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Research Reports |
S Westcott McCoy, PT, PhD, is Associate Professor, Department of Rehabilitation Medicine, University of Washington, 1959 Pacific NE St, Box 356490, Seattle, WA 98195-6490 (USA).
A Bowman, PT, DPT, is Physical Therapist, Clinic of Orthopaedic and Sports Physical Therapy, Tacoma, Washington.
J Smith-Blockley, PT, DPT, is Physical Therapist, Therapeutic Associates, Boise, Idaho.
K Sanders, PT, DPT, is Physical Therapist, Kindering Center, Bellevue, Washington.
AM Megens, MSc, BScPT, is Physical Therapist, Ottawa Children's Treatment Centre, Ottawa, Ontario, Canada.
SR Harris, PT, PhD, FAPTA, is Professor Emerita, Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
Address all correspondence to Dr McCoy at: westcs{at}u.washington.edu
Submitted June 18, 2008;
Accepted November 7, 2008
 | Abstract |
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Objective: The aims of this study were (1) to further evaluate the validity of the HINT by comparing data obtained on US infants who were developing typically with data previously acquired on Canadian infants and (2) to determine the concurrent validity of the HINT with the Ages and Stages Questionnaire (ASQ). Secondary analyses of HINT scores for US white and nonwhite infants and for US infants who had parents with lower levels of education and US infants who had parents with higher levels of education (as a proxy for socioeconomic status [SES]) were conducted.
Design: Cross-sectional exploratory and quasi-experimental comparative research designs were used to evaluate the validity of the HINT.
Methods: Sixty-seven infants from the United States who were developing typically and who were aged 2.5 to 12.5 months were recruited via convenience sampling. Sixty-four of these infants were compared with Canadian infants matched for age, sex, ethnicity or race, and parental education. The HINT was administered by raters who had been trained to attain acceptable levels of interrater reliability, and parents completed the ASQ. The HINT scores for US white versus nonwhite infants (n=46) and infants who had parents with lower SES versus a higher SES (n=52) were compared.
Results: There were no significant differences between HINT total scores for US and Canadian infants or for US racial or ethnic groups and SES groups. There were high correlations (r=–.82 to –.84) between HINT and ASQ scores.
Limitations: The study used a small US sample with limited geographical diversity. Small sample numbers also did not allow for comparisons of specific racial or ethnic groups. The SES groups were created primarily using parental education as a proxy for SES.
Conclusions: The results suggest that HINT screening in the United States is supported on the basis of Canadian norms and the validity of the HINT in screening for motor and cognitive delays. Although there is preliminary support for the HINT as an appropriate screening tool for US infants who are nonwhite or who have parents with a lower SES, more research is warranted.
| Introduction |
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 TopAbstract Introduction MethodResultsDiscussionConclusionReferences |
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The HINT is a noninvasive tool designed for use with infants from 2.5 to 12.5 months of age.4,5 The HINT also aims to validate the importance of parental opinions in making screening decisions.4 The HINT contains 4 general areas: background information on the child and the caregiver; questions assessing the caregiver's level of concern about the infant's movement and play; a 21-item observational or testing section that is scored to assess the infant's movement against gravity, muscle tone, behavior and cooperation, stereotypical behaviors, and head circumference (Tab. 1); and 1 item in which the clinician notes his or her overall clinical impression of the infant's development.6 Items aimed specifically at the identification of early cognitive or behavioral deficits include observation of the infant's behavior and cooperation, the presence of stereotypical behaviors, and measurement of head circumference as an indication of brain volume. Overall, the test takes approximately 15 to 30 minutes to administer and score, depending on the infant's behavior and the skill of the administrator, and is minimally stressful for the infant. Physical therapists, occupational therapists, physicians, pediatric nurses, and other health care providers who have had appropriate training can administer the HINT.
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The HINT has been used primarily to screen for the development of Canadian infants. Normative data have been collected on 412 Canadian infants from 5 provinces. No data on infants from the United States have been published to determine whether HINT scores, reflective of infant developmental trajectories, are similar for infants in the 2 nations. Although the Canadian and US cultures related to caregiving for infants can be considered similar overall, there are environmental (colder climate in Canada) and health care (universal health care in Canada) differences that might affect infants’ development. Although no studies comparing the effects of US and Canadian early child-rearing practices on infant development could be found, it has been shown that subtle cultural preferences for sleep9 and play positions and the use of equipment10 might affect rates of motor development. Research with the HINT should be expanded to include infants from the United States, so that the use of the test can be generalized to this population.
Because the authors of the HINT suggested that parental perceptions are important and that the HINT screens for early cognitive as well as motor delays, an assessment of concurrent validity with a parental report of cognitive and motor development could strengthen an evaluation of the validity of the HINT.11 The Ages and Stages Questionnaire (ASQ) was designed to provide an economical and convenient alternative to professionally administered early infant or child assessments.6,12 Typically requiring 10 to 20 minutes to complete, the ASQ contains 30 questions covering 5 developmental domains—communication, gross motor, fine motor, problem solving, and personal-social—at various ages (including 4, 6, 8, and 12 months). Scores below established cutoff scores in one or more domains suggest developmental delays in the child being assessed.12
Previous research showed that the ASQ is reliable when completed by parents or primary caregivers.6 Compared with established gold standards, the ASQ had a sensitivity of 90%, a specificity of 77%, a positive predictive value of 40%, and a negative predictive value of 98%.13 We concluded that the high negative predictive value of the ASQ supported its use as a screening tool for cognitive and motor delays.13 The ASQ should be comparable to the HINT, especially in the motor and problem-solving domains.
No comparison of HINT scores for infants of different ethnicities or races and socioeconomic status (SES) has been published. As of 2005, it was estimated that 33% of the US population was nonwhite, with the projection that by 2010, approximately 35% of the US population will be of minority ethnicities or races.14,15 Previous research suggested that infants from different ethnic or racial and socioeconomic backgrounds may have different developmental patterns.16–22 For example, a study of full-term Asian American infants found that 40% were identified as having scores on the Movement Assessment of Infants indicating high risk for movement disorders or delays, even though they were not suspected of having any developmental concerns and had unremarkable birth histories.17 Further, both the cognitive development and the motor development of infants from African American and Hispanic backgrounds were shown to be correlated with the home environment, mother-infant interaction, and mother's education.18,19 However, there are conflicting data on the lack of effect of a mother's education on infant development as indicated by HINT scores.23 This information suggests that ethnicity or race and SES may together influence the rate of development of infants. Therefore, it is important to examine scores for infants who are from different ethnic or racial and socioeconomic backgrounds and who are developing typically to determine whether screening with the HINT will be valid for these populations.
Two primary research questions were addressed in this study. First, is there a difference in HINT total scores between matched US and Canadian samples of infants who are developing typically? Second, what is the concurrent validity of the HINT with the ASQ in US infants? Our hypotheses were that HINT scores for US and Canadian infants would be comparable and that the HINT would correlate most highly with the problem-solving and motor domains of the ASQ. Secondary analyses were conducted for the US sample of infants to determine whether there were differences in HINT total scores for white versus nonwhite infants and for infants who had parents with lower SES versus higher SES. We hypothesized that there would be differences in HINT scores between these groups.
| Method |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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Infants who were born full term (37–42 weeks), weighed more than 2,500 g (5.5 lb), and had no history of major prenatal, perinatal, or postnatal medical complications or maternal complications were included in the study. Infants who were born preterm (<37 weeks of gestation), were small for their gestational age (<2,500 g), had a history of maternal alcohol or drug use during pregnancy, or had any other high-risk condition, such as a chromosomal abnormality or a congenital heart defect, were excluded from the study. Attempts were made to select a sample with variability in ethnic or racial and socioeconomic backgrounds. Two facilities were used to help recruit subjects: the Good Samaritan Women, Infants and Children (WIC) clinic in Puyallup, Washington, and the Cottesmore Child Development Center in Gig Harbor, Washington. Table 2 provides details for the sample.
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For further data analysis of the US sample, infants were classified according to ethnicity or race and SES. Two groups were established for ethnicity or race: white and nonwhite. Infants were placed in the nonwhite group if one or both parents were of nonwhite descent. Infants in the nonwhite group were of the following descent: Asian or Pacific Islander (n=3), black or African American (n=3), Spanish, Hispanic, or Latino (n=4), and mixed (n=13). Overall, the race breakdown for our sample—66% white and 34% nonwhite—was similar to that in the US 2000 census (75% white and 25% nonwhite).25 However, our sample overrepresented Asian infants and infants of 2 or more races and underrepresented black or African American infants and infants with Spanish, Hispanic, or Latino ethnic backgrounds.25
Two groups were established for SES, primarily on the basis of parental level of education, which has been correlated with income level26 and which is a common proxy for SES. Infants were placed in the high-SES group if their parents were educated beyond high school. Infants were placed in the low-SES group if their parents had a level of education of high school or less or if they were recruited from the Good Samaritan WIC clinic or the Cottesmore Child Development Center, because low SES is a prerequisite for participation in these programs.
Procedure
Data were collected by 3 of the investigators (AB, JSB, and KS). Interrater reliability was established for all raters during pilot testing by comparison with a rater (SWM) trained and verified as reliable by one of the HINT authors (SRH). The 3 raters achieved an ICC (3,1) of .98 for HINT total scores for 5 infants, with values ranging from .72 to .98 (P<.05) on individual test items.
Testing took place in the infant's home; in the University of Puget Sound Physical Therapy clinic in Tacoma, Washington; at the Good Samaritan WIC clinic; or at the Cottesmore Child Development Center. Parents signed consent forms approved by the University of Puget Sound Institutional Review Board. Descriptive data, including parental ethnicity or race and parental education, were collected from parental report as part of the background information section of the HINT. Parents then were asked to complete the ASQ while the investigators administered the HINT to the infants. Total time to administer and score the HINT was approximately 30 minutes, including breaks for the infants as needed and discussion of results with the parents. Most parents completed the ASQ in approximately 20 minutes. Total testing time with the families was approximately 45 to 50 minutes because parents tended to participate in HINT testing rather than complete the ASQ during HINT testing.
Data Analysis
All data were analyzed with the Statistical Package for the Social Sciences, version 14.0 (SPSS 14.0),* and an alpha value set at .05. The HINT total scores were used for all analyses. Data for all comparisons explained below were verified as being normally distributed across groups.
For comparison of Canadian and US infant HINT total scores, infants were matched for age, sex, parental ethnicity or race, and parental education. An independent sample t test was used to compare Canadian and US data, with 64 infants in each group.
To correlate HINT and ASQ scores, we had to exclude some data because of improper completion (multiple answers for questions) of the ASQ by the parent; therefore, the correlation was calculated for 53 infants. The ASQ data were adjusted to reflect changes in scores across development to allow for determination of the level of correlation with the HINT data. The HINT scores become progressively lower as the infant gains skills across the first year of life. The ASQ scores are calculated for a specific age; therefore, no matter how old the infant, these scores range from 0 to 60. To adjust the ASQ scores so that they progressively increased with the age of the children, we gave each child credit for the 60 points in all age levels below the one in which he or she was tested. For instance, a child tested at the 6-month level and receiving a score of 30 points at his or her age level in one domain was awarded an additional 60 points for all items at the 4-month level (the one level below the 6-month level) in that domain and, therefore, achieved an adjusted score of 90 points for that domain. Pearson correlation coefficients were used to examine the relationship between HINT and ASQ total scores and between the HINT and each ASQ domain (communication, gross motor, fine motor, problem solving, and personal-social).
For comparison of white and nonwhite US infant HINT scores, data were age matched. There was no significant difference in sex across ages, as determined with a chi-square test of independence (
2=8.77, df=8, P>.05). An independent sample t test was used to compare means for 23 infants in each group, because these data represented the infants for whom age matching was possible.
For comparison of low-SES and high-SES infant HINT scores, data were age matched. There was no significant difference in sex across ages, as verified with a chi-square test of independence (2=3.79, df=8, P>.05). An independent sample t test was used to compare means for 26 infants in each group, because these data represented the infants for whom age matching was possible.
| Results |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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| Discussion |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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Strong correlations between the HINT and the ASQ across all individual ASQ domains were found. Because the ASQ has performed well in tests against gold standards for infant developmental screening, these data provide support for the validity of the HINT. On the basis of our second hypothesis, we expected to find stronger correlations between the motor and problem-solving domains of the ASQ and the HINT, but all domains of the ASQ were equally correlated. This result may have occurred because of the screening nature of both tools.
On the basis of a comparison of developmental scores on the ASQ and the HINT, we suggest that there may be differences in the abilities of these tools to screen for mild to moderate developmental delays. Discrete items are provided at various ages in the ASQ; therefore, the assumption is that an infant in a particular age group will have mastered all items in the younger age groups. This may not always be the case; therefore, scores on the ASQ may underrepresent children at risk for delays. Screenings carried out with the HINT require that movement be scored for all test items across all ages to avoid this potential problem. Evaluation of the relationships between these tools would be strengthened by further testing with larger samples that include children at risk for developmental delays. We do not yet know whether the correlations found between the HINT and the ASQ for infants who are developing typically are generalizable to infants at risk for delays or infants with developmental disabilities.
No significant differences were found in HINT total scores for infants who were healthy in the white versus nonwhite groups and in the low-SES versus high-SES groups, thus negating our third hypothesis. However, this finding provides some support for the notion that the HINT can be appropriately applied to infants from various backgrounds. We expected to find differences and perhaps did not find them because our study was limited by a small sample size. Consequently, we were not able to examine the data to determine whether the scores were similar across all age levels of the HINT. The mean scores for 7- to 9-month-old and 10- to 12-month-old infants appeared to be different for both white versus nonwhite groups and low-SES versus high-SES groups (Tab. 3). However, the differences were opposite and were canceled out in the total group comparison analyses. A larger sample would allow the examination of differences at different ages. Ideally, infants also should be divided into several different groups of ethnicity or race and multiple levels of SES to fully understand the effects of ethnicity or race and SES on the rates of typical development.
Further testing is needed with larger numbers of subjects and the ability to stratify samples to support or refute the preliminary results found in the present study. Follow-up studies should aim to collect a sample of sufficient size and diversity to represent US demographic variability. Also, although level of education has been noted as an acceptable proxy measure for SES,26 it is not the most comprehensive SES measure. For instance, we encountered several families whose level of education would place them in a high SES class but who qualified for low-income assistance programs.
Unlike in the United States, which has Part C (for early intervention) of the Individuals With Disabilities Education Act (IDEA, Public Law 108-446),27 Canada has no federal law mandating early intervention services for infants at risk for developmental delays or those with known delays or disabilities. Health care is provided on a provincial basis. In British Columbia, for example, there is a province-wide Infant Development Program that serves children from birth to 3 years of age and their families.28 According to the program's Web site,28 the rationale for this early intervention program is "in common with similar services in the USA and elsewhere in Canada." That is, interventions may be most effective if begun early in life; infancy is an important period of life, and delays during that period may be long lasting; and the family is the most crucial source of learning, emotional support, and developmental encouragement for a child. Major referral sources in both countries include public health nurses, physicians, and parents. The HINT was developed to be used by a variety of health care providers; therefore, it should serve in a similar manner in each country as a possible tool for early screening of infant development.
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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| Footnotes |
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This research was completed as part of Dr Bowman's, Dr Smith-Blockley's, and Dr Sanders's DPT degree requirements at the University of Puget Sound, Tacoma, Washington.
Dr Harris is the primary author of the Harris Infant Neuromotor Test (HINT), to be published by PRO-ED Inc, Austin, Texas. Ms Megens is the second author of the HINT.
The study was approved by the University of Puget Sound Institutional Review Board.
Grant support for this study was provided by the University of Puget Sound Enrichment Committee (grant SR0543). Role of the Funding Source: Funding for the purchase of the equipment for the test kits and forms, and a small present for the families for their participation in the research was provided by the grant.
This research was presented as a poster at the Combined Sections Meeting of the American Physical Therapy Association; February 14–18, 2007; Boston, Massachusetts; and at the 15th International Congress of the World Confederation for Physical Therapy; June 2–6, 2007; Vancouver, British Columbia, Canada.
* SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606. 
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  T. A. Mayson, C. L. Backman, S. R. Harris, and V. E. Hayes Motor Development in Canadian Infants of Asian and European Ethnic Origins Journal of Early Intervention, June 1, 2009; 31(3): 199 - 214. [Abstract] [PDF]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
