Systematization of evaluation instruments for the two first years of life of typical or risk infants according to the ICF model

ABSTRACT

The objective of this study was to identify low-cost instruments of evaluation of neuropsychomotor development (NPMD) of children aged zero to two years, that can be used in the context of daycare and/or clinical environment in early intervention programs, and to systematize these instruments as the biopsychosocial model of the International Classification of Functioning, Disability and Health (ICF). NPMD evaluation instruments with translation or adaptation for Brazil were selected. For this purpose, the ICF domains were chosen triangulating the ICF-CY’s own checklist, the early stimulation core set, and the latest version of the ICF for searching the evaluation instruments in literature. Two physical therapists and a third for discordant items performed the systematization of the selected categories of ICF. The scales that met the criteria were: Alberta Infant Motor Scale (AIMS), Denver II Screening Test, PedIatric Quality of Life Inventory (PedSQl ^™), Affordance in the Home Environment for Motor Development-Infant Scale (AHEMD-IS) and Mother-child bond. Even with these scales, there was a need for a complementary anamnesis questionnaire for the infant’s caregiver, data from the Child Health Handbook and a socioeconomic questionnaire from the Brazilian Association of Research Companies for Brazil (ABEP). This systematization is available in the appendix and seeks to facilitate the broader view of the physical therapist or education professional with a biopsychosocial comprehension of the infants, in addition to allowing the early identification of risks and subsidizing actions of promotion and intervention in different contexts.

Keywords|
International Classification of Functioning, Disability and Health; Child Development; Physical Therapy Specialty; Education

RESUMO

O objetivo deste trabalho foi identificar instrumentos de avaliação do desenvolvimento neuropsicomotor (DNPM) de crianças de 0 a 2 anos, de baixo custo, que possam ser usados no contexto de creche e/ou ambiente clínico em programas de intervenção precoce, sistematizando esses instrumentos conforme o modelo biopsicossocial da Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF). Foram selecionados instrumentos de avaliação do DNPM com tradução ou adaptação para o Brasil. Para isso os domínios da CIF foram escolhidos triangulando o checklist da própria CIF-CJ, core set de estimulação precoce e a última versão da CIF, para busca na literatura de instrumentos de avaliação. A sistematização das categorias selecionadas da CIF foi realizada por dois fisioterapeutas, e um terceiro para itens discordantes. As escalas que responderam aos critérios foram: Alberta Infant Motor Scale (AIMS), Teste de Triagem de Denver II, Inventário Pediátrico sobre Qualidade de Vida (PedSQl^®), Affordance in the Home Environment for Motor Development-Infant Scale (AHEMD-IS) e vínculo mãe-bebê. Mesmo com essas escalas, verificou-se a necessidade de um questionário de anamnese complementar para o responsável, dados da Caderneta de Saúde da Criança e de um questionário socioeconômico da Associação Brasileira de Empresas de Pesquisa para o Brasil (ABEP). Essa sistematização está disponível no apêndice, e procura facilitar o olhar ampliado do fisioterapeuta ou profissional da educação com abrangência biopsicossocial dos bebês, além de possibilitar a identificação de riscos de forma precoce e subsidiar ações de promoção e intervenção em diferentes contextos.

Descritores|
Classificação Internacional de Funcionalidade, Incapacidade e Saúde; Desenvolvimento Infantil; Fisioterapia; Educação

RESUMEN

El objetivo de este estudio fue identificar herramientas de evaluación de desarrollo neuropsicomotor (DNPM) de bajo costo para niños de 0 a 2 años las cuales se pueden utilizar en el contexto de jardines infantiles y/o el entorno clínico en programas de intervención temprana, y sistematizar estos instrumentos como el modelo biopsicosocial de la Clasificación Internacional de Funcionamiento, Discapacidad y Salud (CIF). Se seleccionaron las herramientas de evaluación del DNPM con traducción o adaptación a Brasil. Para esto, los dominios de CIF se eligieron triangulando el checklist de la CIF-IA, core set de estimulación temprana y la última versión de CIF, para buscar en la literatura herramientas de evaluación. La sistematización de las categorías de CIF seleccionadas fue realizada por dos fisioterapeutas, y un tercero para artículos discordantes. Las escalas que cumplieron con los criterios fueron: Alberta Infant Motor Scale (AIMS), Prueba de tamizaje del desarrollo Denver II, Pediatric Quality of Life Inventory (PedSQl®), Affordance in the Home Environment for Motor Development-Infant Scale (AHEMD-IS) y el enlace madre e hijo. Incluso con estas escalas, era necesario un cuestionario de anamnesis complementario para el tutor, datos del Manual de Salud Infantil y un cuestionario socioeconómico de la Asociación Brasileña de Empresas de Investigación para Brasil (Abep). Esta sistematización está disponible en el apéndice y busca facilitar la apariencia ampliada del fisioterapeuta o profesional de la educación con cobertura biopsicosocial de los bebés, así como permitir la identificación temprana de riesgos y subsidiar la promoción e intervención en diferentes contextos.

Palabras clave|
Clasificación Internacional del Funcionamiento, de la Discapacidad y de la Salud; Desarrollo Infantil; Fisioterapia; Educación

INTRODUCTION

The World Health Organization (WHO) suggests that health condition assessments consider, in addition to body structures and functions, the attention to environmental and personal influences - as well as activity and participation - classified in the domains of the International Classification of Functioning, Disability and Health (ICF)¹. This broader view of health meets the current theories of child development, which currently follow the contextual/ecological theoretical model².

The effect of interventions must consider these domains³ under conditions of stimulation of typical development and/or in the existence of neuromotor disorders, considering specific core sets for delays in development⁴ and other Pediatric conditions⁵.

Daycare centers, previously conceived from a welfarist and tutoring vision, now have an elementary educational role in the integral development of children⁶, given that early childhood is a period of intense neuroplasticity, being crucial for future acquisitions⁷. In addition to family support by enabling the family to be inserted in the labor market, daycare centers have a role in educating children, who sometimes spend most of their time in these institutions⁸.

However, there are few studies on typical development², especially in daycare centers. Currently, there is no scale or instrument that contemplates all ICF domains for detection and planning of monitoring and intervention programs in children, especially in the case of infants with risk and/or developmental delay - for whom early intervention programs are indicated.

Therefore, the use of low-cost succinct evaluation scales of development, elaborated for the child population, systematized according to the biopsychosocial model of the ICF and directed to the reality of the daycare environment, can facilitate the professional observation of the categories that require the most attention and subsidize early intervention actions.

Many instruments for assessing child development require training, time and have a high cost⁹, impairing their use in clinical practice and research projects. Moreover, many instruments - when and if used individually - focus on motor, cognitive or language aspects, neglecting emotional and social ones⁹, which are equally relevant for development.

Thus, the main objective of this study was to identify instruments for the evaluation of neuropsychomotor development (NPMD) of children aged 0 to 2, of low cost, that can be used in daycare contexts and/or clinical environment in intervention programs. The secondary objective was to systematize these instruments according to the ICF model and to associate the subcategories of the ICF with the items of the scales.

METHODOLOGY

This research is part of a larger Brazilian study with the public name “Alegria em Movimento”.

The initial step was preparing the core set¹ for early intervention to thus systematize the search according to the most relevant domains in relation to child development². The checklist of the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) ⁽¹⁰ and the ICF manual¹¹ were used to obtain specific descriptions according to the domains and categories related to child development and to ratify items. Following, validated and/or adapted instruments for the Brazilian population were searched considering the main investigated domains. For such, the following keywords were used - in Portuguese and English - in the SciELO and Medline/Pubmed databases, respectively: “desenvolvimento infantil e escala e fisioterapia e típico” and “infant development and scale and physical therapy and typical”. Due to bringing insufficient results for the proposed objective, ICF was not searched. The search was conducted from April to June 2018 and no time period limit was established (Figure 1).

Figure 1
Flowchart of the search for evaluation instruments of infants in databases

The studies selected were those that used assessment scales of neuropsychomotor development for typical children or with risk of delayed NPMD, aged between 0 and 24 months. High-cost scales and scales that were used specifically on pathological conditions were excluded.

To answer the questions related to development and the early intervention program, the ICF categories were chosen relating the ones suggested in the core set of Pan et al. ⁽⁴ for early stimulation, the ICF-CY checklist^{10), (12} and the latest version of ICF¹¹.

After selection, the scales were systematized according to the ICF classification system and divided according to functioning and disability - and its two components: body functions and structure and activities and participation -; and contextual factors such as environmental and personal.

The systematization of ICF was performed by two physical therapists with experience in the evaluation of NPMD and in ICF; they performed the association between the ICF and the items of the scales - independently - to ascertain possible redundancies and/or less relevant items. The opinion of a third physical therapist - who also had experience in the selected theme - was used for items in which an agreement was not reached between the researchers.

RESULTS

When searching the chosen keywords, 35 articles were found (one in SciELO and 34 in Pubmed) that cite the following instruments: General Movements (GM), Early Milestones (EM), Daily Activities of Infants (Dais), Movement Assessment of Infants (MAI), Bayley Scales on Infant Development (BSID), I (TIMP), Alberta Infant Motor Scale (AIMS), Denver II Screening Test, Pediatric Evaluation of Disability Inventory (PEDI) and Harris Infant Neuromotor Test (Hint).

Of these instruments and/or scales, the following were excluded due to not having a validated translation/adaptation for Brazil: EM, Dais, MAI and Hint; and due to not being free and/or low-cost: GM, TIMP, BSID and PEDI (which has a new version, PEDI-CAT, requiring a license for its use) ⁽¹³. TIMP was also excluded due to approaching infants only up to 4 months of age, which does not contemplate the scope of this study. Hint was also excluded because its validation is only for infants in the northeast region of Brazil.

The low-cost, rapid application validated and/or adapted scales for Brazil available in the literature for NPMD assessment were as follows: Alberta Infant Motor Scale (AIMS) ⁽¹⁴ and Denver II Screening Test¹⁵. The Pediatric Quality of Life Inventory (PedSQl^™)¹⁶, Affordance in the Home Environment for Motor Development-Infant Scale (AHEMD-IS) ⁽¹⁷ and Mother-child bond¹⁸ were also selected. Even with these scales, the need for a complementary questionnaire for application with the parent/guardian was verified, so the anamnesis proposed by Araujo, Mélo & Israel³, data from the Child Health Handbook and a questionnaire by Brazilian Association of Research Companies for Brazil (ABEP) ⁽¹⁸ were selected, thus all items of the ICF were contemed, as shown in Figure 2.

Figure 2
List of the evaluation instruments of infants selected by the ICF biopsychosocial model

Chart 1 presents a systematization of the chosen instruments with the ICF components considered as the most relevant for intervention programs in infants aged 0 to 2 years. The ICF facilitated the organization of assessments to contemplate all domains related to health and development conditions.

Chart 1
Infant assessment instruments according to the ICF domains and categories

ICF
Component	Domains	Categories	Assessment instruments
Function	1- Global Mental Functions	b121 Consciousness	Observation
		b134 Sleep	PedsQl™ (emotional aspect)
		b140 Attention	PedsQl™ (cognition)
		b144 Memory	PedsQl™ (cognition)
		b147 Psychomotor	AIMS and Denver II
		b152 Emotional	PedsQl™ (emotional aspect)
		b140 Attention	Observation
		b167 Language	Observation
	2- Sensory functions and pain	b210 Seeing	Denver II
		b230 Hearing	Observation
		b235 Vestibular	Denver II (gross motor)
		b260 Proprioception	Denver II (gross motor)
		b265 Tactile	Observation
		b280 Pain	PedsQl™ (physical capacity)
	3- Voice and speech functions	b310 Voice	Denver II (language)
		b340 Alternative vocalization	Denver II (language) and PedsQl™ (cognition)
	4- Functions of the cardiovascular and respiratory systems	b410 Heart	PedsQl™ (physical symptoms)
		b440 Respiration	PedsQl™ (physical symptoms)
		b499 Cardiovascular and unspecified respiration	PedsQl™ (physical capacity and physical symptoms)
	5- Functions of the digestive and metabolic systems	b510 Ingestion	Denver II (personal-social) and PedsQl™ (physical symptoms)
		b525 Defecation	PedsQl™ (physical symptoms)
		b530 Weight maintenance	Health Handbook (Z-score)
		b535 Associated sensations	PedsQl™ (physical symptoms)
		b560 Growth maintenance	Health Handbook
	7- Neuromusculoskeletal and movement related functions	b710 Mobility of joint	AIMS and Denver II (global and fine motricity)
		b730 Muscle power	AIMS and Denver II (global and fine motricity)
		b735 Muscle tone	Anamnesis and Health Handbook
		B750 Motor reflexes	Anamnesis and Health Handbook
		b760 Control of voluntary movements	AIMS, Denver II (global and fine motricity), PedsQl™ (physical capacity)
		b765 Control of voluntary movements	Anamnesis and Health Handbook
	8- Functions of the skin	b899 Unspecified skin functions	PedsQl™ (physical symptoms)
Structure	1- Structure of the nervous system	s110 Brain	Anamnesis
		s120 Spinal cord	Anamnesis
	4- Structure of the cardiovascular, immunological and respiratory systems	s410 Cardiovascular system	Anamnesis
		s430 Respiratory system	Anamnesis
	5-Structures related to the digestive, metabolic and endocrine systems	5- Unspecified structures related to the digestive, metabolic and endocrine systems	Anamnesis
	7- Structures related to movement	s710 Head and neck region	Anamnesis
		s720 Shoulder region	Anamnesis
		s730 Upper extremity	Anamnesis
		s720 Pelvis	Anamnesis
		s730 Lower extremity	Anamnesis
		S760 Trunk	Anamnesis
	8- Skin and related structures	s899 Unspecified skin and related structures	PedsQl™ (physical symptoms)
Activity and Participation	1- Learning	d d110 Watching	Denver II (fine motricity)
		d115 Listening	Denver II (language and personal-social)
		d120 Other intentional sensory perceptions	Anamnesis
		D130 Imitating	Denver II (personal-social) and PedsQl™ (cognition)
		d132 Acquisition of language	Denver II (language) and PedsQl™ (cognition)
		d155 Acquisition of basic skills	Denver II (personal-social)
		d160 Focus	PedsQl™ (cognition)
	2- General tasks and demands	d210 Undertaking a single task	Denver II (personal-social) and PedsQl™ (cognition)
		d250 Controlling one’s own behavior
	3- Communication		Denver II (personal-social)
		b310 Voice	PedsQl™ (emotional aspect)
		b315 Communicating with - receiving - non-verbal messages	PedsQl™ (social interaction and cognition)
		b330 Speaking	Denver II (language) and PedsQl™ (cognition)
		b331 Pre-linguistic productions	Denver II (language)
		b335 Production of non-verbal messages	Denver II (language)
	4- Mobility		Denver (personal-social)
		d410 Changing the basic positions of the body	AIMS, Denver II (global motricity) and PedsQl™ (physical capacity)
			d4100 Lying down
			d4101 Crouching
			d4101 Kneeling
			d4103 Sitting
			d4104 Standing
			d4105 Leaning
			d4106 Changing the body’s center of gravity
			d4107 Rolling
		d415 Maintaining body position	AIMS, Denver II (global motricity) and PedsQl™ (physical capacity)
			d4150 Remain lying down
			d4151 Remain crouching
			d4152 Remain kneeling
			d4153 Remain sitting
			d4154 Remain standing up
			d4155 Maintaining head position
		d420 Moving	AIMS, Denver II (global motricity) and PedsQl™ (physical capacity)
			d4201 Moving while lying down
		d440 Fine hand use	Denver II (fine motricity)
			d4400 Picking up
			d4401 Grasping
			d4402 Manipulating
			d4403 Releasing
		d445 Hand and arm use	Denver II (fine motricity and personal-social)
			d4450 Pulling
			d4451 Pushing
			d4452 Reaching
			d4454 Throwing
		d450 Walking	AIMS, Denver II (global motricity) and PedsQl™ (physical capacity)
		d455 Moving	AIMS, Denver II (global motricity) and PedsQl™ (physical capacity)
			d4550 Crawling
			d4551 Climbing
			d4552 Running
			d453 Jumping
			d4558 Moving, others
		d460 Moving around different locations	AHEMD-IS (variety of stimulation)
	5- Self Care	d510 Washing oneself	Denver II (personal-social)
		d540 Dressing	Denver II (personal-social)
		d550 Eating	Denver II (personal-social)
		d560 Drinking	Denver II (personal-social)
	7- Interpersonal interactions and relationships	d710 Basic interpersonal interactions	PedsQl™ (emotional aspect and social interaction)
		d760 Family relationships	PedsQl™ (emotional aspect and social interaction), AHEMD-IS (variety of stimulation); Mother-child bond
	8- Major life areas	d810 Informal education	Anamnese, AHEMD-IS (stimulation variety)
		d815 Early childhood education	Anamnesis
		d880 Involvement in playing	AHEMD-IS (variety of stimulation)
Environmental Factors	1- Products and technology	e165 Goods	Anamnesis, ABEP and AHEMD-IS
	3- Support and relationships	e310 Nuclear family	Anamnesis and AHEMD-IS
		e340 Caregivers and personal assistants	Anamnesis
		e355 Health professionals	Anamnesis
	5- Services, systems and policies	e580 Related to health	Health Handbook
Personal Factors	A- Family		Anamnesis and ABEP
	Socioeconomic condition
	Stimulation		AHMED-IS
	Physical Space
	Toys
	B- Daycare center		Anamnesis

• AIMS: Alberta Infant Motor Scale; Denver II: Denver II Screening Test; PedSQl^™: Pediatric Quality of Life Inventory; AHEMD-IS: Affordance in the Home Environment for Motor Development-Infant Scale; ABEP: Brazilian Association of Research Companies for Brazil.

Through the systematization and use of the core set we observed that the joint use of several instruments is necessary to respond to all domains and main categories. The anamnesis proposed by Araujo et al. ⁽³ presents information that respond to various categories of all ICF components. The AIMS, Denver II, DNPM scales and PedsQl^™, an instrument to assess quality of life, respond to the components of function, activity and participation. Moreover, some items are answered by observing the infant during the application of the instruments and depend directly on the evaluator’s experience.

The ICF components related to environmental and personal factors are answered by anamnesis, AHEMD-IS and ABEP. Since some categories cited in the core set do not exist in the most current version of ICF and are not measured in a specific way they were removed. This happened for category b125 (intrapersonal functions), b163 (basic cognitive functions) and d131 (learning through interaction with objects).

Despite being removed from the final version of the ICF, other items were maintained due to being in the checklist of ICF-CY and in the core set, such as: b560 (growth maintenance), considered important and of easy monitoring by the very Caderneta da Criança and kept in the table, d250 (controlling oneself behavior), was also maintained and measured by PedsQl, d331 (pre-linguistic productions), measured by Denver II, d880 (learning through playful activities), measured by AHEMD-IS. Item d133 (acquisition of additional language) does not apply to this proposal and was removed.

Similarly, some categories indicated by the core set for infants do not present specific instruments and do not have objectives related to the intervention program, such as: b121 (consciousness), b156 (perceptiveness), b167 (mental language), b230 (hearing), b265 (tactile function), and can be descriptively evaluated without a specific instrument in the presence of signs and symptoms.

Some items not mentioned in the core set but judged important in the context of early intervention were added: d760 (family relationships), measured by AHEMD-IS, PedsQl^™ and vínculo mãe-bebê, d810 (informal education), investigated by anamnesis and AHEMD-IS, and d815 (early childhood education), verified by anamnesis.

Some categories indicated by the core set do not apply to this proposal: (1) Related to products and technologies: e110 (for personal consumption of food and medicines), e115 (for personal use in daily living), e120 (for facilitating mobility and personal transport), e125 (for communication); (4) Related to attitudes: e410 (individual attitudes of members of the immediate family), e440 (individual attitudes of personal caregivers and personal assistants), e450 (individual attitudes of health professionals); (5) Related to services, systems and policies: e540 (related to transport), e570 (related to social security), e575 (related to general social support).

For the category e580 (related to health), the intervention program in the daycare center, with evaluation and action, is a facilitator of the NPMD of each infant.

Functions and structures of the skin are not mentioned in the core set by Pan et al. ⁽⁴ but were added, since they account for important afferent information and PedsQl^™ presents an item for this.

DISCUSSION

It is known that a single instrument capable of identifying delays in all NPMD areas does not exist; thus, it is necessary to adopt evaluation strategies that include information on clinical evaluation, parental report, and the use of scales and follow-up of child development¹⁹.

By using the ICF and the core set for early stimulation⁴ we identified the main domains and categories of interest to identify low-cost instruments for use in early intervention programs, and systematized each category with regard to each instrument to serve as a guide for professionals to organize their assessments.

Although the use of the ICF is not yet so widespread in Brazil²⁰, the WHO suggests its use to contemplate the evaluation of individuals - in this case, of the infants in an integral way - and facilitate communication among professionals.

The integrality of the ICF was confirmed in this study, and all listed instruments responded to more than one domain of this classification. No instrument was able to contemplate all aspects related to an infant’s health condition separately; however, in an integrated way, it was possible to establish assessment instruments with adaptation and/or validation for Brazil and of low cost. The instruments listed were AIMS, Denver II, PedsQl^™, AHEMD-IS, Mother-child bond, an anamnesis protocol (as proposed by Araujo et al. ⁽³) and ABEP.

The AIMS is a scale with more than 20 years of use and revalidated to assess the gross motricity of infants aged 0 to 18 months¹⁴, and despite no translated version for Brazil existing, there are already scores and percentiles indicated for the Brazilian population²¹. The use of the evaluation form is easy and inexpensive - even in English language - because it is a very visual instrument, with drawings illustrating the motor milestone/skill and short tips below them. Moreover, the Brazilian scores²¹ represent the reality of the country, following the assumptions of the contextual influences that must be considered. This scale enables the evaluation of components of functions, activity and participation of ICF related to motricity, the establishment of whether NPMD is within typical or suspicious patterns (risk/delay), as well as the monitoring of the evolution of the NPMD.

AIMS is cited in NPMD assessments in Brazilian and foreign studies^{22), (23}, having been indicated as a screening assessment instrument by the Brazilian Ministry of Health for infants at risk of developing problems regarding NPMD²⁴. A limitation of AIMS is not being sensitive in the discrimination of developmental percentiles from 14 months onward, and in these cases it should be used with caution and preferably associated with other instruments.

For the authors of the Canadian scale, delay is considered when infants younger than eight months are within the <10 percentile, and within the <5 percentile for infants aged eight months or older²⁶. For the Brazilian population, delay is considered for children in the <5 percentile, suspect if between >5 and ≤25 percentile, and typical if >25 percentile^{25), (27), (28}. More than divergences, such choice of the evaluator/researcher in the “cutoff” point especially depends on one’s objective between screening more infants suspected of delay (sensitivity) or not (specificity) ⁽²⁹, and this decision may be related to other situations of vulnerability and/or risk.

Widely used worldwide³⁰, Denver II is the most used screening test in Brazil³¹. As advantages, it presents cultural adaptation to the Brazilian population and evaluation and training kits available for acquisition³², with relatively low cost³³, which facilitates its use. It presents a rapid evaluation for application (20-30 minutes) and can be used in infants and children up to 6 years, through direct observation of specific items to their age, in each area/domain of the scale³⁴. It thus enables the identification and evaluation of ICF’s domains of function, activity and participation related to NPMD regarding the aspects gross motor, fine-adaptive motor, language, and personal-social³³, thus complementing the evaluation of AIMS. A limitation of Denver II is not being discriminative before six months of age³⁵, reinforcing the need for NPMD assessments with instruments used in an integrative way.

The score is given by correctly performing the item (“passed”), error in the execution (“failed”), refusal by the child to perform the item (“refusal”), also having items not evaluated due to the impossibility of the evaluator to test any of them (“not evaluated” or “no opportunity”). At the end, the infant can be classified as “questionable” or “normal” (typical) ⁽³³. NPMD will be questionable if the infant presents more than one failure and one caution, and typical if there are no failures with a single caution at most. Some works categorize in “typical”, “questionable” and “delayed”. For these cases, if it is a failure and one or two cautions, development will be considered “questionable”, and if it presents two or more failures it will be considered as “delay” or “suspicion of delay” in NPMD³⁵. Again, this cutoff point should be considered by the evaluator/researcher in relation to one’s objective since Denver II is a screening instrument and not a diagnosis one, and if alterations do exist, more specific investigations related to health condition may be required.

To complement categories not existing in AIMS and Denver II - for functions, activity and participation of the ICF - with the objective of verifying the quality of life, a fundamental component of analysis in the establishment of the effects of intervention programs³⁶, we identified the Pediatric Quality of Life Inventory (PedsQl^™) for infants in its Brazilian version, tested for validity and reliability to be used in infants from 1-12 months and 13-24 months¹⁶. The Portuguese version of PedsQl^™ was obtained for research with permission to use from Mapi Research Trust.

This instrument is available free of charge for research projects if permission to use is requested. The evaluation is rapid, via an interview with the infant’s parents and/or caregivers¹⁶. The application can also be made through forms on the internet or by telephone given that there is no difference in the responses between the forms of application³⁷. This instrument enables the assessment of the quality of life in relation to physical capacity, physical symptoms, emotional aspects, social interaction and cognition of the infant, in addition to a total score¹⁶.

The questionnaire uses a conversion from a Likert scale with five scales, from 0 (never) to 4 (almost always), transformed into percentages, considering that the higher the percentage value, the better the quality of life^{16), (37}. However, there are no referential values of what would be “good quality of life” for infants, thus being a gap to be investigated.

Regarding the NPMD, interpersonal relations aspects were considered since, in this case, knowing the dynamics of the mother-child relationship can facilitate the comprehension of aspects related to the infant’s development given that the mother is the provider of care most of the time³⁸. It is suggested that, in the impossibility of applying the questionnaire with the mother, the closest caregiver should be interviewed.

Since the previously mentioned instruments focus on functions, activity and participation, for issues related to environmental and personal factors, socioeconomic issues must be investigated. This is possible by observing the absolute value of declared income, as well as by the socioeconomic classification, in Brazil, ABEP³⁹. The declared value does not always correspond to consumption practices because there is evidence that low-income families sometimes present higher consumption standards, not necessarily reflecting better living conditions⁴⁰.

Another resource that can complement consumption issues - in the case of infants, those focused on the stimulation received - is AHEMD-IS, an instrument with Brazilian validation, of fast use and made available free of charge. It consists of an interview with the infant’s caregiver to investigate issues related to the home environment, physical space, variety of stimulation, toys of gross and fine motricity, having a classification in the end that allows the identification of whether this stimulation in the home environment is adequate or not to the infant’s needs. The instrument is available in two versions: 3-18 months⁴¹ and 18-42 months¹⁷. The instrument has been used in the investigation of daycare environments in its initial 41-items version⁴²; however, it was not validated for this purpose.

To obtain an interview script with neonatal data and complement data not contemplated by this scale, we suggest a general anamnesis. The anamnesis suggested by this study is the one proposed by Araujo et al. ⁽³, which contemplates the main items related to NPMD. However, this anamnesis can and must be adapted to the clinical and/or research context of the evaluator.

This study does not intend to propose a closed systematization but suggests that, over time, new instruments are inserted. Thus, we sought to conduct a search and systematization of low-cost instruments to facilitate the organization of intervention programs.

The organization aspect of these evaluation instruments facilitates the logic of identification of categories so they are sequentially measured when considering the variability of NPMD⁽⁴³⁾ and which risk and delay situations can be identified in early stages. It also facilitates the identification of the effects of intervention programs in a broader way, allowing that the promotion of actions of development to be thought from the direct stimulation of infants in the daycare environment, by health professionals and guidance of teachers/caregivers, as well as at home by instructing caregivers/parents.

As limitations to the study, we cite the difficulty of finding Brazilian instruments specifically created for the Brazilian reality in the literature, considering that most are translations and/or cultural adaptations.

REFERÊNCIAS

• ¹
  Gannotti ME, Christy JB, Heathcock JC, Kolobe TH. A path model for evaluating dosing parameters for children with cerebral palsy. Phys Ther. 2014;94(3):411-21. doi: 10.2522/ptj.20130022
  » https://doi.org/10.2522/ptj.20130022
• ²
  Hwang AW, Liao HF, Chen PC, Hsieh WS, Simeonsson RJ, Weng LJ, et al. Applying the ICF-CY framework to examine biological and environmental factors in early childhood development. J Formos Med Assoc. 2014;113(5):303-12. doi: 10.1016/j.jfma.2011.10.004
  » https://doi.org/10.1016/j.jfma.2011.10.004
• ³
  Araujo LB, Mélo TR, Israel VL. Low birth weight, family income and paternal absence as risk factors in neuropsychomotor development. J Hum Growth Dev. 2017;27(3):272-80. doi: 10.7322/jhgd.124072
  » https://doi.org/10.7322/jhgd.124072
• ⁴
  Pan YL, Hwang AW, Simeonsson RJ, Lu L, Liao HF. ICF-CY code set for infants with early delay and disabilities (EDD Code Set) for interdisciplinary assessment: a global experts survey. Disabil Rehabil. 2015;37(12):1044-54. doi: 10.3109/09638288.2014.952454
  » https://doi.org/10.3109/09638288.2014.952454
• ⁵
  Bickenbach J, Cieza A, Rauch A, Stucki G, editors. ICF core sets: manual for clinical practice. Cambridge, MA: Hogrefe Publishing; 2012.
• ⁶
  Biscegli TS, Polis LB, Santos LM, Vicentin M. Avaliação do estado nutricional e do desenvolvimento neuropsicomotor em crianças freqüentadoras de creche. Rev Paul Pediatr. 2007;25(4):337-42. doi: 10.1590/S0103-05822007000400007
  » https://doi.org/10.1590/S0103-05822007000400007
• ⁷
  Walker SP, Wachs TD, Gardner JM, Lozoff B, Wasserman GA, Pollitt E, et al. Child development: risk factors for adverse outcomes in developing countries. Lancet. 2007;369(9556):145-57. doi: 10.1016/S0140-6736(07)60076-2
  » https://doi.org/10.1016/S0140-6736(07)60076-2
• ⁸
  Gonçalves DMO, Gomes-da-Silva PN, Andrade FCB. No princípio é o ludens: integração do self do bebê através do brincar em creche. Movimento. 2017;23(2):617-32. doi: doi.org/10.22456/1982-8918.64286
  » https://doi.org/doi.org/10.22456/1982-8918.64286
• ⁹
  McCoy DC, Sudfeld CR, Bellinger DC, Muhihi A, Ashery G, Weary TE, et al. Development and validation of an early childhood development scale for use in low-resourced settings. Popul Health Metr. 2017;15(1):3. doi: 10.1186/s12963-017-0122-8
  » https://doi.org/10.1186/s12963-017-0122-8
• ¹⁰
  Modelo de funcionalidade: Checklist da CIF-CJ. [place unknown: publisher unknown]; 2007 [cited 2018 June 20]. Available from: https://bit.ly/2miO6Gd
  » https://bit.ly/2miO6Gd
• ¹¹
  Organização Mundial de Saúde. CIF: Classificação Internacional de Funcionalidade, Incapacidade e Saúde. São Paulo: Edusp; 2015.
• ¹²
  World Health Organization. International Classification of Functioning, Disability, and Health: children & youth version: ICF-CY. Geneva: WHO; 2007.
• ¹³
  Mancini MC, Coster WJ, Amaral MF, Avelar BS, Freitas R, Sampaio RF. New version of the Pediatric Evaluation of Disability Inventory (PEDI-CAT): translation, cultural adaptation to Brazil and analyses of psychometric properties. Braz J Phys Ther. 2016;20(6):561-70. doi: 10.1590/bjpt-rbf.2014.0166
  » https://doi.org/10.1590/bjpt-rbf.2014.0166
• ¹⁴
  Darrah J, Bartlett D, Maguire TO, Avison WR, Lacaze-Masmonteil T. Have infant gross motor abilities changed in 20 years? A re-evaluation of the Alberta Infant Motor Scale normative values. Dev Med Child Neurol. 2014;56(9):877-81. doi: 10.1111/dmcn.12452
  » https://doi.org/10.1111/dmcn.12452
• ¹⁵
  Frankenburg WK, Dodds J, Archer P, Bresnick B, Maschka P, Edelman N, et al. Denver II: Teste de Triagem do Desenvolvimento: manual técnico. Sabatés AL, editor. São Paulo: Hogrefe; 2018.
• ¹⁶
  Varni JW, Limbers CA, Neighbors K, Schulz K, Lieu JE, Heffer RW, et al. The PedsQL(tm) Infant Scales: feasibility, internal consistency reliability, and validity in healthy and ill infants. Qual Life Res. 2011;20(1):45-55. doi: 10.1007/s11136-010-9730-5
  » https://doi.org/10.1007/s11136-010-9730-5
• ¹⁷
  Caçola PM, Gabbard C, Montebelo MI, Santos DC. Further development and validation of the affordances in the home environment for motor development-infant scale (AHEMD-IS). Phys Ther. 2015;95(6):901-23. doi: 10.2522/ptj.20140011
  » https://doi.org/10.2522/ptj.20140011
• ¹⁸
  Mäder CVDN, Monteiro VLDA, Spada PV, Nóbrega FJD. Avaliação do vínculo mãe-filho e saúde mental de mães de crianças com deficiência intelectual. Einstein. 2013;11(1):63-70. doi: 10.1590/S1679-45082013000100012
  » https://doi.org/10.1590/S1679-45082013000100012
• ¹⁹
  Sigolo ARL, Aiello ALR. Análise de instrumentos para triagem do desenvolvimento infantil. Paidéia. 2011;21(48):51-60. doi: 10.1590/S0103-863X2011000100007
  » https://doi.org/10.1590/S0103-863X2011000100007
• ²⁰
  Pernambuco AP, Lana RC, Polese JC. Knowledge and use of the ICF in clinical practice by physiotherapists and occupational therapists of Minas Gerais. Fisioter Pesqui. 2018;25(2):134-42. doi: 10.1590/1809-2950/16765225022018
  » https://doi.org/10.1590/1809-2950/16765225022018
• ²¹
  Saccani R, Valentini NC, Pereira KR. New Brazilian developmental curves and reference values for the Alberta infant motor scale. Infant Behav Dev. 2016;45:38-46. doi: 10.1016/j.infbeh.2016.09.002
  » https://doi.org/10.1016/j.infbeh.2016.09.002
• ²²
  Dornelas LF, Duarte NMC, Magalhães LC. Atraso do desenvolvimento neuropsicomotor: mapa conceitual, definições, usos e limitações do termo. Rev Paul Pediatr. 2015;33(1):88-103. doi: 10.1016/j.rpped.2014.04.009
  » https://doi.org/10.1016/j.rpped.2014.04.009
• ²³
  Vieira ME, Ribeiro FV, Formiga C. Principais instrumentos de avaliação de desenvolvimento da criança de zero a dois anos de idade. Rev Mov. 2009;2(1):23-31.
• ²⁴
  Brasil. Ministério da Saúde. Diretrizes de estimulação precoce: crianças de zero a 3 anos com atraso no desenvolvimento neuropsicomotor decorrentes de microcefalia. Brasília, DF; 2016.
• ²⁵
  Saccani R, Valentini NC. Curvas de referência da Escala Motora Infantil de Alberta: percentis para descrição clínica e acompanhamento do desempenho motor ao longo do tempo. J Pediatr. 2012;88(1):40-7. doi: 10.2223/JPED.2142
  » https://doi.org/10.2223/JPED.2142
• ²⁶
  Darrah J, Piper M, Watt MJ. Assessment of gross motor skills of at-risk infants: predictive validity of the Alberta Infant Motor Scale. Dev Med Child Neurol. 1998;40(7):485-91. doi: 10.1111/j.1469-8749.1998.tb15399.x
  » https://doi.org/10.1111/j.1469-8749.1998.tb15399.x
• ²⁷
  Gerzson LR, Catarino BM, Azevedo KA, Demarco PR, Palma MS, Almeida CS. Frequência semanal de um programa de intervenção motora para bebês de berçário. Fisioter Pesqui. 2016;23(2):178-84. doi: 10.1590/1809-2950/14923223022016
  » https://doi.org/10.1590/1809-2950/14923223022016
• ²⁸
  Saccani R, Valentini NC. Cross-cultural analysis of the motor development of Brazilian, Greek and Canadian infants assessed with the Alberta Infant Motor Scale. Rev Paul Pediatr. 2013;31(3):350-8. doi: 10.1590/S0103-05822013000300012
  » https://doi.org/10.1590/S0103-05822013000300012
• ²⁹
  Mello EQ, Motta-Gallo S, Goulart FC, Herrero D, Gallo PR. O uso da AIMS para detecção precoce de anormalidades em lactentes brasileiros em condições de vida desfavoráveis. Rev Braz Crescimento Desenvolv Human. 2014;24(2):163-7.
• ³⁰
  Wijedasa D. Developmental screening in context: adaptation and standardization of the Denver Developmental Screening Test-II (DDST-II) for Sri Lankan children. Child Care Health Dev. 2012;38(6):889-99. doi: 10.1111/j.1365-2214.2011.01332.x
  » https://doi.org/10.1111/j.1365-2214.2011.01332.x
• ³¹
  Brito CML, Vieira GO, Costa MCO, Oliveira NF. Neuropsychomotor development: the Denver scale for screening cognitive and neuromotor delays in preschoolers. Cad Saude Publica. 2011;27(7):1403-14. doi: 10.1590/S0102-311X2011000700015
  » https://doi.org/10.1590/S0102-311X2011000700015
• ³²
  Frankenburg WK, Dodds J, Archer P, Bresnick B, Maschka P, Edelman, et al. Denver II: Teste de Triagem do Desenvolvimento: manual de treinamento. Sabatés AL, editor. São Paulo: Hogrefe; 2017.
• ³³
  Pinto FCA, Isotani SM, Sabatés AL, Perissinoto J. Denver II: comportamentos propostos comparados aos de crianças paulistanas. Rev CEFAC. 2015;17(4):1262-9. doi: 10.1590/1982-0216201517418214
  » https://doi.org/10.1590/1982-0216201517418214
• ³⁴
  Rydz D, Shevell MI, Majnemer A, Oskoui M. Developmental screening. J Child Neurol. 2005;20(1):4-20. doi: 10.1177/08830738050200010201
  » https://doi.org/10.1177/08830738050200010201
• ³⁵
  Drachler ML, Marshall T, Carvalho-Leite JC. A continuous-scale measure of child development for population-based epidemiological surveys: a preliminary study using Item Response Theory for the Denver Test. Paediatr Perinat Epidemiol. 2007;21(2):138-53. doi: 10.1111/j.1365-3016.2007.00787.x
  » https://doi.org/10.1111/j.1365-3016.2007.00787.x
• ³⁶
  Damiano DL. Rehabilitative therapies in cerebral palsy: the good, the not as good, and the possible. J Child Neurol. 2009;24(9):1200-4. doi: 10.1177/0883073809337919
  » https://doi.org/10.1177/0883073809337919
• ³⁷
  Kruse S, Schneeberg A, Brussoni M. Construct validity and impact of mode of administration of the PedsQL(tm) among a pediatric injury population. Health Qual Life Outcomes. 2014;12(1):168. doi: 10.1186/s12955-014-0168-2
  » https://doi.org/10.1186/s12955-014-0168-2
• ³⁸
  Associação Brasileira de Empresas de Pesquisa. Critério de classificação econômica Brasil. São Paulo; 2015 [cited 2016 Apr 17]. Available from: http://www.abep.org/criterio-brasil
  » http://www.abep.org/criterio-brasil
• ³⁹
  Araujo LB, Novakoski KRM, Bastos MSC, Mélo TR, Israel VL. Caracterização do desenvolvimento neuropsicomotor de crianças até três anos: o modelo da CIF no contexto do NASF. Cad Bras Ter Ocup. 2018;26(3):538-57. doi: 10.4322/2526-8910.ctoAO1183
  » https://doi.org/10.4322/2526-8910.ctoAO1183
• ⁴⁰
  Caçola PM, Gabbard C, Montebelo MI, Santos DC. The new affordances in the home environment for motor development-infant scale (AHEMD-IS): versions in English and Portuguese languages. Braz J Phys Ther. 2015, 19(6):507-25. doi: 10.1590/bjpt-rbf.2014.0112
  » https://doi.org/10.1590/bjpt-rbf.2014.0112
• ⁴¹
  Müller AB, Valentini NC, Bandeira PFR. Affordances in the home environment for motor development: validity and reliability for the use in daycare setting. Infant Behav Dev. 2017;47:138-45. doi: 10.1016/j.infbeh.2017.03.008
  » https://doi.org/10.1016/j.infbeh.2017.03.008
• ⁴²
  Valentini NC, Saccani R. Brazilian validation of the Alberta Infant Motor Scale. Phys Ther. 2012;92(3):440-7. doi: 10.2522/ptj.20110036
  » https://doi.org/10.2522/ptj.20110036

• Finance source: Coordination for the Improvement of Higher Education Personnel (Capes)
• 7
  Approved by the Ethics Committee: Protocol No. 1.714.810
• 8
  Estudo desenvolvido no Programa de Pós Graduação em Educação Física da Universidade Federal do Paraná (UFPR) - Curitiba (PR), Brasil

APPENDIX

Form with the systematization of the ICF domains for patient classification

Child’s name: _____________________________________ Date: ______________

Legal Guardian: ___________________________________________________________

Professional: ____________________________________________________________

Classification regarding Body Functions

Body Functions (b)	0	1	2	3	4	8	9
b121 Consciousness
b134 Sleep
b140 Attention
b144 Memory
b147 Psychomotor
b152 Emotional
b140 Attention
b167 Language
b210 Seeing
b230 Hearing
b235 Vestibular
b260 Proprioception
b265 Tactile
b280 Pain
b310 Voice
b340 Alternative vocalization
b410 Heart
b440 Respiration
b499 Cardiovascular and unspecified respiration
b510 Ingestion
b525 Defecation
b530 Weight maintenance
b535 Associated sensations
b560 Growth maintenance
b710 Mobility of joint
b730 Muscle power
b735 Muscle tone
B750 Motor reflexes
b760 Control of voluntary movements
b765 Control of voluntary movements
b899 Unspecified skin functions

• 0: No disability; 1: Slight disability; 2: Moderate disability; 3: Severe disability; 4: Complete disability; 8: Non-specified1; 9: Not applicable.

Classification regarding body structures

Body structures	Extension							Nature										Location
s110 Brain	0	1	2	3	4	8	9	0	1	2	3	4	5	6	7	8	9	0	1	2	3	4	5	6	7	8	9
s120 Spinal cord
s410 Cardiovascular system
s430 Respiratory system
5- Unspecified structures related to the digestive, metabolic and endocrine systems
s710 Head and neck region
s720 Shoulder region
s730 Upper extremity
s720 Pelvis
s730 Lower extremity
S760 Trunk
s899 Unspecified skin and related structures

• Extension
• 0: No disability; 1: Slight disability; 2: Moderate disability; 3: Severe disability; 4: Complete disability; 8: Non-specified1; 9: Not applicable.
• Nature
• 0: No changes; 1: Complete absence; 2: Partial absence; 3: Additional part; 4: Aberrant dimensions; 5: Discontinuity; 6: Deviant position; 7: Qualitative changes in the structure, including fluid accumulation; 8: Unspecified1; 9:; 9: Not applicable.
• Location
• 0: More than one region; 1: Right side; 2: Left side; 3: Both sides; 4: Forward part; 5: Back part; 6: Proximal; 7: Distal; 8: Unspecified1; 9:; 9: Not applicable.

Classification regarding Activity and Participation

Activity and Participation	0	1	2	3	4	8	9
d110 Watching
d115 Listening
d120 Other intentional sensory perceptions
D130 Imitating
d132 Acquisition of language
d155 Acquisition of basic skills
d160 Focus
d210 Undertaking a single task
d250 Controlling one’s own behavior
b310 Voice
b315 Communicating with - receiving - non-verbal messages
b330 Speaking
b331 Pre-linguistic productions
b335 Production of non-verbal messages
d410 Changing the basic positions of the body
d4100 Lying down
d4101 Crouching
d4101 Kneeling
d4103 Sitting
d4104 Standing
d4105 Leaning
d4106 Changing the body’s center of gravity
d4107 Rolling
d415 Maintaining body position
d4150 Remain lying down
d4151 Remain crouching
d4152 Remain kneeling
d4153 Remain sitting
d4154 Remain standing up
d4155 Maintaining head position
d420 Moving
d4201 Moving while lying down
d440 Fine hand use
d4400 Picking up
d4401 Grasping
d4402 Manipulating
d4403 Releasing
d445 Hand and arm use
d4450 Pulling
d4451 Pushing
d4452 Reaching
d4454 Throwing
d450 Walking
d455 Standing
d4550 Crawling
d4551 Climbing
d4552 Running
d453 Jumping
d4558 Moving, others
d460 Moving around different locations
d510 Washing oneself
d540 Dressing
d550 Eating
d560 Drinking
d710 Basic interpersonal interactions
d760 Family relationships
d810 Informal education
d815 Early childhood education
d880 Involvement in playing

• 0: No disability; 1: Slight disability; 2: Moderate disability; 3: Severe disability; 4: Complete disability; 8: Non-specified1; 9: Not applicable.

Classification regarding Environmental Factors

Environmental Factors	Barriers					Facilitators
	1	2	3	4	0	+1	+2	+3	+4	8	9
e165 Goods
e310 Nuclear family
e340 Caregivers and personal assistants
e355 Health professionals
e580 Related to health

• 0: No facilitator/barrier; 1: Slight facilitator/barrier; 2: Moderate 3: Severe facilitator/barrier; 4: Complete facilitator/barrier; 8: Unspecified1; 9:; 9: Not applicable.

Publication Dates

• Publication in this collection
  02 Dec 2019
• Date of issue
  Oct-Dec 2019

History

• Received
  31 July 2018
• Accepted
  30 Nov 2018