Validation of vulnerability markers of dysfunctions in the socioemotional development of infants

ABSTRACT Objectives: to validate the vulnerability markers of dysfunctions in the socioemotional development of infants. Methods: study with a sequential exploratory mixed-method design. The vulnerability markers elaborated in the qualitative phase were analyzed by experts in the quantitative phase using the Delphi technique with a minimum consensus of 70%. Seventeen judges answered the questionnaire in the first round of analysis and 11 answered in the second round. Results: in the first round, two markers did not reach minimum consensus: the presence of instability in family relationships (66%) and delinquency and/or drug abuse by parents/caregivers (65%). In the second round, all markers were validated, with more than 90% agreement in most of the attributes, and reached the minimum consensus of 73%. Conclusion: the eight vulnerability markers reached the minimum consensus for validation, and a relevant instrument for infant care can be developed after assessing the reliability and clinically validating these markers.


Introduction
The objective of this study was to validate the vulnerability markers of dysfunctions in the socioemotional development of infants. We attempted to construct an instrument that assessed dysfunctions in socioemotional development, which is determined by the maintenance or changes in social and emotional characteristics of children (1) and characterized by the expression of emotions in social contexts, in the social triggers of emotional expressions, and in the social construction of emotional experience and understanding (2) .
Socioemotional development is related to the development of the brain and the interactions or proximal processes experienced by the child from birth (1) and can be analyzed by evaluating developmental milestones from several domains, including attachment, social competence, emotional competence, and selfperception (3) .
The bioecological model of human development indicates that a child living in adverse conditions and in a disorganized environment is susceptible to developmental dysfunctions, including "recurrent difficulties in maintaining emotional control and integrating behavior in different developmental situations and domains" (1) . Therefore, child development is affected by biological and contextual factors (4)(5) .
Developmental dysfunctions include a group of diseases characterized by intellectual, physical, and social-emotional problems (6) . These dysfunctions are related to brain disorders caused by genetic changes or lesions in the central nervous system, exposure to teratogenic agents, trauma, infections, severe nutritional deficiency, and neonatal hypoxia or ischemia (6) . Studies have confirmed that sociocultural, socioeconomic, psychosocial, and biological factors affect child development in all its dimensions, including socioemotional (4,7) .
The technologies available to monitor child development include scales based on markers and expected behaviors for different age groups. These technologies assess the child's abilities but do not consider the factors that affect child development, leaving a significant gap in the analysis of dangerous situations.
The complexity of socioemotional development involves the concept of vulnerability, which is a set of conditions that make the child more susceptible to developmental dysfunctions due to the effect of individual, social, and programmatic dimensions (8) .
The concept of vulnerability demands the proposition of interventions based on health needs, development of social responses, autonomy in care, preservation of health, and integrality and equity of health actions (9) .
The need to instrumentalize health professionals to identify vulnerabilities in child development led to the proposition of the following question: How can professionals assess the vulnerability to dysfunctions in the socioemotional development of infants?
The construction of markers may help health professionals apply the concept of vulnerability as an indicator of qualitative aspects of the health-disease process at the individual and community levels, and these markers allow proposing interventions that address social responses to dysfunctions (9)(10) . The term "vulnerability marker" includes the interaction of subjective and contextual attributes in the healthdisease process as social and historical phenomena (11) .
This study assumes that the use of markers as health technologies, based on vulnerability elements, can improve care and socioemotional development by strengthening proximal processes, which are the specific forms of interaction between children and their environment (1) .

Method
This mixed-method study combined qualitative and quantitative methods (12) . A sequential exploratory design was used, including a first (qualitative) phase for marker construction and a second (quantitative) phase for content validation.
Vulnerability markers were elaborated in the qualitative phase. These markers are thematic categories of exposure factors that affect the socioemotional development of infants (13) and are theoretically based on the context dimensions of the bioecological model of human development-microsystem, mesosystem, exosystem, and macrosystem (1) -and the Child Vulnerability Matrix for situations that jeopardize child development in the individual, social, and programmatic dimensions (8) . In this study, infants are children younger than two years. The Delphi technique (14) was applied in the quantitative phase to validate the content of the markers, components, and operational manuals by researchers Rev. Latino-Am. Enfermagem 2018;26:e3087.

Limited autonomy and/or empowerment because of sociocultural conditions
Are parents/caregivers teenagers (younger than 18 years)? Does the family belong to an ethnic minority and/or vulnerable group (immigrants, refugees, indigenous people, blacks, Quilombola, etc.)? Is the child institutionalized or homeless? Is the family stigmatized because of violence and/or harassment (psychological, sexual, physical violence, bullying, or segregation)? Does the family live in or come from regions in war or regions with violent conflict in urban areas? Does the family have difficulty accessing social rights (health services, education, social assistance, leisure, and recreation)?

Limitations in the socioeconomic conditions of parents/caregivers
Does the family have low income (up to one minimum wage) or live in extreme poverty (income less than one minimum wage)? Do parents/caregivers have low levels of education (less than four years)? Is there unemployment in the family? Does the family live in a borrowed or occupied home or a home in precarious conditions with poor infrastructure (lack of treated water and sewage)?

Programmatic factors
Unavailability of child and family care programs Does the child have access to nutritional programs for treating iron deficiency (iron deficiency anemia due to low food standards)? Does the mother have access to adequate prenatal care (availability of health care, complementary examinations, and safe delivery care)? Does the family have access to social support programs (income transfer and child care support)? Does the child attend school/daycare with inadequate conditions (crowded classes, lack of training of teachers, or lack of emotional support for the child)? The questionnaire was developed using Microsoft Excel. The first page contained the ICF and guidelines for completing the questionnaire. All the content related to the markers was described in a spreadsheet, allowing participants to answer the questions using all available information.
The criteria used during validation to evaluate the attributes and relevance of the markers were simplicity, clarity, pertinence, and precision. The questions asked were 1. "Is the marker easily explained and understood?", 2. "Can data on the marker be easily Only the "yes/agree" question was considered, excluding from the analysis the answers "yes, but requires revision/partial agreement" and "no/disagree." The revisions necessary between each collection stage were made according to the suggestions of the judges.
Possible answers were agreement, partial agreement, or disagreement, and there was room for comments. Descriptive statistics were used for data analysis, and the minimum consensus was 70% (15)(16) . The consensus is the expected result of the Delphi technique. Therefore, the definition of consensus criteria and the description of the degree of agreement and the validation results are essential (15)(16) .

Results
The first round of content validation was completed by 17 participants. Of these, 11 were nurses, two were physical therapists, two were occupational therapists, and two were psychologists. Most participants had a time of academic education longer than 10 years, with an M.S. and/or Ph.D. degree and experience in teaching, research, and care practice.
The judges returned the materials within 30 days and completed 95% of the questionnaires in the first round.
The results of the assessments were tabulated according to pre-established parameters. The level of consensus of the judges in the first round is presented in Table 1. Table 1 It was suggested to include support for mothers in this marker: I suggest leaving this item as "there is no support for childcare" and exclude the sentence "for the mother who works outside" because I consider that support is necessary for all mothers, regardless of working outside.
The relevance of the first, third, and fourth components of the marker "delinquency and/or abuse by parents/caregiver" reached a consensus of 64%.
The simplicity and expression of these components In the second round, the judges returned the materials within 30 days and completed 99% of the questionnaires. The level of consensus of the judges is presented in Table 2. Table 2. Minimum level of consensus of the judges in the second round of content validation. São Paulo, Brazil, 2017

Minimum level of consensus (%)
Operating manual

Attributes of marker components
Difficulty  second). The questionnaire adherence rate was high (95% in the first round and 99% in the second round).
These results corroborate the Delphi technique, whose application demands the recruitment of experienced, socially critical, and professionally self-critical judges who can make significant changes and adaptations to the analyzed material (17)(18) .
The number of participants in the first and second rounds was considered pertinent by the literature, which defines a minimum of 10-15 specialists to obtain a set of high-quality opinions (18) . Therefore, the markers were which makes these parameters accessible to a diverse and geographically dispersed population, allowing the provision of different opinions (19) . and infants (1,20) .
With respect to the marker "illnesses in parents/ caregivers," the judge's recommendation to include the mental health conditions to facilitate their identification by professionals was considered adequate. The presence of mental disorders is related to the lower degree of affection for the infant and the development of weak bonding (20) .
With respect to the marker "presence of instability in family relations," which did not reach the minimum consensus, the judges' suggestions were pertinent because negative experiences might lead to vulnerabilities in caregivers, limit childcare support, and lead to neglect and exposure of the child to dangerous situations (21)(22) .
With regard to the marker "situations of delinquency and/or drug abuse by parents/caregivers," which also did not reach minimum consensus, addressing the drug abuse of parents/caregivers is relevant to identify situations that are adverse to the socioemotional development of the infant (23)(24) . Similarly, home violence suffered by caregivers may impair childcare and consequently the bonding with the child (25) . Therefore, the proposed modifications avoid erroneous interpretations of professionals when using this instrument.
With regard to the marker "limited autonomy of parents/caregivers because of sociocultural conditions," emphasizing the autonomy of caregivers in the title of the marker is relevant because this marker reflects the caregivers' ability to care for the child (8,(22)(23) . Adaptations were made in the component of this marker to characterize violence as a set of conditions that imposed stigma and oppression on caregivers (23) .
The changes in the marker "poor socioeconomic conditions of parents/caregivers" are pertinent because professionals should understand that growth under conditions of poverty exposes the child to poor living conditions. Therefore, the socioeconomic status of the family directly affects childcare (4,8) .
The high agreement rates for vulnerability markers starting in the first round of analysis indicate that such markers are comprehensive for the bioecology of development (1) and vulnerability (8) .
The reliability and clinical validation of the vulnerability markers presented in this study need to be assessed beyond the consensus of expert opinions, and this validation will increase the applicability of primary health care practices to promote the socioemotional development of infants (8) .

Conclusion
The