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Abstract

The aim of this study was to develop a screening tool to screen children for development problems in a low-income setting. Childhood development problems are a major health issue faced by low-income countries. A validated screening tool is needed for early identification of developmental delays. This article contains the first phase of a study that established a relatively simple tool to screen children for developmental problems. The aim of the first phase was to define a set of development indicators for the period of 2 to 12 months of life. The study methodology consisted of an extensive literature review, to develop a set of indicators to measure child development in infancy. The indicators were placed within a framework developed and used by experts in other countries. It consists of major domains, subdomains, specific aspects, and standards of development. This was followed by content validation of the indicators. Following review of literature, 171 indicators were compiled under the framework. At the end of content validation, 125 indicators were retained in the framework. These were pretested, and another 26 were removed following pretesting. The study developed a framework of indicators that could be used as a development tool following a reference-based validation. The second phase of the study that included the assessment of psychometric characteristics and reference-based validation would be published in a separate article.

Keywords

child development development screening development standards

Introduction

Childhood developmental delays and their sequelae are a major public health concern for low-income countries. Grantham-McGregor and colleagues (2007) state that many children in developing countries are exposed to multiple risks for poor development including poverty, poor health, and nutrition. The conservative estimate is that more than 200 million children below 5 years of age in developing countries are not developing to their full potential.

Developmental problems affect both developed and developing countries. For example, in the United Kingdom, an analysis of a cross-sectional survey of 16,000 children aged 0 to 18 years revealed that 7.3% of children were reported as having a developmental disability (Blackburn, Read, & Spencer, 2010). In a comprehensive review done of studies on disability covering intellectual, hearing, speech, vision, motor, and neurologic impairment in low- and middle-income countries (Maulik & Darmstadt, 2007), a 12% overall disability rate was reported among 2- to 9-year-old children from one community-based study in India (n = 640).

Early identification of delays by screening is vital, as interventions could make a big difference to the individual and family, and place less demand on health expenditure (Grantham-McGregor et al., 2007). Development screening of a child is currently measured by a range of developmental screening tests (Frankenburg et al., 1996). Developing countries face a big obstacle in systematic screening due to three factors:

Established development screening tools need to be validated to a country before being used.

Trained people are needed to administer them.

To identify developmental problems, a large number of apparently normal children have to be examined. These three factors require considerable expertise, money, and time, all rare attributes in a developing setup.

To overcome these obstacles, middle- and low-income countries need instruments that could be used in the field by a primary health care worker or caregiver. Normative development standards for young children called Early Child Development Standards (ECDS) could serve this purpose. Standards are statements that specify an expectation for achievement of skills or knowledge that may be used as a basis of comparison in measuring or judging capacity, quality, value, or quantity (Kagan & Britto, 2008).

The age at which development skills appear can be given as a range. These ranges can be considered as age percentiles. A percentile of a development indicator is the age a particular skill is achievable by a percentage of children. Based on the percentiles, norms can be defined. These norms can be used to make relative assessment of children in relation to their level or status of development (Fernald, Kariger, Engle, & Raikes, 2009).

Development of ECDS therefore consists of two components:

development of a tool where early developmental indicators are initially defined and placed in a development framework, and

age validation of the tool to obtain ECDS.

The methods adopted to develop ECDS were recommended in two global workshops held in Shanghai, China, and Kathmandu, Nepal (Kagan & Britto, 2008), in collaboration with the United Nations Children’s Educational Fund (UNICEF).

Aim

This report gives the first component of a study where a series of early developmental indicators for children in second to 12th months of life were defined and adapted to ensure their content and cultural appropriateness.

Method

Development tools generally use a three- to four-domain approach in categorizing the items. For example, the Bayley’s scale uses a three-domain approach (Motor, Cognitive, and Language) in the main scale (Bayley, 2005). The Denver Developmental Screening Test (Frankenburg et al., 1996) uses a three-domain method as well. These scales do not further subdivide the items. The present study further subdivides the items and uses a hierarchy to place the items (refer to Table 1). This hierarchy has been used by countries that have addressed ECDS (Tennesse Department of Education. (2013). In this, there are four domains of development, their subdomains, specific aspects, standards, and indicators. The four major subdomains were utilized as all major development scales used this categorization. The items under the major domains conformed to the placement of items found in widely used scales such as the Bayley’s and Denver Developmental Tool. The subdomains are broad areas of the domain. The specific aspects are the main components of those subdomains. The standards are the expected skills that depict the specific aspects. Standards are measured by the final indicators. The indicators are very specific statements that can be actually measured.

Table 1.

Framework of Domains, Subdomains, Specific Aspects, Standards, and Indicators.

Domain	Subdomain	Specific aspect	Standard
Cognitive Development	Logical Thinking and Numeracy Skills	Comparison and measurement/spatial awareness	• Child demonstrates the ability to make comparisons and measure to some extent• Child develops spatial sense
	Environmental Awareness	Numbers	• Child demonstrates awareness of numbers
		Scientific inquiry	• Child develops an inquiring mind• Surroundings (people and objects)
		Awareness of world around	• Shows interest in surroundings (people and objects)
		Awareness of community	• Child demonstrates an awareness of the community he lives in
	Approaches to Learning	Problem solving	• Child demonstrates ability to use different strategies for problem solving
		Creativity and imagination	• Child demonstrates creativity and imagination
		Curiosity and persistence	• Child demonstrates curiosity and persistence
Social and Emotional Development	Social	Relationship with adults	• Responds to and interacts with familiar adults• Identifies unfamiliar people
		Relationship with peer	• Infant develops positive relationships with peers
		Prosocial behavior	• Develops perception of routines• Demonstrates awareness of some responsibilities (acts independently)• Develops empathy
	Emotional	Self-concept	• Demonstrates the development of a positive self-concept
		Self-control	• Develops the ability to control impulses and regulate himself
		Self-expression	• Develops the ability to express emotions appropriately
		Aesthetic appreciation	• Shows some ability for aesthetic appreciation
Language and Early Literacy skills	Language	Receptive language	• Child demonstrates the ability to understand language to some extent
	Language	Expressive language	• Child demonstrates the ability to express needs, feelings, and experiences for a variety of purposes
	Early Literacy	Participating in experiences that include books; discovering and appreciating books	• Manifests and interest for the book
		Prereading	• Demonstrates prereading skills
		Prewriting	• Demonstrates prewriting skills
Motor	Motor	Gross motor	• Demonstrates ability for movement and coordination
	Motor	Fine motor	• Demonstrates ability to manipulate things briefly/shows visual coordination
	Physical Well-Being	Taken as not applicable

Once the skills are defined, they are made measurable by converting them to indicators; hence, the final hierarchy of a domain is given in Figure 1.

Figure 1.

Hierarchy of a domain.

There are several steps involved in developing and validating an instrument. As the first step, an extensive review of literature is needed to operationalize the construct to be measured (Benson & Clarke, 1982). When the construct is operationalized, the items that can measure the construct as accurately as possible are identified. The team that developed the Denver Developmental Tool identified 336 items initially as the components needed to measure development (Frankenburg et al., 1996). In development of the Canadian Early Development Index (EDI), the items for the EDI were derived from existing instruments, key informant interviews, and focus groups (Janus & Offord, 2007). Content validation is the next step where the items and the table of specifications are given to a panel of experts who are asked to place the items in the suitable grids within the table of specifications. When absolute agreement is not reached, the item is revised until a consensus on its placement is reached. Cronbach and Meehl (1955) state that content validity is established by showing that the test items are a sample of a universe in which the investigator is interested.

Development tools can either use an a priori structure to categorize their indicators or an empirically driven method. An empirically driven structure will decide on the categories where the items will be placed following a mathematical evaluation like factor analysis. Most of the widely used scales like Bayley’s scale have not used an empirically driven method but utilized an a priori structure method. The Bayley Scales of Infant Development II (BSID II) has been subjected to factor analysis to explore the factor structure. For example, one such study is the analysis carried out by Thompson and others (Thompson et al., 1994). The authors conclude that at a second-order factor analysis, the mental and motor components emerge as discrete constructs. Countries developing ECDS have all used an a priori structure method. The present study uses this method as well. The authors are of the view that as the hierarchy used in the present study consists of numerous categories, it would render it unfeasible to do a construct validity at all levels. But a factor analysis at the topmost category that has the four domains of development could certainly be attempted.

Thus, the first phase of the study is comprised of two components:

desk review to generate a tentative list of relevant indicators and

qualitative study to carry out content and cultural validation of the above.

Component A: Desk Review to Generate a Tentative List of Relevant Indicators

The purpose of the desk review was to gather the generic list of expectations on what children should know and be able to do at a given age during the period of 2 to 12 months of their life and to define indicators to reflect them. Therefore, the data items included a comprehensive list of indicators that reflected a particular child’s developmental performance pertaining to each developmental domain (Motor, Socio-emotional, Cognitive, and Language domains). These indicators were finally organized into the hierarchy. The data for the desk review were gathered after review of several sources. These included review of textbooks on child development, existing developmental standards, and developmental scales.

Textbooks reviewed were Child Development by John W. Santrock (2001), Child Psychology: A Contemporary Viewpoint by Hetherington and Parke (1999), The Development of Children by Cole and Cole (1989), Child Development Principles and Perspectives by Cook and Cook (2009) and Psychology: The Science of Behavior by Neil R. Carlson (1984).

Subsequent to this, a review of articles on ECDS in the form of an electronic search was done to cover the standards and indicators already developed in the world. The articles were the following:

“South Africa National Early Learning and Development Standards for children birth to four years. Department of Basic Education, Pretoria, South Africa” (Department of Basic Education, Pretoria, 2009).

“Revised Tennesse Early Learning Developmental Standards” (Tennesse Department of Education, 2013)

Ohio’s infant and toddler guidelines (U.S. Department of Health and Human Services, National Infant & Toddler Child Care Initiative, Child Care Bureau, Office of Family Assistance, Administration for Children and Families, 2006).

“Washington state early learning and development guidelines.” (Washington State Department of Early Learning, 2011)

“Macedonia Early Learning and Development Standards from 0-6 years” (Damovska, Janeva, Palcevska, Panova, & Shaehu, 2006).

Searches in Medline (1970 to present), PsycINFO (1960 to present), and Embase (1960 to present) did not yield any additional information. The search terms used were “development,” “child,” and “standards.” A keyword search and a title search were done.

Next, scales of development commonly in use were reviewed. These were the Bayley Scales of Infant and Toddler Development (Bayley, 2005), the Denver Developmental Screening Tool (Frankenburg et al., 1996), the Parents’ Evaluation of Development Status (Glascoe, 1997), and the Ten Questions Screening Interview (Landers & Kagitcibasi, 1990).

Additional items appearing in these instruments which did not include highly specified test material and items that were not too complex so that it would be understood by the average caregiver were included.

Finally, a comprehensive list of items was obtained, and they were assigned to the domain, subdomain, specific aspect, and standard hierarchy. They were placed in the relevant age groups reflecting the ages of 2 to 3 months, 3 to 6 months, 6 to 9 months, and 9 to 12 months.

The indicators chosen had the following characteristics:

Reflecting only a single skill or activity

Being specific for a particular skill

Having the ability to capture the performance as the skill advances

Qualitative Study to Carry Out Content and Cultural Validation

This was to assess whether the indicators were comprehensive in covering the domains, were actually reflecting the domain under which they were included, and were actually reflecting the specific aspects and standards given. Modified Delphi technique was used for this process. For this, six experts comprising of three local consultant pediatricians (two qualified in developmental pediatrics), two psychologists, and a consultant child psychiatrist were utilized.

They were requested to go through each indicator with regard to the following and give their verdict:

Comprehensiveness of the standards and indicators in covering all aspects of the domain.

Adequacy in reflecting the scope of the domain.

Reflection of the standard, specific aspect, subdomain, and domain under which they were included.

Representation of domains in comparatively equal distribution.

Observability and measurability.

Are a reflection of what children in the age group are expected to know and be able to do.

After the initial round, the comments were analyzed for each item. If four or more out of six agreed on an indicator, it was taken as valid and included in the final instrument. If four or more experts disagreed, they were removed from the list. If three agreed, those indicators were again presented to all six experts. After completion of the second round, if the disagreement still stood at 50% (three disagreeing), the item was removed.

The finalized list of indicators at the end of this phase was transformed into measurable items with the help of a pediatrician involved in development assessment of children. This was brought about by laying out specific instructions to elicit a skill. To maintain uniformity in testing, a testing procedure had to be explained precisely so that the data collectors could conform to the procedure. The Bayley Scales of Infant and Toddler Development was consulted to decide on the positions, objects, and distance that items should be held when testing was done.

Next, a focus group discussion (FGD) of parents was held to gather information required to fine-tune the indicators to ensure their cultural appropriateness. Four FGDs were held on four different occasions, each consisting of eight parents. The indicators were then pretested. Pretesting was done using 10 children from age category. All the indicators in the age group were administered and assessed whether any difficulty arose to their observability.

Results

Following the first component which was the desk review, 171 indicators were compiled under the framework. They were organized under 25 standards which reflected 23 specific aspects in four main domains of development. Table 1 gives the framework of domains, subdomains, specific aspects, and standards.

Tables 2 -5 give the 171 indicators arranged in the framework. Some indicators appeared in more than one age group as the indicators which suited the best age group could be selected once they were age validated.

Table 2.

Indicators for Age 2 to 3 Months.

Domain: Physical Development	Domain: Social and Emotional Development	Domain: Cognitive Development	Domain: Development of Language and Early Literacy Skills
Subdomain: Motor	Subdomain: Social Development	Subdomain: Logical Thinking and Mathematics	Subdomain: Language
Specific aspect: Gross motor	Specific aspect: Relationship with adults	Specific aspect: Comparison, measurement, and spatial awareness	Specific aspect: Receptive language
Standard 1: Demonstrates ability of movement and coordination1. Turns head from side to side when lying on back2. Raise head and chest when lying on stomach3. Holds head erect and steady when held on shoulder4. Extends and flexes legs at will5. Follows moving person through midline to left and right6. Moves arm at sight of toy or objectSpecific aspect: Fine motorStandard 2: Demonstrates ability to hold things briefly/shows visual coordination7. Eyes follow an object from left to right/top to bottom (cognitive)8. A small object placed in hand is accepted and brought to the mouth	Standard 1: Responds to and interacts with familiar adults 9. Follows the caregiver with eyes10. Stops crying when familiar voice is heard11. Cuddles into caregiver’s shoulder when being held (trusts)Specific aspect: Relationship with peersStandard 2: Infant develops positive relationships with peers12. Looks in direction of a child nearby13. Smiles/coos in response to older children’s attentionSpecific aspect: Prosocial behaviorStandard 3: Develops perception of routine	Standard 1: Child demonstrates the development of comparison and measurement concepts21. Watches actions of others22. Reacts to disappearance of caregiver’s face23. Reacts to caregiver/people/objects24. Looks at own hands and observesStandard 2: Child develops spatial sense25. Explores object placed in handsSpecific aspect: NumbersStandard 2: Child demonstrates awareness of numbers Not applicable to this age group	Standard 1: Responds to sights and sounds31. Startles, cries, or wakes when there is a loud sound32. Attentive when spoken to33. Focuses on objects and sound-making toys34. Recognizes mother’s voice and is soothed by itSpecific aspect: Expressive languageStandard 2: Uses sounds and body movements to communicate35. Produces soft, gurgling sounds36. Smiles in response to speaker’s attention37. Makes sound of comfort and displeasure
	Subdomain: Emotional DevelopmentSpecific aspect: Self-conceptStandard 4: Demonstrates the development of a positive self-concept14. Uses crying to signal needs15. Conveys desires—Makes vocal protests when not picked up when he wantsSpecific aspect: Self-control	Subdomain: Awareness of the EnvironmentSpecific aspect: Scientific inquiryStandard 3: Child develops an inquiring mind26. Looks at surroundings in a new place27. Waves arms to touch dangling toy overhead	Subdomain: Early LiteracySpecific aspect: Participating in experiences that include books; discovering and appreciating booksStandard 3: Shows an interest in booksSpecific aspect: PrereadingSpecific aspect: Prewriting
	Standard 5: Develops the ability to control impulses and regulate himself16. Stops crying on seeing a familiar person17. Calms self—Sucks on hand before going to sleepSpecific aspect: Self-expressionStandard 6: Develops the ability to express emotions appropriately18. Uses specific kinds of sounds to signal needs19. Is responsive to an adult’s attempts to comfort—Relaxes when massaged20. Conveys primary desires such as hunger—Protests when not picked up when he wants	Specific aspect: Awareness of living and nonliving worldStandard 4: Shows interest in surroundings (people and objects)28. Focuses on objects which are at close range29. Gazes continuously at objects for at least 3 s30. Child freely turns eyes/head in visual exploration of surroundingsSpecific aspect: Awareness of the communityStandard 5: Child demonstrates an awareness of the community he lives in
		Subdomain: Approaches to learningSpecific aspect: Curiosity, initiative, and persistenceSpecific aspect: Creativity and imaginationStandard 6: Child demonstrates creativity and imaginationSpecific aspect: Problem solvingStandard 7: Child demonstrates ability to use different strategies for problem solving

Table 3.

Indicators for 3 Plus to 6 Months.

Domain: Physical development	Domain: Social and Emotional Development	Domain: Cognitive Development	Domain: Development of Language and Early Literacy Skills
Subdomain: Motor	Subdomain: Social Development	Subdomain: Logical Thinking and Mathematics	Subdomain: Language
Specific aspect: Gross motorStandard 1: Demonstrates ability of movement and coordination 1. Supports upper body on arms when lying on stomach 2. Swipes at dangling objects with hands and feet 3. Rolls both ways (front to back, back to front)—Rolls to prone position	Specific aspect: Relationship with adultsStandard 1: Responds to and interacts with familiar adults 6. Coos or smiles when talked to 7. Kicks legs or reaches with arms when familiar person approaches 8. Looks at and touches the face of someone familiar who moves in closer to baby 9. Smiles or laughs in response to tickling	Specific aspect: Comparison and sorting/spatial awarenessStandard 1: Child develops ability to compare and sort18. Sorts out familiar faces from among a groupStandard 2: Develops spatial senseNo indicators for this age group	Specific aspect: Receptive language
Specific aspect: Fine motorStandard 2: Demonstrates ability to hold things briefly/shows visual coordination 4. Can follow a circular motion of an object (upper and lower quadrants as well) 5. Rotates wrist from palm up to palm down when manipulating an object	Standard 2: Identifies unfamiliar people10. Reaches to a familiar adult to be picked up when a stranger greets him11. Facial expressions change at the sight of an unfamiliar personSpecific aspect: Relationship with peersStandard 3: Infant develops positive relationships with peers12. Directs smiles and vocalizations toward other infants/babies13. Looks toward a peer who is interacting with an interesting objectSpecific aspect: Prosocial behaviorStandard 4: Develops perception of routines	Specific aspect: NumbersStandard 3: Child demonstrates awareness of numbersIndicatorsNo indicators for this age group	Standard 1: Child demonstrates the ability to understand expressions and body language30. Begins to turn head toward sounds that are out of sight31. Responds appropriately to tone of speaker’s voice (distressed when harsh, happy when pleasant)32. Identifies familiar sounds and respondsSpecific aspect: Expressive languageStandard 2: Child demonstrates the ability to express needs, feelings, and experiences for a variety of purposes33. Laughs out loud34. Imitates short string of vowel sounds (double sounds—Ba . . . Ba)35. Makes sounds that go up and down in pitch36. Likes to babbleSpecific aspect: Language ComprehensionStandard 4: Child demonstrates the ability to comprehend gestures and sounds37. Responds to mother’s/caregiver’s gestures—Responds when mother calls him
	Subdomain: Emotional Development	Subdomain: Awareness of the Environment	Subdomain: Early Literacy
	Specific aspect: Self-concept	Specific aspect: Scientific inquiry	Specific aspect: Participating in experiences that include books; discovering and appreciating books
	Standard 5: Demonstrates the development of a positive self-concept14. Responds positively to adults’ attempts to comfort15. Conveys desires/needs through sounds	Standard 4: Child develops an inquiring mind19. Grabs and probes objects20. Reaches out toward objects21. Visually follows object as it moved out of direct line of vision	Standard 3: Shows an interest in books38. Looks intently at pictures for several seconds with thoughtful expression
	Specific aspect: Self-controlStandard 6: Develops the ability to control impulses and regulate himself	Specific aspect: Awareness of living and nonliving world	Specific aspect: PrereadingSpecific aspect: Prewriting
	Specific aspect: Self-expressionStandard 7: Develops the ability to express emotions appropriately16. Uses sounds/facial expressions or actions to show preferences	Standard 5: Shows interest in surroundings (people and objects)22. A toy is held, touched, and tasted23. Inspects own hands24. Eye moves from one object to another in response to sound25. Prefers novel object
	Specific aspect: Aesthetic appreciationStandard 8: Shows some ability for aesthetic appreciation17. Calms when sung to/falls asleep listening to music/lullabies	Specific aspect: Awareness of the communityStandard 6: Child demonstrates an awareness of the community he lives in26. Discriminates family members from others27. Shows awareness of unfamiliar surroundings
		Subdomain: Approach to Learning
		Specific aspect: Curiosity, initiative, and persistence
		Specific aspect: Creativity and imagination
		Standard 7: Child demonstrates creativity and imagination28. Shows delight in producing sounds—Smacks lips, squeals on purpose
		Specific aspect: Problem solving
		Standard 8: Child demonstrates ability to use different strategies for problem solving29. Pulls a cloth with rattle on it to obtain rattle

Table 4.

Indicators for 6 Plus to 9 Months.

Domain: Physical development	Domain: Social and Emotional Development	Domain: Cognitive Development	Domain: Development of Language and Early Literacy Skills
Subdomain: Motor	Subdomain: Social Development	Subdomain: Logical Thinking and Mathematics	Subdomain: Language
Specific aspect: Gross motor	Specific aspect: Relationship with adults	Specific aspect: Comparison and sorting and spatial sense	Specific aspect: Receptive language
Standard 1: Demonstrates ability for movement and Coordination 1. Moves from lying down to sitting position 2. Can sit unsupported 3. Supports whole weight on legs when adult is holding both hands 4. Holds railing to move from sitting to standing position	Standard 1: Responds to and interacts with familiar adults 9. Smiles when familiar person smiles or talks10. Babbles and coos to get attention of someone familiar nearbyStandard 2: Identifies unfamiliar people11. Stops activity and stares at a new person entering roomSpecific aspect: Relationship with peersStandard 3: Infant develops positive relationships with peers12. Kicks feet in excitement at sight of other child/children13. Uses hands to explore face/hair of peer	Standard 1: Child develops ability to compare and sortStandard 2: Child develops spatial sense23. Pulls a string attached to a toy making it come closerSpecific aspect: NumbersStandard 3: Child demonstrates awareness of numbersIndicatorsNo indicators for this age group	Standard 1: Child demonstrates the ability to understand expressions and body language37. Temporarily stops action in response to “no”Specific aspect: Expressive languageStandard 2: Child demonstrates the ability to express needs, feelings, and experiences for a variety of purposes38. Vocalizes in response to speaker’s attention39. Vocalizes at least two different vowel sounds40. Begins to babble in strings—Ba-ba-ba-baSpecific aspect: Language ComprehensionStandard 3: Child demonstrates the ability to comprehend gestures and sounds41. Complies with a request—Examiner shows placement of cube in box and requests baby to do same
Specific aspect: Fine motorStandard 2: Demonstrates ability to hold things/shows visual coordination 5. Grasps and object with thumb and first and second fingers 6. Bangs two hand-held items together 7. Transfers objects from hand to hand 8. Moves his head to search for object which has fallen from the table	Specific aspect: Prosocial behaviorStandard 4: Develops perception of routines14. responds positively to when feeding time approaches15. Complies with bathing/washingStandard 5: Develops empathy16. Watches with an expression of distress when another child criesStandard 6: Develops the ability to corporate17. Begins to watch other children in a group and shows interest in their play
	Subdomain: Emotional Development	Subdomain: Awareness of the Environment	Subdomain: Early literacy
	Specific aspect: Self-conceptStandard 5: Demonstrates the development of a positive self-concept	Specific aspect: Scientific inquiry	Specific aspect: Participating in experiences that include books; discovering and appreciating books
	18. Does not release an object easily19. Tries to grab object from other’s handSpecific aspect: Self-controlStandard 6: Develops the ability to control impulses and regulate himself20. Seeks reassurance from adult when encountering new experienceSpecific aspect: Self-expressionStandard 7: Develops the ability to express emotions appropriately21. Makes responses to express how he feels about what is happeningSpecific aspect: Aesthetic appreciation-Standard 8: Shows some ability for aesthetic appreciation22. Enjoys kids songs	Standard 4: Child develops an inquiring mind24. Explores inside and outside surface of objects—for example, cup25. Repeatedly turns and object over26. Explores and inspects the smallest details floor27. Discovers difference between moving and static objectsSpecific aspect: Awareness of living and nonliving worldStandard 5: Shows interest in surroundings (people and objects)28. Searches for fallen object29. Plays with mirror image by patting, smiling/laughing, reaching playfully30. Holds bell by handle and purposefully bangs itSpecific aspect: Awareness of the communityStandard 6: Child demonstrates an awareness of the community he lives in31. Knows difference between mother and grandmother32. Recognizes different rooms in the homeSubdomain: Approaches to Learning	Standard 4: Shows an interest in books42. Holds book using both hands and manipulates the book to make the pages openSpecific aspect: PrereadingSpecific aspect: Prewriting
		Specific aspect: Curiosity, initiative, and persistenceSpecific aspect: Creativity and imaginationStandard 7: Child demonstrates creativity and imagination33. Child enjoys noises—Bangs objects together over and over again34. Uses body to make sounds—Splashes water, slaps objectsSpecific aspect: Problem solvingStandard 8: Child demonstrates ability to use different strategies for problem solving35. Pulls cloth on table to obtain object36. Searches for item that has been covered completely (covering bangle with cloth)

Table 5.

Indicators for 9 Plus to 12 months.

Domain: Physical Development	Domain: Social and Emotional Development	Domain: Cognitive Development	Domain: Development of Language and Early Literacy Skills
Subdomain: Motor	Subdomain: Social Development	Subdomain: Logical Thinking and Mathematics	Subdomain: Language
Specific aspect: Gross motor	Specific aspect: Relationship with adults	Specific aspect: Comparison and measurement	Specific aspect: Receptive language
Standard 1: Demonstrates ability for movement and coordination 1. Crawls forward on hands and knees 2. Raises self to standing position using a chair/other aid 3. May walk 2 to 3 steps without support 4. Can pivot in the sitting positionSpecific aspect: Fine motorStandard 2: Demonstrates ability to manipulate things briefly/shows visual coordination 5. Uses thumb and first finger to pick up things 6. Puts objects into a container and takes objects out of a container 7. When given a cube, opens his hand and extends it when requested but does not release it	Standard 1: Responds to and interacts with familiar adults 8. Reaches to the caregiver when hurt or upset 9. Actively clings or cries when familiar person says good bye10. Tugs on caregiver or makes noises when felt ignoredStandard 2: Identifies unfamiliar people11. Needs to be comforted or close to the caregiver on arrival of an unfamiliar person12. Demonstrates joy when caregiver returns after being away	Standard 1: Child demonstrates the ability to make comparisons and measure to some extent23. Uses props as aids—Uses a chair to stand up24. Begins to enjoy putting items in a container/getting objects out of a containerStandard 2: Child develops spatial sense25. Explores inside and outside surface of objectsSpecific aspect: NumbersStandard 4: Child demonstrates awareness of numbersIndicatorsNo indicators for this age group	Standard 1: Child demonstrates the ability to understand language to some extent38. Follows one-step routines when presented with gestures—Clapping hands39. Knows own name and responds by looking when called40. Understands the names of familiar objects (leg, cup chain, etc.) by pointing or touching them when they are uttered.
	Specific aspect: Relationship with peers	Subdomain: Awareness of the EnvironmentSpecific aspect: Scientific inquiry	Specific aspect: Expressive language
	Standard 3: Infant develops positive relationships with peers13. Tries to imitate playing with the toy after watching peer play with it14. Watches intently when older children play15. Crawls into an adult’s lap if adult is talking with other childrenSpecific aspect: Prosocial behaviorStandard 4: Develops perception of routines16. Shows anticipation of meal times	Standard 5: Child develops an inquiring mind26. Repeatedly turns an object over27. Explores and inspects the smallest details—for example, bread crumbs fallen on the floor, beads—Also given in previous age groupSpecific aspect: Awareness of living and nonliving worldStandard 6: Shows interest in surroundings (people and objects)28. Regards one or more familiar pictures with interest	Standard 2: Child demonstrates the ability to express needs, feelings, experiences for a variety of purposes41. Vocalizes to get attention42. Produces at least two different distinct consonant sounds43. May say a word—“bah” for bottle, “ma” for mother44. Uses at least one gesture to make wants known45. Babbles extensivelySpecific aspect: Language Comprehension
	Standard 5: Demonstrates awareness of some responsibilities (acts independently)17. Tries to feed self without help—Can feed himself a biscuitStandard 6: Develops empathy18. Cries when hearing another child criesStandard 7: Develops the ability to corporate	29. Interested in three blocks and picks up at least two blocks and visually attends to 3rd block30. Begins to imitate familiar motions such as stirring31. Demonstrates what an object can do (understands function—Dolls walk)Specific aspect: Awareness of the communityStandard 7: Child demonstrates an awareness of the community he lives in32. Shows awareness of neighbors	Standard 3: Shows ability to comprehend information46. Understands a simple gesture—Gives the cube in his hand when mother asks for itSubdomain: Early LiteracySpecific aspect: Participating in experiences that include books; discovering And appreciating books
	Subdomain: Emotional DevelopmentSpecific aspect: Self-conceptStandard 5: Demonstrates the development of a positive self-concept19. Pays attention to own reflection in mirror20. Responds to name being calledSpecific aspect: Self-controlStandard 6: Develops the ability to control impulses and regulate himself21. Halts action on reprimand “no” but may cry simultaneouslySpecific aspect: Self-expressionStandard 7: Develops the ability to express emotions appropriately22. Indicates desire for specific items—for example, favorite toySpecific aspect: Aesthetic appreciationStandard 8: Shows some ability for aesthetic appreciation	Subdomain: Approaches to LearningSpecific aspect: Curiosity, initiative, and persistenceStandard 8: Shows curiosity and persistence33. Pokes fingers into holes, gapsSpecific aspect: Creativity and imaginationStandard 8: Child demonstrates creativity and imagination34. Claps or bounces up and down on his own35. Experiments with sound—Dumps blocks, pots, and pans on floor an repeatsSpecific aspect: Problem solvingStandard 9: Child demonstrates ability to use different strategies for problem solving36. Pulls things off shelves, baskets37. Begins to put knowledge of inside to use—Stack two to three cups	Standard 4: Shows an interest in books47. Shows an increase in visual attention to book48. Turns pages, has some difficulty in separating papers but succeeds49. Laughs or smiles to show recognition of pictures50. Makes appropriate noises when he sees familiar animal/object (Booh, booh for dog)51. Points to individual pictures and vocalizesSpecific aspect: PrereadingStandard 7: Prereading: Child demonstrates interest in interacting with story52. Makes appropriate noises when sees familiar animal or object53. Laughs or smiles to show recognition of pictures54. Points to individual pictures and vocalizes while pointingSpecific aspect: Prewriting

Out of the 171 indicators, 46 indicators were removed at the end of content validation. Tables 6 and 7 summarize how these indicators were reduced during content validation.

Table 6.

Indicators Removed in 2 to 3 Months and 3 Plus to 6 Months Age Groups.

Indicator		Postexpert validation
Age 2 to 3 months		Why indicator was removed
1	11. Cuddles into caregiver’s shoulder when being held (trusts)	Not age appropriate
2	16. Stops crying on seeing a familiar person	Standard itself Removed—Not age appropriate
3	17. Calms self—Sucks on hand before going to sleep	Standard itself Removed—Not age appropriate
4	20. Conveys primary desires such as hunger—Protests when not picked up when he wants	Not objectively measurable
5	21. Watches actions of others	Relocated under standard—Develops an inquiring mind
6	22. Reacts to disappearance of caregiver’s face	Not appropriate for the age
7	23. Reacts to caregiver/people/objects	Not appropriate for the age
8	24. Looks at own hands and observes	Was relocated under standard—Shows interest in surroundings
9	25. Explores object placed in hands	Not appropriate for the age
10	37. Makes sound of comfort and displeasure	Not appropriate for the age
Age 3 plus to 6 months
11	8. Looks at and touches the face of someone familiar who moves in closer to baby	Not objectively measurable
12	10. Reaches to a familiar adult to be picked up when a stranger greets him
13	11. Facial expressions change at the sight of an unfamiliar person
14	12. Directs smiles and vocalizations toward other infants/babies
15	16. Uses sounds/facial expressions or actions to show preferences
16	17. Calms when sung to/falls asleep listening to music/lullabies
17	18. Sorts out familiar faces from among a group	Not age appropriate
18	26. Discriminates family members from others	Not age appropriate
19	30. Begins to turn head toward sounds that are out of sight	Not objectively measurable
20	35. Makes sounds that go up and down in pitch	Not objectively measurable

Table 7.

Indicators Removed in 6 Plus to 9 Months and 9 Plus to 12 Months Age Groups.

Age 6 plus to 9 months		Why indicator was removed
21	14. Responds positively to when feeding time approaches	Not objectively measurable
22	15. Complies with bathing/washing
23	16. Watches with an expression of distress when another child cries
24	17. Begins to watch other children in a group and shows interest in their play
25	18. Does not release an object easily
26	19. Tries to grab object from other’s hand
27	20. Seeks reassurance from adult when encountering new experience
28	21. Makes responses to express how he feels about what is happening
29	22. Enjoys kids songs
30	23. Pulls a string attached to a toy making it come closer	Overlapped with another indicator No. 35
31	24. Explores inside and outside surface of objects—for example, cup	Same indicator present in 9- to 12-month group
32	27. Discovers difference between moving and static objects	Not objectively measurable
33	31. Knows difference between mother and grandmother
34	32. Recognizes different rooms in the home
35	37. Temporarily stops action in response to “no”	Overlapped with other indicators—No.46 of subsequent age group and thus administered in this age group as well
36	41. Complies with a request—Examiner shows placement of cube in box and requests baby to do same
Age 9 plus to 12 months		Why indicator was removed
37	7. When given a cube, opens his hand and extends it when requested but does not release it	Not objectively measurable
38	11. Needs to be comforted or close to the caregiver on arrival of an unfamiliar person
39	12. Demonstrates joy when caregiver returns after being away
40	15. Crawls into an adult’s lap if adult is talking with other children
41	16. Shows anticipation of meal times
42	18. Cries when hearing another child cries
43	21. Halts action on reprimand “no” but may cry simultaneously
44	22. Indicates desire for specific items—for example, favorite toy
45	23. Uses props as aids—Uses a chair to stand up	Did not reflect the standard properly—Demonstrates the ability to make comparisons and measurements
46	24. Begins to enjoy putting items in a container/getting objects out of a container
47	25. Explores inside and outside surface of objects—for example, cup	Better indicator No. 37 present
48	36. Pulls things off shelves, baskets	Did not reflect the standard

As 46 indicators were removed at the end of content validation, 125 indicators proceeded to the next step of the study which was the FGD with parents to ensure cultural appropriateness. Although removal of 48 indicators is shown, in actuality, only 46 indicators were removed as two were relocated elsewhere. No major modifications were needed following the FGDs.

The development framework with the 125 indicators is given in Tables 8 -11

Table 8.

Final Indicators for Age 2-3 Months.

Domain: Physical Development	Domain: Social and Emotional Development	Domain: Cognitive Development	Domain: Development of Language and Early Literacy Skills
Subdomain: Motor	Subdomain: Social Development	Subdomain: Logical Thinking and Mathematics	Subdomain: Language
Specific aspect: Gross motor	Specific aspect: Relationship with adults	Specific aspect: Comparison and spatial awareness	Specific aspect: Receptive language
Standard 1: Demonstrates ability of movement and coordination 1. Turns head from side to side when lying on back 2. Raises head and chest when lying on stomach 3. Holds head erect and steady when held on shoulder 4. Extends and flexes legs at will 5. Follows moving person through midline to left and right 6. Moves arm at sight of toy or objectSpecific aspect: Fine motorStandard 2: Demonstrates ability to hold things briefly/shows visual coordination 7. Eyes follows an object from left to right/top to bottom (cognitive) 8. A small object placed in hand is accepted and brought to the mouth	Standard 1: Responds to and interacts with familiar adults 9. Follows the caregiver with eyes10. Stops crying when familiar voice is heardSpecific aspect: Relationship with peersStandard 3: Infant develops positive relationships with peers11. Looks in direction of a child nearby12. Smiles/coos in response to older children’s attentionSpecific aspect: Prosocial behaviorStandard 4: Develops perception of routinesSubdomain: Emotional DevelopmentSpecific aspect: Self-conceptStandard 5: Demonstrates the development of a positive self-concept13. Uses crying to signal needs14. Conveys desires—Makes vocal protests when not picked up when he wantsSpecific aspect: Self-controlStandard 6: Develops the ability to control impulses and regulate himselfSpecific aspect: Self-expressionStandard 7: Develops the ability to express emotions appropriately15. Uses specific kinds of sounds to signal needs16. Is responsive to an adult’s attempts to comfort—Relaxes when massaged	Standard 1: Child demonstrates the development of comparison conceptsStandard 2: Child develops spatial senseSpecific aspect: NumbersStandard 3: Child demonstrates awareness of numbersSubdomain: Awareness of the EnvironmentSpecific aspect: Scientific inquiryStandard 4: Child develops an inquiring mind17. Watches actions of others18. Looks at surroundings in a newplace19. Waves arms to touch dangling toy overheadSpecific aspect: Awareness of living and nonliving worldStandard 5: Shows interest in surroundings (people and objects)20. Focuses on objects which are at close range21. Looks at own hands and observes22. Gazes continuously a objects for at least 3 s23. Child freely turns eyes/head in visual exploration of surroundingsSpecific aspect: Awareness of the communityStandard 6: Child demonstrates an awareness of the community he lives inSubdomain: Approach to LearningSpecific aspect: Curiosity, initiative, and persistenceSpecific aspect: Creativity and imaginationStandard 7: Child demonstrates creativity and imaginationSpecific aspect: Problem solvingStandard 8: Child demonstrates ability to use different strategies for problem solving	Standard 1: Responds to sights and sounds24. Startles, cries or wakes when there is a loud sound25. Attentive when spoken to26. Focuses on objects and sound-making toys27. Recognizes mother’s voice and is soothed by itStandard 2: Uses sounds and body movements to communicate28. Produces soft, gurgling sounds29. Smiles in response to speaker’s attentionSubdomain: Early LiteracySpecific aspect: Participating in experiences that include books; discovering and appreciating booksStandard 3: Shows an interest in booksSpecific aspect: PrereadingSpecific aspect: Prewriting
			Specific aspect: Expressive language

Table 9.

Final Indicators for 3 Plus to 6 Months.

Domain: Physical Development	Domain: Social and Emotional Development	Domain: Cognitive Development	Domain: Development of Language and Early Literacy Skills
Subdomain: Motor	Subdomain: Social Development	Subdomain: Logical Thinking and Mathematics	Subdomain: Language
Specific aspect: Gross motor	Specific aspect: Relationship with adults	Specific aspect: Comparison and sorting	Specific aspect: Receptive language
Standard 1: Demonstrates ability of movement and coordination 1. Supports upper body on arms when lying on stomach 2. Swipes at dangling objects with hands and feet 3. Rolls both ways (front to back, back to front)	Standard 1: Responds to and interacts with familiar adults 6. Coos or smiles when talked to 7. Kicks legs or reaches with arms when familiar person approaches 8. Smiles or laughs in response to tickling	Standard 1: Child develops ability to compare and sortStandard 2: Develops spatial sense	Standard 1: Child demonstrates the ability to understand sounds/expressions and body language22. Responds appropriately to tone of speaker’s voice (distressed when harsh, happy when pleasant)23. Identifies familiar sounds and respondsSpecific aspect: Expressive languageStandard 2: Child demonstrates the ability to express needs, feelings, experiences for a variety of purposes24. Laughs out loud25. Imitates short string of vowel sounds (double sounds—Ba . . . Ba)26. Likes to babble
Specific aspect: Fine motorStandard 2: Demonstrates ability to hold things briefly/shows visual coordination 4. Can follow a circular motion of an object (upper and lower quadrants as well) 5. Rotates wrist from palm up to palm down when manipulating an object	Standard 2: Identifies unfamiliar peopleSpecific aspect: Relationship with peersStandard 3: Infant develops positive relationships with peers 9. Looks toward a peer who is interacting with an interesting objectSpecific aspect: Prosocial behaviorStandard 4: Develops perception of routinesSubdomain: Emotional DevelopmentSpecific aspect: Self-conceptStandard 5: Demonstrates the development of a positive self-concept	Specific aspect: NumbersStandard 8: Child demonstrates awareness of numbersSubdomain: Awareness of the EnvironmentSpecific aspect: Scientific inquiryStandard: Child develops an inquiring mind12. Grabs and probes objects13. Reaches out toward objects14. Visually follows object as it moved out of direct line of vision
	10. Responds positively to adults’ attempts to comfort11. Conveys desires/needs through sounds	Specific aspect: Awareness of living and nonliving worldStandard 4: Shows interest in surroundings (people and objects)	Specific aspect: Language comprehensionStandard 3: Child demonstrates the ability to comprehend gestures and sounds
	Specific aspect: Self-controlStandard 6: Develops the ability to control impulses and regulate himselfSpecific aspect: Self-expressionStandard 7: Develops the ability to express emotions appropriatelySpecific aspect: Aesthetic appreciationStandard 8: Shows some ability for aesthetic appreciation	15. A toy is held, touched, and tasted16. Inspects own hands17. Eye moves from one object to another in response to sound18. Prefers novel objectSpecific aspect: Awareness of the communityStandard 12: Child demonstrates an awareness of the community he lives in19. Shows awareness of unfamiliar surroundingsSubdomain: Approaches to LearningSpecific aspect: Curiosity, initiative, and persistenceSpecific aspect: Creativity and imagination	27. Responds to mother’s/caregiver’s gestures—Responds when mother calls himSubdomain: Early LiteracySpecific aspect: Participating in experiences that include books; discovering and appreciating booksStandard 4: Shows an interest in books28. Looks intently at pictures for several minutes with thoughtful expressionSpecific aspect: PrereadingSpecific aspect: Prewriting
		Standard 7: Child demonstrates creativity and imagination20. Shows delight in producing sounds—Smacks lips, squeals on purposeSpecific aspect: Problem solvingStandard 8: Child demonstrates ability to use different strategies for problem solving21. Pulls a cloth with rattle on it to obtain rattle

Table 10.

Final Indicators for 6 Plus to 9 Months.

Domain: Physical Development	Domain: Social and Emotional Development	Domain: Cognitive Development	Domain: Development of Language and Early Literacy Skills
Subdomain: Motor	Subdomain: Social Development	Subdomain: Logical Thinking and Mathematics	Subdomain: Language
Specific aspect: Gross motor	Specific aspect: Relationship with adults	Specific aspect: Comparison and sorting and spatial sense	Specific aspect: Receptive language
Standard 1: Demonstrates ability for movement and coordination 1. Moves from lying down to sitting position 2. Can sit unsupported 3. Supports whole weight on legs when adult is holding both hands 4. Holds railing to move from sitting to standing position	Standard 1: Responds to and interacts with familiar adults 9. Smiles when familiar person smiles or talks10. Babbles and coos to get attention of someone familiar nearbyStandard 2: Identifies unfamiliar people11. Stops activity and stares at a new person entering room	Standard 1: Child develops ability to compare and sortStandard 2: Child develops spatial senseSpecific aspect: NumbersStandard 3: Child demonstrates awareness of numbers	Standard 1: Child demonstrates the ability to understand expressions and body languageSpecific aspect: Expressive languageStandard 2: Child demonstrates the ability to express needs, feelings, experiences for a variety of purposes23. Vocalizes in response to speaker’s attention24. Vocalizes at least two different vowel sounds25. Begins to babble in strings—Ba-ba-ba-ba
Specific aspect: Fine motorStandard 2: Demonstrates ability to hold things/shows visual coordination 5. Grasps and object with thumb and first and second fingers 6. Bangs two hand-held items together	Specific aspect: Relationship with peersStandard 3: Infant develops positive relationships with peers12. Kicks feet in excitement at sight of other child/children13. Uses hands to explore face/hair of peer	Subdomain: Awareness of the EnvironmentSpecific aspect: Scientific inquiryStandard 4: Child develops an inquiring mind
7. Transfers objects from hand to hand 8. Moves his head to search for object which has fallen from the table	Specific aspect: Prosocial behaviorStandard 4: Develops perception of routinesStandard 5: Develops empathy	14. Repeatedly turns and object over15. Explores and inspects the smallest details—for example, bread crumbs fallen on the floor	Specific aspect: Language ComprehensionStandard 3: Child demonstrates the ability to comprehend gestures and sounds
	Standard 6: Develops the ability to corporateSubdomain: Emotional DevelopmentSpecific aspect: Self-conceptStandard 5: Demonstrates the development of a positive self-concept	Specific aspect: Awareness of living and nonliving worldStandard 5: Shows interest in surroundings (people and objects)16. Searches for fallen object17. Plays with mirror image by patting, smiling/laughing, reaching playfully	Subdomain: Early LiteracySpecific aspect: Participating in experiences that include books; discovering and appreciating booksStandard 4: Shows an interest in books26. Holds book using both hands and manipulates the book to make the pages open
	Specific aspect: Self-control	18. Holds bell by handle and purposefully bangs it
	Standard 6: Develops the ability to control impulses and regulate himself		Specific aspect: Prereading
	Specific aspect: Self-expressionStandard 7: Develops the ability to express emotions appropriately	Specific aspect: Awareness of the communityStandard 6: Child demonstrates awareness of community he lives in	Specific aspect: Prewriting
		Subdomain: Approaches to Learning
	Specific aspect: Aesthetic appreciation	Specific aspect: Curiosity, initiative, and persistence
	Standard 8: Shows some ability for aesthetic appreciation	Specific aspect: Creativity and imaginationStandard 7: Child demonstrates creativity and imagination19. Child enjoys noises—Bangs objects together over and over again20. Uses body to make sounds—Splashes water, slaps objects
		Specific aspect: Problem solving
		Standard 7: Child demonstrates ability to use different strategies for problem solving
		21. Pulls cloth on table to obtain object22. Searches for item that has been covered completely (covering bangle with cloth)

Table 11.

Final Indicators for 9 Plus to 12 Months.

Domain: Physical Development	Domain: Social and Emotional Development	Domain: Cognitive development	Domain: Development of Language and Early Literacy Skills
Subdomain: Motor	Subdomain: Social Development	Subdomain: Logical Thinking and Mathematics	Subdomain: Language
Specific aspect: Gross motor	Specific aspect: Relationship with adults	Specific aspect: Comparison and measurement	Specific aspect: Receptive language
Standard 1: Demonstrates ability for movement and coordination 1. Crawls forward on hands and knees 2. Raises self to standing position using a chair/other aid 3. May walk two to three steps without support 4. Can pivot in the sitting position	Standard 1: Responds to and interacts with familiar adults 7. Reaches to the caregiver when hurt or upset 8. Actively clings or cries when familiar person says good bye 9. Tugs on caregiver or makes noises when felt ignored	Standard 1: Child demonstrates the ability to make comparisons and measure to some extentStandard 2: Child develops spatial sense	Standard 1: Child demonstrates the ability to understand language to some extent26. Follows one-step routines when presented with gestures—Clapping hands27. Knows own name and responds by looking when called28. Understands the names of familiar objects (leg, cup chain, etc.) by pointing or touching them when they are uttered.
Specific aspect: Fine motorStandard 2: Demonstrates ability to manipulate things briefly/shows visual coordination	Standard 2: Identifies unfamiliar peopleSpecific aspect: Relationship with peers	Specific aspect: NumbersStandard 3: Child demonstrates awareness of numbers
5. Uses thumb and first finger to pick up things	Standard 3: Infant develops positive relationships with peers	Subdomain: Awareness of the Environment	Specific aspect: Expressive language
6. Puts objects into a container and takes objects out of a container	10. Tries to imitate playing with the toy after watching peer play with it11. Watches intently when older children play (watch children in a group)Specific aspect: Prosocial behaviorStandard 4: develops perception of routines	Specific aspect: Scientific inquiryStandard 4: Child develops an inquiring mind15. Repeatedly turns an object over16. Explores and inspects the smallest details—for example, bread crumbs fallen on the floor, beads—Also given in previous age group	Standard 2: Child demonstrates the ability to express needs, feelings, experiences for a variety of purposes29. Vocalizes to get attention30. Produces at least two different distinct consonant sounds31. May say a word—“bah” for bottle, “ma” for mother32. Uses at least one gesture to make wants known33. Babbles extensively
	Standard 5: Demonstrates awareness of some responsibilities (acts independently)	Specific aspect: Awareness of living and nonliving world
	12. Tries to feed self without help—Can feed himself a biscuit	Standard 5: Shows interest in surroundings (people and objects)	Specific aspect: Language Comprehension
	Standard 6: Develops empathyStandard 7: Develops the ability to corporateSubdomain: Emotional DevelopmentSpecific aspect: Self-conceptStandard 5: Demonstrates the development of a positive self-concept13. Pays attention to own reflection in mirror	17. Regards one or more familiar pictures with interest18. Interested in three blocks and picks up at least two blocks and visually attends to third block19. Begins to imitate familiar motions such as stirring20. Demonstrates what an object can do (understands function—Dolls walk)—Small dollSpecific aspect: Awareness of the communityStandard 6: Child demonstrates an awareness of the community he lives in21. Shows awareness of neighbors	Standard 3: Shows ability to comprehend information34. Understands a simple gesture—Gives the cube in his hand when mother asks for itSubdomain: Early literacySpecific aspect: Participating in experiences that include books; discovering and appreciating books
	14. Responds to name being called		Standard 4: Shows an interest in books
	Specific aspect: Self-control	Subdomain: Approaches to Learning	35. Shows an increase in visual attention to book
	Standard 6: Develops the ability to control impulses and regulate himselfSpecific aspect: Self-expressionStandard 7: Develops the ability to express emotions appropriatelySpecific aspect: Aesthetic appreciationStandard 8: Shows some ability for aesthetic appreciation	Specific aspect: Curiosity, initiative, and persistenceStandard 7: Shows curiosity and persistence22. Pokes fingers into holes, gapsSpecific aspect: Creativity and imaginationStandard 8: Child demonstrates creativity and imagination23. Claps or bounces up and down on his own24. Experiments with sound—Dumps blocks, pots and pans on floor an repeats	36. Turns pages, has some difficulty in separating papers but succeeds37. Laughs or smiles to show recognition of pictures38. Makes appropriate noises when he sees familiar animal/object (booh, booh for dog)39. Points to individual pictures and vocalizesSpecific aspect: PrereadingStandard 7: Child demonstrates interest in interacting with story40. Makes appropriate noises when sees familiar animal or object41. Laughs or smiles to show recognition of pictures
		Specific aspect: Problem solvingStandard 8: Child demonstrates ability to use different strategies for problem solving	42. Points to individual pictures and vocalizes while pointing
		25. Begins to put knowledge of inside to use—Stack two to three cups	Specific aspect: Prewriting

Next, the indicators were pretested. Following pretesting, 26 indicators had to be removed due to issues in measurability. Table 12 gives the indicators removed following pretesting.

Table 12.

List of Indicators Removed Following Pretesting.

Age group	Indicator with number
2 to 3 months	6. Moves arm at sight of toy or object
	8. A small object placed in hand is accepted and brought to the mouth
	12. Smiles/coos in response to older children’s attention
	13. Uses crying to signal needs
	15. Uses specific kinds of sounds to signal needs
	19. Waves arms to touch dangling toy overhead
	23. Child freely turns eyes/head in visual exploration of surroundings
3 plus to 6 months	3. Rolls both ways (front to back, back to front)
	4. Can follow a circular motion of an object (upper and lower quadrants as well)
	5. Rotates wrist from palm up to palm down when manipulating an object
	15. A toy is held, touched, and tasted
	19. Shows awareness of unfamiliar surroundings
	20. Shows delight in producing sounds—Smacks lips, squeals on purpose
6 plus to 9 months	1. Moves from lying down to sitting position
	8. Moves his head to search for object which has fallen from the table
	18. Holds bell by handle and purposefully bangs it
	20. Uses body to make sounds—Splashes water, slaps objects
9 plus to 12 months	4. Can pivot in the sitting position
	6. Puts objects into a container and takes objects out of a container
	9. Tugs on caregiver or makes noises when felt ignored
	10. Tries to imitate playing with the toy after watching peer play with it
	17. Regards one or more familiar pictures with interest
	21. Shows awareness of neighbors
	22. Pokes fingers into holes, gaps
	23. Claps or bounces up and down on his own
	24. Experiments with sound—Dumps blocks, pots, and pans on floor and repeats

Discussion

Due to lack of trained personnel and funds, developing countries are not in a position to hold a regular development screening program. Recognizing this fact, several countries have developed ECDS. The ECDS developed in this study was used as a pilot to develop national standards for child development in Sri Lanka. The first objective of the study was to define a set of tentative indicators to reflect the development in the four domains of development. This took the form of a desk review that generated a tentative list of indicators. The indicators were placed in the development framework described in the methodology. The main issue faced by the researchers was that most literature on child development gives indicators only under the four main domains. Fitting these indicators into the framework was a complicated task. The dearth of measurable indicators in the social and cognitive domains was another issue.

During content validation, the domain in which the most number of indicators was removed was the socio-emotional domain. Twenty-four were removed as they were not observable, and three were removed as they were too advanced for the given age groups in which the indicator would be tested. The reason for this is that social and emotional skills depict an unquantifiable aspect of a person and therefore are more qualitative than quantitative. Development scales like the Bayley Scales of Infant and Toddler Development therefore do not include socio-emotional skills in their scoring component (Bayley, 2005). Indicators for social development skills taken from Western literature tend to cause issues when used in a non-Western setup. In a preliminary survey done for the Malawi Developmental Assessment Tool, it was found that a significant amount of social indicators taken from Western literature had to be discarded as they did not qualify following a logistic regression analysis to obtain population norms (Gladstone et al., 2010).

The Cognitive domain had altogether 14 indicators removed. Eight of these indicators were initially placed under the two standards: (a) comparison and sorting and (b) spatial awareness which were in the subdomain Logical Thinking and Mathematics in the Cognitive domain. The issue arose as to whether these standards were applicable in infancy. Although it is said that mathematical skills operate even in early infancy, there is a problem in including it in an instrument for two reasons. First, it cannot be accurately said that functions like comparison and sorting operate in very early life. Although research has found that even newborns have rudimentary mathematical knowledge (Cook & Cook, 2009), there is not enough evidence to include these skills in a document such as this.

In the Language domain, four indicators were removed as they overlapped with other indicators in measuring the standard.

In the Motor domain, only one indicator was removed as it was not objectively measurable. This domain shows indicators that are less complicated and have fewer aspects than other domains. This could be the reason that indicators belonging to this domain form the bulk in assessment systems of child development in the first half of the 20th century (Gessel & Amatruda, 1947). Improvements in psychometrics in the latter half of the century have made it possible to measure less straightforward aspects in development like socio-emotional components.

Conclusion

The development indicators in the framework could be used as a tool to screen children for development delays after undergoing a reference-based validation. The second part of the study (to be included in a separate article) describes the assessment of psychometric properties of the tool along with reference-based validation. The tool utilizes simple equipment and does not need highly specialized training. This allows it to be used in a low-income setting.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research and/or authorship of this article.

Author Biographies

Buddhi U. W.P. Lokuketagoda, MBBS, MSc and MD in Community Medicine. Dr. Lokuketagoda is a public health specialist working at the Ministry of Health, Sri Lanka. One of her interests is child development and she has experience working for the National Programme for Child Development and Children with Special Needs at the Ministry of Health, Sri Lanka.

Dr. Neil Thalagala, MBBS, MSc and MD in Community Medicine. Dr. Thalagala is the National Programme Officer for Child Development and Children with Special Needs in the Ministry of Health Sri Lanka. He has wide experience in child development assessment and development of assessment tools in the international arena.

Dr. Pushpa Fonseka, MBBS, MSc and MD in Community Medicine . Dr. Fonseka is a public health specialist and was one time Professor at the Department of Community Medicine, Faculty of Medicine, University of Sri Jayawardenepura, Sri Lanka.

Dr Thach Tran, BA(Hons), MSc, MIRB, PhD. Dr Tran has more than 10 years’ experience as a public health research officer in Vietnam, working for the Research and Training Centre for Community Development (RTCCD, 1998-2009). He was awarded a 2014 Bridging Postdoctoral Fellowship by The Faculty of Medicine, Nursing & Health Sciences at Monash University, Melbourne.

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