Journal of Pediatric Psychology, Vol. 26, No. 1, 2001, pp. 33-40
© 2001 Society of Pediatric Psychology
Use of the Bayley Infant Neurodevelopmental Screener With Low Birth Weight Infants
1 University of California, San Francisco, 2 California School of Professional Psychology
All correspondence should be sent to Carol H. Leonard, Box 0748, UCSF, San Francisco, California 94143. E-mail: cleonard{at}peds.uscf.edu .
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Abstract |
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Objective: To examine the utility of the Bayley Infant Neurodevelopmental Screener (BINS) as a screening technique for premature, low birth weight infants.
Methods: One hundred thirty-three preterm infants <1,500 grams received a BINS assessment at mean adjusted age 6.8 months and a Bayley Scales of Infant Development, Second Edition (BSID-II) assessment at mean adjusted age 12.9 months. Infants' BINS scores were compared to their BSID-II Mental Development Index (MDI) and Psychomotor Development Index (PDI) scores.
Results: The BINS score showed significant association with the MDI (r =.40, p = <.001) and with the PDI (r =.35, p = <.001). The BINS showed moderate predictive validity (67%-76%) for identifying lower functioning infants.
Conclusions: The BINS is a satisfactory screening tool for low birth weight infants when used in conjunction with other known biologic and social risk factors.
Key words: high risk infant; screening; low birth weight; Bayley Scales.
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Introduction |
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Low birth weight infants (<1,500 grams) are at increased risk for neurologic abnormalities and developmental delays (Hack, Friedman, & Fanaroff, 1996
; Veen et al.,
1991). Although some disabilities, such as specific learning
disabilities, may be subtle and not apparent until school age, other deficits
such as cerebral palsy and significant developmental delay appear earlier.
Early diagnosis can lead to interventions, such as physical therapy,
occupational therapy, and infant stimulation programs, designed to facilitate
optimal development. Screening and assessments in the first year of life are
complicated because some infants may have transient tone differences that
resolve by one year, and they may be going through periods of reorganization
following their hospitalization as a newborn. Additionally, within the
category of low birth weight, some infants will have additional medical risk
factors such as asphyxia and maternal substance abuse and social risk factors,
such as low socioeconomic status (SES), low maternal education, or teenage
parenting (Bendersky & Lewis,
1994; Brazy, Goldstein, Oehler,
Gustafson, & Thompson, 1993;
Degraw et al., 1988;
Kirby, Swanson, Kelleher, Bradley, &
Casey, 1993; Korner et al.,
1993; Msall et al.,
1991; Thompson et al.,
1997). The developmental course of the low birth weight infant is
affected by these many factors.
Several techniques can determine if the infant is making normal
developmental progress: neurologic examinations
(Wildin et al., 1995;
Wildin et al., 1997), parent
questionnaires (Heiser, Grimmer, Metze,
& Obladen, 1995; Ireton
& Glascoe, 1995; Squires,
Bricker, & Potter, 1997), developmental screening techniques
such as the Denver Developmental Screening Test II
(Frankenburg, Dodds, Archer, Shapiro,
& Bresnick, 1992), the Battelle
(Glascoe & Byrne, 1993),
the CAT/CLAMS (Rossman et al.,
1994), and developmental assessments, such as the Bayley Scales of
Infant Development, Second Edition (BSID-II) (Bayley, 1992), the Gesell
(Knoblock & Pasamanick,
1974), and the Mullen Scales of Early Learning
(Mullen, 1985).
The utility of developmental screening measures is affected by many
factors: professional staff qualifications to administer, cost of the
instrument, time to administer, and adequacy of the results
(Dworkin, 1989;
Frankenburg, Chen, & Thornton,
1988; Kopp & Kaler,
1989; Meisels, 1988). Full assessments such as the BSID-II Scales
require 45 minutes to an hour to administer and require an advanced level of
training and expertise in administration. In high-risk clinics set up to
follow the growth and development of low birth weight infants, infants may
receive either a neurological examination or a developmental assessment; or
both examinations which have overlap in items that might be administered,
particularly in assessing gross and fine motor skills.
The Bayley Infant Neurodevelopmental Screener (BINS) is a recently
developed instrument designed specifically for a high-risk infant population
based on an earlier screening instrument, the ENORS
(Aylward, 1995;
Aylward, Verhulst, & Bell,
1988). It consists of items from the BSID-II Scales that assess
cognitive, social, language, gross, and fine motor skills. Typical items in
the age ranges under study include reaching for and transferring blocks,
looking for fallen items, types of vocalizations, and prewalking progression
(scooting, stepping movements). The BINS also includes items that measure
neurological intactness, such as ratings of active and passive tone in the
upper and lower extremities, and scoring of quality of movement of the upper
and lower extremities.
Although using items from the BSID-II Scales, the scoring is different and
the inclusion of tone and quality of movement items differentiates this
screening test from other developmental screening tests and the BSID-II. The
BINS was validated on a high-risk infant population as well as normal infants
in test construction. One study has reported on its concurrent validity with
two other instruments in a mixed high-risk infant (term and pre-term)
population (Macias et al.,
1998). This study examines the relationship of the BINS scores at
6 months to later development as measured by the Bayley Scales at 1 year.
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Method |
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The study group consisted of 133 preterm infants weighing <1,500 grams born April 1994 through September 1997 and treated in an intensive care nursery at an urban university medical center. The longitudinal study of the outcome of these infants is approved by the university Committee on Human Research. The mean gestational age of the infants was 27.5 weeks (range: 24-34 weeks), and mean birth weight was 976 grams (range: 570-1, 465 grams). The racial composition of the group was representative of our geographical catchment area with 57% white and 43% nonwhite. Table I presents characteristics of the study group.
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Following attendance at a BINS training workshop for providers and practice in administration and scoring supervised by a psychologist, the BINS was routinely administered by the physician or nurse in the program at the 6-month visit, and the BSID-II was administered by the psychologist at 1 year or soon thereafter. Ages were adjusted for prematurity. The mean age of testing on the BINS was 6.8 ± 1.4 months (Mean ± standard deviation) and on the BSID-II was 12.9 ± 1.2 months. The mean time between the BINS assessment and the BSID-II assessment was 6.1 ± 1.5 months. Five infants had their PDI scores deferred due to late arrival for appointments or in one case, an infant who was casted for club feet. All five infants were seen by the physician for a neurodevelopmental examination and were considered to have normal neurologic development. The number of subjects for the PDI data is 128 and for the MDI data is 133.
The BINS consists of 11-13 items for different age levels. The total number of items failed places the infant in a category of low, moderate, or high risk for developmental delay. Within the moderate risk range, a cut score is indicated at which optimal sensitivity and specificity are reached. Scores below this cut line are considered high moderate scores, indicating that the infant is approaching a high-risk range. Scores above the cut line are considered low-moderate scores, indicating that the infant is closer to the low-risk range. We could categorize an infant's BINS score thus as 0 = low risk, 1 = low moderate risk, 2 = high moderate risk and 3 = high risk.
The BSID-II MDI and PDI have mean scores of 100, with a standard deviation
of 15. Although traditional cut-offs of one and two standard deviations below
the mean are often utilized, we included a third category of 1.5 standard
deviations below the mean as this is the criterion for entrance to some infant
special education programs. Since the lowest BSID-II MDI or PDI score that can
be obtained is a categorical score of <50, the MDI and PDI scores cannot be
used directly in mathematical calculations unless scores of <50 are
assigned a common data point, such as 50 and the data are treated as
continuous. We chose to do categorical analyses that are consistent with the
noncontinuous form of the original data set. We therefore categorized the MDI
and PDI scores as within or above one standard deviation from the mean,
(scores 
85); from 1 to 1.5 SD below the mean, (scores 77-84);
1.5-2 SD below the mean (scores 70-76); and at 2 or more two standard
deviations below the mean (scores 
69).
Analyses
The association (Spearman rho) between the infant's BINS risk status and
MDI score, and BINS risk status and PDI score, was calculated.
Positive predictive value (PPV) is a measure of the ability of the screening test to accurately identify low scoring infants, as measured by a later criteria. We used the Bayley Scales of Infant Development at 1 year as our criteria for development. Positive predictive values were calculated for the BINS and the MDI, and BINS and the PDI. We looked at positive predictive value comparing and contrasting the different categories of performance on both tests.
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The BINS showed a significant association with the BSID-II MDI score (Spearman rho =.40, p = <.001) and with the BSID-II PDI score (Spearman rho =.35, p = <.001), when four risk ranges on the BINS were used (low, low-moderate, high-moderate, and high) and the MDI and PDI scores were categorized into four ranges.
Ten of 15 infants obtaining high risk BINS scores at 6 months of age showed MDI scores of <85 at 1 year, giving a positive predictive value of 67% on the BINS screening (Table II). Similarly for the PDI, positive predictive value was 67%, with 10 of 15 infants designated high risk on the BINS actually having scores <85 on the BSID-II PDI.
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In Table II, the highest
PPVs are seen when the low and moderate BINS scores are considered versus high
risk BINS scores. This is true for the MDI scores, regardless of whether the
MDI scores grouped -1, -1.5, or -2 standard deviations from the mean. For the
PDI, the same trend is seen with the exception that for infants with PDIs of
-1 standard deviation (>85 versus 84), PPV increased when the BINS
scores were grouped as low and low-moderate versus high-moderate and high. The
PPV increased from 67% to 72% in this grouping.
Since the BINS is not specific for cognitive versus motor deficits, an analysis was done looking at infants who had either an MDI or a PDI or both scores <85. The predictive validity of the BINS (grouping low and low-moderate versus high-moderate and high risk BINS scores) was 76%.
Among the false negatives were eight infants who scored in the low risk
range on the BINS, but who obtained both BSID-II MDI and PDI scores of <85.
Four additional infants scored in the low risk range on the BINS and had MDI
scores of <85, with PDI scores 85. There were no infants in the
remaining category of low risk on BINS with MDI 85 and PDI <85.
(Table III).
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As Table III shows, of the eight infants scoring <85 on the both MDI and PDI, seven infants were in the gestational age range 24-26 weeks. In the total study group of 133, 39% of the sample were in the gestational age range of 24-26 weeks. The eighth infant in this group of infants <85 on both the MDI and PDI was born at 29 weeks gestation and had a diagnosis of cerebral palsy at 1 year that was not identified at 6 months.
Since seven of eight false negatives, or infants who were low risk on the
BINS but who scored <85 on the Bayley MDI and PDI, were of extremely low
gestation, we separated the study group by gestational age (27 weeks
versus 26 weeks) and reanalyzed the data. With the BINS categorized into
low versus moderate and high risk scores, and Bayley MDI scores within or
<1.0 SD below the mean (85 versus 84), the PPV was 33% for
the 27 weeks' gestation infants and 59% for the infants 26 weeks'
gestation. For the PDI, the PPV was 65% for the 27 weeks' gestation
infants and 66% for the 26 weeks' gestation infants.
Reasons for poor performance on the BSID-II PDI were those generally seen in this low birth weight population: infants of 12-13 months adjusted age who were showing a normal progression of skills (crawling, pulling to stand, cruising) but who may not have been standing alone, or taking steps alone. One infant had a diagnosis of cerebral palsy. Based on review of test reports commenting on performance for each infant in the areas of gross motor skills, fine motor skills, language skills, problem-solving skills and behavior, the reasons for poor scores on the MDI fell into three patterns: (1) poor attention with increased activity level interfering with performance, (2) sparse language skills for age, and (3) fine motor incoordination.
Three of five infants who were false positives scored in the high risk
range on the BINS but obtained scores 85 on both the MDI and PDI on the
BSID-II. These three infants showed a similar pattern of failed items on the
BINS, failing items primarily in the Expressive and Cognitive categories. A
fourth false positive infant showed the same pattern, but although this infant
improved on the MDI, his PDI of 84 fell in a borderline range. The fifth false
positive infant had a different pattern: he failed four neurologic items and
at 1 year he continued with slow and clumsy gross motor development, but he
did not have a neurologic diagnosis. His PDI was 74, with an MDI of 99.
Although this infant was a false positive for the MDI, his pattern of failed
items on the BINS was consistent with the slow motor development reflected in
his PDI. (Table IV).
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There were 34 infants who had BINS scores in the moderate risk range. Of
these 34 infants, 69% of infants with scores in the low-moderate risk range on
the BINS obtained MDI scores of 85, and 61% of infants in the
high-moderate risk range obtained MDI scores of 85. There was a slightly
wider distribution of MDI scores for those infants obtaining high-moderate
risk scores (Figure 1).
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Less "normalization" of scores was seen for infants with moderate risk BINS scores on their PDI scores. Infants obtaining a high-moderate risk score on the BINS had fairly even distribution later on their PDI scores, with similar numbers of infants falling at 1, 1.5, and 2 standard deviations below the mean. Infants with a low-moderate risk score on the BINS showed a stepwise progression, with 50% of infants having normal PDI scores, 31% from 1-1.5 SD below the mean, 25% from 1.5-2 SD below the mean, and 6% at or more than 2 SD below the mean (Figure 2).
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Discussion |
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By definition a screening test casts a wide net to select those children who may need closer monitoring. Any screening test will make classification errors; both in identifying infants as abnormal who were later found to be normal and in underidentifying infants who presented later with deficits. This study examined the relationship of the 6-month BINS score to the 12-month Bayley scores. The Bayley Scales of Infant Development, as with other infant tests, does not predict long-term outcome. Infant tests are measures of present developmental status and are widely utilized as formal indicators of need for timely intervention services.
This study examined the predictive value of using the BINS at a typical 6-month adjusted age examination of low birth weight infants to screen for emerging disabilities, as a lower cost measure than administering a full Bayley assessment at 6 months, and as able to be incorporated in the physician's examination of the infant. This represents cost efficiency in staff time and length of visit for the patient.
The BINS was moderately effective in correctly predicting as low risk those
infants at 6 months who later had a normal developmental assessment on the
BSID-II and in identifying abnormal infants who remained abnormal at 12
months. Consideration of the efficacy of any screening measure depends on the
base rate in the population being screened. A base rate of 50% normal and 50%
abnormal is likely to be the most efficacious for using a screening measure
(Murphy and Davidshofer,
1988). In the premature, low birth weight infant population, more
than 50% of infants are likely to have normal development at one year
(Hack et al. 1996;
Piecuch. Leonard, & Cooper,
1998; Piecuch, Leonard,
Cooper, & Sehring, 1997). The BINS was able to predict 67%-72%
of the low functioning infants correctly, given a likely base rate of
abnormality of 20%-40% in this population.
The BINS manual is clear in acknowledging the moderate risk range as one
requiring clinical judgment in deciding whether to further assess or refer
infants obtaining a moderate risk score. The moderate risk range has been
found to be a less consistent classification than initial classification in
the low or high risk range in a study of BINS performance over the first 2
years of life for high-risk infants
(Aylward, Verhulst, & Bell,
1996). In the age ranges in this study, infants had to miss only
two or three items to fall in the moderate risk range. If an infant is at the
lower end of the age range, failure of items may be more likely than at the
upper end of the age range. In this study, however, 13/14 infants at the lower
end of the age range obtained scores in a low risk range. The best clinical
practice may be to report scores in the moderate risk range as low-moderate
risk or high-moderate risk, utilizing the cut score on the record form, and to
monitor those infants obtaining high-moderate scores more frequently than
those obtaining low-moderate scores.
In the total group of 133 infants, some infants in each BINS risk range were receiving services from infant programs by 1 year of age. Eleven percent (9/84) of infants who had BINS scores in the low risk range were enrolled in an infant program as were 25% (4/16) of infants who had a low-moderate risk score, 22% (4/18) who had a high-moderate risk score, and 27% (4/15) who had a high risk BINS score. Reasons for referral to the programs varied with "prematurity" as the usual intake reason.
The BINS at 6 months would not be expected to accurately identify subtle aspects of development emerging at 1 year of age: refinements in fine motor skills, progress in receptive and expressive language, efficiency in imitation, and problem solving skills. The BINS at 6 months may also not accurately identify developmental delay that is not neurologically based but may reflect subtle aspects of behavioral organization and attention span that are expected to emerge by 1 year of age.
Many aspects of development are affected by factors in the social
environment, such as adequacy of parenting, levels of parental education, and
cultural differences in child rearing practices, among others. Medical risk
factors such as significant intracranial hemorrhage, periventricular
leukomalacia, and maternal substance abuse in the high risk infant's medical
history may place him or her at risk for development. Extremely low
gestational age may be a biological risk for later cognitive skills. Our
finding of the preponderance of infants at 24-26 weeks gestational age who had
low risk BINS scores but who gave a poor performance on the BSID-II at 1 year
may indicate a medical risk factor of very early gestational age, which has
been reported elsewhere (Piecuch et al.,
1997). Serial evaluations may reveal a pattern of change related
to biological risk, similar to those observed by Liaw and Brooks-Gunn
(1993) in low birth weight
infants.
Prediction of developmental outcome at 1 year from a 6-month screening for
a high-risk infant is a complicated issue. In addition to social factors and
medical risk factors, there is the physical recovery from the neonatal
hospitalization and the resilience of the infant, which affects the trajectory
of developmental outcome. No screening tool at 6 months is likely to
accommodate to a perfect degree the multitudinous effects on an infant's
development at 1 year. Social or biologic risk factors, and perhaps their
additive effects, as discussed by Aylward
(1992), continue to be an
important aspect of the assessment of developmental risk to be considered in
conjunction with test scores in initiating referral for services. Our clinical
experience with the BINS and this study suggest that it is a useful tool.
Received May 28, 1999; revision received October 14, 1999; accepted February 29, 2000
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