. Further study should be
undertaken to validate on larger sample. Larger sample would
also help to narrow down the confidence interval range.
Additional study would also be needed to consider intratester
reliability. The validity of the scale may need to be established
with other standardized scales, which measure the same
dimension of “head control”. However, a degree of content
validity can be assumed because the test was based on the
literature. Further review of the contents by several expert
therapists as well as the clinical applicability of the scale
would be essential.
LIMITATIONS
The sample consisted of children with impairment and
therefore the higher degree of control was not repeatedly
evident. Hence, inclusion of sample with typical development
may have given a wider interpretation of the scale at high
level of functioning.
IJOT : Vol. XXXIX : No. 3
CONCLUSION
This scale provides the clinical therapist to grade the postural
control required for head control in children with the
neurologically impaired or developmentally delayed. The
therapist may have a baseline data to identify the components
missing in the child from the three dimensions. This scale
gives the advantage of using with the children who do not
follow verbal commands or imitate actions as it can be scored
on observation or on parent’s response. The interrater
reliability proves to be satisfactory except for the prone
dimension. The scale can be better interpreted and
administered with therapist having prior experience in
pediatric habilitation. Further study should investigate
whether the reliability is improved on large sample. In
addition, the sensitivity of the scale to detect the changes
with response to the therapy needs to be investigated.
ACKNOWLEDGEMENT
I would like to thank, Dr. B. Rajashekar, Dean, Manipal
College of Allied Health Sciences (MCOAHS), Manipal for
allowing to conduct this study and use the facilities. I wish
to thank Mrs. Vasanthi P., and Mrs. Deena A. for serving as
the examiners during the development of the scale, Jamie
DeCoster, a consultant for Stat-Help.com and Sreekumar Nair
(Ph.D.), for their statistical advice at various stages of the
process, parents and children from Kasturba Hospital without
whom this work could not have been accomplished. My
sincere thanks to all the participants of this study which had
helped me transform the idea into research paper. Finally
but not least Mrs. Priti P, and Ms. Bobby S. for reading
through the manuscript.
REFERENCES
1. Brenneman SK: Tests of infant and child development. In Tecklin
JS, editor. Pediatric Physical Therapy 9 th ed. Philadelphia:
Lippincott, Williams & Wilkins. 1999. p. 28-70
2. Bobath K.: A neurophysiological basis for the treatment of cerebral
palsy. Clinics in developmental medicine. Spastics international
medical publication, No. 75, 2nd edition of CDM 23. Oxford:
Blackwell Scientific Publication. Philadelphia. 1980.
3. Scherzer AL, Tscharnuter I Early diagnosis and therapy in cerebral
palsy- a premier on infant developmental problems, 2nd ed. New
York: Marcel Dekker. 1990.
4. Kramer JF, Ashton B, Bander R. Training of head control in the
sitting and semi prone positions (abstract). Child Care Health Dev.
1992; 18 (6): 365-376.
5. Pratt PN, Coley IL. Basic methods of assessment and screening.
In Prat PN, Allen AS, editor. Occupational therapy for children, 2nd
ed. Place: CV Mosby company. 1989; p. 149-167.
6. Halpern D. Rehabilitation of children with brain damage. In Kottke
FJ & Lehmann JF editor. Krusen’s handbook of physical medicine
and rehabilitation. Philadelphia: W.B. Saunders Co. 1990.
7. Colangelo CA. Biomechanical frame of reference. In Kramer P,
Hinojosa J editor. Pediatric occupational frames of reference for
63 December, 2007 - March, 2008
 therapy, 2nd ed. Philadelphia: Lippincott, Williams & Wilkins. 1983;
p. 257-322.
8. Hinderer KA, Richardson PK, Atwater SW. Clinical implications of
the Peabody developmental Motor Scales: A constructive review.
Physical and Occupational therapy in Pediatrics. 1989; 9(2): 81-
106.
9. Gebhard AR, Ottenbacher KJ, and Lane SJ. Interrater reliability of
the Peabody developmental Motor Scales: Fine motor Scale.
American Journal of Occupational Therapy. 1994; 48 (11): 976-
981.
10. Palisano RJ, Kolobe TH, Haley SM, Lowes LP, Jones SL. Validity
of the Peabody developmental gross motor scale as an evaluative
measure of infants receiving physical therapy (discussion). Physical
Therapy. 1995; 75(11): 948-951.
2002 Oct. 20].Available from http://www.uvm.edu/~cdci/pedilinks/
pediatric /tools/alberta.htm
12. Russell D, Rosenbaum PL, Lane M, Gowland C, Goldsmith CH,
Boyce WF & Plews N. Training users in the gross motor function
measure: Methodological and practical issues. Research Report.
Physical Therapy. 1994; 74(7): p. 630-636.
13. Russell D. Gross motor function measure (GMFM0 score sheet
(GMFM-88 andGMFM-66 scoring): version1.0. [Cited 2002 July 08].
Available from http://www.fhs.Mcmaster.ca/canchid
14. Altman DJ. Practical statistics for medical research. New York,
Chapman & Hall. 1990.
15. Fleiss JL. Statistical methods for rates and proportions. New York,
John Wiley and Sons. 1981. p. 217-225.

11. Piper MC, Darrah J. Developmental screening tools. Alberta infant

motor scales. Pedi-links for early interventionists articles. [Cited

APPENDIX A:
CLINICAL SCALE FOR HEAD CONTROL.
Day of Administration.
Position Grade Description
1 2 3 4 5
0 Does not lift head at all. Weight bearing on the cheek/chest or on the shoulder.
An effort to raise the head results in asymmetry and/or increased extensor
1 hypertonicity throughout the body. Elbows are positioned closer to the trunk and
behind shoulders. Arms cannot be brought forward into weight bearing pattern.
Lifts head in prone but cannot sustain for longer duration. Cannot turn to look
2
Prone over shoulders.
Lifts head in prone with hyperextension of head and neck. Elevation of shoulder
3 usually accompanies this posture (i.e. decreased shoulder stability). Bring arms
actively to weight bearing upon forearm and can turn to look over shoulders.
No abnormal pattern observed. Keeps the head steady while playing with one or
4
both hands. Movement of head is possible in all the planes.
On pulled to sit from supine exhibits complete head lag. (Not able to keep the
0
head in midline).
Able to keep the head in midline but complete head lag present on being pulled to
1
sit.
Supine
On being pulled to sit initial head lag present. However, soon aligns the head
2
with the trunk.
No abnormal pattern observed. On being pulled to sit initiate and sustain lifting
3
of head in supine. Keeps the head steady in midline.
0 Head wobbles on either side. Requires full support to prevent head drop.
Head remains in midline position for a brief interval of time. Intermittent support
1 required preventing head drop.
Supported On reclining at 15-20 degrees maintains head in midline. However, cannot
2
sitting and/or sustain head in midline beyond 45 degrees or reclining.
on reclining. On reclining more than 45 degrees sustains head in midline. Head is steady
3 during play or movement of the head however poor dissociation between head
and shoulder girdle.
No abnormal pattern observed. Keeps the head steady during play with good
4
dissociation between head and shoulder girdle.

IJOT : Vol. XXXIX : No. 3 64 December, 2007 - March, 2008

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