Item name and score definitions
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Comments, instructions
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1.
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Gross Motor Skills
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Consider aids of two small blocks, a small handheld bell, small spoon, stuffed animal or other bright toy to test visual tracking
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- Hold head upright against gravity while sitting
- Child cannot hold head erect for at least 3 seconds without support (Score = 0)
- Child holds head erect for at least 3 seconds without support (Score = 1)
- Child holds head erect and steady for at least 15 seconds without support (Score = 2)
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- Typically performed on exam table
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- Roll over
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- Child does not roll front to back or back to front (Score = 0)
- Child rolls front to back or back to front, but not both (Score = 1)
- Child rolls front to back and back to front (Score = 2)
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- Typically performed on exam table
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- Sit with support
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- Child cannot sit with support (Score = 0)
- Child tenses muscles in an effort to maintain sitting position (Score = 1)
- Child sits with slight support for at least 30 seconds (Score = 2)
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- Typically performed on exam table
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- Sit without support
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- Child cannot sit without support (Score =0)
- Child sits without support for at least 5 seconds (Score = 1)
- Child sits without proper support for at least 30 seconds (Score = 2)
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- Typically performed on exam table
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- Stand aided
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- Child cannot stand aided (Score = 0)
- Child can stand aided (Score = 1)
- Child raises self to a standing position, using a chair or other convenient object for support
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- Stand unaided
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- Child cannot stand unaided (Score = 0)
- Child can stand alone for at least 3 seconds after you release his or her hands (Score = 1)
- Child comes to a standing position without using any support (Score = 2)
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- Does head lag with dynamic change of position?
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- Child cannot hold head when raised from supine to sitting by pulling on the arms (Score = 0)
- Child has head lag when raised from supine to sitting by pulling on the arms (Score = 1)
- Child has no head lag when raised from supine to sitting by pulling on the arms (Score = 2)
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- Peripheral limb function: Hand
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- Child has no hand grip and/or contractures (Score = 0)
- Child shows finger grip (pincer) (Score = 1)
- Child holds object in hand (Score = 2)
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- Give child block or small toy
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- Peripheral limb function: Feet
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- Child has contractures of both feet (Score = 0)
- Child has pes equinus or pes cavus without contracture (Score = 1)
- Child has no foot deformity (Score = 2)
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- Crawling
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- Child cannot crawl (Score = 0)
- Child moves from lying prone to being up on hands and knees (Score = 1)
- Child makes forward progress of at least 5 feet by crawling on hands and knees (Score = 2)
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- Walk aided
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- Child cannot walk with support (Score = 0)
- Child walks with support by a person and initiates multiple steps (Score = 1)
- Child walks independently while using or holding onto support (Score = 2)
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- Walk unaided
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- Child cannot walk without support (Score = 0)
- Child takes at least 3 steps without support, even if gait is stiff-legged and wobbly (Score = 1)
- Child takes at least 5 steps independently, displaying coordination and balance (Score = 2)
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2.
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Fine Motor Skills
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- Reaches for objects
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- Child does not reach for an object (Score = 0)
- Child extends one or both arms forward to reach object, but does not touch object (Score = 1)
- Child extends one or both arms forward to reach object and touches object with any part of either hand (Score = 2)
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- Ensure object is light (e.g. light-weight block, light-weight bell)
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- Grasps small objects
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- Child cannot pick up block (Score = 0)
- Child picks up block using one or both hands (Score = 1)
- Child uses pad of his or her thumb and any fingertip to grasp block (Score = 2)
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- Picks up food or spoon
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- Child cannot pick up food pellet or spoon (Score = 0)
- Child grasps food pellet or spoon, but does not bring it to his/her mouth (Score = 1)
- Child grasps food pellet or spoon and brings it to his/her mouth (Score = 2)
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- Use plastic spoon, put in child’s hand and see if brings to mouth
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- Rings bell
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- Child does not reach for bell (Score = 0)
- Child extends one or both arms forward to reach bell and touches bell with any part of either hand (Score = 1)
- Child picks up bell and attempts to ring bell (Score = 2)
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- Transfer objects
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- Child does not grasp ring when handed (Score = 0)
- Child uses at least one hand to grasp ring for at least 2 seconds (Score = 1)
- Child grasps ring and transfers from hand to hand (Score = 2)
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- Place one block on another
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- Child does not attempt to place one block on another (Score = 0)
- Child attempts to place one block on another, but is unsuccessful (Score = 1)
- Child is successful to place one block on another (Score = 2)
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3.
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Bulbar Function
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- Swallows saliva
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- Child drools most of the time, requiring bib or several shirt changes per day (Score = 0)
- Child drools occasionally (does not require a bib or a shirt change) (Score = 1)
- Child does not drool (Score = 2)
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- Swallows pureed food
- Child cannot eat pureed food (Score = 0)
- Child can occasionally eat pureed food (Score = 1)
- Child can eat pureed food with no problem (Score = 2)
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- Swallows solid food (including soft foods)
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- Child cannot eat solid food (Score = 0)
- Child can occasionally eat solid food (Score = 1)
- Child can eat solid food with no problem (Score = 2)
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- Bite strength
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- Absent (Score = 0)
- Weak (Score = 1)
- Strong (Score = 2)
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- Can place gloved hand in mouth to assess bite strength
- Alternatively can be history based by asking parents / caregivers
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- Nourishes liquids by syringe or tube feeding
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- Syringe feeding or tube feeding only (Score = 0)
- Syringe feeding or tube feeding most of the time or occasional (Score = 1)
- No syringe or tube feeding (Score = 2)
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- Tube feeding
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- Permanent (Score = 0)
- Occasional (Score = 1)
- Never (Score = 2)
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- Upper Airway
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- Tracheotomy or CPAP support (Score = 0)
- Child has sleep apnea (Score = 1)
- Child has normal sleep respiration (score = 2)
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4.
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Ocular
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- Nystagmus
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- Child has nystagmus most of the time (Score = 0)
- Child has occasional nystagmus (Score = 1)
- Child has no nystagmus (Score = 2)
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- Observe at rest, some have constant nystagmus, some only brief when shifting gaze
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- Strabismusa
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- Severe (Score = 0)
- Moderate (Score = 1)
- Mild/No Strabismus (Score = 2)
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- Severe Strabismus: Constant exotropia
- Moderate Strabismus: Exotropia > 50 % of the exam before dissociation, or Exotropia < 50 % of the exam before dissociation
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- Mild Strabismus: No exotropia unless dissociated, recovers in > 5 seconds; no exotropia unless dissociated, recovers in 1-5 seconds; or no exotropia unless dissociated, recovers in < 1 second (phoria)
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- Tracks human face
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- Child does not track human face (score = 0)
- Child fixes gaze on a person for at least 2 seconds (score = 1)
- Child turns head to follow a person through the room (score = 2)
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- Asses if they track face from around 1 ft away
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- Tracks object
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- Child does not track an object (score = 0)
- Child’s eyes follow an object that is moved horizontally or vertically (Score = 1)
- Child’s eyes follow an object that is moved in a circular motion (Score = 2)
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- Optic atrophy/temporal pallor
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- Child has severe optic atrophy/temporal pallor (Score = 0)
- Child has moderate optic atrophy/temporal pallor (Score = 1)
- Child has mild or no optic atrophy/temporal pallor (Score = 2)
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- Either by way of indirect fundoscopy or slit-lamp exam by pediatric ophthalmologist
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5.
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Temporo-frontal
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- Interacts with parents or examiner
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- Child does not interact with parent or examiner (Score = 0)
- Child clearly responds to the person’s voice (Score = 1)
- Child actively participates in at least one play routine (Score = 2)
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- Helpful to have parents elicit emotional response to parental voice or movement
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- Responds to verbal commands
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- Child does not respond to verbal commands (Score = 0)
- Child stops reaching for objects in response to “no,” but does not respond in an appropriate manner to other requests (Score = 1)
- Child responds in an appropriate manner to at least one spoken request more complex than “no” (does not need to complete task) (Score = 2)
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- Repeats simple sounds
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- Child does not repeat simple sounds (Score = 0)
- Child repeats a single vocalization only (Score = 1)
- Child repeats two different, distinct vocalizations (Score = 2)
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- Smiles
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- Child does not smile nor vocalize mood (Score = 0)
- Child expresses at least one mood (Score = 1)
- Child‘s mood or focus can change in response to speaker’s attention (Score = 2)
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- What is the child’s affect?
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- Sad, distressed or crying a lot (Score = 0)
- Neutral affect (Score =1)
- Happy, ebullient, or cooperative (Score = 2)
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- Speaks individual words
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- Child does not speak individual words (Score = 0)
- Child imitates at least one word, even if imitation consists of vowels only (Score = 1)
- Child uses at least one word to make wants known (Score = 2)
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- Puts words together
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- Child does not use words (Score = 0)
- Child uses at least one word to make wants known (Score = 1)
- Child produces at least one utterance that includes two or more words (Score = 2)
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- Point to objects in a book
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- Child does not attempt to point to an object in a book (Score = 0)
- Child points to object in a book, but does not identify object that was named (Score = 1)
- Child points to object in a book that was named (Score = 2)
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6.
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Autonomic Nervous System
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- Constipation
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- Child has fewer than 2 bowel movements per week and is dependent on a laxative (Score = 0)
- Child has 2 or more bowel movements per week and is dependent on a laxative (Score = 1)
- Child has 2 or more bowel movements per week without a laxative (Score = 2)
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- Urinary
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- Indwelling catheter or dependent upon catherization (Score = 0)
- Catherization no more than once per day (Score = 1)
- No catherization required (Score = 2)
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