Functional Capacity Index

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

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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

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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.

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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

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Level B:

Level A: No Controllable Level C: Moderate Level D: Severe

Function limitation excretory excretory excretory

difficulty difficulty difficulty

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1yr-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.

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Sexual Intercourse Functioning (Prediction of Adult Sexual Function)

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Level C: Severe

Function Leval A: No limitation Level B: Moderate limitation (or no sexual

difficulty function possible)

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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).

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Ambulation (Stair Climbing)

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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

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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.

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Ambulation (Standing, Walking, Running)

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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

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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.

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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

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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

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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.

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Bending and Lifting

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Level A: No Level B: Minor Level C: Major Level D: Cannot

Function limitation limitation limitation bend or lift

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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.

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* Norms are needed for ``appropriate'' amount and minimal amount of weight to age for a pediatric population.

Vision

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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

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1yr-10 yrs120 months. significant loss loss of VA; VA vision; VA is 20/ vision; VA is 20/ vision; legally vision; VA is z 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.

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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

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Level C: Moderate-

Function Level A: No Level B: Mild severe limitations Level D: Global

limitations limitations limitations

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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]]

5-10 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.

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Cognition

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Level C: Moderate-

Function Level A: No Level B: Mild severe limitations Level D: Global

limitations limitations limitations

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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.

5-10 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