Neuropsychomotor development screening of Brazilian children : a systematic review of the literature

The assessment of child development through screening has been a frequent topic in research. However, little is known about the achievements and outcomes generated by such studies at the national level. With the purpose of analyzing studies that evaluated the neuropsychomotor development of Brazilian children through the Denver Development Screening Test II, a systematic review of the literature in accordance with the PRISMA recommendations was performed with search in the Medline, Lilacs, Scielo, PubMed, Scopus and Web of Science databases, including original articles that evaluated typical and atypical Brazilian children through the Denver Test II, published between 2005 and 2015 in English and Portuguese. Results: 1,016 studies were found and 67 were selected to be fully read, resulting in 31 articles that met the criteria for inclusion. Most of the studies evaluated the development of typical children in outpatient settings, who live in the Southeastern region of the country and with ages up to 3 years old, using cross-sectional research approaches. The percentage of suspected delay or delay in development for typical children ranged from none to 46.3% and from 14.2% to 100% for atypical children. Several risk factors and high percentages of suspicions of and delays in the neuropsychomotor development of children can be noted, suggesting the need for standardized screening services that are better nationally distributed. The resulting data may imply preventive actions to the risks and delays in the development of Brazilian children.


INTRODUCTION
The screening of the neuropsychomotor development (NPMD) of children refers to the process of applying tests to a large population of children, in order to identify practical and standardized risks or delays in development [1][2][3] .Regarding the factors associated with delays, aspects ranging from conception, pregnancy and birth, to neurological causes, malnutrition, environmental, socioeconomic and family factors, causing permanent or transitional delay conditions, are some of the most prominent, assuming an adequate and periodical monitoring of the child [3][4][5][6][7] .Despite their importance, there are few studies with national approaches, in particular those that make a systematic review of the literature and address issues related to the surveillance of the development of children, both typical and atypical, as well as its outcomes 2,3,8,9 .
One of the main instruments of the NPMD used in national studies is the Denver Development Screening Test II (DDST II), due to its practicality, low cost and quick implementation in relation to other existing instruments 2,5,7-12 .DDST II assesses the personal and social area, fine and gross motricity and language, and can be applied for children from zero to six years old, classifying them as normal or suspected of being delayed in development.
This study consists of a systematic review of the literature based on the Population, Intervention Comparison, Outcome (PICO) model 13 , with the objective of verifying studies concerning the NPMD assessment of Brazilian children through DDST II, with the intention of proposing preventive actions to the risks and delays in development based on the analysis of empirical studies that have already been conducted.This study stands out for providing an unprecedented overview of the national literature on the analysis of the development of typical and atypical Brazilian children through screenings that have already been performed.
Thus, this study is expected to contribute with the suggestion of research methodologies that use procedures of screening of child development, seeking to identify the prevalent risk factors in the populations evaluated and in the Brazilian regions where children have been less considered for this type of research.

METHODOLOGY
This review is in accordance with the PRISMA model 13 , which includes the choice of data sources, descriptors, search for articles, analysis of titles and abstracts, reading of the full texts, adopting inclusion and exclusion criteria, data extraction and assessment of selected publications.
Articles belonging to the Medline, Lilacs, Scielo, Pubmed, Scopus and Web of Science databases published between January 2005 and July 2015 were included, that is, studies conducted in the past ten years, as it was intended to analyze current NPMD-related aspects in Brazilian children.The terms used were those present in Health Sciences Descriptors (DeCS) and some free terms: (neuropsychomotor development OR child development OR soreening) AND (Denver II OR Denver test II OR Denver Development Screening Test II) AND (Brazil) and their equivalents in Portuguese, with all possible intersections of descriptors.
The downloaded articles were added to the software Mendley Desktop for verification of duplicity.After this procedure, titles and abstracts were read and the integral reading of the articles was subsequently made for the application of the inclusion and exclusion criteria, always by two researchers and independently.
The inclusion criteria used were: original empirical studies in Portuguese or English, full text available for free download, and studies that used DDST II to evaluate Brazilian healthy-typical children or those with any pathological and atypical condition.Studies with non-Brazilian children or with children evaluated through another screening test and validation of instruments were excluded.
After this stage, information from the following variables were extracted: region and context of study; methodological aspects; use of complementary instruments and outcome observed through the DDST II, which were then inserted into a spreadsheet in Excel, also by the same two researchers.Subsequently, the studies were assessed through a Test of Relevance (TR) by three external judges, in order to assess their methodological quality and the existence of possible biases of research, deciding whether they would be included or not.
Finally, the formula to calculate the Reliability Index (RI) proposed by Polit et al. 14 was applied: RI= [(number of agreements)×100] ÷ [(number of agreements) + (number of disagreements)], with RI≥80% being considered acceptable.In this study, an RI of 93.33% was obtained, thus being considered credible.

RESULTS
We found 1,016 studies.After reading the titles and abstracts, 67 studies were left, in which the inclusion and exclusion criteria for the reading of the texts in full were applied, resulting in a total of 31 articles subjected to the TR.The judges decided for the inclusion of 31 studies in the review (Figure 1).

Figure 1. Flowchart of the articles selected according to PRISMA recommendations
There was a predominance of studies in the Southeast region and in outpatient settings (Table 1).Most used cross-sectional approaches with small samples of typical children up to 3 years old (Table 2).Regarding the use of other instruments, the use of socioeconomic surveys prevailed (Table 3).
The outcomes of the DDST II revealed percentage of suspicion of or delays to the NPMD between zero 15 and 46.3% for typical children and from 14.2 16 to 100% 6,17,18 for atypical children.North 37 1 Total 31
In the home environment, 33% of children were suspected of having delayed NPMD, language being the most affected area (35% and 4% of delay) and fine Motricity (19%) 26 the least affected.In typical children assessed in clinics, 12.8% were suspected of being delayed, especially in the gross motor skill area 27 .
Atypical conditions of children in clinics or hospitals 7,28,16,[29][30][31][32][33] such as low weight at birth and prematurity were correlated with suspicion of delayed NPMD 7,32 , particularly in the gross motor skill and language areas.Neurological changes and changes in the transfontanelar ultrasound, respiratory failure and hospitalization in ICU, have also contributed to a worse performance of the DDST II in all areas 30,33 .
Exposure to HIV/AIDS and the implementation of antiretroviral therapy in the intrauterine and/or neonatal period was one of the factors for suspicion of delayed NPMD (50% of children), particularly in the areas of language (50% suspicion) and to a lesser extent gross motricity (8.3% suspicion) 29 .In addition, children with heart conditions contributed to suspicion of delayed NPMD, being the gross motor skill area the most affected (50% suspicions) 16 .Epilepsy, seizures and altered electroencephalogram exams also contributed to suspicion of delay 31,18 .
Children with malnutrition or starvation risk had more suspicions and delays according to the DDST II in relation to children who were eutrophic in the gross motor skill (25% versus 12.5%), fine motor skill (80% versus 68.75%) and language (85% vs. 75%) areas 5 .Phenylketonuria was a factor for suspicion of and delayed NPMD in relation to healthy children, being the worst affected areas the personal-social (40% suspicions and 60% delays against 10% suspicions) and language (70% suspicions and 30% delays against 10% suspicions) areas 6 .Disabilities in hearing were also a factor for suspicion of delayed NPMD in all areas if compared to children without hearing deficits (100% suspicions against 6.3%) 17 .
Main factors associated with delayed NPMD of typical or atypical children in Brazil were the poor socioeconomic conditions, including low education level of the parents 26 , poor nutrition and low weight 8,34,35 , pathological conditions, poor conditions of birth and exposure to certain therapies.Children of mothers with less than six consultations of prenatal, birth order, having no access to running water, incomplete vaccination schedule and ignorance of the family on child development can also influence NPMD 35 .In contrast, depression and postpartum maternal anxiety, high blood pressure and gestational diabetes and the use of hypoglycaemic medications seem to not have significantly contributed in many of the children for suspicion of or delayed NPMD [36][37][38] according to the DDST II.

DISCUSSION
Several studies point out the influence of biological, nutritional, socioeconomic, family factors and the availability of access to services on the NPMD reinforcing its multifactorial potential 4,5,7,8,[25][26][27][28]30,[34][35][36] . However,it is observed that such conditions, in particular those that induce an atypical NPMD in children and that need more rigorous screening throughout childhood, are scarcely studied.The need to perform screenings that may involve all children or most of them is reaffirmed, regardless of them having or not special health needs 2 , since even in those considered typical evidence was found suspicion of or delayed NPMD.
Conditions of the institutions and early childhood education as well as the educator/child ratio, qualification of educators, child's age, quality and structure of the place and the length of stay of the child 24 are correlated with suspicions of delayed NPMD 23,24,26 .Such aspects determine the performance of interpersonal relationships between child and educator, patterns of activities and stimuli 1 and stability and emotional attachment of the child 23 .Thus, they may also have contributed to the significant language delays, due to the decrease in the linguistic repertoire and low speech stimulation and the prioritization of the care focused on basic needs of the child (hygiene and food) 24 .The lack of attention given to the measurement of environmental features and their impact on the development of children should be noted as well.
Regarding institutions for children, the age of admission of the child 1 and the socioeconomic characteristics of the original families also stand out 25 .Furthermore, although the clinic is the primary context for evaluating child development, the knowledge on the social context of the child, information about his/ her family, pregnancy, primary caregiver, his/her routine and possible risk factors are also important 2 .
Moreover, there was a predominance of children between zero and three years old, which implies a greater interest of researchers in evaluating them at this age for it being considered a critical period from the neural point of view, which is particularly susceptible to the influence of external factors, making them more vulnerable to severe risks to the NPMD.
Although a considerable amount of studies that evaluated the NPMD of Brazilian children through screening tests was found, it should be noted that in Brazil there are no parameters for assessment of children through norm-referenced tests 2,3,8,25 .This may contribute to the fact that changes in the NPMD often pass by unnoticed, only becoming evident when the child is at school age, justifying the need for early and systematic evaluation in different contexts and regions of the country, minimizing further health problems or delays.It should be also noted the need for analysis of studies that used other screening instruments to achieve broader results and discussions concerning the Brazilian child population.

CONCLUSIONS
Several risk factors and high percentages of Brazilian children with suspicion of or delayed NPMD can be noted.In addition, regional differences were observed in the distribution of the studies, still concentrated in the Southeast region of the country.Thus, investment in education and child development screening services in a standardized manner and more equally distributed between Brazilian regions is suggested.With this, we expect to the encourage systematic and contextual studies, stimulating not only the early detection of health problems, but also the implementation of assistance, socioeconomic and family aspects in the poorest regions in order to prevent the worsening of situations of vulnerability in a decisive period of the NPMD.

Table 1 .
Geographical dis-2015tion and contexts of the studies that evaluated Brazilian children throughDDST II a , 2005-2015

Table 2 .
Methodological aspects of the studies that evaluated Brazilian children throughDDST IIa, 2005-2015

Table 3 .
Use of complementary Instruments