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Assessment of gross
motor skills of at-risk
infants: predictive
validity of the Alberta
Infant Motor Scale
Johanna Darrah* PhD PT, Assistant Professor, Faculty of
Rehabilitation Medicine, University ofAlbcrta, Edmonton,
AB, Canada, T6G 2G4;
Martha Piper PhD, President, University of British Columbia,
Vancouver, BC;
ManJoe Watt MB BS FHCP(C) FAAEM, Pediatric Site Chief,
Glenrose Rehabilitation Site, Edmonton, AB; Canada.
*Correspondence tofirst author.
The Alberta Infant Motor Scale (AIMS) is a norm-referenced
measure of infant gross motor development. The objectives of
this study were: (1) to establish the best cut-off scores on the
A I M S for predictive purposes, and (2) to compare the
predictive abilities of the AMIS with those of the Movement
Assessment of Infants (MAI) and the Peabody
Developmental’GrossMotor Scale (PDGMS). One hundred
and sisty-four infants were assessed at 4 and 8 months
adjusted ages on the three measures. A pediatrician assessed
each infant’s gross motor development at 18 months as
normal, suspicious, or abnormal. For the AIMS, two different
cut-off points were identified: the 10th centile at 4 months
and the 5th centile at 8 months. The MAI provided the best
specificity rates at 4 months while the Aws was superior in
specificity at 8 months. Sensitivityrates were comparable
between the two tests. The PDGMS in general demonstrated
poor predictive abilities.
Assessment for motor dysfunction or delay in at-risk infants
is an accepted practice at neonatal follow-up clinics. It is
important to evaluatc the accuracy of the standardized mea-
sures used to evaluate infant gross motor skills for two rea-
sons. First, the evaluation of the efficacy of early treatment
for infants with motor dysfunction requires that screening
tests correctly identify both infants who will have persistent
.motor dysfunction, and infants who have normal gross
motor abilities. If infants with eventual normal motor abili-
ties are identified early in their lives as having motor dysfunc-
tion, the internal validity of an efficacy study is severely
compromised. These infants may receive intervention ser-
vices and be classified as normal due to the intervention,
when in fact they would be normal without intervention.
Second, clinicians who arc administering screening tests
need to know the predictive abilities of the tests to correctly
interpret the significance of an infant’s score to the parents.
Parents need to know both how accurate a test is at predict-
ing the eventual motor abilities of infants (provided by sensi-
tivity and specificity calculations) and, given their infant’s
performance on the test, the likelihood that their infant will
encounter difficulty in their gross motor development (pro-
vided by the positive predictive value and negative predictive
value of a test). Definitions of sensitivity, spccificity, positive
predictive value, and negative predictive value are provided
in Figure 1.
Unfonunately, the accuracy of tests to identify motor
problems in both the neonatal period and in the first year of
life is disappointingly low. Investigators evaluating the pre-
dictive abilities of a variety of neonatal tests all report high
false-positive rates (Dubowitz et al. 1984. Allen and Capute
1989, Touwen 1990, Bozynski et al. 1993). That is, the
neonatal assessments correctly identified many infants with
eventual motor problems, but at the expense of incorrectly
labeling many normally developing infants. The same trend
applies to motor measures used by occupational and physi-
cal therapists during the first year of life. The Movement
Assessment of Infants (MA) (Chandler et al. 1980) and the
Peabody Developmental Gross Motor Scale (PDGMS), a sub-
scale of the Peabody Developmental Motor Scales (PDMS)
(Folio and Fewell 1983), are two tests often used to evaluate
. the gross motor abilities of infants at neonatal follow-up clin-
ics, Poor specificity rates have been reported using the MAI at
4 and 8 months (Harris 1987, Swanson et al. 1992). and
Palisano (1986) reported low correlations between 12-
month and 18-month scores on both the PDMS and the
Bayley Scales of Infant Development (BSID) (Bayley 1969).
The Alberta Infant Motor Scale (AIMS) (Piper and Darrah
1994) is a recently published measure of infant gross motor
development used in neonatal follow-up clinics in the United
States and Canada.’. The AIMS demonstrates excellent inter-
rater reliability, test-retest reliability, and concurrent validity
with the PDGMS and the gross motor scale of the BSID (Piper
and Darrah 1994). As the next: step in evaluation of the AIMS,
clinicians need information regarding its predictive validity
and the cut-off points to use on the scale to-identlfy most
accurately the eventual motor abilities of at-risk infants.
The objectives of this study were: (1) to establish the scores
T h e AIMS score shcets are available from W 6.Saunders Company.
6277 Sea Harbor Dr, Orlando, FL 32821-9816, USA or. outside the
USA, from the local W B. Saunders Company representative.
DeL,elopnrentalnledicine& CbfldNeumlogy 1998,JO: 48-9 1 485

on the A I M S that provided the best sensitivity and specificity
rates, and (2) to compare the predictive abilities of the NMS
with the predictive abilities of the A M and the PDGMS. A
prospective longitudinal design was conducted.
Method
SAMPLE
Infants were recruited during their hospital stay from two
tertiary neonatal intensive care units (NICU) in Edmonton,
Alberta. Any infant whose binhwcight wa.. I1500gwas eligi-
ble for inclusion. Pretern infants weighing > 1500g with a
history of intraventricular hemorrhage Grades III or lv
(Levene et al. 1982) identified by ultrasound assessment,
were also included because of their increased risk of motor
dysfunction. Full-tern infants with hypoxic-ischemic
encephalopathy (HIE) Stage I1 or I11 by Sarnat scoring
(Sarnat and Sarnat 1976) were also eligible for inclusion.
Infants with congenital anomalies were excluded from the
study as these infants' problems can be readily identified at
birth. The sample recruited wa. representative of infants typ-
ically seen at neonatal follow-up clinics.
Two hundred and one infants were recruited to the study.
Twenty-six infants were lost to follow-up, and two infants
died before completing the study; one before discharge from
the NICU, and the other from sudden infant death syn-
drome. One hundred and seventy-three infants completed
the study, and were assessed by the developmental pediatri-
cian at 18 months adjusted age. Complete data were
obtained on 164 infants (87 male, 77 female). One hundred
and fifty-six infants were born at I 3 6 weeks' gestation
(mean=28.47 wk, SD 2.58 wk) with a mean birthweight of
1108g (SD 301.63g). Eight term infants, mean birthweight
31 15g (SD 748.29g) were recruited, seven of these infants
had Stage I I Sarnat score, and one infant had Stage 1 Sarnat
score with a neonatal history of seizures.
Method 1 Melhod 2
Abnormal Normal Abnormal Normal
rusDicious suspr10us
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MEASURES
Three motor measures were administered at 4 and 8months:
the hW, the PDGMS, and the AIMS. The hW is a standard-
ized, criterion-referenced assessment tool developed by
physical and occupational therapists. It contains a total of 65
items divided into four subscales: muscle tone and posture,
primitive reflexes, automatic reactions, and volitional move-
ment. Muscle tone items are scored on a 6-point, bidirection-
al scale to indicate hypotonic, normal, and hypertonic
muscle tone. Items in the other three subsections are scored
on a 4-point unidirectional scale, with 1 representing the
most developmentally mature response. The authors have
developed 4- and 8-month risk profiles that indicate scores
considered to be deviant for each item. Risk points are
summed to yield a total risk score. No norms are available.
'I'he PDGMS, the gross motor component of thc PDMS, is
a standardized assessment tool that evaluates gross motor
development of children between birth and 83 months of
age. It consists of 170 items divided into 17 age levcls and
coven five motor domains: reflexes, balance, non-locomo-
tion mobility, locomotion, and receipt and propulsion.
Items are scored on a 3-point ordinal scale with the middle
score representing an emerging skill. Norms were gcnerat-
ed using 617 children stratified o n geographical region of
the United States, race, sex, and age. Raw scores may be con-
vened into age equivalents, developmental quotients, and
centile ranks.
The NMS is designed to measure motor skills from 40
weeks postconception to independent walking. It contains
58 items divided into foursubscalcs: prone, supine. sit, and
stand. Each item is specifically described in terms of the
weight-bearing surface of the body, the posture necessary
to achieve the gross motor skill, and the antigravity or vol-
untary movement performed by the infant in the position
(Fig. 2). The AIMS has been developed as an observational
assessment requiring minimal handling and can be com-
pleted in 10 to 20 minutes. It has been normed o n 2202
infants aged 1 week to 18 months born in the province of
Alberta, Canada. Raw scores can be converted to centile
ranks and compared with the ranks of age-equivalent peers
in the normative sample.

Sensitivity = a/(a+c)
Proportion of infants claksdied as
abnormal or abnormaVsuspicious
at 18 mo who were correctly
identified by the cut-off
Positive Predictive Vabe = &(aib)
Proportion of infants classified as
abnormal or abnormahsp'kious by
the c u t d l who were classified as
abnormal or abnormaVsuspmous at
18 mo
Figure 1:Two methods of calculation ofpredictive values.
cui-on IOC
PROCEDUHES
abnormal A physical therapist, unaware of the infants' medical histories,
sospicious b
a, assessed each infant on all three measures at 4 and 8 months
of age. Corrected ages were used for preterm infants. These
cui-on C d
lor ages were selected as the MAI provides cut-off scores todistin-
normal guish infants most at risk for motor dysfunction for only these
two points in time. I'he measures were administered simulta-
neously; an infant's spontaneous movements were first
Specificity = dl(d+b)
Proportion of intanls classified as observed, and then specific items on the MAI and the PDGMS
normal at 18 mo who were were administered. The average time to complete all three
correctly identified by the cut-off assessments was 30 to 45 minutes.
A developmental pediatrician assessed each infant blindly
Negative Predictive Vabe = d/\d+c) at 18 months adjusted age to determine the final motor out-
Proportion of infants classified as come. His assessment included an evaluatip of posture,
normal by the cut-off who were
classified as normal at 18 mo oral-motor control, strabismus, muscle tone, evolution of
milestones, and reflexes, as described by Levine (1980).
From the results of this assessment, each infant's motor abili-
ties were classified as normal, suspicious, o r abnormal.
Criteria for suspicious and abnormal classifications are pro-
vided in Table 1.

486 DevelopmentalMedicine G Child Neurology 1W8.40:4 8 5 4 0 1

 14698749, 1998, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.1998.tb15399.x by Zentralbibliothek Zuerich, Wiley Online Library on [03/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
DAlA ANALYSES athetoid quadriplegia (N=3), and severe global develop-
Sensitivity, specificity, and positive and negative predictive mental delay (N=5).
values were calculated for each of the three motor measures Table 11 provides the predictive values obtained on the
at both 4- and 8-month assessments. All values were calculat- three measures from the 4 and 8 months data when the
ed from a 2 x 2 table. To accommodate the suspicious group, intent is to identify only infants classified as abnormal at 18
which represents a third classification category, nvo methods months adjusted age. A range of centile ranks on the AiMS is
were used to calculate the values: first the infants in the sus- shown to illustrate the related changes in sensitivity and
picious category were included with the infants in the nor- specificity as the cut-offpoint increases. Selection of a cut-off
mal category; second, the values were calculated combining point must take into consideration the consequences ofbotlg
the infants in the suspicious category with the infants in the false-negative and false-positive identification. While ideally:
abnormal classification (Fig. 1). a test would provide 100%sensitivity and specificity, in reali-
ty a compromise must always be made between the two Val-
Results ues. Acut-off yielding the highest sensitivitywill result in low
At the 18-month evaluation, 128 infants (78.05%)were classi- specificity and increased false-'positive identification of nor-
fied as normal in their motor development, 14 infants mally developing infants. Because of our concern about the
(8.54%) were classified in the suspicious motor develop
ment group, and 22 infants (13.41%) were classified as
abnormal in their motor devclopment. The prevalence rate
of the suspiciousgroup is slightly lower than the 15% to 25%
usually cited in the literature (Bennett 1988). The suspicious
category typically includes children identified with commu-
nication disorders and fine motor dysfunction. The classifi-
cation of suspicious in this study was limited to mild
neuromotor abnormalities affecting only gross motor abili-
ties, and is similar to a recent study by Campbell et al. (1993)
which also defined the suspicious group only by motor
development, and reported a prevalence rate of8.496. Of the
14 infants in the suspicious category, four were not yet walk- Anhgtmty Movement
ing, nine had subtle signs of increased muscle tone, and one
demonstrated immature motor skills in association with a
hearing impairment.
The prevalence rate of 13.61% for infants classified as
abnormal in their gross motor skills is companble'with rates
cited in ocher studies (Coolrnan et al. 1985, Ornstein et al.
1991, Campbell et al. 1993). Diagnoses for children in the
abnormal category at 18 months included: spastic diplegia
( N = 6 ) , spastic triplegia (N=2), spastic quadriplegia ( N = 4 ) ,
spastic hemiplegia (N= I), hypotonic cerebral palsy ( N = l),

z'ir-
Table I Criteria for outcome classification at 18 months of age
Suspiciousclassitication
Must include one or more of the following criteria:
1. Not yet walking
2 . Asymmetry (movement and posture)
3. Retention of primitive retlexes
4. Isolated toe waikingwirh evidence of increased deep tendon
reflexes
5 . Walkingwith awide baseofsupport f
3 a
6..Severely pronated feet
7. Muscle weakness
Abnormal classification 20
Includes one or more of the following criteria:
1.Abnormal muscle tone (hypotonia or hypenonia) 0
0 1 2 3 4 5 6 7 8 D1011121314151617Ul
2. Absent or decreased deep tendon reflexes Age ImOnmS)
3. Retention ofprimitive reflexes
And
Significantly delayed motor abilities. Figure 2 Exaniple offormat ofALMS itenis. From 'Motor
If an infant has very delayed motor milestones without neurological Assessment of the Developing Infant. (Piper and Darrah
signs, the infant should be classified as abnormal in their gross 1394).Reprinted witb permissiotz of W B. Saunders
motor development. Conipany.

Motor Assessment of &-Risk InfantsJobannaDan& ef al. 487


harmful effects on families of false-positive identification, we
selected cut-off points that represented the best balance
between sensitivity and specificity. Using information from
evaluations at 4 months, the 10th centile rank on the AIMS
produced the best combination of sensitivity and specificity
values. At 8 months, three cut-off points on the AIMS had
acceptable combinations of sensitivity and specificity values.
The 7th centile rank is optimal, but given the difficulty of
interpolating to this centile rank on the graph, either the 5th
or 10th centile can be considered as an appropriate cut-off
point at 8 months.
The cut-off points selected for the MAI came from two
sources: > 9 risk points was recommended by Swanson et al.
(1992), and > 4 risk points by Piper et al. (1992). The cut-off
points selected for the PDGMS correspond to -1.0 SD (16th
centile rank), -1.5 SD (6th centile rank), and-2 SD (2nd cen-
tile rank); these cut-off points are suggested in the manual to
delineate between normal, suspicious, and abnormal scores.
At 4 months, the MAl cut-off of >9 risk points provided the
best combination of sensitivity and specificity valucs. While
the AIMS had slightly better sensitivity (one more abnormal
infant identifies, the MAI classified more infants in the sus-
picious/normal classification. In contrast, at 8 months, the
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tification. The sensitivity rates for both the AlMS and MAI fall
at both ages compared with the values obtained when identi-
fication is limited only to infants with an abnormal classifica-
tion at 18 months. The cut-off points used on the PDGMS d o
not provide an acceptable combination of sensitivity and
specificity values: at 4 months the sensitivity is poor while at
8 months the specificity values are poor.
Positive predictive values represent the proportion of
infants identified by the cut-off as being abnormal or suspi-
cious who actually are classified as abnormal or suspicious at
18 months. Positive predictive values are affected by the
prevalcnce of the disorder. Mausner and Kramer (1985) pro-
posed that it is only when the prevalence of the disorder in
the screening group reaches 15% to 20% that a 'respectable'
positive predictive value is achievable; in their exampie a
respectable positive predictive value is between 75% and
80%.The highest positive predictive values obtained in this
study occurred when the suspicious infants w e e included
with the abnormal infants (steTabk Ill). At 4 months the MA1
cut-off point of >9 risk points had the highest positive pre-
dictive value (69.2%), while at 8 months the highest positive
predictive value (79.3%) was obtained o n the AIMS using the
5th centile as a cut-off point. ,

AIMS has the best specificityvalue, especially using the 5th or

7th centile as cut-off points. The only cut-off point on the
PDGMS that provided an acceptable combination of sensitiv-
ity and specificity values was the 16th centile at the 4-month
assessment.
Table 111 provides the predictive values when the suspi-
cious infants are included in the abnormal category for iden-
Discussion
Three areas have been selected for discussion: (1) recom-
mended cut-off points on the AIMS, (2) comparison of the
predictive abilities of the three measures, and (3) the
effect of identification of suspicious infants o n predictive
abilities.

Table Ik Sensitivity, specificity, positive predictive value and negative predictive

value far abvormal vs normal/suspicious classification (N=164)
Agekest Crct-ofl Sensitivity (%I SpeciJTcity(%) +PV V") -PV(%)
(N=22) (N=142)

4 months
AIMS centile 2nd 40.9 95.8 60.0 91.3
5th 54.5 89.4 44.4 92.7
10th 77.3 81.7 39.5 95.8
16th 77.3 77.5 34.7 95.7
25th 86.4 67.6 29.2 97.0
Icw total risk score > 4 81.8 74.6 33.3 96.3
>9 72.7 93.0 58.3 95.7
PDCMS cenrile 2nd 36.4 95.1 53.3 90.6
6th 50.0 93.0 52.4 92.3
16th 81.8 71.8 31.0 96.2
8 months
AlMS ccntilc 2nd 72.7 94.4 66.7 95.7
5th 86.4 93.0 65.5 97.8
7th 90.9 91.5 62.5 98.5
. 10th 90.9 85.9 50.0 98.4
16th 95.5 82.4 45.7 ,99.2
25th 100.0 63.4 29.7 100.0
MAI total riskscore >.I 100.0 57.0 26.5 100.0
>9 95.5 80.3 42.9 99.1
PDGMS ccntile 2nd 95.5 57.0 25.6 98.8
6th 95.5 48.6 22.3 98.6
16th 100.0 42.3 16.3 100.0

+p\! positive predictive values; -mnegative predictive values.

488 I~euelopmentalMedicineC ChildNeumlogy 1998.40: 485491


'
RECOMMENDED CUT-OFF POINTS O N THE AIMS
Two different cut-off points are recommended for use with
the AIMS to identify infants with abnormal motor develop-
ment. At 4 months, the 10th centile clearly provides the best
combination of sensitivity and specificity values, while at 8
months the 5th centile provides the optimal values. Our
choice of cut-off points is influenced by the conviction that
false-positive identification of normally developing infants is
just as detrimental as false-negative identification of infants
with abnormal motor development. From this perspective,
more infants are Correctly identified at 8 months using the
5th centile rank, even though the sensitivity value obtained
using the 10th centile rank is higher. The difference in sensi-
tivity values between the 5th and 10th centiles represents
identification of one more abnormal infant using the 10th
centile, while the specificityvalues account for 10 more nor-
mally developing infants correctly classified using the 5th
centile. Thus there are more infants correctly classified using
the 5th centile at 8 months as a cut-off rather than using the
10th centile rank. However, ifthe intent is to identify as many
infants with abnormal development as possible without
regard to the concomitant decrease in specificity, then the
10th centile rank should be used as a cut-off at 8 months.
These choices reflect the complexity of choosing cut-off
options.
In the AIMS manual (Piper and Darrah 1994) we reported
a case-validation study evaluating the ranking of infants with
established diagnoses and at-risk preterm infants. We used
the traditional cut-off point of <-2 SD to delineate abnormal
development, and scores between -1 SD and -2 SD to repre-
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sent suspicious motor development. Of the 44 at-risk infants
assessed, 10 had scores between 1and 2 SD below the mean
and three had scores that fell < 2 S D below the mean. We con-
cluded that these results concurred with the known preva-
lence of neuromotor disturbances occurring in preterm
infants in the first year of life. However, given the new infor-
mation available from this predictive study,we suggest using
the identified centile ranks to select infants for continued fol-
low-up. Use ofthe 16th centile (-1 SD) on the AIMS results in
over-identification of normally developing infants, while use
of the 2nd centile (-2 SD) will result in a poor rate of identifi-
cation of infants with abnormal motor development. The
results of this study question the use of the traditional stan-
dard deviation cut-off points in screening for motor dysfunc-
tion. Rather, the data suggest that the best centile ranks to
use as cut-off points on the AIMS are between the 16th cen-
tile and the 2nd centile.
Unfortunately, different cut-off points on the AIMS have
been identified at different ages. What centile rank should
be used as a cut-off between the two ages, or when screen-
ing infants older than 8 months? The answer must take into
consideration the concern regarding identification of nor-
mally developing infants. To maintain the highest specifici-
ty values, the cut-off should be the 5th centile, realizing
that some infants with motor problems may be missed,
resulting in a lower sensitivity rate. If the intent of the
screening program 'is identification of the greatest number
of infants with abnormal motor development and a lower
specificity rate will be tolerated, then the cut-off should be
at the 10th centile.

Table IIk Sensitivity, specificity, positive predictive value and negative predictive
value for abnormal/suspicious vs normal classification (N=164)

Agehest Cut-ofl Sensitivity c4;) Speci@ity 6) +PV(%) -pvc36)

(N=36) (N= 128)
4 months
AIMS centile 2nd 30.6 96.9 73.3 83.2
5th 41.7 90.6 55.6 84.7
10th 58.3 82.8 48.8 87.6
16th 58.3 78.1 42.9 87.0
25th 72.2 69.5 40.0 89.9
M N total risk score >4 63.9 75.8 42.6 88.2
>9 50.0 93.8 69.2 87.0
P D C M S centile 2nd 25.0 95.3 60.0 81.9
6th 36.1 93.8 61.9 83.9
16th 63.9 72.7 39.7 87.8
8 months
AIMS centile 2nd 52.8 96. I 79.2 87.9
5th 63.9 95.3 79.3 90.4
7th 69.4 94.5 78.1 91.7
10th 72.2 89.1 65.0 91.9
16th 77.8 85.9 60.9 93.2
25th 86.1 66.4 41.9 94.4
MAI total risk score >4 88.9 60.2 38.6 95.1
>9 77.8 83.6 57.1 93.0
P D C M S centile 2nd 86.1 60.2 37.8 93.9
6th 91.7 52.3 35.1 95.7
16th 97.2 46.1 33.7 98.3

+ PV positivc predictive values; -W, negative predictive values.

M o t o r Assessment of At-Risk lnfantsjobonna Darrab el al. 489


COMPARISON OF T H E PHEL)ICllVE VAI.UES 01;AIMS, M N , AND PDCMS
Referring to Table II and the early identification of infants
with definite diagnoses at 18 months, three conclusions are
made: (1) sensitivity values of the AIMS and MAI are similar at
both ages of assessment, (2) specificity values obtained on
the AIMS and MAI are different at different ages, and (3) the
PDGMS does not provide a very acceptable combination of
sensitivity and specificityvalues at either age.
By using the recommended cut-off points for the AIMS at 4
and 8 months and a cut-off of > 9 risk points for the MAI, we
obtained similar sensitivity values on both tests at 4 months
(AIMS 77.3%versus MAI 72.7%). The MAI, however, provided
greater specificity at 4 months (MAI 93.0% versus AIMS
81.7%). In contrast, at 8 months, while the sensitivity values
again were comparable (AIMS 86.4% versus MAI 95.5%), the
AIMS obtained better specificity values (AIMS 93.0% versus
MAI 80.3%).It must be recognized that because of the small
sample o f infants classified as abnormal or suspicious, all sen-
sitivity values am subject to sampling error. The diffcrencc in
specificityvalues at the different ages may be explained by the
specific motor constructs emphasized by each measure. At 4
months, the intewation ofprimitive reflexes may be the motor
construct that bcst distinguishes between abnormal and nor-
mal infants. The MI,with its emphasis on isolated testing of a
series of primitive reflexes, thus provides the best diSCrimind-
tion of normally developing infants. At 8 months, voluntary,
spontaneous movement may be the motor construct that dif-
ferentiates between normal and abnormal motor abilities.
Thus the items on the AIMS, with their emphasis o n successful
execution of voluntaly movcments, may contribute to the
accurate identification of normally developing infants on the
AIMS at this age. Although the MAI alsoevaluates postural con-
trol and voluntary movement, the style of assessment, which
requires extensive handling of infants, may impede the obscr-
vation of the infant's true spontaneous abilities.
The MAI may be the best screening test to use at or before
4 months, given its better specificity values. After 4 months,
the AIMS provides better specificityvvalucswhile maintaining
acceptable sensitivity values. Of course, choice of a test must
also include ease of administration and scoring. 'The AIMS,
with its observational format, is quick and easy to administer.
The main disadvantage of the MI is the inability to interpret
scores except at 4 and 8 months of age.
On the PDGMS, only the 16th centile at 4 months provid-
ed a combination of sensitivity and specificity values that
could be considered acceptable (81.8%and 7 1.8%).This rel-
atively high cut-off results in a lowered specificity value.
Other cut-off points at 4 months produced very low sensitivi-
ty values and high specificity values, while at 8 months the
sensitivity values were high and the specificity values were
unacceptable. The contents of the items o n the PDGMS pro-
vide the most likely explanation for these results. Many of the
4- to 5-month items can bc accomplished by infants with
impaired motor function (e.g. 'extending arms and legs',
'pedaling action', 'propping on extended arms'), resulting in
poor sensitivity values. In contrast, the 8- to 9-month items
involve complex skills (pivoting, creeping position [hands
. and knees], crawling [hands and legs in contact with sur-
face]) that many normally developing infants are not yet
practising. In addition, two items, 'raising up' (pull to sit
from supine using a chair) and 'scooting' (moves forward in
a sitting position), are rarely observed even in infants with
490 "neveIopmenraIMedicineG- ChiIdNerrroIogy 1998,40: 48549
14698749, 1998, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.1998.tb15399.x by Zentralbibliothek Zuerich, Wiley Online Library on [03/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
normal gross motor abilities. This combination of difficult
and eccentric itcms may contribute to the low levels ofspeci-
ficity achieved on rhe PDGMS at 8 months.
CIASSIFICATION OF 'SUSPICIOUS' INFANTS
Typically with screening tests, a cut-off equivalent to -2 SD is
recommended to identify infants with Significantly delayed
motor abilities, and a cut-off equivalent to the -1 SD is rec-
ommended to identify infants with mild or suspicious motor
delays (Folio and Fewell 1983, Bayley 1993). Use ofthese cut-
off points is based on the assumption that infants with suspi-
cious motor development demonstrate motor abilities that
are superior to infants with abnormal motor skills, but inferi-
or to infants with normal motorabilities. That is, their motor
abilities are assumed to 'fall b e p e c n ' the two extremes o f
abnormal and normal motor abilities.
In this study, when the infants identified as suspicious in
their motor development at 18 months were grouped with
infants with abnormal motor skills at 18 months, the sensitiv-
ity values decreased, regardless of the cut-off used or the test
administered. In fact, the scores of infants classified as suspi-
cious did not fall between the scores of infants classified as
normal and abnormal in their motor abilities. Instead, their
scores display a large range of values. Centile ranks obtained
from the raw scores of the suspicious infants on the AIMS
ranged from 0 to the 75th centile at 4 months and from 0 to
the 35th centile at 8 months. The range of these scores con-
firm that t o identify the majority of suspicious infants at
either 4 or 8 months of age, a very high cut-off point would be
needed. Use ofa high centile rank as a cut-off to obtain good
sensitivity will result in poor classification of normally devrl-
oping infants (low specificity). The assumption that these
infants' motor abilities represent a continuum between
those o f normal and abnormal infants may be too simplistic
and merits re-evaluation. It appears that their pattern of
motor abilities is different but does not consistently place
them o n a theoretical continuum between the normal and
abnormal infants. These infants are heterogeneous in their
motor abilities and may represent an artificial grouping of
infants with an array ofdifficulties.
This study exemplifies the challenges of choosing appro-
priate cut-off scores on standardized tests to scrcen for
motor dysfunction with at-risk infants. Choice of a cut-off
must take into account the consequences of both false-nega-
tive and False-positiveidentification of infants. We agree with
Allen and Alexander (1991) that false-positive identification
is costly both in terms of parental anxiety and the economic
costs of follow-up and intervention. Also, considering the
lack ofstrong evidence of an efficacious treatment for infants
with motor dysfunction, we chose to consider specificity val-
ues as important as sensitivity values, and recommended cut-
off points on the AIMS that reflected this philosophy. If
clinicians using the AIMS are more concerned with the great-
est identification ofinfants with abnormality, then the centile
rank chosen as a cut-off point should be increased. However,
the results of this study also suggest that arbitrarily increas-
ing the value of the cut-off point does not guarantee
improved identification of infants with suspicious motor
dcvelopment at 18 months of age. Assessment of the early
signs of dysfunction shown by these children may need to
include more than an evaluation oftheir gross motor abilities
to improve identification.
 14698749, 1998, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.1998.tb15399.x by Zentralbibliothek Zuerich, Wiley Online Library on [03/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Palmer F,Shapiro B, Wachtel R, Allen M,Hiller J, Harryman S,
Clinicians must be aware of the complexities of screening
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Motor AssessmentofAt-RiskInfantsJobunnaDam&et al. 491