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The Capute Scales

The Capute Scales

Cognitive Adaptive Test and Clinical Linguistic & Auditory Milestone Scale (CAT/CLAMS)
Authors: Pasquale J. Accardo M.D., Arnold J. Capute   With Authors: Anna Bennett M.P.H., Elena S. Keshishian, Mary O'Connor Leppert, Thomas R. Montgomery, Michael E. Msall, Brian T. Rogers, Paul F. Visintainer Ph.D., Robert G. Voigt   Volume Editor: Barbara Y. Whitman M.S.W., Ph.D.

ISBN: 978-1-55766-813-4
Pages: 136
Copyright: 2005
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Size:  8.5 x 11.0
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Created for use in clinical settings, The Capute Scales are effective both as a screener for general practitioners and as an assessment tool for specialists such as developmental pediatricians, speech-language pathologists, and occupational therapists. With its high correlation with the Bayley Scales of Infant Development, this standardized instrument will assist clinicians in making developmental diagnoses, counseling families, and guiding them to appropriate intervention services.

The Capute Scales Manual includes an explanation of the scales' development, guidelines on administration and scoring, an overview of clinical and research use, and information on standardization of the scales and their use in other languages.

Available in other languages! Spanish and Russian translations of The Capute Scales are included in the manual, and work on other translations is ongoing.

This manual is part of The Capute Scales, a norm-referenced, 100-item screening and assessment tool that helps experienced practitioners identify developmental delays in children from 1–36 months of age. Developed by Arnold J. Capute, the founding father of neurodevelopmental pediatrics, this reliable, easy-to-administer tool was tested and refined at the Kennedy Krieger Institute for more than 30 years.

Learn more about The Capute Scales.

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Review by: Paul Lipkin, Kennedy Krieger Institute, Johns Hopkins University School of Medicine
"I've been using this unique tool for many years! It offers the clinician a broader view of the neurologic development of children in a quick and easy administration format, making it well suited to the clinical setting."
Review by: Claudine Amiel-Tison, Professor of Pediatrics, University of Paris
"A great assessment tool. . . . Pediatricians will rapidly understand how much they learn about child development."
Review by: Isabelle Rapin, Albert Einstein College of Medicine
"Great advantages of The Capute Scales are that they are quick and cheap because they require limited training and can be given reliably by a variety of clinicians. . . . I foresee their increasing use in infant and toddler research."

About the Authors
Advisory Board and Contributors

  1. Development of the Capute Scales
    Mary L. O'Connor Leppert

  2. Administration and Scoring of the Capute Scales
    Mary L. O'Connor Leppert

  3. The Clinical Use of the Capute Scales
    Brian T. Rogers and Pasquale J. Accardo

  4. The Capute Scales in Research
    Robert Voigt

  5. Standardization of the Capute Scales
    Paul F. Visintainer and Anna Bennett
Appendix A: The Capute Scales in Spanish: Pilot Study for Use Among Hispanic Children During Well-Child Care
Michael E. Msall

Appendix B: The Capute Scales in Russia
Thomas Montgomery and Elena S. Keshishian

Appendix C: Sample Capute Scales Scoring Sheets
Mary L. O'Connor Leppert


Excerpted from Chapter 1 of The Capute Scales: Cognitive Adaptive Test and Clinical Linguistic and Auditory Milestone Scale, by Pasquale J. Accardo, M.D., and Arnold J. Capute, M.D., M.P.H., with Anna Bennett, M.P.H., Elena S. Keshishian, M.D., Ph.D., Mary L. O’Connor Leppert, M.D., Thomas R. Montgomery, M.D., Michael E. Msall, M.D., Brian T. Rogers, M.D., Paul F. Visintainer, Ph.D., Robert G. Voigt, M.D., and Barbara Y. Whitman, Ph.D.

Copyright©2005 by Paul H. Brookes Publishing Co. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

The Capute Scales are among the many contributions of Dr. Arnold J. Capute to the field of developmental disabilities. The Capute Scales are designed to assess the cognitive (language and visual-motor) streams of development in children with a cognitive age of 36 months or younger. The assessment batteries are intended for use in any setting in which the expeditious evaluation of the cognitive levels of young children is required. Dr. Capute began his work in developmental disabilities in the mid-1960s at The Johns Hopkins Hospital and continued shortly thereafter at the John F. Kennedy Institute (later called the Kennedy Krieger Institute), where he spent the rest of his career developing the field and improving the evaluation and treatment of children with varied disabilities. As the “father of developmental pediatrics” in the United States, he contributed a tremendous amount to the body of knowledge, research, care, and advocacy for children with special needs. Dr. Capute left a legacy that includes hundreds of trainees around the United States and the world who are dedicated to improving the care of children with disabilities. Publication of this manual ensures that this important work will continue.


In 1986, Congress passed PL 99-457, the Education of the Handicapped Act Amendments, which provided incentives for establishing early intervention programs to children with developmental delays who are younger than 3 years of age (DeGraw et al., 1988). Subsequently, the Individuals with Disabilities Education Act and its Amendments have mandated early identification and intervention for infants and toddlers (Sandler et al., 2001). Thus, families have easy access to appropriate services for children who are determined to be eligible for interventions such as special education, audiological assessment, and physical, occupational, and speech therapies. Identification of children who have or are at risk for delay is often determined by the pediatrician or primary care provider, who is uniquely positioned and trained to observe infant development and respond to parental concerns about development. Suspicion of atypical development must prompt further assessment of all streams of development — gross motor, visual-motor, language, social, and adaptive skills — in order to identify the areas of disability.

The care of the child with a disability begins with the identification of delay and medical diagnosis of the disability. The purpose of early diagnosis is fivefold:

  1. To define the disorder causing concerns about development (e.g., mental retardation, cerebral palsy, autism, hearing impairment, communication disorders)

  2. To investigate the etiology of the disorder (e.g., metabolic derangement, genetic disorder, anoxic injury, toxic exposure)

  3. To assess for the presence of associated disorders

  4. To direct intervention services and follow up needs

  5. To provide appropriate counsel to the child’s family regarding the implications of the diagnosis

It is in defining the diagnosis that we can begin to inform the parents about their child’s disability and any associated difficulties that may need to be addressed, what the diagnosis may mean for siblings or future offspring, and what the future is likely to hold for the child who is being assessed. However, until now, primary care physicians have been challenged to find tests that can quantify developmental rates and allow them to apply the results of testing to determine the presence of delay in order to formulate diagnoses.


Dr. Capute continually acknowledged the work of Dr. Arnold Gesell, who assiduously recorded the typical sequence and timing of milestone acquisition in each of the five streams of development: gross motor, visual-motor, language, adaptive, and social. Gesell observed that in typical children, development is an orderly, timed, and sequential process that occurs with such regularity that it is predictable (Gesell & Amatruda, 1947). The predictable timing and sequence of milestone acquisition is the basis of all developmental assessment.

Gesell contributed the first developmental assessment measure for infants and young children (Gesell & Amatruda, 1947). Gesell’s initial test battery included a large number of test items, employed many test instruments, and took quite a bit of time to administer. The quantification of development was accomplished with the developmental quotient (DQ), which measures the rate of development within a given stream. Gesell considered the DQ the representation of the proportion of typical development present in a given child at the time of testing (Gesell & Amatruda, 1947). Arithmetically, the DQ is defined as the age-equivalent at which a child is functioning in any given stream of development divided by the chronological age of the child and represented as a percentage. So, for example, a child whose best motor function is to sit unsupported (a 6-month age-equivalent) at a chronological age of 12 months would have a DQ of 50; thus, the child would be exhibiting 50% of the development expected for a 12-month-old child. The regularity and predictability of typical development provides a paradigm by which atypical development may be appreciated. Atypical development may take any one or a combination of three patterns: delay, deviancy, or dissociation. These are discussed in the section that follows.


Developmental delay is defined as a slower rate of milestone acquisition than is normally expected, but the order and sequence of milestone acquisition are typical. Delay may be seen in a single stream of development or across several streams and is determined by the presence of a DQ that is less than 70%–75%. The pattern of a child’s developmental rate over time may be of both diagnostic and prognostic value. Longitudinal assessments of development that portray a consistent, albeit delayed, developmental pattern are prognostic of future delay. A pattern of normal developmental rate followed by a plateau or regression in developmental rate raises etiologic concerns of degenerative disorders. In addition, developmental rate may be used to monitor recovery or the response to therapy in a child who has previously demonstrated a delay.

Deviancy is the nonsequential acquisition of milestones within a specific developmental stream. As an example, a parent may report that a child rolls over at 2 months (the age expected for this milestone is 4–5 months), but examination indicates that the child’s highest motor skill is propping up on his or her elbows in prone position (a 3-month age skill). This motor vignette is considered deviant in that propping up to elbows then to wrists in prone position should precede rolling. In the language stream, deviancy is seen in the uncoupling in the rate of acquisition of receptive and expressive milestones, or in the uncoupling of expressive milestones alone, such as the child reported to have a 100-word vocabulary (age expectancy of greater than 24 months) but who cannot speak in phrases (age expectancy of 21 months). In contrast to delay and dissociation, deviancy does not imply a diagnosis but indicates to the clinician that an underlying pathology is likely to be causing the deviancy within that stream and therefore requires further assessment.

Dissociation is an uneven rate of milestone acquisition (DQ) when comparing two or more streams of development. An example of dissociation is seen in a 24-month-old child with gross motor skills at a 12-month age-equivalent (DQ = 50) but with language and visual-motor skills that approximate his or her chronological age (DQs = near 100). In this example, the child demonstrates significant motor delay that is dissociated from other streams of development, suggesting the possible presence of cerebral palsy (see Table 1.1).

Gesell’s observations and study of normal milestone acquisition, and his contributions of the DQ and the principles of development (delay, deviancy, and dissociation), have provided the necessary components of most standardized developmental assessment tools that have followed Gesell’s original test. Gesell’s test was revised by Cattell, who considerably shortened the assessment test (Cattell, 1940). Cattell eliminated test items that were cumbersome, items that employed instruments that were used at limited test ages, and items that were subjective in their interpretation and were therefore less likely to be scored consistently. The works of Gesell and then Cattell have been modified further by a number of clinicians dedicated to the study of development in young children, including Ronald Illingsworth (1987), Mary Sheridan (1968), and Nancy Bayley (1969, 1993), among others.


Language delay is a common complaint that parents bring to the attention of their child’s primary care physician. Dr. Capute taught that language delay is a marker for three common disorders in children younger than 36 months but that these three disorders have very different prognoses. The differential diagnosis of language delay includes hearing impairment, mental retardation, and communication disorders.

The three primary differential diagnoses present with similar concerns: failure to understand spoken words, limited vocabulary, lack of phrase or sentence use at appropriate ages, or failure to produce intelligible speech. The age at which children present with these very different diagnoses is similar and therefore not helpful in distinguishing the underlying problem. The average age of presentation for children with mental retardation is 27 months, whereas the average age of presentation for communication disorders is 32 months in the unscreened population (Lock, Shapiro, Ross, & Capute, 1986). Communication disorders consist of a plethora of differential diagnoses including speech production disorders, receptive and expressive language disorders, expressive language disorders, autism spectrum disorders, and selective mutism.

Determination of the etiology of language delay begins with an audiological assessment to rule out hearing impairment. In the presence of adequate hearing, assessment turns to the two cognitive streams of development: language skills and visual motor abilities. In the primary care setting, one should be able to measure language and visual-motor skills with an instrument that can quantify the rate of development in each stream individually. By using a DQ, one can determine the rate of development within the stream and identify delay. The presence of delay and the application of dissociation form the premises of diagnoses. A child with normal hearing who has significant delay (DQ < 70) in both cognitive streams is likely to have mental retardation. A child with delay in language but normal abilities in visual-motor skills (dissociation) likely has normal cognition with a communication disorder (see Table 1.1).


The precursor to the language battery of the Capute Scales was initially introduced in 1973 (Capute & Biehl, 1993). A revised language scale was published in 1978 with the intention of “providing the pediatrician with a scale of linguistic and auditory milestones, which can be rapidly applied within the constraints of a busy practice” (Capute & Accardo, 1978). The original language test battery was known as the Clinical Linguistic & Auditory Milestone Scale (CLAMS). The CLAMS delineated 29 sequential milestones from birth to 24 months of age. In 1986, Capute and colleagues published normative data on the age of attainment of 25 linguistic and auditory milestones in the first 24 months of life, based on parental report of infants and toddlers followed longitudinally (Capute, Palmer, et al., 1986). Following the standardization study, the CLAMS was found to adequately identify children with cognitive delay when correlated to the Bayley Scales of Infant Development (BSID) in a group of children with motor impairment (Capute, Shapiro, Wachtel, Gunther, & Palmer, 1986).

In an effort to provide a means of distinguishing isolated language delays or communication disorders from more global cognitive impairments, a visual-motor battery was added to the existing language scale. The original test measure was called the Cognitive Adaptive Test/Clinical Linguistic & Auditory Milestone Scale (CAT/CLAMS). The visual-motor battery (CAT) was drawn largely from the Cattell test of development but was modified further to make it practical in the office setting. Capute and his colleagues reduced the number of test items and limited the items to those that involve test instruments that cover a wide range of testing ages. Employing test items that can be used across a range of ages minimizes the number of shifts from one test item to another and maintains the engagement of the child. Test items that require subjective interpretation were also removed from the test battery. Finally, the CAT is not timed, in order to avoid penalizing the children with motor dysfunction, who may have poor quality of movement and require more time to execute test items such as arranging blocks or putting pegs into the pegboard.

Hoon and colleagues (1993) assessed the correlation of the CAT/CLAMS DQs and the BSID DQs in children with suspected developmental delay and found strong agreement between the assessment measures. Leppert and colleagues (1998) assessed the correlation of the CAT/CLAMS DQ and the Bayley Scales of Infant Development–Second Edition (BSID–II) DQ in their capacity to detect delay in a population of asymptomatic children with no known risk for delay. Again the DQs proved to correlate well, supporting the use of the CAT/CLAMS as a pediatric assessment tool in the primary care setting.

Most recently, a large multicenter standardization study was undertaken to assess the age-equivalents of visual-motor milestone attainment and to reassess the accuracy of attainment ages of language milestones as given in the Capute Scales. The details of the standardization study described in Chapter 5 support the current milestone age equivalents in both streams of the Capute Scales (Visintainer, Leppert, Bennett, & Accardo, in press).