CAT/CLAMS: its use in detecting early childhood cognitive impairment.

The Cognitive Adaptive Test/Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS), a neurodevelopmental tool for the cognitive assessment of infants and toddlers, correlates well with the Bayley Scales of Infant Development. In 1993 the Bayley Scales were revised and the second edition published (BSID-II). This study was designed to determine how well the CAT/CLAMS correlates with the BSID-II and its utility in identifying mild and severe cognitive impairment. Sixty-eight infants and toddlers (age range = 14-48 months), referred for suspected developmental delays, were administered the CAT/CLAMS and BSID-II and the results compared. The correlation between the two instruments was strong (r = 0.89, P<0.0001). The CAT/CLAMS was sensitive (81%) and specific (85%) for detecting overall cognitive impairment (BSID-II less than 70) and was even more sensitive (100%) and specific (96%) in detecting severe cognitive impairment (BSID-II less than 50). The physician using the CAT/CLAMS formulated a clinical impression of cognitive impairment that was sensitive (95%) and specific (84%) compared with formal psychologic testing. The CAT/CLAMS correlates well with the BSID-II. It is useful for detecting and quantifying mild and severe cognitive impairment. It permits the physician to formulate an accurate clinical impression of cognitive impairment consistent with possible mental retardation.

Classification of developmental delays.

Developmental delay is frequently used to identify children with delay in meeting developmental milestones in one or more streams of development. There is no consensus on the specific definition. Developmental delay is best viewed generically as a chief complaint rather than a diagnosis. A child suspected to have delays should always be assessed in each of the major streams of development: expressive and receptive language, including social communication; visual problem solving (nonverbal cognition); motor development; neurobehavioral development; and social-emotional development. A model developed by the National Center for Medical Rehabilitation Research is used to compare existing classifications of developmental delays. This model defines the five domains in the disability process: pathophysiology, impairment, functional limitation, disability, and societal limitation. An etiology domain is added. This model is used to illustrate how existing classification systems of cerebral palsy, mental retardation, autism, and language delay draw on information from one or more domains. The model illustrates some of the conflicts between different systems. For example, most classification systems for cerebral palsy emphasize only impairment (spasticity, dyskinesias, and topography). The current definition and classification system for mental retardation focuses on functional limitations (IQ), disability, and societal limitations, ignoring pathophysiology and details of impairment. Given the complexity of neurodevelopmental disabilities, it is unlikely that a single classification system will fit all needs.

Persistent school dysfunction: unrecognized comorbidity and suboptimal therapy.

To determine reasons for continued school dysfunction in children previously diagnosed as having attention deficit hyperactivity disorder (ADHD) or enrolled in a special education program (spec. ed.), a retrospective chart review of patients referred for interdisciplinary evaluations at a tertiary center for hyperactivity and learning problems was completed. Interdisciplinary clinical recommendations were used to define reasons for treatment failure in 116 children with prior diagnosis of ADHD or spec. ed. placement. Results showed 45% of children enrolled in spec. ed. had previously undiagnosed ADHD. Thirty-one percent of those with ADHD, 55% of those in spec. ed., and 55% of those diagnosed with ADHD and in spec. ed. (Both) received a new educationally handicapping diagnosis. Psychiatric comorbidity was present in 28% of those with ADHD, 18% of those in spec. ed., and 23% of Both subjects. Thirteen percent of those in spec. ed. had significant coexisting medical conditions. Special education services were insufficient in 55% of children in spec. ed. and 55% of Both subjects. A significant difference (P < 0.01) in medication use was noted between the groups with 56% of the ADHD group, 55% of the Both group, and none of the spec. ed. group treated with medication. Of all subjects with ADHD, 76% were receiving insufficient or no medication. This review suggests the following: (1) Comorbidity in children with school dysfunction is frequently not recognized. (2) Educational therapy alone may not be sufficient treatment for school dysfunction, and in cases where the treatment program is failing, the appropriateness of the program should be reviewed. (3) ADHD is commonly seen in conjunction with other educationally handicapping conditions. Therefore, in cases of continuing school dysfunction, children previously diagnosed has having ADHD should be assessed for other educationally handicapping conditions; those previously diagnosed as educationally handicapped should be assessed for ADHD. (4) Suboptimal medication use may be associated with treatment failure.