The Development and Content Validation of Brief ICF Category Sets for 6 - 12-Year-Old Children with Cerebral Palsy, from the Perspective of Iranian Occupational Therapists

authors:

avatar Alireza Amiri ORCID 1 , avatar Ali Hosseini ORCID 1 , avatar Nazila Akbarfahimi ORCID 1 , * , avatar Abbas Ebadi ORCID 2

Department of Occupational Therapy, Pediatric Neurorehabilitation Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
Behavioral Sciences Research Centre, Life style institute, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran

how to cite: Amiri A, Hosseini A, Akbarfahimi N, Ebadi A. The Development and Content Validation of Brief ICF Category Sets for 6 - 12-Year-Old Children with Cerebral Palsy, from the Perspective of Iranian Occupational Therapists. Iran J Psychiatry Behav Sci. 2024;In Press(In Press):e143577. https://doi.org/10.5812/ijpbs-143577.

Abstract

Background:

There is uncertainty in identifying which aspects of functioning should be prioritized in the clinical brief assessment of children with cerebral palsy (CP). Brief ICF category sets specify the essential aspects of functioning that should be addressed in such assessments.

Objectives:

This study aimed to develop five brief ICF category sets based on the functional limitations of children with CP, as viewed by Iranian occupational therapists (OTs).

Methods:

This cross-sectional, multi-method study was conducted from January to May 2022 in Iran. Nineteen OTs were recruited through purposive sampling for a Delphi process, and ten OTs through snowball sampling for an expert panel, all experienced in CP and ICF. The Delphi involved two rounds of electronic surveys, where participants identified categories that should be minimally addressed in brief assessments of children aged 6 - 12 with CP based on their functional limitations. The content validity of these sets was then quantitatively evaluated by the expert panel.

Results:

Most confirmed categories in the gross and fine motor brief sets pertained to body structure and function, while those in the eating-and-drinking and communication-function brief sets related to cognition and motor reflexes. Categories in the visual function brief set mostly pertained to activity, participation, and environmental factors. Content validity ratio (CVR) and item-content validity indexes (I-CVI) ranged from 0.80 to 1 across all categories/brief sets, with scale-content validity index/Average (S-CVI/Ave) ranging from 0.95 to 0.98.

Conclusions:

These functional-based ICF brief sets are the first developed for children with CP in this age group and provide occupational therapists with tools to address crucial aspects of functioning, tailored to specific functional limitations. However, cultural biases and the generalizability of these brief sets remain limitations.

1. Background

There is a lack of deep knowledge and consensus regarding the functional problems of children with cerebral palsy (CP), a group characterized by permanent brain abnormalities primarily affecting mobility and posture, among rehabilitation professionals (1, 2). The International Classification of Functioning, Disability and Health (ICF) and its Children and Youth version (ICF-CY), which adopt a bio-psychosocial model, offer a comprehensive framework to understand and address human functioning and related phenomena. This model encompasses four components: body functions and structures, activities and participation, personal factors, and environmental factors (3, 4). Consequently, the ICF is a valuable tool for systematically addressing the various aspects of functional abilities and challenges of children with CP in daily activities (4). However, some studies have noted that clinical practices of Occupational Therapists (OTs) often focus more on body functions and structures than on environmental and contextual factors when treating these children (2, 5). Yet, environmental and contextual factors significantly influence their functioning, including social and school participation (6, 7). These findings underscore the potential utility of the ICF-CY (hereafter referred to simply as ‘ICF’ in this article) in the clinical practices of OTs for these children. To enhance the application of the ICF in clinical settings, a concise list of ICF categories called the ICF core set (ICF-CS) has been developed for children aged 0 - 18 with CP (8). This ICF-CS includes a Comprehensive version and three age-based Brief versions for the age groups 0 - 6, 6 - 14, and 14 - 18 years (8). The brief ICF-CSs consist of essential categories that should be considered in clinical settings requiring brief assessments to address the functioning and related environmental challenges of these children, while the comprehensive set serves as a framework for use in interdisciplinary teamwork (8, 9).

The validation studies of the ICF core sets (ICF-CS) have been particularly emphasized in low- and middle-income countries (10, 11). In our previous study, the content validity of the comprehensive version of this ICF-CS was evaluated for 6 - 12-year-old children with CP from the perspective of Iranian occupational therapists (OTs), resulting in the confirmation of 119 categories. However, it remains unclear which ICF categories should be minimally addressed in clinical settings when only a brief assessment is feasible for such children.

Extensive research indicates that the level of functional limitation in children with CP significantly influences their participation in various situations and the corresponding environmental challenges they face (6, 12-15). Children with CP typically experience functional limitations in gross motor (GM), fine motor (FM), eating and drinking (E&D), communication function (CF), and visual function (VF) due to CP or its secondary consequences (16-19). Literature suggests that the dependency of children with CP on assistance, assistive devices, and/or modifications in activity and environment for these functions exposes them to substantial functional and environmental challenges (20, 21).

These findings collectively indicate that creating brief ICF category sets based on the significant functional limitations of children with CP in GM, FM, E&D, CF, and VF could define the most relevant categories that should be minimally considered in clinical brief assessments to address their functioning and related environmental challenges. However, such brief sets have not yet been developed for these children.

2. Objectives

This study aimed to develop and validate the content of five ICF brief sets for 6 - 12-year-old children with CP based on their significant limitations in GM, FM, E&D, CF, and VF, from the perspective of Iranian OTs.

3. Methods

3.1. Study Design

This cross-sectional, multi-method study was conducted in two phases. The first phase involved developing brief sets through a Delphi process among Iranian OTs experienced in CP and the ICF. The second phase focused on content validation of the brief sets, where the content validity ratio (CVR), content validity index (CVI), modified Kappa (K*), and Scale-CVI (S-CVI) were calculated through an electronic survey with an expert panel of Iranian OTs.

3.2. Participants

To recruit Iranian OTs expert in CP and ICF, a combination of literature search, personal recommendations, and contact with the Iranian Occupational Therapy Association (IROTA) was employed. From the initially identified OTs across the country, 23 who met the inclusion criteria were purposively selected for the Delphi process. The inclusion criteria specified at least five years of experience in CP treatment and familiarity with ICF, as detailed in the invitation letter. Nineteen OTs agreed to participate in the Delphi process. For the second phase, the inclusion criteria for the expert panel required a minimum of ten years of educational and research experience in CP and ICF. Potential participants were further identified through a literature search and referrals from initially identified participants, employing a snowball sampling method. Thirteen OTs were identified, and 10 agreed to participate in the expert panel upon receiving the invitation letter.

3.3. Development Phase (Generation of the Brief ICF Category Sets)

A Delphi process involving two rounds of electronic mail surveys was utilized to generate the brief sets. Initially, for the first round of the Delphi, participants were provided with general information, a demographic questionnaire, and an Excel file containing 119 categories identified in our previous study as the comprehensive ICF-CS for 6 - 12-year-old children with CP. Participants were requested to evaluate each of the 119 categories by answering five targeted questions for each category, applicable to GM, FM, E&D, CF, and VF. For example, for GM, the question was: "Do you agree that this category should be minimally addressed in the brief assessments of 6 - 12-year-old children with CP who require assistance and/or assistive devices and/or activity and environmental modifications in their GM?" Additionally, participants were asked to provide information based on their professional experience and demographic data. A two-week deadline was set for the completion and return of the questionnaire in each Delphi round. Reminder emails were sent one week before and one week after the deadline. Responses were collected and a descriptive analysis was performed to determine the percentage of participants who answered “Yes” for each category/brief set.

In the second round, an Excel file containing the 119 categories, along with the percentage of group answers for each category/brief set from the first round, was sent to participants. They were asked to consider the group responses and their own judgments before re-answering the same question for those categories/brief sets that achieved an agreement percentage of 50 - 75% in the first round. Descriptive analysis was again conducted after collecting the responses.

3.4. Validation Phase

During the validation phase, participants received general information, a demographic questionnaire, and an Excel file containing the categories generated for each of the brief sets from the Delphi process via email. The experts were tasked with rating the essentiality and relevancy of each category for each brief set using a 3-point Likert scale ("Essential," "Useful, but not essential," or "Not necessary") and a 4-point Likert scale (ranging from 1 [not relevant or not representative] to 4 [extremely relevant or representative]), respectively. Participants were given a two-week deadline to complete and return the questionnaire, with reminders sent one week before and two days after the deadline. The CVR, CVI, K*, and Scale-CVI (S-CVI) were calculated once responses were collected. Figure 1 provides an overview of the development and validation processes for the brief sets.

An overview of the development and validation phases of the brief category set
An overview of the development and validation phases of the brief category set

3.5. Data Analysis

3.5.1. Development Phase (Delphi Process)

To assess the participants’ characteristics and calculate the frequencies of answers in the Delphi rounds, descriptive statistics were conducted using SPSS software version 16.0 (IBM Corporation, USA). In each Delphi round, the percentage of participants who answered “Yes” to the question for each category/brief set was determined. It has been established that an agreement percentage of at least 75% among participants is considered sufficiently high (22, 23). Consequently, for each brief set, categories that achieved at least 75% agreement from participants in the Delphi process were included.

3.6. Validation Phase

For each category/brief set, the CVR was calculated. To ensure that the agreement among experts was not due to chance, the minimum required CVR for each category/brief set was set at 0.62 (one-tailed test, α = 0.05) given the total number of experts (24). Additionally, the CVI for each category/brief set (Item-level CVI or I-CVI) and for each of the brief sets (scale-level CVI or S-CVI) were calculated. An I-CVI of at least 0.78 was accepted, adhering to Lynn’s proposed guidelines (25). To adjust the I-CVIs for chance agreement, the K* was calculated for each category/brief set using the formula: K* = (I-CVI - Pc) / (1 - Pc), where Pc (Probability of chance) = N! / (A! * ((N-A)!) * 0.5N, and N is the number of experts, and A is the number of experts agreeing on good relevance. Although the values of K* and I-CVI become closer as the number of experts increases, K* values of 0.74 or higher for each category/brief set were accepted, as these values are considered to fall within the range deemed excellent (26).

The S-CVI for each brief set was calculated using the S-CVI/Ave technique. An S-CVI/Ave of 0.90 or higher is considered to indicate excellent content validity (27).

3.7. Ethics

The study protocol was approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences in October 2021 (IR.USWR.REC.1400.164). Children were not directly involved in this study. All participants were informed about the study objectives, and informed consent was obtained from each participant. All procedures adhered to the ethical standards of the Regional Research Committee and were in accordance with the Declaration of Helsinki of 1964 and its later amendments.

4. Results

4.1. Participants

Out of 23 identified OTs from across the country, three declined to participate in the Delphi process and one did not return the questionnaires despite two reminders. Consequently, 19 OTs participated in the first round of the Delphi process, resulting in a dropout rate of 17.40% (19/23; 82.60%). All 19 OTs also participated in the second round of the Delphi. In the validation phase, of the 13 identified experts, 10 agreed to participate in the expert panel and returned the completed questionnaires (10/13; 76.92%). Three experts declined to participate in the panel due to personal reasons. The demographic and professional characteristics of the participants are shown in Table 1.

Table 1.

Demographic and Professional Characteristics of the Participants in the Study Phases a

Study PhaseNumber Male GenderAge, yProfessional Experience, yCP Experience, y
5 - 10> 10
Development phase (Delphi)
Round 11910 (52.6)40 (28 - 56)18 (6 - 29)5 (26.3)14 (73.7)
Round 21910 (52.6)40 (28 - 56)18 (6 - 29)5 (26.3)14 (73.7)
Validation phase (Expert panel)
CVR and CVI105 (50)42.5 (36 - 56)19.5 (10 - 29)1 (10)9 (90)

4.2. Development Phase

In the first round of the Delphi, participants confirmed 53, 58, 42, 68, and 54 categories respectively for the GM, FM, E&D, CF, and VF brief sets. Collectively, 205 categories/brief sets were rejected in the first round due to an agreement percentage of less than 50%. Additionally, 115 categories/brief sets that obtained an agreement percentage of 50-75% in the first round were revisited in the second round. Of these, 67 categories/brief sets were collectively confirmed in the second round, resulting in totals of 74, 69, 52, 73, and 74 categories respectively for GM, FM, E&D, CF, and VF brief sets. Therefore, 48 categories/brief sets were rejected due to their agreement percentage of less than 50% in this round. Table 2 presents the final agreement percentage for each category within each brief set obtained in the first or second round of the Delphi.

Table 2.

The Categories of Five Brief Sets with Their Final Agreement Percentage in the Delphi Rounds

ICF CodeFinal Agreement in the Delphi Rounds, %
2nd Level3rd LevelGMFME & DCFVF
s11084 a89 a84 a78 a84 a
s73084 a100 a100 a4726
s750100 a15101015
s76094a84 a89 a4242
s770084 a84 a78 a2115
s770378 a78 a78 a2147
b11477 a474794 a78 a
b11794 a78 a78 a100 a78 a
b126363177 a94 a31
b130189 a89 a89 a100 a78 a
b13442314277 a47
b14078 a89 a84 a100 a94 a
b14431363689 a94 a
b147347100 a89 a4778 a
b147478 a94 a78 a4278 a
b1524777 a77 a94 a47
b15689 a94 a78 a100 a100 a
b16378 a89 a100 a100 a100 a
b1644778 a47100 a78 a
b16721364794 a36
b2104283 a4778 a100 a
b230151015100 a42
b235 100 a47474478 a
b260100 a100 a78 a4247 a
b26577 a100 a94 a7778 a
b28094a94 a78 a4747 a
b320101031100 a21
b44077 a26100 a84 a21
b44577 a3684 a78 a15
b455100 a94 a78 a3621
b510151589 a4721
b525312178 a3121
b620211578 a2121
b710100 a100 a78 a2110
b715100 a100 a78 a2126
b730100 a100 a84 a2615
b735100 a100 a89 a2621
b740100 a100 a78 a3121
b750100 a94 a89 a4278 a
b75594 a89 a84 a4736
b760100 a100 a94 a4747
b76584 84 a94 a4736
b770100 36213131
d11026364784 a100 a
d11515212694 a42
d1204777 a78 a84 a77 a
d1304794 a3684 a78 a
d1313678a4789 a89 a
d133101026100 a47 a
d13726364294 a78 a
d14021312684 a78 a
d1454278 a262688 a
d15583 a89 a77 a94 a78 a
d1604777 a48100 a89 a
d16177 a84 a84 a94 a89a
d16621312689 a89 a
d1704278 a2689 a89 a
d17210361522 44
d17526363189 a78 a
d17731363677 a44
d21078 a84 a78 a84 a84 a
d22036424277 a47
d23094 a94 a89 a89 a94
d25031313694 a38
d310151526100 a44
d31536313194 a94 a
d330212136100 a42
d335314742100 a78 a
d350100 a1031100 a44
d360263636100 a78 a
d410100 a78 a77 a3677 a
d41594 a94 a78 a3677 a
d420100 a47363177 a
d430100 a100 a423647
d43594 a21152677 a
d44047100 a84 a4277 a
d44583 a94 a84 a4783 a
d45094 a15153677 a
d455100 a36264483 a
d460100 a26214778 a
d46589 a77 a264278 a
d47094 a83 a3184 a84 a
d51078 a94 a364777 a
d52089 a100 a474789 a
d53089a100 a364289 a
d54094 a100 a3636100 a
d55077 a94 a94 a3189 a
d5604789 94 a3194 a
d57078 a84 474789 a
d710212126100 a78 a
d75026211589 a47
d760212121100 a36
d82077 a78 a47100 a89 a
d88089 a100 a36100 a100 a
d92094 a94 a47100 a100 a
e11584 a94 a78 a78 a100 a
e12089 a84 a424484 a
e1254478 a31100 a100 a
e1304489 a36100 a94 a
e14094 a89 a4784 a89 a
e15094 a94 a4778 a89 a
e15584 a89 a474794 a
e31077 a4777100a77 a
e31542363689 a47
e32077 a4742100 a47
e32547424294 a78 a
e34078 a78 a78 a89 a84 a
e35584 a84 a78 a94 a84 a
e41077 a77 a7789 a77 a
e41577 a474784 a77 a
e42077 a474789 a47
e42577 a474789 a47
e44077 a77 a77 a89 a77 a
e45077 a4777 a89 a77 a
e46077 a77 a77 a89 a77 a
e46577 a474789 a47
e54078 a77 a3177 a77 a
e57577 a473177 a77 a
e58078 a78 a 7778 a78 a

4.3. Validation Phase

Out of the 74, 69, 52, 73, and 74 categories respectively confirmed for GM, FM, E&D, CF, and VF brief sets in the Delphi process, a total of 71 categories/brief sets were rejected in the expert panel because their CVR, I-CVI, and K* values were less than 0.62, 0.78, and 0.74, respectively. Consequently, the final confirmed categories for the GM, FM, E&D, CF, and VF brief sets were reduced to 61, 57, 37, 59, and 57 categories respectively in the quantitative validation phase. The CVR and I-CVI values ranged from 0.80 to 1 among all finally confirmed categories/brief sets. Additionally, the lowest and highest S-CVI values of the brief sets were 0.95 and 0.98 respectively, calculated using the S-CVI/Ave method. According to the results, twelve categories (5 body functions, 3 activities and participation, and 4 environmental factors) were consistently confirmed across all five brief sets. Table 3 presents the quantitative validation statistics of the categories/brief sets obtained in the expert panel.

Table 3.

Quantitative Validation Statistics of the Categories in Each of the Brief Sets

ICF CodeQuantitative Validation Statistics CVR (I-CVI) K*
2nd Level3rd LevelGMFME & DCFVF
s1100.80 (0.90) 0.899 a0.80 (0.90) 0.899 a0.80 (0.90) 0.899 a0.40 (0.70) 0.6600.40 (0.70) 0.660
s7300.80 (0.90) 0.899 a1 (1) 1 a1 (1) 1 a--
s7501 (1) 1 a----
s7601 (1) 1 a1 (1) 1 a0.80 (1) 1 a--
s77000.80 (0.90) 0.899 a0.80 (0.90) 0.889 a0 (0.70) 0.660--
s77031 (1) 1 a0.80 (1) 10.40 (0.60) 0.497--
b1140.80 (0.80) 0.791 a--0.80 (1) 1 a0.80 (0.90) 0.899 a
b1170.80 (0.90) 0.899 a0.80 (1) 10.80 (0.90) 0.899 a1 (1) 1 a0.80 (0.90) 0.899 a
b126--0.40 (0.60) 0.4971 (1) 1 a-
b13010.80 (0.80) 0.791 a0.80 (0.90) 0.889 a1 (1) 1 a1 (1) 1 a0.80 (0.90) 0.899 a
b134---0.80 (0.90) 0.899 a-
b1400.80 (1) 1 a0.80 (1) 1 a0.80 (1) 1 a0.80 (1) 1 a0.80 (1) 1 a
b144---1 (1) 1 a0.80 (0.90) 0.899 a
b1473-1 (1) 1 a1 (1) 1 a-0.80 (0.90) 0.899 a
b14740.80 (0.90) 0.899 a0.80 (0.90) 0.889 a0.60 (0.70) 0.660-0.80 (0.90) 0.899 a
b152-0.80 (0.90) 0.889 a0.80 (0.90) 0.899 a0.80 (1) 1 a-
b1560.80 (0.90) 0.899 a1 (1) 1 a0.80 (1) 1 a0.80 (1) 1 a1 (1) 1 a
b1630.80 (0.80) 0.791 a0.80 (0.90) 0.889 a0.80 (1) 1 a1 (1) 1 a0.80 (1) 1 a
b164-1 (1) 1 a-1 (1) 1 a0.80 (1) 1 a
b167---1 (1) 1 a-
b210-1 (1) 1 a-0.80 (1) 1 a1 (1) 1 a
b230---1 (1) 1 a-
b235 1 (1) 1 a---1 (1) 1 a
b2600.80 (1) 1 a1 (1) 1 a0.80 (1) 1 a--
b2650.40 (0.70) 0.6601 (1) 1 a0.60 (0.60) 0.4970.20 (0.50) 0.3370.80 (0.90) 0.899 a
b2800.80 (1) 1 a0.80 (1) 10.80 (1) 1 a--
b320---1 (1) 1 a-
b4400.20 (0.70) 0.660-0.80 (1) 1 a0.40 (0.70) 0.660-
b4450.40 (0.60) 0.479-0.80 (1) 1 a0.60 (0.70) 0.660-
b4551 (1) 1 a0.60 (0.70) 0.6600.60 (0.70) 0.660--
b510--1 (1) 1 a--
b525--0.80 (1) 1 a--
b620--0.80 (1) 1 a--
b7101 (1) 1 a1 (1) 1 a0.80 (1) 1 a--
b7151 (1) 1 a0.80 (1) 1 a0.40 (0.70) 0.660--
b7301 (1) 1 a0.80 (1) 1 a0.40 (0.60) 0.497--
b7351 (1) 1 a0.80 (1) 1 a0.80 (1) 1 a--
b7401 (1) 1 a0.80 (1) 1 a0.80 (1) 1 a--
b7500.80 (1) 1 a0.40 (0.60) 0.4970.40 (0.70) 0.660-0.20 (0.60) 0.497
b7551 (1) 10.80 (1) 1 a0.80 (1) 1 a--
b7601 (1) 11 (1) 11 (1) 1--
b7650.80 (0.90) 0.899 a0.80 (0.90) 0.889 a0.80 (0.90) 0.899 a--
b7701 (1) 1----
d110---1 (1) 1 a1 (1) 1 a
d115---1 (1) 1 a-
d120-0.80 (0.90) 0.889 a1 (1) 1 a0.40 (0.70) 0.6600.40 (0.70) 0.660
d130-0.60 (0.70) 0.660-0.80 (0.90) 0.899 a0.80 (1) 1 a
d131-1 (1) 1 a-1 (0.90) 0.8991 (1) 1 a
d133---1 (1) 1 a-
d137---1 (1) 1 a0.80 (0.80) 0.791 a
d140---0.80 (1) 1 a1 (1) 1 a
d145-0.80 (1) 1 a--0.80 (1) 1 a
d1550.80 (0.90) 0.899 a1 (1) 1 a0.80 (0.80) 0.791 a0.80 (0.90) 0.899 a0.80 (1) 1 a
d160-0.80 (1) 1 a-1 (1) 1 a0.80 (0.80) 0.791 a
d1610.80 (0.90) 0.899 a0.80 (0.90) 0.889 a0.80 (0.90) 0.899 a1 (1) 1 a1 (1) 1 a
d166---0.80 (1) 1 a1 (1) 1 a
d170-0.80 (1) 1 a-0.80 (1) 1 a0.80 (1) 1 a
d172-----
d175---0.80 (1) 1 a0.60 (0.70) 0.660
d177---0.60 (0.40) 0.245-
d2100.20 (0.40) 0.2450.20 (0.60) 0.4970 (0.50) 0.3370.60 (0.40) 0.2450.40 (0.60) 0.497
d220---0.60 (0.60) 0.497-
d2301 (1) 1 a1 (1) 1 a1 (1) 1 a1 (1) 1 a1 (1) 1 a
d250---1 (1) 1 a-
d310---1 (1) 1 a-
d315---1 (1) 1 a0.80 (1) 1 a
d330---1 (1) 1 a-
d335---1 (1) 1 a0.80 (1) 1 a
d350---1 (1) 1 a-
d360---1 (1) 1 a0.80 (1) 1 a
d4101 (1) 1 a0.60 (0.70) 0.6600.40 (0.60) 0.497-0.40 (0.60) 0.497
d4151 (1) 1 a1 (1) 1 a0.80 (1) 1 a-0.40 (0.70) 0.660
d4201 (1) 1 a---0.40 (0.70) 0.660
d4301 (1) 1 a1 (1) 1---
d4351 (1) 1 a---0.60 (0.70) 0.660
d440-1 (1) 1 a0.80 (0.90) 0.899 a-0.80 (1) 1 a
d4450.80 (1) 1 a1 (1) 1 a1 (1) 1 a-0.80 (1) 1 a
d4501 (1) 1 a---0.40 (0.60) 0.497
d4551 (1) 1 a---0.80 (1) 1 a
d4601 (1) 1 a---1 (1) 1 a
d4651 (1) 1 a0.20 (0.60) 0.497--0.80 (1) 1 a
d4701 (1) 1 a0.60 (0.60) 0.497-0.80 (0.90) 0.899 a1 (1) 1 a
d5100.80 (1) 1 a1 (1) 1 a--0.80 (1) 1 a
d5200.80 (1) 1 a1 (1) 1 a--0.80 (1) 1 a
d5301 (1) 1 a1 (1) 1 a--0.80 (1) 1 a
d5401 (1) 1 a1 (1) 1 a--0.80 (1) 1 a
d5500.40 (0.70) 0.6600.80 (1) 1 a0.80 (1) 1 a-0.20 (0.70) 0.660
d560-0.80 (1) 1 a0.80 (1) 1 a-0.40 (0.70) 0.660
d5700.80 (0.90) 0.899 a0.80 (0.90) 0.899 a--0.80 (0.90) 0.899 a
d710---1 (1) 1 a-
d750---0.80 (1) 1 a-
d760---1 (1) 1 a-
d8200.20 (0.60) 0.4971 (1) 1 a-1 (1) 1 a0.80 (1) 1 a
d8801 (1) 1 a1 (1) 1 a-1 (1) 1 a1 (1) 1 a
d9200.80 (1) 1 a0.80 (1) 1 a-0.80 (1) 1 a1 (1) 1 a
e1150.80 (1) 1 a0.80 (1) 1 a0.80 (0.90) 0.899 a0.80 (0.90) 0.899 a0.80 (1) 1 a
e1201 (1) 1 a1 (1) 1 a--1 (1) 1 a
e125-0.80 (1) 1 a-0.80 (1) 1 a0.80 (1) 1 a
e130-0.80 (1) 1 a-0.80 (1) 1 a0.80 (1) 1 a
e1400.80 (1) 1 a0.80 (1) 1 a-0.40 (0.60) 0.4970.80 (1) 1 a
e1500.80 (1) 1 a0.40 (0.70) 0.660-0.40 (0.70) 0.6600.80 (1) 1 a
e1550.80 (1) 1 a0.40 (0.70) 0.660--0.80 (1) 1 a
e3100.20 (0.60) 0.497-0 (0.50) 0.3370.80 (1) 1 a0.20 (0.60) 0.497
e315---0.20 (0.70) 0.660-
e3200.20 (0.60) 0.497--0.80 (1) 1 a-
e325---0.80 (1) 1 a0.20 (0.70) 0.660
e3400.40 (0.70) 0.6600.20 (0.70) 0.6600.40 (0.50) 0.3370.40 (0.60) 0.4970.80 (1) 1 a
e3551 (1) 1 a1 (1) 1 a0.40 (0.70) 0.6600.80 (1) 1 a0.80 (1) 1 a
e4100.80 (0.80) 0.791 a0.80 (0.80) 0.791 a0.80 (0.80) 0.791 a0.80 (0.90) 0.891a0.80 (1) 1 a
e4150.40 (0.70) 0.660--0.20 (0.50) 0.3370.20 (0.50) 0.337
e4200.20 (0.50) 0.337--0.80 (0.90) 0.891 a-
e4250.40 (0.70) 0.660--0.20 (0.60) 0.497-
e4400.40 (0.60) 0.4970.40 (0.50) 0.3370.40 (0.50) 0.3370.80 (0.90) 0.891 a0.60 (0.40) 0.245
e4500.80 (0.90) 0.899 a-0.80 (0.90) 0.899 a1 (1) 1 a0.80 (1) 1 a
e4601 (0.80) 0.7911 (0.80) 0.7910.80 (0.80) 0.791 a1 (1) 1 a1 (1) 1 a
e4650.80 (0.90) 0.899 a--1 (1) 1 a-
e5400.80 (1) 1 a0.60 (0.60) 0.497-0.80 (1) 1 a1 (1) 1 a
e5750.80 (0.90) 0.899 a--0.80 (1) 1 a0.80 (1) 1 a
e5800.80 (0.90) 0.899 a0.80 (0.90) 0.899 a0.80 (0.90) 0.899 a1 (1) 1 a0.80 (1) 1 a
Statistics of the whole brief sets0.80 - 10.80 - 10.80 - 10.80 - 1 0.80 - 1
0.80 - 10.80 - 10.80 - 10.90 - 10.80 - 1
0.960.970.950.980.97

5. Discussion

This study aimed at developing and validating five functional-based brief ICF category sets for 6-12-year-old children with CP from the perspective of Iranian OTs. These brief sets contained the minimal ICF categories that should be addressed in clinical settings where brief assessments are necessary for such children, given their significant functional limitations in GM, FM, E&D, CF, and VF. It is anticipated that functional-limitation-based brief sets can potentially result in a more precise description of the functioning of such children than diagnostic-based brief sets, as the environmental factors and ICF elements of activity and participation can cross diagnostic boundaries (11).

In these brief sets, the majority of categories confirmed in the components of body structures and functions related to movement and its associated structures/functions. This focus reflects the primary manifestations of CP, which are predominantly movement and postural disorders (28). Additionally, in these brief sets, the component of activity and participation received considerable attention from OTs, resulting in the most confirmed categories. This aligns with the development process of ICF-CS for children aged 0 - 18 with CP, where therapists often concentrated on areas of activity and participation, while physicians tended to focus on body structures (29). The component of body functions was the second most frequently addressed component among these brief sets. Interestingly, the ICF components of body functions and structures align with what is defined in the occupational therapy practice framework, which may explain why these components are emphasized by OTs (30).

In the domain of environmental factors, categories related to individual, family, and social attitudes were prominently addressed in these brief sets. It has been observed that such attitudes significantly influence the participation rate of children with CP in social, leisure, and daily activities (31, 32). This finding is consistent with the inclusion of these categories in the ICF-CS for children with CP (8).

In the E&D brief set, categories related to cognition and motor reflexes were prominently addressed by OTs. This focus is supported by evidence that motor reflexes, poor trunk control, and mental and cognitive challenges are associated with dysphagia and feeding problems in children with CP (33, 34). Regarding the CF brief set, the categories most approved by OTs were related to cognitive functions and the application of knowledge. Other studies have also highlighted the correlation between cognitive abilities and communication skills in children with CP (35, 36).

For the VF brief set, the most approved categories fell within the components of activity and participation and environmental factors. Although research on visual impairments in children with CP is limited, a systematic review has found that visual impairments can affect half of these children and significantly impact their quality of life (16). Further studies have shown that social life, community participation, daily activities, and transportation use are more adversely affected in children with severe visual impairments (37, 38).

According to the results, twelve categories were confirmed for all five brief sets implying that they should be addressed in the clinical brief assessments of children with CP regardless of their functional limitations. Intellectual, basic cognitive, perceptual, and attention functions as well as motivation and acquiring skills were some of such categories. It was consistent with our expectation since the presence of cognitive impairments in a large proportion of children with CP has been approved and it has been demonstrated that these impairments expose them to learning disabilities and problems in peer relations (39, 40). Carrying out daily routines and individual, family, and social attitudes were some other common categories among all brief sets. The carrying out of daily activities is the highest priority of parents of children with CP (41), however, it has been demonstrated that while increasing the impairments of children with CP, their participation in everyday activities was more restricted (42). Moreover, as stated by parents, participation in everyday activities can affected by individual and social attitudes in such children (43). These results highlight the common categories to be addressed in the brief assessments of children with CP regardless of their limitations.

We employed the Delphi technique to develop the brief sets in this study, a method often utilized in previous research for developing or validating ICF core sets (8, 44, 45). The Delphi process in this study achieved a 100% response rate across its rounds, ensuring no attrition (46, 47). Additionally, we employed the calculation of CVR, I-CVI, K*, and S-CVI to assess the content validity of each brief set. However, this study encountered some limitations. Firstly, as these brief sets were developed from the perspective of OTs, the priorities of children and/or their families were not included in the creation of these brief sets. Secondly, while these brief sets address five types of functional limitations commonly associated with CP or its secondary consequences, other potential functional limitations related to CP should be considered in clinical brief assessments. Thirdly, these brief sets specify which categories should be minimally addressed in clinical brief assessments based on functional limitations but do not specify how to measure these categories. Nevertheless, this study has notable strengths: it was the first to develop brief sets based on functional limitations, and these five brief sets can result in more precisely addressing functioning and related phenomena in clinical brief assessments.

5.1. Conclusions

Five brief sets containing 61, 57, 37, 59, and 57 categories, respectively, were confirmed by Iranian OTs for 6-12-year-old children with CP who have significant functional limitations in GM, FM, E&D, CF, and VF. These brief sets also demonstrated excellent content validity from the perspective of Iranian OTs. They encompass the minimal categories that should be addressed by OTs in clinical settings when a brief assessment is required for such children based on their functional limitations. Therefore, it is recommended that OTs utilize these brief sets in their clinical assessments of 6 - 12-year-old children with CP. While these brief sets identify what aspects of functioning should be addressed based on children's functional limitations, they do not prescribe how these aspects should be measured. Consequently, further research is necessary to develop or recommend appropriate measurement tools for assessing these aspects.

Acknowledgements

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