RISK FACTORS FOR INFANT DEVELOPMENTAL PROBLEMS

Este estudo descritivo-correlacional teve por objetivo detectar riscos para problemas do desenvolvimento da criança nos quatro primeiros anos, identificar recursos protetores no ambiente familiar e verificar as melhores variáveis preditoras do desenvolvimento em risco, em amostra não-clínica composta por 120 crianças cadastradas em um Programa de Saúde da Família. Utilizaram-se instrumentos de avaliação do desenvolvimento global, da linguagem expressiva da criança e do ambiente familiar. A análise de regressão logística indicou que quanto menor a escolaridade do pai, maior a chance de risco para problemas de desenvolvimento. A história do estado nutricional abaixo do normal aos seis meses de idade e o risco psicossocial no ambiente familiar aumentava a probabilidade de problemas de linguagem expressiva. Conclui-se que a triagem de riscos para problemas de desenvolvimento da criança e a análise dos fatores psicossociais do contexto familiar devem ser incluídas como procedimento de intervenção preventiva em Programas de Saúde da Família.


INTRODUCTION
The first three years of life have been prioritized because it is a development stage characterized by important acquisitions and by cerebral plasticity (1) .In this phase, great advancements occur in the motor, cognitive and social area (2) , as well as the acquisition and control of language (3) , which are essential for the child's global development and learning.
A search for quality of life has been observed in Family Health Programs inserted in the community, seeking a good adaptation during the development process.In this sense, the risk focus has been used for the recognition and early follow-up of some groups that are more vulnerable to morbidities.This action is important for care delivery according to the person's level of risk, considering risk as "the greatest probability an individual or group of people has of suffering any damage to their health in the future" (4) .
The effective identification of children at risk, using a comprehensive approach, starts with an examination of risk factors that contribute to children's disorders, making them vulnerable to cope with the developmental tasks of the life cycle.The risks to development can be present in the children themselves (biological components, temperament and symptoms), in the family (parents' history and family dynamics) or in the environment (socioeconomic level, social support, education and cultural context) (5) .
When assessing risk factors to "resilience", it should be taken into account that it are individual differences in people's response to stress and adversity that work as protection mechanisms (6) .Thus, the family context can contribute to resilience processes in development courses.Children must be understood in their different development contexts, including the range from the family micro-system to the cultural macro-system they are inserted in (7) .The family's psychosocial risk can be evaluated through an index that includes relevant variables present in the child's daily reality, such as: the parents' low education level, frequent marital problems, overloaded houses, rejection of pregnancy, early motherhood/ fatherhood, among others (8) .
In the prevention sphere, tracking risks in initial development requires instruments for largescale application by different professionals, in order to detect potential problems in advance.This practice is in accordance with primary child health care objectives.In this sense, instruments under the form of Lists and Inventories, such as the Denver II Development Screening Test (2,9) and the Language Development Survey (LDS) (3,10) .In parallel with the evaluation of infant development indicators, risks and resources in the family environment context also need to be assessed, in this case, using the HOME Inventory (11)(12)(13) .
Experts in child development in primary child Interview Guide for Biopsychosocial Risk (14) , the Psychosocial Risk Index (8) , the LDS (10) ) (only for children from 24 to 44 months), the Vital Events Scale (15) and the ABIPEME (Brazilian Association of Market Research Institutes) questionnaire (16) .The Home Observation for Measurement of the Environment (13) was filled out through the researcher's observation of the child's home during the home visit.
In addition to the descriptive statistical analysis of the sociodemographic characteristics and the variables studied in terms of the results obtained through the assessment instruments, a logistic regression analysis was also performed.The Statistical Package for Social Sciences for Windows (SPSS) version 12.0 was used for data analysis and a 5% significance level was adopted (= 0.05).

RESULTS
The sample was composed of 120 children from 6 to 44 months old (median=22 months), 58% Regarding LDS results, for the 56 children evaluated between 24 and 44 months old, a median standard score of 90.95 was found.There was a predominance of normal classification (93%), with a small risk percentage (7%) for problems of specific development of expressive language, which involved the evaluation of vocabulary in the children's speech repertory.
Considering the HOME inventory, the median score of 30 in a set of 45 items was verified.In addition, 74% of the children presented a medium level of stimulation in the family environment.High scores were found for the subscales of responsiveness, acceptance of the child, organization of the physical environment in general, maternal involvement with the child and opportunities to vary daily stimuli, except for the provision of material appropriate for the child's age.It can be highlighted that, in this subscale, as well as in the acceptance of the child and in maternal involvement, the inferior limit of the variation range was zero; which means that, in some families, there were no toys available to the child, little acceptance of the child and little involvement by the mothers.
Regarding potentially stressing vital events the families experienced in the last year, reported by the mothers in the Vital Events Scale, the median was six events, ranging from zero to 15.The highest occurrence of adverse events was in the areas related Risk factors for infant developmental... Maria-Mengel MRS, Linhares MBM.
The times more chances of presenting language problems.
In addition, the presence of high psychosocial risk in the family's environment (8) implied four times more chances of a child having expressive language development problems (Table 1).

Table 1 -Logistic regression analysis of risk factors
for the child's development Test, was higher that the one found by the LDS (7%).
The Denver II Test evaluates receptive and expressive language in terms of comprehension and expression, not only by words, but also by sounds imitating the adult or by the baby's pointing movement.
The LDS evaluates expressive language, which is presented by means of words expressed comprehensively to relatives and people non-familiar to the child.The presence of children at risk in this area in the first years of life deserves attention and care, because it is an area of extreme importance for development, as it is directly linked with social communication, cognitive development and school learning (17) .
Regarding The parents' education and employment variables are considered distal variables, according to the ecological theory, in the contexts of the child's development, which in turn can directly influence the social proximal interactions that occur in the family micro-system, thus indirectly affecting his(er) development (7) .This configuration of indicators permitted identifying that the children's development contexts contained multiple psychosocial distal risks, involving low education and insufficient family income to provide basic material resources for their support.
Regarding the proximal variables of the family context, good levels of environmental stimulation were found.Therefore, the facts that children are cared for by their biological parents, living in a stable union, and receive positive stimuli at their homes seem to act as protection mechanisms in the context of psychosocial adversity the families live in.
On the other hand, the children's caregivers reported family matters and personal, financial or work difficulties as sources of stress.Literature appoints that the family environment with less resources and higher adversity, including problems in interpersonal relationships, can cause problems for the child's emotional and behavioral development (18)   .

DISCUSSION
The results regarding the children's difficulties and individual resources showed that, in this sample, 33% of them were at risk of developing problems.
More care than delay indicators were present in the acquisition of developmental abilities.These results are similar to the Brazilian study that used the Denver II Test and found 34% of suspicion of delay in the development of children without risk established at 12 months of corrected chronological age, who had been born at the hospital of Pelotas and lived in the urban area (2) .
It should be highlighted that the suspicion level of risk in language, identified through the Denver II Risk factors for infant developmental... Maria-Mengel MRS, Linhares MBM.
health care need to know how a child with a typical development behaves, as well as to identify which factors can contribute to atypical development.The objectives of the present study were: a) to detect risk factors for child development problems in the four first years of life; b) to identify protection resources in the family environment context; c) to identify the best variables to predict these risks.METHOD The sample consisted of 120 male and female children, between 6 and 44 months old, from a nonclinical sample of a community attended in Family Health Nucleus IV, affiliated with the University of São Paulo at Ribeirão Preto Medical School.At the time of data collection, the population registered at this Nucleus was composed of 311 children, 76 of whom were newborns under 12 months of age and 235 were children between 12 and 48 months old.The initial potential sample was composed of 199 children; however, 79 (40%) did not participate in the study due to the following reasons: refused to participate (16%), moved outside the area covered by the Nucleus (18%) and impossibility to participate due to the mother's work hours (6%).The families' registration files from the community agents and the files of children attended at Nucleus IV were consulted in order to identify those who met the age criterion.After the children's identification, the family was contacted and invited to participate in the study.The families signed a free and informed consent term and participated in a feedback interview on the results of the evaluation, received orientation and were referred to experts when necessary.This study was approved by the Academic Directory of Teaching and Research at the Teaching Health Center at Ribeirão Preto Medical School -FMRP -USP and by the same Center's Research Ethics Committee.Risk factors for infant developmental... Maria-Mengel MRS, Linhares MBM.The evaluation of the child and family environment was previously scheduled and performed during one single home visit.The children were individually assessed through the Denver II Test, which indicates development risk or normality, identifying delay or care indicators.The mothers answered the the development context of children in the study sample, it was observed that, in the family environment, there were indications of severe psychosocial risk.The children's caregivers presented low education levels (around four years of study) and semi-qualified or non-qualified professions, belonged to socioeconomic class D and had a median family income of less than to two current minimum wages.Most mothers did not generate income, because they stayed at home (53%) or were unemployed (24%).