Predictive Validity of the Infant Toddler Checklist in Primary Care at the 18-month Visit and School Readiness at 4 to 6 Years
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OBJECTIVE: The American Academy of Pediatrics recommends developmental surveillance and screening in early childhood in primary care. The 18-month visit may be an ideal time for identification of children with delays in language and communication, or symptoms of autism spectrum disorder (ASD). Little is known about the predictive validity of developmental screening tools administered at 18 months. Our objective was to examine the predictive validity of the Infant Toddler Checklist (ITC) at the 18-month health supervision visit, using school readiness at kindergarten age as the criterion measure. METHODS: We designed a prospective cohort study, recruiting in primary care in Toronto, Canada. Parents completed the ITC at the 18-month visit. Teachers completed the Early Development Instrument (EDI) when the children were in Kindergarten, age 4-6 years. We calculated screening test properties with 95% confidence intervals (CIs). We used multivariable logistic and linear regression analyses adjusted for important covariates. RESULTS: Of 293 children (mean age 18 months), 30 (10.2%) had a positive ITC including: concern for speech delay (n = 11, 3.8%), concern for other communication delay (n = 13, 4.4%), and concern for both (n = 6, 2.0%). At follow-up (mean age 5 years), 54 (18.4%) had overall EDI vulnerability, 19 (6.5%) had vulnerability on the 2 EDI communication domains. The ITC sensitivity ranged from 11% to 32%, specificity from 91% to 96%, false positive rates from 4% to 9%, PPV from 16% to 35%, NPV from 83% to 95%. A positive ITC screen and ITC concern for speech delay were associated with lower scores in EDI communication skills and general knowledge (β = -1.08; 95% CI: -2.10, -0.17; β = -2.35; 95% CI: -3.63, -1.32) and EDI language and cognitive development (β = -0.62; 95% CI: -1.25, -0.18; β = -1.22; 95% CI: -2.11, -0.58). CONCLUSIONS: The ITC demonstrated high specificity suggesting that most children with a negative ITC screen will demonstrate school readiness at 4-6 years, and low false positive rates, minimizing over-diagnosis. The ITC had low sensitivity highlighting the importance of ongoing developmental surveillance and screening.
