[Federal Register Volume 62, Number 168 (Friday, August 29, 1997)]
[Notices]
[Pages 45908-45916]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-22795]


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DEPARTMENT OF TRANSPORTATION

National Highway Traffic Safety Administration
[Docket No. 91-33, Notice No. 03]


Functional Capacity Index

AGENCY: National Highway Traffic Safety Administration (NHTSA), 
Department of Transportation (DOT).

ACTION: Notice and request for comment on proposed Pediatric Functional 
Capacity Index.

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SUMMARY: The National Highway Traffic Safety Administration (NHTSA) is 
developing a scale to quantify the consequences of pediatric injuries 
received in motor vehicle crashes based on adjusted life-years. This 
index is an extension of the basic index described in Docket No. 91-33, 
Notice No. 01. The factor used to adjust the injured person's remaining 
life-years is called the Functional Capacity Index (FCI). It combines 
decrements in each of ten dimensions of functioning into a whole body 
score. The development of the definitions of the functional attributes 
and their various capacity levels has

[[Page 45909]]

been completed. This notice requests comments on the approach being 
taken and on the attribute definitions.

DATES: Comments are requested no later than October 14, 1997.

ADDRESSES: Written comments should refer to the docket and notice 
number of this document and should be submitted, (preferably in ten 
copies) to: Docket Section, National Highway Traffic Safety 
Administration, Room 5109, Nassif Building, 400 Seventh Street S.W., 
Washington, D.C. 20590. (Docket hours are 9:30 a.m. to 4:00 p.m.)

FOR FURTHER INFORMATION CONTACT: Stephen Luchter, Senior Policy 
Advisor, Office of Plans and Policy, National Highway Traffic Safety 
Administration, 400 7th St. S.W., Washington, D.C. 20590. Telephone 
202/366-2576.

SUPPLEMENTARY INFORMATION: NHTSA's mission is to save lives, prevent 
injuries, and reduce traffic-related health and other economic costs. 
To accomplish this mission efficiently, the agency needs accurate and 
reliable methods of quantifying the consequences of injuries to those 
who are injured, as well as to their families and society in general.
    NHTSA has developed sophisticated methods for quantifying the 
economic consequences of deaths and injuries. These have been available 
for some time and are widely applied. NHTSA uses these for, among other 
things, resource allocation, regulatory analysis, and in support of 
state and local programs.
    In addition, the agency is developing methods to quantify injury 
consequences based on the injured person's functional capacity. An FCI 
is being developed for measuring a previously healthy adult's 
functional capacity one year post-injury. This notice describes a 
program to develop a pediatric version of the FCI and requests comments 
on the first phase of this effort, definition of functional attributes.

General Description

    The basic assumption of the FCI is that life is its own best 
measure of value. If there are things a person cannot do as well 
following an injury as before, there is a reduction in their overall 
functional capacity. With the functional capacity approach, individuals 
of the same age and gender are counted equally. The injury consequences 
to young children are not discounted, and the longer average lifespan 
of females is accurately reflected.
    The FCI is a measure of the relative degree to which an injured 
person is unable to function at their pre-injury level on a scale of 0 
to 100, where 0 represents no limitation of function and 100 represents 
maximum limitation of function. The overall consequences of an injury 
are found by multiplying the FCI, as a decimal between 0 and 1.0 by the 
injured person's remaining life expectancy. Note that the FCI can vary 
with time as the injured person's condition changes. The product of the 
FCI and the life expectancy is the number of years of reduced 
functional capacity. Any effects of reduced life expectancy as a result 
of the injury also can be accounted for.

Attribute and Severity Level Definitions

    The work of selecting the attributes to be included in Pediatric 
Functional Capacity Index (PFCI), and defining each attribute and each 
severity level has been completed. The same attributes were chosen for 
the PFCI as for the adult version. The choice was pragmatic, attempting 
to have as few as possible yet to have a sufficient number to fully 
describe the functioning of a complete human being. In addition, the 
effects of childhood development were accounted for by developing 
definitions that vary with the child's age.
    The number of levels within each attribute were chosen as needed to 
reflect observable variation in functional capacity for that attribute 
rather than arbitrarily deciding that some number of levels would be 
used for all attributes. In some cases, the number of levels differs 
from that in the adult FCI. Similarly, age categories required to 
differentiate the differences in development as children mature were 
also selected as appropriate for each attribute. Each attribute has 
levels of functioning ranging from no reduction in functional capacity 
to maximum reduction. Definitions were developed for each attribute and 
each severity level as well as for appropriate age categories. The 
definitions were reviewed and refined based on suggestions made by a 
panel of nationally recognized experts in pediatric trauma, as well as 
physicians and allied health professionals specializing in pediatric 
rehabilitation medicine.
    The results are shown in Tables 1 through 10.
    Eating (Table 1)--Difficulty eating is characterized by limitations 
in the ability to chew and swallow foods. Defined in this manner, the 
ability to eat is independent of the ability to hold or use utensils.
    Excretory Function (Table 2)--Excretory function is characterized 
by control over urinary and fecal elimination.
    Sexual Function (Table 3)--This function is determined by physical 
capabilities anticipated to occur as an adult; dysfunction due to 
psychological reasons is not considered. Note that this attribute is 
the only one that does not relate directly to the injured child's 
current situation.
    Ambulation (Table 4)--Ambulation is characterized by the ability to 
(1) stand, walk and run and (2) climb stairs. Limitations are described 
in terms of distance, speed, the need for a mechanical device or human 
assistance. Limitations may be due to motor impairments, contractures, 
pain, loss of equilibrium, reduced sensation or poor cardiopulmonary 
function.
    Hand and Arm Function (Table 5)--Upper limb function is 
characterized by the ability to (1) grasp and manipulate objects, (2) 
write, (3) move hand to mouth, (4) move arms over head, and (5) 
bilateral skills. Grasping and manipulating is described in terms of 
the size of the object. Writing is described in terms of use of a 
crayon in age appropriate motions. Hand to mouth movement is described 
in terms of number of repetitions and speed. Bilateral skills are 
described in terms of manipulating objects. Movement of the upper limbs 
may be limited by motor impairment, contracture, pain, or reduced 
sensation.
    Bending and Lifting (Table 6)--Neuro-musculoskeletal function of 
the trunk is characterized by the ability to bend over from a sitting 
position and touch hand to foot, and by the ability to lift. 
Limitations in bending and lifting may be due to motor impairments, 
pain, or loss of equilibrium.
    Visual Function (Table 7)--Visual function is characterized by 
visual acuity and presence or absence of functional diplopia. The 
levels of visual acuity parallel those delineated in the 9th revision 
of the International Classification of Diseases (ICD-9).
    Auditory Function (Table 8)--Auditory function is described by 
degree of difficulty hearing under everyday listening conditions and by 
the average of hearing threshold levels at four standard frequencies.
    Speech (Table 9)--Limitations of speech include difficulties in 
voice production and articulation and in use of age appropriate 
vocabulary.
    Cognitive Function (Table 10)--Cognitive function is described by 
the capacity of the individual to perform age appropriate activities, 
demonstrate age appropriate learning memory abilities, and for school 
age children having age appropriate academic progress.

Applying the Definitions to the AIS 90 Dictionary

    The attribute and severity levels will be applied to each injury 
listed in the

[[Page 45910]]

AIS 90 Dictionary by an expert panel based upon their clinical 
judgment. These judgements will then be validated by interviewing a 
sample of people who experienced the injuries.

Developing a Numerical Scale

    The final step in the development of the FCI is to translate the 
sets of qualitative statements applicable to each injury into numerical 
values. The approach taken for the PFCI follows that of the adult 
version. Values are assigned to each severity level within an attribute 
on a scale of 0 to 100. Each number on this scale represents a degree 
of severity such that 50 is ten degrees higher than 40, 90 is ten 
degrees higher than 80 and so forth. The number 0 reflects the lowest 
degree of severity (no limitation in functional capacity), and 100 
reflects the highest degree of severity (maximum limitation in 
functional capacity). The numbers reflect the rater's judgment of the 
relative severity of the limitation in terms of its likely impact on 
overall function in everyday living. The major aspects of life for 
children are intended to include social interaction and major usual 
activity such as play, school or for older children, work. A separate 
chart is used for each of the attributes. In these charts the end 
points are preprinted and the rater places the remaining intermediate 
levels of function on the scale such that the relative spacing between 
levels reflects their judgments of the expected degree of severity.
    Once the within-attribute scaling has been completed, the second 
step is to rate the relative weights of the attributes with respect to 
each other. This step is more complex than the rating within attributes 
because it must consider the possibility that the attributes may not be 
completely independent. Also, some combined states are added to assist 
in the final step of combining into the whole body factor and to cover 
situations not included in the single state listing, for example, total 
blindness in one eye and both eyes, profound or total loss of auditory 
function in one or both ears, quadriplegia, deaf-blind, and 
simultaneously being at the most severe level on all 10 dimensions. 
Death is also scaled to provide an anchor point.
    In this step, the rater first considers the most severe level for 
each of the attributes and identifies which has the greatest impact on 
everyday living by placing a mark on a scale of 0 to 100. The rater 
then places the remaining most severe states for the remaining nine 
attributes on the scale relative to the one judged to have the greatest 
impact. Death is scaled next. A scale value greater than 100 is 
acceptable. Next, the rater assigns a numerical value to the state 
representing the state of being at the most severe of all of the 
dimensions, and to some combined states not included in the list of 
attributes, such as quadriplegia and deaf-blind. These will be placed 
at scale values less than the value assigned to death.
    Following these two steps, the values and weights will be 
normalized to a 0 to 100 scale with death as 100 and the remaining 
states relative to that. These values will then be combined using an 
appropriate model.
    As part of this work the judgments of parents, teachers, both 
special education and mainstream education, and children will be 
obtained. In addition, an effort will be made to determine if value 
judgements vary with cultural background.

Limitations

    Although every attempt has been made to make the PFCI as broadly 
applicable as possible, certain limitations are acknowledged. Some of 
these are topics that could be considered for further development.
    1. With a few exceptions, the index in its present state of 
development is applicable to single injuries. Methodologies to estimate 
the change in functional capacity resulting from any synergistic 
effects of more than one injury, particularly injuries to different 
body regions, remain to be developed.
    2. Changes in functional capacity from pre-existing conditions are 
not included, as this would require knowledge of differences in the 
consequences of injuries to different sub-populations. An average 
healthy child prior to injury is assumed in the current development.
    3. The present effort to develop a PFCI will be limited to the 
injury definitions in the 1990 version of the Abbreviated Injury Scale. 
Although the International Classification of Disease injury 
descriptions are widely used, they generally do not contain sufficient 
detail for the agency's countermeasure development purposes.

Comments

    NHTSA requests comments on the proposed PFCI. General and detailed 
comments on this proposal are welcome in order to benefit from the 
opinions that interested parties and the public may wish to forward. 
All comments submitted in response to this notice will be considered by 
the agency.
    Comments are specifically solicited on the following issues with 
respect to the material shown in Tables 1 through 10 of this Notice.
    1. Do the 10 attributes reasonably cover the range of functions 
found in people age 1 and older?
    2. Do the levels of functional capacity shown in Tables 1 through 
10 reasonably cover the range for the individual functions?
    3. Are the definitions of the functional capacity levels shown in 
Tables 1 through 10 unambiguous?
    4. Are the definitions shown in Tables 1 through 10 comprehensible 
to a lay person?
    Written comments should be submitted to:NHTSA Docket Section,Room 
5109, Nassif Building, 400 Seventh Street S.W., Washington, D.C. 20590.
    Comments should refer to Docket #91-33, Notice 03.
    It is requested, but not required, of interested persons that ten 
copies of each comment be submitted. All comments must not exceed 
fifteen pages in length. (49 CFR 553.21). Necessary attachments may be 
appended to these suggestions without regard to the fifteen page limit. 
This limitation is intended to encourage commenters to present their 
views in a concise fashion.
    All comments received before the close of business on the comment 
closing date listed above will be considered and will be available for 
examination in the docket at the above address both before and after 
that date. To the extent possible, comments filed after the closing 
date will be considered. However, this action may proceed at any time 
after that date. The agency will continue to file relevant information 
as it becomes available. It is recommended that interested persons 
continue to examine the docket for new material. Those persons desiring 
to be notified upon receipt of their comments by the docket should 
include a self-addressed, stamped postcard in the envelope with their 
comments. Upon receiving the comments, the docket supervisor will 
return the postcard by mail.

    Issued on: August 22, 1997.
William H. Walsh,
Associate Administrator, Plans and Policy.

[[Page 45911]]



                                                     Eating                                                     
----------------------------------------------------------------------------------------------------------------
                                                                Level C:                                        
                                             Level B: No        Requiring                                       
                                               dietary           dietary                                        
                                           modifications.    modifications.   Level D: Limited                  
                           Level A: No        Requires         May require       P.O. intake      Level E: Tube 
       Function            limitations      supervision,      supervision,     supplemented by    feeding only  
                                            compensatory      compensatory      tube feeding                    
                                           strategies and/   strategies and/                                    
                                             or adaptive       or adaptive                                      
                                              equipment         equipment                                       
----------------------------------------------------------------------------------------------------------------
Swallowing Liquids 12   Drinks liquids    Requires grading  Requires use of   Tolerates small   All nutritional 
 mo+.                    primarily from    amount of         thickening        amount of         needs met via  
                         cup, however      liquid, or        agent or rice     liquid            tube feeding as
                         may               compensatory      cereal to         following         child is unable
                         occasionally      strategies        safely tolerate   safety            to safely take 
                         use bottle or     (i.e., jaw        liquids.          precautions       any liquids    
                         breast.           support, etc.).                     however, child    P.O. secondary 
                         Coughing and                                          is unable to      to impaired    
                         choking are                                           meet              oral motor     
                         rare.                                                 nutritional       skills and/or  
                                                                               needs P.O.        risk for       
                                                                               requiring tube    aspiration.    
                                                                               feeding.                         
Swallowing Solids 12-   Effectively       Requires          Requires pureed   Tolerates small   All nutritional 
 18 mo.                  chews and         adaptive          diet (i.e. baby   amount of         needs met via  
                         swallows          positioning       food) secondary   solids            tube feeding as
                         ground, mashed,   techniques,       to difficulty     following         child is unable
                         or chopped        adaptive          chewing,          safety            to safely take 
                         table foods.      placement of      swallowing or     precautions       any solids P.O.
                         May lose          food in mouth     digesting.        however, child    secondary to   
                         minimal amounts   (i.e. flat-                         is unable to      impaired oral  
                         of food/saliva    based spoon) or                     meet              motor skills   
                         during chewing    smaller sized                       nutritional       and/or risk for
                         and swallowing.   bolus to                            needs P.O.        aspiration.    
                                           tolerate solids.                    requiring tube                   
                                                                               feeding.                         
18 mo+................  Effectively       Requires          Requires pureed   Tolerates         All nutritional 
                         chews and         adaptive          diet (i.e. baby   limited amount    needs met via  
                         swallows all      positioning       food) secondary   of solids         tube feeding as
                         solids well       techniques,       to difficulty     following         child is unable
                         with good lip     adaptive          chewing,          safety            to safely take 
                         closure. No       placement of      swallowing or     precautions       any solids P.O.
                         loss of food/     food in mouth     digesting.        however, child    secondary to   
                         saliva during     (i.e. flat-                         is unable to      impaired oral  
                         swallowing.       based spoon) or                     meet              motor skills   
                                           smaller sized                       nutritional       and/or risk for
                                           bolus to                            needs P.O.        aspiration.    
                                           tolerate solids.                    requiring tube                   
                                                                               feeding.                         
----------------------------------------------------------------------------------------------------------------
Reference: Pre-Feeding skills--Suzanne Evans Morris, PhD and Marsha Dunn Klein, M.Ed, OTR, Therapy Skill        
  Builders, 1987, P.O. (Per Os)=By Mouth.                                                                       


                                               Excretory Function                                               
----------------------------------------------------------------------------------------------------------------
                                                         Level B:                                               
                                  Level A: No          Controllable      Level C: Moderate     Level D: Severe  
          Function                 limitation           excretory            excretory            excretory     
                                                        difficulty           difficulty           difficulty    
----------------------------------------------------------------------------------------------------------------
1yr-<2yrs (12-23 mnths).....  No significant       No retention         Moderate retention.  Severe difficulty  
                               difficulty           problems.            Difficulty           eliminating urine 
                               eliminating urine    Dependent, but       eliminating urine    or fecal matter   
                               or fecal matter      controlled use of    or fecal matter      (into diaper)     
                               (into diaper); No    catheterization      (into diaper)        despite use of    
                               constipation or      device +/or ostomy   despite use of       catheterization   
                               urinary retention.   or controlled with   catheterization      device +/or ostomy
                                                    medication +/or      device +/or ostomy   or medication +/or
                                                    diet.                or controlled with   ostomy or         
                                                                         medication +/or      medication +/or   
                                                                         diet.                diet.             
2yrs-3\1/2\yrs (24-42 mnths)  No significant       No retention         Moderate retention.  Severe difficulty  
                               difficulty           problems.            Difficulty           eliminating urine 
                               eliminating urine    Dependent, but       eliminating urine    or fecal matter   
                               or fecal matter      controlled use of    or fecal matter      (into diaper)     
                               (into diaper); No    catheterization      (into diaper)        despite use of    
                               constipation or      device +/or ostomy   despite use of       catheterization   
                               urinary retention.   or controlled with   catheterization      device +/or ostomy
                                                    medication +/or      device +/or ostomy   or medication +/or
                                                    diet.                or controlled with   diet.             
                                                                         medication +/or                        
                                                                         diet.                                  
>3\1/2\yrs-10yrs (42-120 mnths).  difficulty           Controlled use of    incontinence         (urinary +/or     
                               controlling the      catheterization      (urinary +/or        fecal); frequency 
                               elimination of       device +/or ostomy   fecal); frequency    everyday & night  
                               urine or fecal       with 1 person        greater than 2x/wk   despite use of    
                               matter. No           assistance or        by night and by      catheterization   
                               incontinence day/    controlled with      day despite use of   device +/or ostomy
                               night; No            medication +/or      catheterization      with 1 person     
                               constipation or      diet. No retention   device +/or ostomy   assistance or     
                               urinary retention.   problems.            with 1 person        controlled with   
                                                    Dependent, but       assistance or        medication +/or   
                                                    controlled use of    controlled with      dietary influence.
                                                    catheterization      medication +/or      Severe retention  
                                                    device +/or ostomy   diet. Moderate       difficulty despite
                                                    or controlled with   retention            use of            
                                                    medication +/or      difficulty despite   catheterization   
                                                    diet.                use of               device +/or ostomy
                                                                         catheterization      or medication +/or
                                                                         device +/or ostomy   diet.             
                                                                         or medication +/or                     
                                                                         diet.                                  
----------------------------------------------------------------------------------------------------------------


                      Sexual Intercourse Functioning (Prediction of Adult Sexual Function)                      
----------------------------------------------------------------------------------------------------------------
                                                                                             Level C: Severe    
             Function                Leval A: No limitation       Level B: Moderate     limitation (or no sexual
                                                                     difficulty            function possible)   
----------------------------------------------------------------------------------------------------------------
1yr + (12+ mnths).................  Sexual function will be   Sexual function will be   Sexual function will not
                                     possible without          possible but with         be possible or there   
                                     difficulty.               varying degrees of        will be severely       
                                                               difficulty due to         impaired difficulty.   
                                                               physical impairment(s).                          
----------------------------------------------------------------------------------------------------------------


                                                               Ambulation (Stair Climbing)                                                              
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                            Level C:                                                                    
                                                                          Independent,      Level D: Minimally                                          
         Function               Level A: No         Level B: Minor      requires device,   dependent; requires  Level E: Moderately  Level F: Completely
                                limitations          limitations        takes more than         assistance            dependent            dependent    
                                                                        reasonable time                                                                 
--------------------------------------------------------------------------------------------------------------------------------------------------------
Stair climbing 12-17       Crawls up or down     ...................  May require extra    ...................  ...................  Severe limitation, 
 months.                    stairs, may walk up                        time and/or an                                                 no ability to     
                            stairs with one                            assisted device.                                               climb stairs.     
                            hand held.                                                                                                                  
18-23 months.............  Walks up and down     Walks up w/one hand  ...................  Crawls on stomach    ...................  Severe limitation, 
                            holding rail. May     held, may crawl up                        and elbows (not                           no ability to     
                            need one hand held    or down stairs.                           quadruped) up                             climb stairs.     
                            walking down stairs.                                            stairs.                                                     
24-29 months.............  Walks up and down     Needs 1 hand held    Crawls up or down    ...................  Crawls on stomach    Severe limitation  
                            holding rail.         walking down         stairs, may walk                          and elbows (not      no ability to     
                                                  stairs.              up with one hand                          quadruped)           climb stairs.     
                                                                       held and/or use                           upstairs.                              
                                                                       assisted device.                                                                 
30-35 months.............  Alternates feet       Alternates feet      Walks up and down    Crawls up or down    ...................  Severe limitation, 
                            going up and down     going down stairs.   holding rail, may    stairs.                                   crawls on stomach 
                            stairs.                                    need 1 hand held                                               up stairs, no     
                                                                       and/or assisted                                                ability to stair  
                                                                       device.                                                        climb.            

[[Page 45912]]

                                                                                                                                                        
36 months and older......  No limitation.        Minimal limitation,  Climbing 12 stairs   Can climb minimum    Stair climbing less  Severe limitation, 
                            Climbs up and down    may have             without assistance   of 12 steps with     than 12 steps with   cannot walk up    
                            12 steps without      deviations in gait   takes more than a    or without           or without           minimum of 12     
                            difficulty.           pattern.             reasonable time,     assistance and/or    assistance and/or    steps.            
                                                                       requires device or   device.              device.                                
                                                                       handrail.                                                                        
--------------------------------------------------------------------------------------------------------------------------------------------------------


                                                         Ambulation (Standing, Walking, Running)                                                        
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                            Level C:                                                                    
                                                                          Independent,                                                                  
                                Level A: No         Level B: Minor      requires device,    Level D: Minimally  Level E: Moderately  Level F: Completely
         Function               limitations          limitations        takes more than    dependent; requires       dependent            dependent     
                                                                       reasonable amount        assistance                                              
                                                                            of time                                                                     
--------------------------------------------------------------------------------------------------------------------------------------------------------
Standing/Walking/Running   Walks alone seldom    Walks with 1 hand    Walks with 2 hands   Cruises with 1 hand  Cruises with 2       Completely         
 12-17 Months.              falls (may be wide    held.                held may require     (may need assisted   hands (may need      dependent, crawl  
                            based gait) may                            assisted device      device).             assisted device).    and/or stands at  
                            only walk several                          (orthotics,                                                    rail, including no
                            steps independently.                       walker, etc.).                                                 crawling or       
                                                                                                                                      standing or pull  
                                                                                                                                      to standing       
                                                                                                                                      position.         
18-23 Months.............  Walks alone without   Walks alone seldom   Walks with 1 hand    Walks with 2 hands   Cruises with 1 hand  Completely         
                            falling, runs.        falls.               held may require     held may require     (may need device).   dependent; crawls,
                                                                       some device.         device.                                   stands, cruises   
                                                                                                                                      with 2 hands; may 
                                                                                                                                      not crawl or pull 
                                                                                                                                      to stand.         
24 Months and Older......  No limitations, able  Some limitation,     Can walk 150'        Can walk minimum of  Walking limited to   Difficulty standing
                            to walk at least      can walk 150'        without              150' with            50-150' with/or      for long periods  
                            150', no deviations   without assistance   assistance, but      assistance may or    without assistance   of time or walk   
                            in gait pattern.      but with             takes more than a    may not require      and/or device.       minimum of 50'    
                                                  increasing           reasonable amount    device.                                   including unable  
                                                  problems over        of time and                                                    to walk at all.   
                                                  increased            requires some                                                                    
                                                  distances; may       device.                                                                          
                                                  have minimal                                                                                          
                                                  deviation; does                                                                                       
                                                  not require device.                                                                                   
--------------------------------------------------------------------------------------------------------------------------------------------------------
Note: Cruising: ``Sidewards walking, holding rail for support, shifting hands.'' Taken from Manual of Developmental Diagnosis by Knobloch, Stevens and  
  Malone (p. 68).                                                                                                                                       


                                                         Pediatric Better Hand and Arm Function                                                         
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                    Level B: Minor       Level C: Major        Level D: No                                              
                                                  limitation in hand   limitation in hand   limitation in hand   Level E: Moderate    Level F: Complete 
         Function               Level A: No          function: No         function: No       function: Min to    limitation in hand   or near paralysis 
                                limitation        limitation in arm    limitation in arm   moderate limitation    and arm function     or loss of both  
                                                       function             function         in arm function                                limbs       
--------------------------------------------------------------------------------------------------------------------------------------------------------
Grasp and release of       Grasps tiny objects   Uses immature grasp  Uses immature grasp  No difficulty        Moderate difficulty  Max difficulty or  
 small and large objects    using tips of thumb   (scissor grasp) of   (palmer grasp)       grasping pellet or   grasping small and   inability to grasp
 (12 mos. +).               and index finger.     tiny object with     with max             large objects.       large objects        small and large   
                            No difficulty with    increased time. No   difficulty with      Release is           using immature       objects. Release  
                            large objects in      difficulty with      tiny and large       controlled.          grasp patterns       is uncontrolled.  
                            relation to the       large objects.       objects (including                        (raking). May                          
                            child's hand.         Requires increased   not being able to                         require increased                      
                            Releases objects in   time for             do it at all).                            time. Release is                       
                            a controlled manner.  controlled release.  Release is                                clumsy but                             
                                                                       uncontrolled.                             purposeful.                            
Writing (15-23 mos.).....  Holds crayon in palm  Minor difficulty to  Max difficulty       No difficulty        Moderate difficulty  Max difficulty     
                            and scribbles         grasp crayon in      grasping crayon      grasping crayon in   to grasp crayon in   grasping crayon   
                            spontaneously.        palm and write       including            palm. May require    palm and write       including         
                            Writes using whole    using whole arm      inability to grasp   increased time to    using whole arm      inability to grasp
                            arm movement.         movement. Imitates   crayon effectively   scribble using       movement. Requires   crayon or         
                                                  scribble with        for scribble.        whole arm            increased time to    scribble.         
                                                  increased time.                           movements.           scribble.                              
(24-30 mos.).............  Holds crayon in palm  Holds crayon in      Max difficulty       No difficulty        Moderate difficulty  Max difficulty     
                            and writes using      palm and writes      grasping crayon      grasping crayon in   to grasp crayon in   grasping crayon;  
                            forearm movement.     using forearm        including            palm. Writes using   palm and write       including         
                            Imitates vertical     movement.            inability to grasp   whole arm            using whole arm      inability to grasp
                            stroke and circular   Demonstrates         crayon effectively   movements.           movements.           crayon or         
                            scribble.             vertical stroke      for scribble.        Demonstrates age-    Requires increased   scribble.         
                                                  and circular                              appropriate          time to grossly                        
                                                  scribble with                             strokes.             imitate vertical                       
                                                  increased time.                                                and circular                           
                                                                                                                 strokes.                               
(31-59 mos.).............  Holds crayon with     Holds crayon with    Max difficulty       No difficulty        Uses immature grasp  Max difficulty     
                            fingers and writes    fingers and writes   grasping crayon.     grasping crayon      (palmer) to hold     grasping crayon   
                            using whole hand      using whole hand     Uses immature        with fingers.        crayon and writes    including         
                            and wrist movement.   and wrist            grasp patterns       Writes using whole   using forearm or     inability to grasp
                            Imitates horizontal   movement. Imitates   (palmer). Writes     hand or wrist        arm movement.        crayon or         
                            stroke, V+H strokes.  horizontal, V+H      using forearm        movement with        Requires increased   scribble.         
                                                  strokes with         movement.            forearm supported.   time to grossly                        
                                                  increased time.                           Demonstrates age-    imitate horizontal                     
                                                                                            appropriate          and vertical                           
                                                                                            strokes.             strokes.                               
(60 mos. +)..............  Holds crayon with     Holds crayon with    Max difficulty       No difficulty        Requires increased   Max difficulty     
                            fingers and writes    fingers and writes   grasping crayon.     grasping crayon.     time to grasp        grasping crayon   
                            using fine finger     using wrist and      Uses whole hand or   Writes using fine    crayon with          including         
                            movement. Prints      finger movement.     forearm movement     finger movements     fingers and write    inability to grasp
                            own name.             Prints own name      to write. Imitates   with forearm         using forearm        crayon or         
                                                  with increased       immature stroke      supported.           movement. Grossly    scribble.         
                                                  time.                patterns grossly.    Demonstrates age-    prints own name.                       
                                                                                            appropriate                                                 
                                                                                            strokes.                                                    
Hand Movement to mouth(12  No difficulty moving  No difficulty        No difficulty        Minimal to mod       Requires increased   Cannot move either 
 mos. +).                   hands to mouth at     moving hands to      moving hands to      difficulty moving    time to take hand    hand to mouth at  
                            least 5 times.        mouth at least 5     mouth at least 5     hands to mouth at    to mouth.            least 5 times.    
                                                  times.               times.               least 5 times.                                              
Arm Movement over head(12  No difficulty         No difficulty        No difficulty        Min to mod           Requires increased   Cannot reach over  
 mos. +).                   reaching for toys     reaching for toys    reaching for toys    difficulty           time or assistance   head with either  
                            over head with both   over head with       over head with       reaching over head   to reach above       arm.              
                            arms.                 both arms.           both arms.           for toys with one    head.                                  
                                                                                            or both arms.                                               
Bilateral UE skills (12-   No difficulty using   Min difficulty       Max difficulty or    No difficulty using  Uses uncoordinated   Max difficulty or  
 15 mos.).                  both hands to         using both hands     inability to use     both hands to        movement patterns    inability to use  
                            manipulate            to manipulate        both hands to        manipulate           to manipulate        both hands to     
                            different objects     different objects    manipulate           different objects    different objects    manipulate        
                            simultaneously.       simultaneously.      different objects    simultaneously.      simultaneously in    different objects 
                                                  May require          simultaneously.                           both hands. May      simultaneously.   
                                                  increased time.                                                drop objects                           
                                                                                                                 frequently during                      
                                                                                                                 task.                                  

[[Page 45913]]

                                                                                                                                                        
16-23 mos.)..............  No difficulty         Min difficulty       Min to mod           Min to mod           Moderate difficulty  Max difficulty or  
                            stabilizing object    stabilizing object   difficulty           difficulty           to stabilize         inability to      
                            with one hand while   with one hand        stabilizing object   stabilizing object   object with hand     stabilize object  
                            manipulating object   while manipulating   with one hand        with hand while      while manipulating   with one hand     
                            with the other hand.  object with the      while manipulating   manipulating with    object with other    while manipulating
                                                  other hand. May      with the other       the other hand.      hand. May use        object with other 
                                                  use forearm rather   hand. Uses forearm   Uses forearm         trunk or leg to      hand.             
                                                  than hand to         rather than hand     rather than hand     assist to                              
                                                  stabilize.           to stabilize.        to stabilize.        stabilize object.                      
(24 mos. +)..............  No difficulty         Min difficulty       Max difficulty or    Min to Mod           Requires increased   Max difficulty or  
                            completing            completing           inability to         difficulty           time to complete     inability to      
                            bilateral opposing    bilateral opposing   complete bilateral   completing           bilateral opposing   complete bilateral
                            UE movements (i.e.,   UE movements. May    opposing UE          bilateral opposing   UE movements. May    opposing UE       
                            tearing paper).       require increased    movements.           UE movements. May    require several      movements.        
                                                  time.                                     require increased    attempts to                            
                                                                                            time.                successfully                           
                                                                                                                 complete task.                         
--------------------------------------------------------------------------------------------------------------------------------------------------------


                                               Bending and Lifting                                              
----------------------------------------------------------------------------------------------------------------
                                Level A: No         Level B: Minor        Level C: Major       Level D: Cannot  
         Function               limitation            limitation            limitation           bend or lift   
----------------------------------------------------------------------------------------------------------------
Bending from Sitting       No difficulty         Minimal difficulty    Can bend over from    Cannot with        
 Position (1 yr. +).        bending over from     bending over from     sitting position in   controlled motion 
                            sitting position in   sitting position in   an appropriate        bend over from    
                            appropriate sized     appropriate sized     sized chair, touch    sitting position, 
                            chair to touch hand   chair to touch hand   hand to foot and      touch hand to foot
                            to foot and return    to foot and return    return to sitting     and return to     
                            to sitting at least   to sitting 5 times.   at least 2 times.     sitting position. 
                            5 times.              May require           Requires maximum                        
                                                  increased amount of   increased time or                       
                                                  time.                 use of adaptive                         
                                                                        techniques, i.e.,                       
                                                                        assisting with                          
                                                                        upper extremities                       
                                                                        to push self up                         
                                                                        into sitting.                           
Bending from Standing      Holds supporting      Holds supporting      ....................  Cannot bend from   
 Position (12-18 mos).      surface to bend       surface to bend                             standing to pick  
                            from standing         from standing                               up object from    
                            position and return   position and return                         floor and return  
                            to upright position   to upright position                         to upright.       
                            at least 3 times.     at least 3 times.                                             
                            May lose balance      Requires repeated                                             
                            occasionally.         attempts secondary                                            
                                                  to frequent loss of                                           
                                                  balance.                                                      
Bending from Standing      No difficulty         Minimal difficulty    Maximal difficulty    Cannot bend over   
 Position (18 mos +).       bending over from     bending over from     bending over from     from standing     
                            standing position     standing position     standing position     position to pick  
                            to pick up object     to pick up object     to pick up object     up object from    
                            from floor and        from floor and        from floor and        floor and return  
                            return to upright     return to upright     return to upright     to upright        
                            position at least 5   position at least 5   position. Requires    position for a    
                            times.                times. May require    increased time and    minimum of 2      
                                                  increased time or     may use adaptive      times. Includes   
                                                  adaptive              techniques, i.e.      not being able to 
                                                  techniques, i.e.      holding onto stable   bend in a         
                                                  holding onto stable   surface.              controlled manner 
                                                  surface.                                    from standing at  
                                                                                              all.              
Lifting from Standing *    No difficulty         Minimal difficulty    Major difficulty or   Inability to lift  
 (1 yr. +).                 lifting amounts       lifting amounts       inability to lift     any weight.       
                            appropriate for age   appropriate for age.  amounts appropriate                     
                            and body weight.                            for age; but able                       
                                                                        to lift a lesser                        
                                                                        amount.                                 
----------------------------------------------------------------------------------------------------------------
* Norms are needed for ``appropriate'' amount and minimal amount of weight to age for a pediatric population.   


                                                                         Vision                                                                         
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                         Level B: No loss                                         Level E: Severe        Level F:                       
      Function          Level A: No       in VA but with     Level C: Near-   Level D: Moderate- low vision (legal    Preferred low      Level G: Total 
                        limitations          Diplopia        normal vision        low vision     blindness in USA)        vision           blindness    
--------------------------------------------------------------------------------------------------------------------------------------------------------
1yr-<2yrs (12-23     .................  .................  Able to I.D.       Recognizes         .................  Everything close   Without visual   
 mnths).                                                    favorite toy 5cm   relative across                       to face.           response even to
                                                            in size from       room without                         without             light.          
                                                            across room with   voice.                                recognition of                     
                                                            nystagmus.        With possible                          faces or objects                   
                                                                               nystagmus.                            without cues.                      
                                                                                                                    with nystagmus                      
                                                                                                                     possible.                          
2yrs-<5yrs (24-59    .................  .................  Near-normal        Moderate low       .................  Profound low       Total visual     
 mnths).                                                    vision; VA is 20/  vision; VA is 20/                     vision; VA is <5/  impairment;     
                                                            30-20/60.          70-20/160.                            200 (count         black blind; no 
                                                           Look out window    Without                                fingers at less    light           
                                                            and ID objects     recognition of                        than 3 mo) but     perception.     
                                                            i.e. birds.        people without                        with light                         
                                                           Not on top of TV.   stimuli.                              perception.                        
                                                           Recognizes         Without seeing                        Near TV, loses                      
                                                            relative across    small objects                         interest if not                    
                                                            room without       out the window                        close.                             
                                                            voice.            With possible                         Everything close                    
                                                                               nystagmus.                            to face.                           
                                                                                                                    Without                             
                                                                                                                     recognition of                     
                                                                                                                     faces or objects                   
                                                                                                                     without stimuli                    
                                                                                                                     with possible                      
                                                                                                                     nystagmus.                         

[[Page 45914]]

                                                                                                                                                        
5yrs-<10yrs (60-119  Normal vision; no  No significant     Near-normal        Moderate low       .................  Profound low       Total visual     
 mnths).              significant loss   loss of VA; VA     vision; VA is 20/  vision; VA is 20/                     vision; VA is <5/  impairment;     
                      of VA; VA is 20/   is 20/25 or        30-20/60.          70-20/160.                            200 (count         black blind; no 
                      25 or better; no   better but                           Face close to                          fingers at less    light           
                      functional         functional                            page                                  than 3mo) but      perception.     
                      diplopia.          diplopia is                          Up close to                            with light                         
                                         present.                              blackboard or                         perception.                        
                                                                               front of room.                                                           
>10 yrs120 months.       significant loss   loss of VA; VA     vision; VA is 20/  vision; VA is 20/  vision; legally    vision; VA is <5/  impairment;     
                      of VA; VA is 20/   is 20/25 or        30-20/60.          70-20/160.         blind in USA; VA   200 (count         black blind; no 
                      25 or better; no   better but                                               is 20/200-5/200.   fingers at less    light           
                      functional         functional                                                                  than 3 mo) but     perception.     
                      diplopia.          diplopia is                                                                 with light                         
                                         present.                                                                    perception.                        
--------------------------------------------------------------------------------------------------------------------------------------------------------
Best Eye--Remember most Pedi Injuries unilateral and until 8-10 years old children will have only transient diplopia and then suppression of the poorer 
  eye.                                                                                                                                                  
School Age--can ask regarding school eye screen.                                                                                                        
Without visual field.                                                                                                                                   


                                          Auditory Function in One Ear                                          
----------------------------------------------------------------------------------------------------------------
                                                                                                    Level E:    
       Function            Level A: No     Level B: Minor       Level C:       Level D: Severe     Profound or  
                           limitations          loss          Moderate loss         loss           total loss   
----------------------------------------------------------------------------------------------------------------
1yr-<2yrs (12-23        No significant    ................  Moderate to       ................  Profound to     
 mnths).                 loss able to                        moderately                          total loss; non-
                         hear under                          severe loss;                        correctable;   
                         everyday                            average hearing                     average hearing
                         listening                           level at 500,                       level at 500,  
                         conditions;                         1000, 2000 and                      1000, 2000 and 
                         average hearing                     3000 Hz is 41-                      3000 is Hz >91 
                         level at 500,                       70 Difficulty                       Difficulty     
                         1000, 2000 and                      with                                hearing all but
                         3000 Hz 25 with                          beyond 3-5 ft.,                     sounds Failure 
                         understanding                       classroom or                        to respond,    
                         of simple                           group                               awaken, or move
                         phrases.                            discussion with                     to loud        
                                                             significant                         environmental  
                                                             difficulty                          sounds.        
                                                             understanding                                      
                                                             simple phrases.                                    
2yrs->10yrs (24mnths--  No significant    Minor loss        Moderate to       Severe loss;      Profound to     
 120 mnths).  loss able to      correctable       moderately        average hearing   total loss; non-
                         hear under        with readily      severe loss;      level at 500,     correctable;   
                         everyday          available         average hearing   1000, 2000 and    average hearing
                         listening         hearing aid;      level at 500,     3000 Hz is 71-    level at 500,  
                         conditions;       average hearing   1000, 2000 and    91 Difficulty     1000, 2000 and 
                         average hearing   level at 500,     3000 Hz is 41-    with anything     3000 Hz is >91 
                         level at 500,     1000, 2000 and    70 Difficulty     but shouted or    Difficulty     
                         1000, 2000 and    3000 Hz is 26-    with              amplified         hearing all but
                         3000 Hz25.            with faint or     beyond 3-5 ft.,                     sounds.        
                                           distant speech.   classroom or                                       
                                                             group                                              
                                                             discussion.                                        
----------------------------------------------------------------------------------------------------------------
Reference                                                                                                       
* Goodman, A.C. and Chasin, W.D.: In Gellis, SS and Kagan B.M. (Eds): Current Pediatric Therapy 7th Ed W.B.     
  Saunders Co. Phila, 1976 p.518 (or whole Pedi Catalog Vol 1 p.15).                                            


                                                 Speech/Language                                                
----------------------------------------------------------------------------------------------------------------
                                                                       Level C: Moderate-                       
       Function              Level A: No           Level B: Mild       severe limitations      Level D: Global  
                             limitations            limitations                                  limitations    
----------------------------------------------------------------------------------------------------------------
12-14 mos.............  Vocabulary of 4-6      Vocabulary of 1-2      Sparse output mainly  Maximum difficulty; 
                         words; recognizes      words; imitates        jargon; does not      no speech; minimal 
                         own name; mixes        sounds of adults       recognize name or     comprehension of   
                         words with jargon;     inconsistently;        follow motor          commands.          
                         follows simple motor   minimal language       instructions.                            
                         instructions (esp.     comprehension;                                                  
                         if accompanied by      smiles in response                                              
                         visual cue).           to presence of                                                  
                                                caregiver or                                                    
                                                familiar person;                                                
                                                listens at least                                                
                                                momentarily when                                                
                                                spoken to by a                                                  
                                                caregiver.                                                      
15-18 mos.............  Vocabulary of 8-20     Vocabulary of 4-6      Vocabulary of 1-2     Maximum difficulty; 
                         words; uses words      words; recognizes      words; recognizes     no speech; minimal 
                         and jargon in          own name, but does     own name, but does    comprehension of   
                         conversation;          not follow motor       not follow motor      commands.          
                         identifies some body   instructions; smiles   instructions;                            
                         parts; sings           in response to         intelligibility of                       
                         spontaneously.         presence of            speech compromised                       
                                                caregiver or other     by articulation                          
                                                familiar person;       defect.                                  
                                                mild articulation                                               
                                                defect without                                                  
                                                compromise of                                                   
                                                intelligibility.                                                
19-23 mos.............  Vocabulary of 30-300   Vocabulary of 8-20     Vocabulary of 4-6     Maximum difficulty; 
                         words; uses ``I''      words; mixes words     words; mixes words    no speech; minimal 
                         and ``mine''; tries    with jargon; follows   with jargon;          comprehension of   
                         to tell experiences;   simple motor           follows simple        commands.          
                         uses short,            instructions and       motor instructions;                      
                         incomplete             identifies some body   intelligibility of                       
                         sentences; uses        parts; mild            speech compromised                       
                         prepositions and       articulation defect    by articulation                          
                         regular verb           without compromise     defect.                                  
                         endings; follows 1-2   of intelligibility.                                             
                         step commands.                                                                         
24-36 mos.............  Uses a range of words  Vocabulary of 30-300   Vocabulary of 8-20    Maximum difficulty; 
                         which is normal for    words; uses words      words; mixes words    no speech; minimal 
                         age (vocabulary of     and jargon in short,   with jargon;          comprehension of   
                         900-1000 words);       incomplete             follows simple        commands.          
                         sentences have 8 or    sentences;             motor instructions;                      
                         more words; uses       identifies some body   intelligibility of                       
                         ``he'' and ``she''     parts; sings           speech compromised                       
                         correctly; recites     spontaneously; mild    by articulation                          
                         rhymes, songs;         articulation defect    defect.                                  
                         follows 2-3 step       without compromise                                              
                         commands; identifies   of intelligibility.                                             
                         2 colors; sentences                                                                    
                         have subject and                                                                       
                         verb; talks about                                                                      
                         present.                                                                               
37-47 mos.............  Uses a range of words  Uses a range of words  Vocabulary of 30-300  Maximum difficulty; 
                         which is normal for    slightly below other   words; uses words     no speech; minimal 
                         age (Vocabulary of     children of same age   and jargon in         comprehension of   
                         1,000-1,500 words);    (vocabulary of 900-    short, incomplete     commands.          
                         talks about the        1000 words);           sentences;                               
                         present; states        sentences have 8 or    identifies some                          
                         number of siblings.    more words; uses       body parts; sings                        
                                                ``he'' and ``she''     spontaneously;                           
                                                correctly; recites     intelligibility of                       
                                                rhymes, songs;         speech compromised                       
                                                follows 2-3 step       by articulation                          
                                                commands; identifies   defect.                                  
                                                2 colors; sentences                                             
                                                have subject and                                                
                                                verb; talks about                                               
                                                present; mild                                                   
                                                articulation defect                                             
                                                without compromise                                              
                                                of intelligibility.                                             
48-59 mos.............  Uses a range of words  Uses a range of words  Uses significantly    Maximum difficulty; 
                         which is normal for    slightly below other   fewer words than      no speech; minimal 
                         age (vocabulary of     children of same age   other children of     comprehension of   
                         1500-2200 words);      (vocabulary of 1000-   same age              commands.          
                         increases complexity   1500 words); uses      (vocabulary of 900-                      
                         of sentences;          ``I'' and ``mine'';    1000 words); uses                        
                         recounts the past;     tries to tell          words and jargon in                      
                         asks many questions;   experiences; uses      conversation;                            
                         understands most       short sentences        identifies body                          
                         questions about the    which range from       parts;                                   
                         immediate              complete with          intelligibility of                       
                         environment; has       subject and verb to    speech compromised                       
                         75%+ grammar           incomplete             by articulation                          
                         acquisition;           sentences; follows 1-  defect.                                  
                         discusses feelings;    2 step commands;                                                
                         follows 3-step         mild articulation                                               
                         commands.              defect without                                                  
                                                compromise of                                                   
                                                intelligibility.                                                

[[Page 45915]]

                                                                                                                
5-<8 years............  Uses a range of words  Uses a range of words  Uses significantly    Maximum difficulty; 
                         which is normal for    slightly below other   fewer words than      no speech; minimal 
                         age (vocabulary of     children of same age   other children of     comprehension of   
                         2,500+ words);         (vocabulary of 1500-   same age              commands.          
                         understands a range    2200 words);           (vocabulary of 1000-                     
                         of words which is      sentences have 8+      1500 words); uses                        
                         normal for age         words; uses ``he''     ``I'' and ``mine'';                      
                         (20,000-24,000         and ``she''            tries to tell                            
                         words); uses all       correctly; follows 2   experiences; uses                        
                         parts of speech to     step commands; mild    short, incomplete                        
                         some degree;           articulation defect    sentences; follows                       
                         verbalizes ideas;      without compromise     1-2 step commands;                       
                         talks a lot.           of intelligibility.    intelligibility of                       
                                                                       speech compromised                       
                                                                       by articulation                          
                                                                       defect.                                  
8-<10 years...........  Uses a range of words  Uses a range of words  Uses significantly    Maximum difficulty; 
                         which is normal for    slightly below other   fewer words than      no speech; minimal 
                         age (vocabulary of     children of same age   other children of     comprehension of   
                         5,000+ words);         (vocabulary of         same age              commands.          
                         understands a range    2,500+ words); 75%     (vocabulary of 1500-                     
                         of words which is      grammar acquisition;   2200 words);                             
                         normal for age         follows 3 step         recites alphabet;                        
                         (25,000+ words);       commands; verbalizes   tells plot of a                          
                         able to write          ideas; mild            fairy tale; follows                      
                         fluently either in     articulation defect    2-step commands;                         
                         cursive or in          without compromise     25% grammar                              
                         printed characters;    of intelligibility.    acquisition;                             
                         prints or writes                              intelligibility of                       
                         sentences of 3 to 4                           speech compromised                       
                         words; reads at or                            by articulation                          
                         above second grade                            defect.                                  
                         level; gives complex                                                                   
                         directions to others.                                                                  
>10 years.............  Uses a range of words  Uses a range of words  Uses significantly    Maximum difficulty; 
                         which is normal for    slightly below other   fewer words than      no speech; minimal 
                         age (vocabulary of     children of same age   children of same      comprehension of   
                         25,000+ words);        (vocabulary of         age (vocabulary of    commands.          
                         talks a lot;           5,000+ words);         2,500 words);                            
                         understands a range    increases complexity   sentences have 8+                        
                         of words which is      of sentences using     words; uses ``he''                       
                         normal for age         all parts of speech    and ``she''                              
                         (approximately         to some degree;        correctly; follows                       
                         50,000 words).         understands a range    2 step commands;                         
                                                of words slightly      intelligibility of                       
                                                below other children   speech compromised                       
                                                of same age (20,000+   by articulation                          
                                                words); 75% grammar    defect.                                  
                                                acquisition; follows                                            
                                                3-step commands;                                                
                                                mild articulation                                               
                                                defect without                                                  
                                                compromise of                                                   
                                                intelligibility.                                                
----------------------------------------------------------------------------------------------------------------


                                                    Cognition                                                   
----------------------------------------------------------------------------------------------------------------
                                                                       Level C: Moderate-                       
       Function              Level A: No           Level B: Mild       severe limitations      Level D: Global  
                             limitations            limitations                                  limitations    
----------------------------------------------------------------------------------------------------------------
12-14 mos.............  Uses common objects    Brings 2 blocks        Inconsistent          No response to book;
                         appropriately; helps   together, usually      response to book;     no response to     
                         to turn pages; tries   lifting them and       variable response     blocks; no use of  
                         to pick up cubes;      comparing them, but    to blocks; no use     crayon; fails to   
                         builds tower of 2      does not build a       of crayon;            attend to          
                         blocks;                tower; touches book    inconsistently        interactive toy or 
                         spontaneously          but does not turn      maintains attention.  picture.           
                         scribbles or           page; picks up                                                  
                         imitates; searches     crayon but fails to                                             
                         for objects;           scribble; maintains                                             
                         maintains attention    attention for one                                               
                         for 2 minutes to an    minute to an                                                    
                         interactive toy or     interactive toy/                                                
                         picture.               picture.                                                        
Learning/memory.......  Searches in a          Fails to consistently  No response to        Max difficulty; does
                         location where an      search for hidden      hidden object.        not search.        
                         object was last        object.                                                         
                         hidden.                                                                                
15-18 mos.............  Imitates adult object  Uses common objects    Inconsistent          No response to book;
                         use and motor acts;    appropriately; helps   response to toy or    no response to     
                         turns 2-3 pgs at a     to turn pages; tries   to book;              blocks; no use of  
                         time; initiates        to pick up cubes;      inconsistently uses   crayon; no response
                         crayon stroke;         builds tower of two    crayon; no response   to toy; no response
                         builds 3 block         blocks;                to placing            to placing         
                         tower;places           spontaneously          different shaped      different shaped   
                         different shaped       scribbles or           objects in            objects in         
                         objects in different   imitates; searches     different sized       different sized    
                         sized holes;           for objects; mild      holes; fails to       holes; max         
                         maintains attention    difficulty             maintain attention    difficulty.        
                         for 2 minutes or       sustaining attention   for 2 minutes to an                      
                         more to an             for more than 2        interactive toy or                       
                         interactive toy or     minutes, easily        picture; brings 2                        
                         picture.               distracted.            blocks together,                         
                                                                       usually lifting                          
                                                                       them and comparing                       
                                                                       them, but does not                       
                                                                       build a tower.                           
Learning/memory.......  Remembers places       Searches in a          Fails to              Max difficulty; no  
                         where familiar         location where an      consistently search   response.          
                         objects are usually    object was last        for hidden object.                       
                         located (toys in       hidden.                                                         
                         toybox).                                                                               
19-23 mos.............  Builds tower of 5-7    Builds 3 block tower;  Builds tower of 2     No response to book;
                         blocks; imitates       turns 2-3 pages at a   blocks;               no response to     
                         circular scribble      time; initiates        inconsistently uses   blocks; no use of  
                         and/or vertical        crayon stroke;         crayon;               crayon; no response
                         stroke; places         places different       inconsistently        to toy; no response
                         different shaped       shaped objects in      places different      to placing         
                         objects in different   different sized        shaped objects in     different shaped   
                         sized holes even       holes; mild            different sized       objects in         
                         after rotation; sits   difficulty             holes; inconsistent   different sized    
                         alone for short        sustaining attention   response to toy;      holes; max         
                         periods with book;     for more than 2 to 3   scribbles with        difficulty.        
                         maintains attention    minutes, easily        crayon;                                  
                         for 3 to 4 minutes     distracted.            inconsistently                           
                         or more to an                                 maintains attention                      
                         interactive toy or                            for 2 minutes.                           
                         picture.                                                                               
Learning/memory.......  Recognizes pictures    Remembers places       Searches in a         Max difficulty;     
                         in picture book.       where familiar         location where an     minimal search.    
                                                objects are usually    object was last                          
                                                located (toys in       hidden.                                  
                                                toybox).                                                        
24-30 mos.............  Matches familiar       Builds 5-7 block       Builds tower of 3 or  No response to book;
                         objects; builds        tower; scribbles       fewer blocks; plays   no response to     
                         tower of 8-9 blocks;   spontaneously with a   with crayon but not   blocks; no use of  
                         makes circular         crayon; places         without prompting/    crayon; no response
                         strokes with crayon;   different shaped       imitation scribbles   to toy; no response
                         knows big and little   objects in different   using crayon; tries   to placing         
                         concepts;maintains     sized holes even       but usually unable    different shaped   
                         attention for 5        after rotation; mild   to place different    objects in         
                         minutes or longer on   difficulty             shaped objects in     different sized    
                         one interactive        sustaining attention   different sized       holes; max         
                         activity.              for more than 3-4      holes.                difficulty.        
                                                minutes, easily                                                 
                                                distracted.                                                     
Learning/memory.......  Remembers one item;    Recognizes pictures    Remembers places      Max difficulty;     
                         repeats 2 items, 1     in picture book.       where familiar        minimal search.    
                         of 3 trials.                                  objects are usually                      
                                                                       located (toys in                         
                                                                       toybox).                                 
31-36 mos.............  Creates                Builds 8-9 block       Builds 5-7 block      No response to book;
                         representational       tower; imitates a      tower; places         no response to     
                         art; matches primary   circular scribble;     different shaped      blocks; no use of  
                         colors; engages in     mild difficulty        objects in            crayon; no response
                         make-believe play      sustaining attention   different shaped      to toy; no response
                         unconstrained by       for more than 5        holes even after      to placing         
                         objects; builds        minutes; easily        rotation;             different shaped   
                         tower of 10 cubes;     distracted.            inconsistently        objects in         
                         imitates bridge;                              maintains attention   different sized    
                         copies circle;                                for 3-4 minutes on    holes; max         
                         places 7 different                            one toy or activity.  difficulty.        
                         shaped objects in                                                                      
                         different sized                                                                        
                         holes; maintains                                                                       
                         attention for 6-7                                                                      
                         minutes or longer on                                                                   
                         one interactive                                                                        
                         activity.                                                                              
Learning/memory.......  Remembers 2 items;     Remembers one item;    Recognizes pictures   Max difficulty;     
                         repeats 3 items, 1     repeats 2 items, 1     in picture book.      minimal search.    
                         of 3 trials.           of 3 trials.                                                    
37-47 mos.............  Knows 4 actions;       Creates                Builds 8-9 block      No response to book;
                         maintains attention    representational       tower; imitates a     no response to     
                         for 10-11 min; can     art; matches primary   circular scribble;    blocks; no use of  
                         show use of 2          colors; engages in     mild difficulty       crayon; no response
                         objects; imitates a    make-believe play      sustaining            to placing         
                         square or better;      unconstrained by       attention for more    different shaped   
                         can build a bridge     objects; builds        than 5 minutes;       objects in         
                         with blocks.           tower of 10 cubes;     easily distracted.    different sized    
                                                imitates bridge;                             holes; max         
                                                copies circle;                               difficulty.        
                                                places 7 different                                              
                                                shaped objects in                                               
                                                different sized                                                 
                                                holes; maintains                                                
                                                attention for 6-7                                               
                                                minutes or longer on                                            
                                                one activity.                                                   
Learning/memory.......  Remembers 3 items;     Remembers 2 items;     Remembers one item;   Inconsistently      
                         repeats 4 items, 1     repeats 3 items; 1     repeats 2 items, 1    recognizes picture 
                         of 3 trials.           of 3 trials.           of 3 trials.          Max difficulty; no 
                                                                                             response.          

[[Page 45916]]

                                                                                                                
48-59 mos.............  Knows own right and    Matches familiar       Builds 10 block       No response to book;
                         left; develops time    objects; knows big     tower; imitates a     no response to     
                         concepts; recognizes   and little; builds     circle; repeats 1     blocks; no use of  
                         relationships of       bridge with blocks;    item, 1 of 3          crayon; no response
                         parts to whole;        imitates a circle      trials, places 7      to formboard or    
                         categorizes types of   with a crayon; knows   different shaped      other toy; max     
                         animals; counts        big and little         objects in            difficulty.        
                         rotely up to 13; can   concepts; mild         different sized                          
                         show 3 objects;        difficulty             holes;                                   
                         understands concepts   sustaining attention   inconsistently                           
                         of 3; labels some      for 10 minutes;        maintains attention                      
                         coins; maintains       easily distracted.     for 7-8 minutes.                         
                         attention for 11-13                                                                    
                         minutes on one                                                                         
                         interactive activity.                                                                  
Learning/memory.......  Remembers 4            Remembers 3 items;     Remembers 2 items;    Max difficulty; may 
                         items;repeats 5        remembers places       repeats 3 items, 1    recall 1 item.     
                         items, 1 of 3          where familiar         of 3 trials.                             
                         trials; learns         objects are usually                                             
                         sequences such as      located; repeats 4                                              
                         days of the week;      items, 1 of 3 trials.                                           
                         recalls gist of a                                                                      
                         short story;                                                                           
                         recognizes series of                                                                   
                         pictures.                                                                              
5-<8 years............  Longer attention span  Builds tower of 6-7    Builds tower of 4-5   No response to book;
                         for 15 minutes or      blocks; creates        blocks; imitates a    no response to     
                         more on one            representational       circle;               blocks; no use of  
                         activity; knows left   art; matches primary   inconsistently        crayon; no response
                         and right of others;   colors; engages in     maintains attention   to placing         
                         understands            make-believe play      for 9-10 minutes.     different shaped   
                         conversation; knows    unconstrained by                             objects in         
                         differences and        objects; mild                                different sized    
                         similarities; reads    difficulty                                   holes; max         
                         spontaneously.         sustaining attention                         difficulty.        
                                                for more than 10                                                
                                                minutes, easily                                                 
                                                distracted.                                                     
Learning/memory.......  Remembers and repeats  Remembers 4 items;     Remembers 1-2 items;  Max difficulty.     
                         5 items; learns a      learns sequences       partial recall of a                      
                         list of 6-8 words.     such as months of      short story;                             
                                                the year; recalls      repeats 1-2 items,                       
                                                gist of a short        1 of 3 trials                            
                                                story; recognizes a    Remembers 3 items;                       
                                                series of pictures;    remembers places                         
                                                repeats 5 items, 1     where familiar                           
                                                of 3 trials.           objects are usually                      
                                                                       located; repeats 4                       
                                                                       items, 1 of 3                            
                                                                       trials.                                  
Academic progress.....  No change from         Some decline in        Some or all classes   Homebound or        
                         preinjury.             grades since injury    are resources         institutionalized. 
                                                but remains in         (special                                 
                                                similar classes        education), but                          
                                                (e.g. mainstream).     attends school full                      
                                                                       time.                                    
8-<10 years...........  Reads books at second  Knows own right from   Builds tower of 6-7   Max difficulty; no  
                         to fourth grade        left; develops time    blocks; creates       response to book or
                         level; writes neatly   concepts; recognizes   representational      blocks.            
                         most of the time;      relationships of       art; matches                             
                         can give complex       specific parts to      primary colors;                          
                         directions to          whole; counts rotely   engages in make-                         
                         others, i.e. how to    up to 13; prints/      believe play;                            
                         use key to unlock      writes at least 10     inconsistently                           
                         door; knows right      words from memory      maintains attention                      
                         and left of others;    states month and day   for 10-15 minutes.                       
                         understands            of birthday; recites                                            
                         conversation;          alphabet; reads at                                              
                         maintains attention    least 3 common                                                  
                         for 30 minutes or      signs; mild                                                     
                         more on one activity.  difficulty                                                      
                                                sustaining attention                                            
                                                for 15 minutes or                                               
                                                more; easily                                                    
                                                distracted.                                                     
Learning/memory.......  Remembers and repeats  Remembers and repeats  Remembers 4 items;    Max difficulty;     
                         6 items; recalls       5 items; learns a      learns sequences      minimal recall or  
                         events, actions of a   list of 6-8 words;     such as months of     recognition of 1-2 
                         short story; learns    recalls gist of        the year; recalls     items.             
                         a list of 8-10 words.  story but not          gist of a short                          
                                                specific events and    story; recognizes a                      
                                                actions.               series of pictures;                      
                                                                       repeats 5 items, 1                       
                                                                       of 3 trials.                             
Academic progress.....  No change from         Some decline in        Some or all classes   Homebound or        
                         preinjury.             grades since injury    are resource          institutionalized. 
                                                but remains in         (special                                 
                                                similar classes        education), but                          
                                                (e.g. mainstream).     attends school full                      
                                                                       time.                                    
10 years...  Plans future actions;  Knows left and right;  Knows own right and   No response to book;
                         engages in abstract    understands            left; develops time   no response to     
                         thought; i.e. can      conversation; knows    concepts;             blocks; no use of  
                         interpret proverb      differences and        recognizes            crayon; no response
                         providing more than    similarities; reads    relationships of      to form board or   
                         a concrete             spontaneously; mild    parts to whole;       other toy; max     
                         explanation; solves    difficulty             categorizes; counts   difficulty.        
                         problems with only     sustaining attention   rotely up to 13;                         
                         minimal physical       for more than 30       can show 3 objects;                      
                         input; writes in       minutes, easily        understands concept                      
                         cursive, maintains     distracted.            of 3; labels some                        
                         attention for 60                              coins;                                   
                         minutes or more on                            inconsistently                           
                         one activity.                                 maintains attention                      
                                                                       for more than 15                         
                                                                       minutes.                                 
Learning/memory.......  Remembers and repeats  Remembers and repeats  Remembers and         Max difficulty; may 
                         7 items; repeats       6 items; learns a      repeats 5 items;      recall or recognize
                         details of short       list of 8-10 words.    learns a list of 6-   1-3 items.         
                         story; learns a list                          8 words.                                 
                         of 11-12 words;                                                                        
                         recognizes series of                                                                   
                         100+ pictures;                                                                         
                         memory approaches                                                                      
                         the level in                                                                           
                         adolescents and                                                                        
                         young adults (e.g.,                                                                    
                         recognizes faces of                                                                    
                         100+ classmates,                                                                       
                         friends, relatives).                                                                   
Academic progress.....  No change from         Some decline in        Some or all classes   Homebound or        
                         preinjury.             grades since injury    are resource          institutionalized. 
                                                but remains in         (special                                 
                                                similar classes        education), but                          
                                                (e.g. mainstream).     attends school full                      
                                                                       time.                                    
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[FR Doc. 97-22795 Filed 8-28-97; 8:45 am]
BILLING CODE 4910-59-P