Validity of the Test of Infant Motor Performance for prediction of 6-, 9- and 12-month scores on the Alberta Infant Motor Scale

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1 Validity of the Test of Infant Motor Performance for prediction of 6-, 9- and 12-month scores on the Alberta Infant Motor Scale Suzann K Campbell* PT PhD; Thubi H A Kolobe PT PhD, University of Illinois at Chicago; Benjamin D Wright PhD; John Michael Linacre PhD, University of Chicago, Chicago, IL, USA. *Correspondence to first author at Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, 1919 W Taylor St, M/C 898, Chicago, IL , USA. The Test of Infant Motor Performance (TIMP) is a test of functional movement in infants from 32 weeks postconceptional age to 4 months postterm. The purpose of this study was to assess in 96 infants (44 females, 52 males) with varying risk, the relation between measures on the TIMP at 7, 30, 60, and 90 days after term age and percentile ranks (PR) on the Alberta Infant Motor Scale (AIMS). Correlation between scores on the TIMP and the AIMS was highest for TIMP tests at 90 days and AIMS testing at 6 months (r=0.67, p=0.0001), but all comparisons were statistically significant except those between the TIMP at 7 days and AIMS PR at 9 months. In a multiple regression analysis combining a perinatal risk score and 7-day TIMP measures to predict 12-month AIMS PR, risk, but not TIMP, predicted outcome (21% of variance explained). At older ages TIMP measures made increasing contributions to prediction of 12-month AIMS PR (30% of variance explained by 90-day TIMP). The best TIMP score to maximize specificity and correctly identify 84% of the infants above versus below the 10th PR at 6 months was a cut-off point of 1 SD below the mean. The same cut-off point correctly identified 88% of the infants at 12 months. A cut-off of 0.5 SD, however, maximized sensitivity at 92%. A negative test result, i.e. score above 0.5 SD at 3 months, carried only a 2% probability of a poor 12- month outcome. We conclude that TIMP scores significantly predict AIMS PR 6 to 12 months later, but the TIMP at 3 months of age has the greatest degree of validity for predicting motor performance on the AIMS at 12 months and can be used clinically to identify infants likely to benefit from intervention. Increasing numbers of infants with very low birthweight (VLBW) are surviving as a result of advanced technology and care, but developmental morbidity associated with this trend persists (Fanaroff et al. 1995). Especially likely to have poor motor outcomes that do not show recovery after infancy are extremely-low-birthweight infants (McCormick et al. 1993), infants with chronic lung disease (Skidmore et al. 1990, Vohr et al. 1991, Singer et al. 1997, Majnemer et al. 2000), and infants with CNS insults (Papile et al. 1983, Sinha et al. 1990, Vohr et al. 1991, Paneth 1993, Pinto-Martin et al. 2000). Although efforts to identify accurately infants with developmental problems are prominent in the literature (Korner et al. 1994, Piper and Darrah 1994, Wildin et al. 1995, Anderson et al. 1996, Molteno et al. 1999), improving the accuracy of identification of infants who are likely to experience subsequent developmental delays continues to be a challenge to clinicians. Because neurodevelopmental abnormalities observed in preterm infants during the first year of life may be transient in nature (Drillien 1972, Coolman et al. 1986, Piper et al, 1988, Wildin et al. 1995), it is important that efforts to predict outcome based on early detection entail repeated assessments at multiple points during the first year of the infant s life. Such studies can be helpful in informing clinicians about how to use the results of single tests as well as identifying the best ages for identification of problems that are likely to persist. The Test of Infant Motor Performance (TIMP) is a 25- to 35- minute functional motor scale for newborn infants and infants under 4 months of age (Campbell et al. 1995). The purpose of this longitudinal study was to examine the predictive relation between infants motor performance on the TIMP at 7, 30, 60, and 90 days postterm and the infants percentile rank (PR) on the Alberta Infant Motor Scale (AIMS; Piper and Darrah 1994) at 6, 9, and 12 months of age (all ages corrected for preterm birth when necessary). The AIMS is used as the criterion measure of delayed motor performance at 6, 9, and 12 months of age because of its excellent normative data and previously demonstrated predictive validity at 4 and 8 months of age for identifying infants who will have poor neuromotor outcome at 18 months of age (Darrah et al. 1998). The TIMP has two types of items designed to assess postural and selective control of movement. Twenty-eight dichotomous Observed Items are used to examine spontaneously emitted movements, such as head centering and individual finger, ankle, and wrist movements. Thirty-one Elicited Items are scored on 5-, 6-, or 7-point ordinal scales. These items test the infant s movement responses, especially head control, to placement in various spatial orientations and to interesting sights and sounds (Campbell et al. 1995). The Appendix contains a list of the TIMP items and a sample of the type of clinical report that can be derived from information obtained by testing. The TIMP can be used with infants from 32 weeks postconceptional age through to 4 months corrected age (or 4 months chronologic age in infants born at term). The TIMP is sensitive to age-related changes in motor performance (r=0.83), and children with many medical complications have significantly lower scores than healthier children (Campbell et al. 1995). Many of the item administration procedures used to elicit movements in the TIMP are similar to demands for movement placed on infants during naturalistic interactions such as dressing, bathing, and play (Murney and Campbell 1998). A pilot version of the TIMP was sensitive to Developmental Medicine & Child Neurology 2002, 44:

2 the effects of physical therapy provided to infants of 34 weeks postconceptional age in a controlled clinical trial in the special care nursery setting (Girolami and Campbell 1994). Based on the research described, the TIMP is believed to be a useful clinical assessment of developmental change in motor behaviors that have functional relevance in daily life as well as change produced by physical therapy. To conform to accepted standards, a test should be assessed for various types of validity when scores are used for the intended purpose of the test (Task Force on Standards for Measurement in Physical Therapy 1991). Assessment of the concurrent validity of the TIMP with the AIMS at 3 months showed that a cut-off point of 0.5 SD below the mean on the TIMP identified 80% of the same infants as the AIMS cut-off score of the 10th PR at 3 months (Campbell and Kolobe 2000). Another commonly assessed type of validity for tests intended for use in screening or diagnosis is predictive validity (Dubowitz et al. 1984, Morgan and Aldag 1996, Darrah et al. 1998), the subject of the research reported here. Method PARTICIPANTS Participants in this study were recruited as a sample of convenience from the special care nurseries of three hospitals and from the community within the Chicago metropolitan area. Participant recruitment methods were approved by the Institutional Review Board for the protection of the rights of human participants at the University of Illinois at Chicago and at each field testing site. The sample of 96 infants was specifically selected in order to provide a range of risk for poor motor outcome. The five risk groups were as follows: Term (T): infants born following a term gestation with no significant medical problems were deemed to be at low risk for motor developmental delay (n=19). Preterm (PT): infants born preterm but with no significant medical problems were considered medium risk (n=20). Low birthweight (LBW): infants born weighing less than 1500 grams or before 32 weeks gestational age (GA) but without chronic lung disease or brain insults were considered to be of high risk of developing motor problems (n=11). Bronchopulmonary dysplasia (BPD): infants with chronic lung disease but no CNS insult other than Grade-I or -II intraventricular hemorrhage (IVH) were also considered to be at high risk (n=27). CNS insult: infants with a CNS insult documented medically or with brain imaging technology were considered very high risk for poor motor performance (n=19). Brain insults in this group were distributed as follows: nine with Grade-III or Grade IV IVH, one with Grade-III IVH and meningitis, five with periventricular leukomalacia, two with hypoxic ischemic encephalopathy, and two with asphyxia as defined by the pediatric and obstetric medical associations (American Academy of Pediatrics, American Academy of Obstetrics and Gynecology 1992). Infants with any type of paralysis, such as brachial plexus injury, were excluded from the study. Within each group, a systematic attempt was made during recruitment to have approximately equal numbers of participants who were non- Latino/a White, African or African American, and Latino/a. Fifty-four percent of the sample was male. Table I shows the distribution of birthweight, GA at birth, medical complications score based on the Problem-Oriented Perinatal Risk Assessment System (POPRAS) derived from medical record review (Davidson and Hobel 1978, Molfese and Thompson 1985, Ross et al. 1986), sex, and race/ethnicity for the infants by group assignment. RESEARCH METHODS Having obtained the consent of a parent to test an eligible participant and medical clearance from the infant s physician, TIMP testing was scheduled every week until 4 months corrected age. The number of weekly tests each infant received ranged from 7 to 23, but 88 (92%) of the 96 infants had a minimum of 11 tests and 70 (73%) had at least 15 tests. Test numbers varied because of (1) GA at birth, age, and health status of Table I: Characteristics of infants by group assignment (n=96) Term (n=19) Preterm (n=20) VLBW (n=11) BPD (n=27) CNS insult (n=19) Birthweight, mean (g) a 1658 SD Range GA at Birth, mean (wks) SD Range Number at term POPRAS, mean SD Range % Male Ethnicity % White % Black % Latino/a a Birthweight is missing for one infant in the group. GA, gestational age; POPRAS, Problem-Oriented Perinatal Risk Assessment System. 264 Developmental Medicine & Child Neurology 2002, 44:

3 the infant at the time of recruitment, (2) subsequent illnesses, or (3) family scheduling conflicts. For the purposes of this study, performance on tests performed closest in age to 7, 30, 60, and 90 days of age (postterm or 40 weeks postconceptional age) were used in the analyses. At initial TIMP testing, infants were off mechanical ventilation but could be receiving oxygen by nasal canula. Infants were tested in their current environments (isolette/incubator with vital signs monitors in place, open crib, home, or during an outpatient clinic visit) about 1 hour before expected feeding time for preterm infants or about mid-way between feedings for older infants. Testers were not told the age or medical history of the infant before testing (unless information was needed to guarantee safe handling of an infant during assessment). Eleven testers (physical therapists or occupational therapists) participated in this study. Scoring consistency for ratings from 14 videotapes was evaluated with the Facets computer program for Rasch psychometric analysis (Linacre 1988); raters needed to have fewer than 5% misfitting ratings, i.e. unexpected ratings given the infant s level of ability on an item and the item difficulty, in order to qualify for being a tester in this study. Following scoring training, testers performed three tests on infants of different ages while observed for administration reliability by one of the test developers. AIMS testing was performed at 3, 6, 9, and 12 months of age (corrected for prematurity; 3-month AIMS data were previously reported in Campbell and Kolobe 2000). The number of AIMS tests each infant received ranged from 1 to 4; 70 (73%) of the 96 infants completed all four AIMS tests. Test numbers varied because of (1) health status on the test date, (2) family scheduling conflicts, or (3) study attrition either because the family moved out of the area or because of inability to locate the family on the required test date. Testers were unaware of previous TIMP or AIMS scores when performing assessments. Each tester had been trained to achieve reliability on the AIMS in a 1-day workshop presented by one of the test developers. This was followed by evaluation of ratings from one live and one videotaped AIMS performance using the same Rasch methodology and criteria as used for training on the TIMP. Risk for developmental morbidity was quantified using the POPRAS (Davidson and Hobel 1978, Molfese and Thompson 1985, Ross et al. 1986) based on complications extracted from the medical record. In the POPRAS, identified medical conditions, such as low Apgar scores, preterm birth, intracranial bleeds, or chronic lung disease, were given a score of 10 points, while factors with less risk for mortality or morbidity received a score of 5. Points were totaled to obtain a perinatal risk score (see Table I). Based on our experience with the POPRAS, scores over 90 represent exceptionally high risk for developmental morbidity (Campbell et al. 1995). DATA ANALYSIS All scores from TIMP and AIMS tests were age-corrected for prematurity. Raw data from 1719 TIMP tests were subjected to psychometric analysis using the Bigsteps computer program (version 2.65, MESA Press Chicago, IL, USA) in order to transform the raw ordinal scores into interval-level logit measures with the mean set to 50 and one logit equal to 10 points (Wright and Masters 1982, Wright and Linacre 1996). The one-parameter item response theory of the Rasch psychometric model proposes that the probability of passing an item is based only on the ability of the participant and the difficulty of the item, and that analysis yields both populationindependent estimates of item parameters and individual ability estimates for the latent trait being measured, in this case functional motor performance (McHorney 2000). The average error of the Rasch measures was Internal consistency measures for persons resulted in a reliability of 0.96, person separation index of 4.91 (a measure indicating that the test discriminates approximately five distinctly different levels of infant ability), and item separation index of (a measure indicating that items reflect about 23 levels of difficulty). The participants and the items fit the Rasch psychometric model well. Rasch measures on the TIMP obtained from the tests performed closest in age to 7, 30, 60, and 90 days of age (postterm or 40 weeks postconceptional age) were used in the analyses. TIMP measures were correlated with PR on the AIMS at 6, 9, and 12 months of age using Pearson s product moment correlation coefficient. Multiple regression equations were used to assess the contribution to explaining variation in AIMS PR at 12 months of TIMP scores at 7, 30, 60, or 90 days and the POPRAS score obtained from medical record review in the perinatal period (Davidson and Hobel 1978, Ross et al. 1986). Risk scores were included in the equation because previous research has indicated a significant negative relation between a high degree of risk and motor performance (Molfese and Thomson 1985, Campbell et al. 1995). The age at which the best correlation occurred between TIMP scores and 6- or 12-month AIMS performance was selected for analysis of sensitivity and specificity for predicting AIMS performance below the 10th PR at 6 months and below the 5th PR at 12 months. Different AIMS cut-off points were chosen for the two prediction time points because in previous research the highest validity for predicting 18- month neuromotor outcome from AIMS tests at 4 months of age was the 10th PR, however, better prediction occurred at 8 months when using the 5th PR (Darrah et al. 1998). Because previous research on the concurrent validity of the TIMP and the AIMS at 3 months of age (Campbell and Kolobe 2000) indicated that a cut-off point on the TIMP of 0.5 SD below the mean created the best match with AIMS scores divided at the 10th PR, this cut-off on the TIMP was first compared with the 10th PR cut-off on the AIMS at 6 months and the 5th PR on the AIMS at 12 months. Additional analyses assessed predictability to 12-month AIMS PR below the 5th centile of TIMP performance at 7, 30, and 60 days. Results are presented as diagnostic validity analyses in terms of sensitivity (prediction of abnormal performance at 6 or 12 months), specificity (prediction of normal performance at 6 or 12 months), and positive and negative predictive validity. To demonstrate clinical utility, results are also interpreted as the difference between the pretest probability of poor outcome at 12 months and the posttest probability when TIMP score is known. Stability of individual infants performance across repeated AIMS testing was summarized in tabular form for all infants with one or more AIMS scores below the established cut-off score as (1) no change from one assessment to another, i.e. below the cut-off point on both, (2) improvement in performance from one assessment to another, i.e. below the cut-off point on the first test but above it on the second, or Predictive Validity of Test of Infant Motor Performance Suzann K Campbell et al. 265

4 (3) deterioration from one test to another. Results Rasch measures on the TIMP for the four ages used in this study ranged from 3 to 83 with a mean at 7 days of 48 (SD 4.4, n=79), at 30 days of 52 (SD 4.9, n=87), at 60 days of 58 (SD 6.2, n=90), and at 90 days of 63 (SD 8.6, n=94). At 6 and 9 months, PR on the AIMS ranged from 1 to 99 with a median of 29 at 6 months (n=87) and 42 at 9 months (n=81). At 12 months the range was 1 to 90 with a median of 49 (n=83). Thus, infant outcomes on the AIMS spanned the whole range of possible performance levels but, on average, the group improved with age. AIMS PERFORMANCE BELOW THE CUT-OFF CRITERIA At 6 months, 24 infants (28%) fell below the 10th PR on the AIMS (of whom, 19 fell below the 5th PR). At 9 months there were 14 (17%) below the 5th PR and at 12 months there were 12 (16%). Table II shows the risk groups to which infants scoring below the AIMS cut-off point at each age belonged. By 12 months, those scoring below the 5th PR included only infants from the CNS insult group (n=8) and the BPD group (n=4). To summarize the data on stability of AIMS performance in individual infants over time, Table III details how infants who fell below the cut-off score at 6 or 9 months changed at successive test sessions. The table shows how Table II: Infants below AIMS cut off a at each age by risk group (total n=96) Risk group 6-month AIMS 9-month AIMS 12-month AIMS CNS insult BPD LBW 1 Low risk PT 1 1 Term 2 2 a Risk for poor motor developmental performance is defined as a score on AIMS that is below the 10th centile at 6 months or below the 5th centile at 9 or 12 months. BPD, bronchopulmonary dysplasia; LBW, low birthweight; PT, preterm. Table III: Examples of frequency of change in AIMS risk classification a from 6 to 12 months (total n=96) Result Infants at Infants at 6 and 12 mo. 9 and 12 mo. n (%) n (%) Total below cut-off criterion at 1st age 24 (28) 14 (17) Missing at 2nd age 2 1 Below cut off on both tests 12 (50) 9 (64) Below cut off on 1st but not 2nd test 10 (42) 4 (29) Total below cut off at 12 months Above cut-off on 1st but below on 2nd 0 1 (8) b a Risk for poor motor developmental performance is defined as a score on the AIMS that is below the 10th percentile at 6 months or below the 5th percentile at 9 or 12 months. b Two missing at 9 or 12 months. many infants had the same status on successive tests (i.e. below the cut-off score on both), and how many improved from one test to the next (i.e. below the cut-off score at the first age, but above at the second age). Of the 24 infants who scored below the cut-off point at 6 months, only half did so at 12 months, but infants were much more likely to remain below the cut-off score at 12 months if they had scored below the 5th centile at 9 months (64%). Infants who did well at 6 or 9 months were unlikely to perform below the 5th PR at 12 months as no infant who did well at 6 months and only one infant who did well at 9 months (8th PR) fell below the 5th PR at 12 months. RELATION BETWEEN TIMP AND AIMS PERFORMANCE Table IV presents a matrix of correlations among TIMP measures at 7, 30, 60, and 90 days postterm with AIMS PR at 6, 9, and 12 months. Of 12 correlation coefficients comparing TIMP and AIMS scores, 11 are significant at p<0.01. Only 7- day TIMP scores do not significantly predict 9-month AIMS PR (r=0.20, p=0.12, n=65). As would be expected, correlations are higher when tests are performed closest together in time, i.e. correlations with TIMP scores at any age systematically decrease with increasing age at AIMS testing with one exception. At 7 days, the significant correlation of 0.37 with AIMS PR at 6 months is followed by a non-significant correlation (r=0.20) at 9 months but then again a significant correlation at 12 months of r=0.32. The best correlation between TIMP scores and AIMS outcome is for 90-day TIMP measures when the correlation with 6-month AIMS PR is 0.67 (p=0.0001, n=86). Again, the correlation between 90-day TIMP scores and AIMS performance is less, although statistically significant, at later ages: at 9 months r=0.56 (p=0.0001, n=80) and at 12 months r=0.55 (p=0.001, n=82). Table V summarizes results of the four multiple regression equations exploring the individual and joint contributions to explaining variance in 12-month AIMS PR of the perinatal POPRAS score and TIMP measures at 7, 30, 60, and 90 days, Table IV: Pearson s correlation between TIMP and AIMS test results at various ages (total n=96) TIMP measures AIMS centile AIMS centile AIMS centile rank at 6 mo rank at 9 mo rank at 12 mo TIMP at 7 days r p a a n TIMP at 30 days r p a a a n TIMP at 60 days r p a a a n TIMP at 90 days r p a a a n a Statistically significant at p< Developmental Medicine & Child Neurology 2002, 44:

5 respectively. At 7 days TIMP scores did not significantly predict 12-month outcome, but the perinatal POPRAS risk score was a statistically significant predictor (p=0.001). In each analysis, the amount of variance explained was modest but statistically significant. Together, the TIMP at 7 days and the POPRAS score explained 21% of the variance in 12-month AIMS PR (r=0.49, p=0.0001). With increasing age at TIMP examination, test results became better predictors of 12- month AIMS score, while POPRAS perinatal scores became less significant. When TIMP scores at 30 days were entered in the equation with POPRAS scores, both contributed significantly to explaining 16% of the variance in AIMS scores (p=0.032 and 0.008, respectively; r=0.43, p=0.001). When TIMP scores at 60 or 90 days were used, the POPRAS was no longer a significant predictor of 12-month AIMS PR. TIMP scores at 60 days contributed to explaining 18% of the AIMS variance; at 90 days, the variance explained increased to 30% (r=0.56, p=0.0001). Thus, prediction of 12-month AIMS performance was modest but improved with age. DIAGNOSTIC VALIDITY OF THE TIMP Table VI presents the diagnostic efficiency data comparing AIMS performance at 6 months that falls below the 10th centile against a cut-off score on the TIMP of 0.5 SD below the mean at 90 days. The resulting sensitivity of the TIMP for predicting 6-month AIMS PR is 0.63, specificity 0.77, positive predictive validity 0.52, and negative predictive validity Overall, 73% of the infants were correctly classified as high versus low scoring at 6 months. Comparable data for prediction to 12-month AIMS performance below the 5th centile using 90-day TIMP measures is shown in Table VII. Sensitivity is 0.92, specificity 0.76, positive predictive validity 0.39, and negative predictive validity Overall, 78% of the children were correctly classified as high versus low scoring at 12 months. As the pretest probability (Elmore and Boyko 2000) of a poor outcome at 12 months is 0.15 (12 of 82) and the posttest probability of a poor outcome is 0.39 (11 of 28), given a TIMP test score below the criterion Table V: Results of multiple regression equations for prediction of 12-month AIMS scores from risk score and TIMP tests at 7, 30, 60, and 90 days Equation Standardized regression t p coefficient (Beta) r=0.49, p= a, Adj R 2 =0.21 TIMP 7 da Perinatal POPRAS a r=0.43, p=0.001 a, Adj R 2 =0.16 TIMP 30 da a Perinatal POPRAS a r=0.45, p= a, Adj R 2 =0.18 TIMP 60 da a Perinatal POPRAS r=0.56, p= a, Adj R 2 =0.30 Perinatal TIMP 90 da a POPRAS a Statistically significant at p<0.05. Adj, adjusted; POPRAS, Problem- Oriented Perinatal Risk Assessment System. cut-off score, knowledge of the infant s TIMP performance at 3 months modestly increases the clinician s ability to identify infants who are likely to have poor motor performance at 12 months (while missing only one child with poor outcome). On the other hand, the posttest probability of poor outcome, given a TIMP test score at 3 months above the cut-off of 0.5 SD, is only 0.02, therefore greatly increasing one s confidence that a child doing well on the TIMP at 3 months will have a good outcome at 12 months. Sensitivity, specificity, and positive and negative predictive values were also calculated for prediction of 12-month AIMS performance from 7-, 30-, and 60-day TIMP measures below 0.5 SD for comparison with 90-day prediction accuracy. Table VIII summarizes the results for all four ages. Sensitivity of the TIMP gradually improves from 0.45 at 7 days to 0.92 at 90 days. Specificity changes little across test ages, ranging between 0.68 and Negative predictive values are consistently high, ranging between 0.88 and 0.98, while positive predictive values range between 0.25 and 0.39, indicating that, depending on age of TIMP testing, 60 to 75% of low-scoring children will eventually do well at 12 months as would be expected in a group of children with early medical complications from which recovery to varying degrees is possible. To explore the best cut-off score on the TIMP at 90 days for predicting AIMS performance above and below the 10th centile at 6 months and the 5th centile at 12 months, similar sensitivity and specificity analyses were conducted for cut-off points on the TIMP of 0.25, 0.75, and 1 SD. Table IX summarizes Table VI: Comparison of TIMP and AIMS in classifying development of 86 infants at 6 months: TIMP cut-off point 0.5 SD TIMP score AIMS centile AIMS centile Total <10 10 Standard score < Standard score Total Sensitivity of TIMP: 15/24=0.63. Specificity of TIMP: 48/62=0.77. Positive predictive value: 15/29=0.52. Negative predictive value: 48/57=0.84. Overall correct classification: 73%. Pretest probability of poor outcome: Posttest probability, score < 0.5: Posttest probability, score 0.5: Table VII: Comparison of TIMP and AIMS in classifying development of 82 infants at 12 months: TIMP cut-off point 0.5 SD TIMP score AIMS centile AIMS centile Total <5 5 Standard score < Standard score Total Sensitivity of TIMP: 11/12=0.92.Specificity of TIMP: 53/70=0.76. Positive predictive value: 11/28=0.39. Negative predictive value: 53/54=0.98. Overall correct classification:78%. Pretest probability of poor outcome: Posttest probability, score < 0.5: Posttest probability, score 0.5: Predictive Validity of Test of Infant Motor Performance Suzann K Campbell et al. 267

6 the results of these analyses for predicting 6-month AIMS performance, and Table X shows the same analysis for 12 months. In both cases, a cut-off level of 1 SD produces the most correct classifications overall, 84% at 6 months and 88% at 12 months. For prediction to 6-month AIMS performance, the 0.25 SD cut-off point on the TIMP at 90 days maximizes sensitivity at 71% while using the cut-off score of 1.0 maximizes specificity at 97%. Results are similar at 12 months. Compared with using the cut-off core of 0.5 SD on the TIMP at 90 days for prediction to 12-month AIMS PR, the 1 SD cutoff level maximizes specificity (0.91 versus 0.76), again at the expense of sensitivity (0.67 versus 0.92). Thus, a single cutoff cannot be used to optimize both sensitivity and specificity; if the clinician prefers to focus on high sensitivity in order to maximize early identification of all children who will perform poorly at 12 months, there will be a relatively high number of false positives (i.e. low scoring children at 90 days who will do well at 12 months). Discussion Longitudinal weekly scores on the TIMP discriminate between infants with few medical complications and those with highrisk conditions (Campbell and Hedeker 2001), but this study is the first to report longitudinal data on the predictive utility of TIMP scores at a variety of ages during the first year of life. The data are particularly important in documenting the need for repeated assessment (Dworkin 1989), accurate interpretation of the results obtained (Fletcher et al. 1996), and the incidence of recovery of function observed in infants during the early months of life (Aylward and Verhulst 2000). Results of this study provide support for the validity of the TIMP by demonstrating significant ability to predict AIMS outcome at 12 months, especially from TIMP testing at 3 months. COMPARISON OF TIMP DIAGNOSTIC VALIDITY WITH THAT OF OTHER MOTOR TESTS The ability of the TIMP to predict motor performance at 6 and 12 months of age is comparable to 12- and 18-month outcomes for motor tests which are currently used for early identification of high-risk infants. Sensitivity, specificity, and negative predictive values for the 3-month TIMP on infants with varying degrees of risk (92%, 76%, and 98%, respectively, at 12 months), compare favorably with the 4-month AIMS (77%, 81%, and 96% at 18 months; Darrah et al. 1998), Movement Assessment of Infants (MAI; 72%, 93%, and 96% at 18 months; Swanson et al. 1992), Peabody Developmental Gross Motor Scale (PDGMS; 81%, 71%, and 96% at 18 months; Darrah et al. 1998), and the 18- week Infant Neuromotor Assessment (INA; 90%, 98%, and 99% at 12 months; Magasiner et al. 1997). Indeed, the 3-month sensitivity of the TIMP exceeds that of any of these tests at a similar age. Sensitivity of 0.92 demonstrates that virtually no children with poor outcome at 12 months will be missed by predicting outcome from a 3-month TIMP assessment. The positive predictive value of the 3-month TIMP measures Table VIII: Summary of diagnostic validity data for prediction of AIMS scores below 5th centile at 12 months from TIMP scores at 7, 30, 60, and 90 days (total n=82) Age at TIMP testing (d) Sensitivity Specificity Positive predictive value Negative predictive value Table IX: Summary of diagnostic efficiency of TIMP at 90 days in predicting performance on AIMS below 10th centile at 6 months (total n=86) TIMP cut-off score Sensitivity Specificity Positive predictive value Negative predictive value Overall correct classification % Table X: Summary of diagnostic efficiency of TIMP at 90 days in predicting performance on AIMS below the 5th centile at 12 months (total n=82) TIMP cut-off score Sensitivity Specificity Positive predictive value Negative predictive value Overall correct classification % Developmental Medicine & Child Neurology 2002, 44:

7 for 6-month (52%) and 12-month (39%) AIMS outcome, like the 4-month MAI (58%), AIMS (39%), and PDGMS (31%) for prediction to 18 months, and the 18-week INA (56%) for prediction to 12 months, is low. That is, our findings indicate that 52% of infants who were classified as delayed on the TIMP at 3 months were classified as such on the AIMS at 6 months and 39% were classified as delayed at 12 months. Although the overall predictive values of infant motor tests tend to be low when the criterion test is administered at less than 24 months of age (Darrah et al. 1998), there may be an additional explanation for the relatively high number of false positives observed on the TIMP in relation to the AIMS outcome as observed in this study, namely, the diagnostic efficiency of the outcome measure used (AIMS). CONSISTENCY OF PERFORMANCE ON THE AIMS AND THE NEED FOR REPEATED ASSESSMENT The accuracy of prediction is only as good as the criterion measure used because the limitations of the criterion measure may obscure the predictive value of the target measure. Although the AIMS was selected as a reference standard in this study because its construct is similar to that of the TIMP, our findings revealed an inconsistent pattern of early performance on the AIMS by infants who were classified later as showing delays. An earlier classification of delay on the AIMS was not necessarily maintained over the first year. Only 54% and 64% of the children who scored below the 10th centile at 6 months or the 5th centile cut-off point at 9 months, respectively, also scored below the cut-off level at 12 months. Because the sensitivity of a criterion measure tends to affect the positive predictive value of the target measure, it is possible that some of the infants in our study may have been correctly classified by the TIMP, but inappropriately classified on the AIMS at one or more ages. This possibility requires future study by comparing the TIMP s predictive validity to other assessments of neuromotor outcome and at other ages. Our findings highlight the importance of repeated developmental assessments at various ages when studying cut-off scores for predictive purposes, particularly during the first year of life when different cut-off points at different ages may be necessary. For example, in determining the predictive validity of the Early Motor Patterns Profile, Morgan and Aldag (1996) observed that using cut-offs of 9 to 10 points at 6 months and 3 to 4 points at 12 months, provided the best prediction to 36 months. Prediction using the TIMP was also not consistent across the age range assessed in this study. If the purpose of testing is to maximize the probability of identifying all children who will perform poorly at later ages, clinicians involved in developmental follow-up programs may find the cut-off score of 0.25 SD most appropriate when using the TIMP at 3 months to predict outcome at 6 months and 0.5 SD to predict outcome at 12 months. A trend towards improved motor performance among infants during the first year of life was noted in this study. The number of infants who were classified as delayed on the AIMS at 6 months decreased by half at 12 months; these infants were reclassified as typical in their motor development. The shift was related to the degree of medical risk for poor motor outcome (see Table II) and these findings may explain the TIMP s high sensitivity but low positive predictive value. It is likely that the TIMP gives a true picture of what is happening, i.e. infants with perinatal medical complications may have poor performance on the TIMP at 3 months but show recovery over the next 6 to 9 months and be non-delayed at 12 months. Similar trends toward recovery in the same time frame were reported by others (Wildin et al. 1995, 1997; Anderson et al. 1996; Morgan and Aldag 1996; Aylward and Verhulst 2000). Certainly the findings reflect the complexity of identifying those infants whose developmental status is not likely to change over time, and highlight the importance of repeated observation and testing. CLINICAL IMPLICATIONS Clinical decisions for assessment of high-risk infants entail not only selection of diagnostic tests, but also identifying the value of test results, i.e. whether or not the infant is likely to experience developmental delays given the results of the test. The findings on diagnostic validity using 0.5 SD as the cut-off point on the TIMP mean that 39% of infants who test poorly on the TIMP at 3 months can be predicted to have motor development below the 5th centile at 12 months. Given that the pretest probability of having poor outcome at 12 months was 15% in this group, a TIMP test score that falls below 0.5 SD increases the probability of a poor outcome to 39%. Such infants should be considered for referral for intervention or periodic assessment. Typical ranges of raw scores for infants from 34 weeks postconceptional age through 13 weeks postterm have been published (Campbell 1999) and can be used to identify those infants who might benefit from early intervention. Using this approach ensures that virtually all infants with poor motor development at 12 months will be identified (92%). From the opposite perspective, 61 percent of infants who score poorly at 3 months will improve (although not necessarily to the average range), having perhaps received more follow-up or intervention services than necessary. A sensitive test is most effective when the results are negative (Fletcher et al. 1996). The TIMP has its greatest use in ruling out problematic motor development. An infant who performs well on the TIMP at 3 months has a 98% chance of performing above the 5th centile in motor development at 12 months. Because such infants comprise 65 to 75% of infants tested in an at-risk population, the TIMP is extremely useful in reassuring parents of those infants who perform well. In comparison to the 15% pretest probability of poor outcome at 12 months, a 3-month TIMP test score better than 0.5 SD reduces to 2% the likelihood of poor motor development at 12 months. Because the TIMP is the only test which has been developed to assess comprehensively functional motor performance in infants between 32 weeks postconceptional age and 14 weeks postterm age, it is the only assessment that can be used in both the special care nursery and in community-based early intervention programs for infants less than 4 months of age. Having demonstrated ecologic validity (Murney and Campbell 1998) with a relationship between TIMP items and caregiver handling, the TIMP can also be used for parent education. Currently under development is an illustrated version of the test, which will visually depict the progression of development for family members. For example, in one TIMP item the infant s legs are lifted in a way similar to that used in diaper changing. When infants pound their feet on the surface after the legs are released, parents can celebrate the appearance of an advanced form of lower Predictive Validity of Test of Infant Motor Performance Suzann K Campbell et al. 269

8 extremity function and can use information such as this to understand and encourage extremity motor development. On the negative side, the high rate of false positive results are of concern when using the TIMP because some infants with early motor delays who are likely to recover without intervention may be over treated, and their parents may experience unnecessary worry about their child s development. With the availability of a high-precision test of functional movement like the TIMP, however, research on these infants can be conducted in order to test the hypothesis that recovery might be hastened by early intervention. In any case, we recommend that clinicians should always consider repeated testing over time. Conclusions Although correlations between TIMP scores in the first 3 months of life and AIMS PR at 6, 9, and 12 months are moderate, the relation is consistently statistically significant for tests performed at 30 days or later. Scores on the TIMP at 3 months of age are moderate predictors of AIMS performance at 6 months of age and TIMP scores 0.5 SD below the mean successfully identify 92% of those who will be delayed in standing and walking at 12 months of age. A high score on the TIMP at 3 months of age can be used to reassure parents that their child is highly likely to continue to do well. Accepted for publication 31st August Acknowledgments Research was conducted at the University of Illinois at Chicago Medical Center, the University of Chicago Hospitals, and Lutheran General Hospital, Park Ridge, IL, with funding (R01 HD 32567) from the National Center for Medical Rehabilitation Research of the National Institute of Child Health and Human Development, USPHS. We are grateful to the physicians at each institution Nagamani Beligere, Jaideep Singh, and David Sheftel for providing access to their patients. The authors would like to thank Dolores Schorr, Pat Byrne-Bowens, Dawn Kuerschner, Carrie Ryan, and Kathy Tolzien for assistance in recruiting participants; Beth Osten, Kathy Kamm, Pai-jun Miao, Vinod Subramonian, and Sriram Balachandran for assistance with data management; Johanna Darrah for AIMS rater reliability training; and Betty Brannen, Mary Carter, Judy Flegel, LouAnn Gouker, Maureen Lenke, Gail Liberg, Mary Murney, Elizabeth Osten, Jennifer Padek, Celina Martin, and Laura Zawacki for testing of infants. Without the participation of infants and their families who believed that our research would help other infants, this work would not have been possible. References American Academy of Pediatrics, American College of Obstetricians and Gynecologists. (1992) Relationship between perinatal factors and neurologic outcome. In: Poland RL, Freeman RK, editors. Guidelines for Perinatal Care. 3rd edn. Elk Grove Village, IL: American Academy of Pediatrics. p 221. Amiel-Tison C, Grenier A. (1986) Neurological Assessment During the First Year of Life. New York, NY: Oxford University Press. Anderson AE, Wildin SR, Woodside M, Swank PR, Smith KE, Denson SE, Miller CL, Butler IJ, Landry SH. (1996) Severity of medical and neurologic complications as determinant of neurodevelopmental outcome at 6 and 12 months in very low birth weight infants. Journal of Child Neurology 11: Aylward GP, Verhulst SJ. (2000) Predictive utility of the Bayley Infant Neurodevelopmental Screener (BINS) risk status classifications: clinical interpretation and application. Developmental Medicine & Child Neurology 42: Brazelton TB. (1973) Neonatal Behavioral Assessment Scale. Philadelphia, PA: JB Lippincott. Campbell SK. (1999) The infant at risk for developmental disability. In: Campbell SK, editor. Decision Making in Pediatric Neurologic Physical Therapy. Philadelphia, PA: Churchill Livingstone. p Campbell SK, Hedecker D. (2001) Validity of the Test of Infant Motor Performance for discriminating among infants with varying risk for poor motor outcome. Pediatrics. 139: Campbell SK, Kolobe THA. (2000) Concurrent validity of the Test of Infant Motor Performance with the Alberta Infant Motor Scale. Pediatric Physical Therapy 12: 1 8. Campbell SK, Kolobe THA, Osten ET, Lenke M, Girolami GL. (1995) Construct validity of the Test of Infant Motor Performance. Physical Therapy 75: Coolman RB, Bennett FC, Sells CJ, Swanson MW, Andrews MS, Robinson NM. (1985) Neuromotor development of graduates of the neonatal intensive care unit: patterns encountered in the first two years of life. Developmental and Behavioral Pediatrics 6: Darrah J, Piper M, Watt M-J. (1998) Assessment of gross motor skills of at-risk infants: predictive validity of the Alberta Infant Motor Scale. Developmental Medicine & Child Neurology 40: Davidson EC, Hobel CJ. (1978) POPRAS: A Guide to Using the Prenatal, Intrapartum, Postpartum Record. Torrence, CA: South Bay Regional Perinatal Project Professional Staff Association. Drillien CM. (1972) Abnormal neurologic signs in the first year of life in low-birthweight infants: possible prognostic significance. Developmental Medicine & Child Neurology 14: Dubowitz LMS, Dubowitz V, Palmer PG, Miller G, Fawer CL, Levene MI. (1984) Correlation of neurologic assessment in the preterm newborn infant with outcome at 1 year. Journal of Pediatrics 105: Dubowitz LMS, Dubowitz V. (1981) Neurological Examination of the Preterm and Full-term Newborn Infant. Philadelphia, PA: JB Lippincott. Dworkin PH. (1989) British and American recommendations for developmental monitoring: the role of surveillance. Pediatrics 84: Elmore JG, Boyko EJ. (2000) Assessing accuracy of diagnostic and screening tests. In: Geyman JP, Deyo RA, Ramsey SD, editors. Evidence-Based Clinical Practice. Concepts and Approaches. Boston, MA: Butterworth Heinemann. p Fanaroff AA, Wright LL, Stevenson DK, Shankaran S, Donovan EF, Ehrenkrans RA, Younes N, Korones SB, Stoll BJ, Tyson JE et al. (1995) Very-low-birth-weight outcomes of the National Institute of Child Health and Human Development Neonatal Research Network, May 1991 through December American Journal of Obstetrics and Gynecology 173: Fletcher RH, Fletcher SW, Wagner EH. (1996) Clinical Epidemiology: the Essentials. Baltimore, MD: Williams & Wilkins. p Girolami G, Campbell SK. (1994) Efficacy of a Neuro-Developmental Treatment program to improve motor control of preterm infants. Pediatric Physical Therapy 6: Hadders-Algra M, Prechtl HFR. (1992) Developmental course of general movements in early infancy. I. Descriptive analysis of change in form. Early Human Development 28: Korner AF, Stevenson DK, Forrest T, Constantinou JC, Dimiceli S, Brown BW. (1994) Preterm medical complications differentially affect neurobehavioral functions results from a new neonatal medical index. Infant Behavior and Development 17: Magasiner V, Molteno C, Lachman P, Thompson C, Buccimazza S, Burger E. (1997) A neuromotor screening test for high risk infants in a hospital or community setting. Pediatric Physical Therapy 9: Majnemer A, Riley P, Shevell M, Birnbaum R, Greenstone H, Coates AL. (2000) Severe bronchopulmonary dysplasia increases risk for later neurological and motor sequelae in preterm survivors. Developmental Medicine & Child Neurology 42: McCormick MC, McCarton C, Tonascia J, Brooks-Gunn J. (1993) Early educational intervention for very low birth weight infants: results from the Infant Health and Development Program. Journal of Pediatrics 123: McHorney CA. (2000) Concepts and measurement of health status and health-related quality of life. In: Albrecht GL, Fitzpatrick R, Scrimshaw SC, editors. 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9 Molfese VJ, Thomson B. (1985) Optimality versus complications: assessing predictive values of perinatal scales. Child Development 56: Molteno CD, Thompson MC, Buccimazza SS, Magasiner V, Hann FM. (1999) Evaluation of the infant at risk for neurodevelopmental disability. South African Medical Journal 89: Morgan AM, Aldag JC. (1996) Early identification of cerebral palsy using a profile of abnormal motor patterns. Pediatrics 98: Murney ME, Campbell SK. (1998) The ecological relevance of the Test of Infant Motor Performance Elicited Scale items. Physical Therapy 78: Paneth N. (1993) The causes of cerebral palsy. Recent evidence. Clinics in Investigative Medicine 16: Papile L, Munsick-Bruno G, Schaefer A. (1983) Relationship of cerebral intraventricular hemorrhage and early childhood neurologic handicaps. Journal of Pediatrics 103: Pinto-Martin JA, Whitaker AH, Feldman JF, Van Rossem R, Paneth N. (2000) Relation of cranial ultrasound abnormalities in lowbirthweight infants to motor or cognitive performance at ages 2, 6, and 9 years. Developmental Medicine & Child Neurology 41: Piper MC, Darrah J. (1994) Motor Assessment of the Developing Infant. Philadelphia, PA: WB Saunders. Piper MC, Mazer B, Silver KM, Ramsay M. (1988) Resolution of neurological symptoms in high-risk infants during the first two years of life. Developmental Medicine & Child Neurology 30: Ross MG, Hobel CJ, Bragonier JR, Bear MB, Bemis RL. (1986) A simplified risk-scoring system for prematurity. American Journal of Perinatology 3: Singer L, Yamashita T, Lilien L, Collin M, Baley J. (1997) A longitudinal study of developmental outcome of infants with bronchopulmonary dysplasia and very low birth weight. Pediatrics 100: Sinha SK, D Souza SW, Rivlin E, Chiswick ML. (1990) Ischaemic brain lesions diagnosed at birth in preterm infants: clinical events and developmental outcome. Archives of Disease in Childhood 65: Skidmore MD, Rivers A, Hack M. (1990) Increased risk of cerebral palsy among very low-birthweight infants with chronic lung disease. Developmental Medicine & Child Neurology 32: Swanson M, Bennett F, Shy K, Whitfield M. (1992) Identification of neurodevelopmental abnormality at four and eight months by the Movement Assessment of Infants. Developmental Medicine & Child Neurology 34: Task Force on Standards for Measurement in Physical Therapy. (1991) Standards for tests and measurements in physical therapy practice. Physical Therapy 71: Vohr BR, Coll CG, Lobato D, Yunis KA, O Dea C, Williams OH. (1991) Neurodevelopmental and medical status of lowbirthweight survivors of bronchopulmonary dysplasia at 10 to 12 years of age. Developmental Medicine & Child Neurology 33: Wildin SR, Anderson AE, Woodside M, Swank PR, Smith KE, Denson SE, Landry SH. (1995) Prediction of 12-month neurodevelopmental outcome from a 6-month neurologic examination in premature infants. Clinical Pediatrics: Wildin SR, Smith KE, Anderson AE, Swank PR, Denson SE, Landry SH. (1997) Prediction of developmental patterns through 40 months from 6- and 12-month neurologic examinations in very low birth weight infants. Developmental and Behavioral Pediatrics 18: Wright BD, Masters GN. (1982) Rating Scale Analysis: Rasch Measurement. Chicago, IL: MESA Press. Wright BD, Linacre JM. (1996) A User s Guide to BIGSTEPS. Chicago, IL: MESA Press. Appendix: Test of Infant Motor Performance (version 3) Observed items of posture and active movement (Spontaneously-emitted actions in supine unless otherwise indicated) 1. Head in midline 2. Head turning right to left 3. Head turning left to right 4. Hands together 5. Right hand to mouth (prone or supine) 6. Left hand to mouth (prone or supine) 7. Mouths right hand 8. Mouths left hand 9. Individual right finger movement (any position) 10. Individual left finger movement (any position) 11. Isolated right wrist movement (any position) 12. Isolated left wrist movement (any position) 13. Fingers objects/surfaces on right (any position) 14. Fingers objects/surfaces on left (any position) 15. Pelvic lifting 16. Bilateral hip and knee flexion 17. Isolated right ankle movements (any position) 18. Isolated left ankle movements (any position) 19. Reciprocal kicking 20. Prone head turning from left to right 21. Prone head turning from right to left 22. Head lift in prone 23. Arm movement away from body with elbows on support 24. Arm movement away from body with elbows off support 25. Fidgety movements a 26. Ballistic movements of the arms or legs (swipes or swats) a 27. Oscillation of arm or leg during movement a 28. Reaches for person or object (supine or sitting) Elicited items (Tested by positioning in space and with visual and auditory stimuli) 1 Head rotation side to side b 2. Head control in supported sitting 3. Trunk control in supported sitting 4. Head control posterior neck muscles c 5. Head control anterior neck muscles c 6. Head control when lowered from sitting 7/8. Inhibition of neonatal neck righting (right and left) 9. Head held in midline without visual stimulation 10. Head held in midline with visual stimulation 11/12. Supine neck rotation (to right and left) 13. Defensive reaction to cloth over eyes head and neck response b 14. Defensive reaction to cloth over face arm movements b 15. Hip and knee flexion in supine 16/17. Rolling elicited from the legs (to right and left) 18/19. Rolling elicited from the arms (to right and left) 20. Pull to sit 21. Lateral straightening of the head and body with arm support d 22. Lateral hip abduction reaction d 23. Head and trunk extension in prone suspension 24. Head lift in prone 25. Crawling movements in prone 26/27. Head turn in prone to sound (to right and left) 28. Arm movement in prone c 29. Standing 30/31. Lateral head righting (to right and left) a Adapted from Hadders-Algra and Prechtl (1992). b Adapted from Brazelton (1973). c Adapted from Dubowitz and Dubowitz (1981). d Adapted from Amiel-Tison and Grenier (1986). Predictive Validity of Test of Infant Motor Performance Suzann K Campbell et al. 271

10 Sample report of TIMP performance Baby (name) was assessed on (date) at the age of (weeks) with the Test of Infant Motor Performance (TIMP), an assessment of the postural and selective control needed for functional movement in infants under 4 months of age. The baby s total raw score on the TIMP was ( ). Although the TIMP has not yet been normed, based on a previous study of more than 150 infants assessed at ages from 34 weeks postconceptional age through 4 months of corrected age, this score is (within the average range/below average/far below average) for infants his/her age. On items related to head control, the infant was able to (insert an example, e.g. lift the head briefly when held upright/right the head when tilted laterally in the upright position/lift the head to 45 degrees in prone for a couple seconds/turn the head from side to side, etc.). On items related to trunk control, the infant was able to (insert an example, e.g. push up to sitting from side-lying/rotate the trunk to turn to side-lying when an arm or leg was drawn across the body, etc.). Responses to visual or auditory stimuli included (insert an example, e.g. turning the head to find a sound in prone/turning the head from side to side to follow a moving ball in supine/turning the head 90 degrees to follow the examiner s face in upright sitting/holding the head in midline alignment for about seconds while focusing on a bright ball, etc.). The infant was able/not able to selectively move the (ankles/fingers/hand to reach toward objects) while keeping other joints still. (Add comments about alertness, irritability, behavior such as ability to use hand to mouth for self-comforting, excessive fatigue or physiologic instability, etc., as appropriate). (Finish with mention that: no concerns about motor development at this time/infant appears to have delayed development relative to age peers/abnormal tone noted, etc. Indicate what parents were told and note next test date and any recommendations, such as close follow-up, intervention, etc.). Mac Keith Meetings Programme Feeding Pre-term and Term Babies (Open meeting) see advertisement page 282 Royal Society of Medicine, London, UK. 17 May 2002 The Management of Hip Dysplasia in Children with Cerebral Palsy (Open meeting) see advertisement page 277 Derbyshire Royal Infirmary, Derby, UK. 21 May 2002 Scope 50 (Open meeting) Royal Society of Medicine, London, UK. 6 June 2002 Speakers include Martin Bax, Lesley Carroll-Few, Gregory O Brien, Michael Prendergast Organised by Gregory O Brien, Anne Murphy, Pauline Fiddler Headache in Childhood (Open meeting) Royal Society of Medicine, London, UK. 11 or 12 September 2002 (TBC) Organised by Richard Morton Child Head Injury, Recovery, Development and Outcome (Closed meeting) Edinburgh, UK September 2002 Organised by David Johnson Non-drug Treatment of Epilepsy in Childhood (Open meeting) Royal Society of Medicine, London, UK. 27 November 2002 Speakers include Jean Aicardi, Stephen Brown, John Freeman, Richard Newton, JoAnne Dahl Olerud, Arnold J Wilkins. Organised by Michael Prendergast Head Injury: Long-term Outcomes (Open meeting) Royal Society of Medicine, London, UK. 16 December 2002 Organised by David Johnson, Gregory O Brien Dentistry and Disability (Open meeting) Royal Society of Medicine, London, UK. 24 February 2003 Organised by Michael Prendergast Creating Relationships with Voluntary Groups and Parents (Open meeting) Royal Society of Medicine, London, UK. 30 May 2003 Organised by Martin Bax New Neurosurgery for Children (Open meeting) Royal Society of Medicine, London, UK. 5 November 2003 Organised by Michael Prendergast and Johnathon Punt To reserve places at Open Meetings please contact: Melanie Armitage, Academic Administrator, Mac Keith Meetings, CME Department, The Royal Society of Medicine 1 Wimpole Street, London W1M 8AE, UK Tel: +44 (0) , Fax: +44 (0) Developmental Medicine & Child Neurology 2002, 44:

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