Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF): análise de associação com qualidade de vida no contexto da avaliação fonoaudiológica de crianças e adolescentes

Abstract

Introduction: The International Classification of Functioning, Disability, and Health (ICF) has already been approached in speech-language-hearing (SLH) research, but its use in clinical practice is still incipient. Also, few studies include the effects of functioning on the quality of life of children and adolescents, especially in the context of SLH assessment. Objectives: To investigate the use of ICF and its components and their associations with the quality of life, self-perception of health, and clinical and sociodemographic aspects of children and adolescents in the process of SLH assessment and diagnosis. The specific objectives were to characterize the study population; verify associations between SLH diagnoses and Environmental Factors; analyze the psychometric properties of preselected ICF categories; verify the influence of clinical, sociodemographic, and health self-perception aspects on functioning, and that of functioning on the quality of life, both self-reported and reported by parents/guardians of children and adolescents in the SLH assessment process; and lastly, propose an ICF checklist for outpatient clinical use with children and adolescents. Methods: This cross-sectional observational analytical study comprised children and adolescents in the process of SLH assessment between 2016 and 2019 at the SLH outpatient center of the Clinics Hospital of the Federal University of Minas Gerais. The study population included participants aged 5 to 16 years, whose medical records were complete and available for consultation, and who, along with their parents/guardians, respectively signed informed assent and consent forms. Those diagnosed with hearing or intellectual disability or Autistic Spectrum Disorders were excluded. Data were collected with the Brazilian Economic Classification Criteria (CCEB, in Portuguese) administered to the parents/guardians; the Pediatric Quality of Life Inventory (PedsQL™ 4.0), both child and parent reports; and the faces scale, to assess the self-perception of health in children and adolescents. Sociodemographic (age, sex, participant's and parental education) and clinical (complaints, speech therapy diagnosis and conduct after evaluation) data were collected from the medical records, as well as information to identify content related to the preselected ICF categories in Body Functions, Activities and Participation, and Environmental Factors. Descriptive, bivariate, multivariate, factorial, and structural equation modeling (SEM) analyses were performed. The descriptive analysis, in Stage 1, was performed with frequency distribution and measures of central tendency and dispersion. In Stage 2, the bivariate analysis used the Pearson chi-square and Fisher exact tests, with the significance level set at 5%. In stages 3 and 4, second-order factorial analysis was performed with the ICF and its components and both PedsQL versions, using the main component extraction method and Promax rotation. The quality of the indicators was assessed with analysis of convergent validity, reliability, technique adequacy, and dimensionality of each construct. The multivariate analysis included linear regression with robust standard errors for the covariance matrix of estimated coefficients. The stepwise method was used, as well as the Mann-Whitney test and Spearman correlation in the forward method to enter the univariate analysis, setting the significance level at 15%. Then, the backward method was used, with the significance level set at 5%. SEM was performed likewise using the stepwise method, with the forward method for univariate analysis, with the Mann-Whitney test and Spearman correlation, and the significance level set at 15%. Later, SEM was fitted, and the backward method was applied to it, using p-values at the 5% significance level. The model quality-of-fit assessment used R². The analyses were performed in SPSS, version 25.0, and R-STUDIO, version 4.1.0. Results: The study included 84 children and adolescents, predominantly males (71.4%), aged 8 to 12 years (63.1%), who attended elementary school (70.5%), and belonged to social class C2 in CCEB (40.5%). The most prevalent complaints were related to school difficulties/reading and writing (61.9%) and speech changes (57.8%), and the most recurrent diagnoses were changes in oral language acquisition/development (83.3%), written language issues (75.0%), and oral-motor control (63.1%). As for the ICF, the most prevalent disability classifications were in b167 – Mental functions of language (96.4%) and b320 – Articulation functions (63.2%); the greatest difficulties were verified in d325C – Communicating with/receiving written messages – Capacity (89.2%) and d160D – Focusing attention – Performance (79.7%); the Environmental Factors most reported as barriers were e165 – Assets (28.9%) and e580 – Health services, systems, and policies (7.2%). In PedsQL, the highest mean scores in the parent report were in the physical (84.2819.40) and social domains (76.6025.47), while in the child report, they were in the social (81.3321.94) and physical domains (80.6617.18). Most participants’ self-perception of health was either good (24.4%) or very good (54.9%). Environmental Factors codes were associated with diagnostic hypotheses of changes in cognitive aspects of language, speech, and voice. The factorial analysis performed with the ICF showed four unidimensional constructs – one for each component and one for the ICF as a single factor. After performing the univariate and multivariate model analyses, it was found that sex; complaints of speech changes and school difficulties/written language changes; diagnostic hypotheses of changes in cognitive aspects of language and voice, oral language acquisition/development, auditory processing, speech, and the number of procedures per case had a direct and negative effect on the four factors retained for ICF analysis. The paternal educational attainment and complaints of fluency changes had a direct and positive effect respectively on the Environmental Factors, functioning, and Body Functions. The factorial analysis performed with PedsQL showed two factors – one for the parent report and the other for the child report. SEM, in the two models performed with the ICF as a single factor, did not show a direct effect of functioning on the quality of life; in the parent report, oral-motor function complaints indicated participants’ worse quality of life. In the two models separately analyzing the ICF components, neither Body Functions nor Environmental Factors influenced the quality of life. Activities and Participation, on the other hand, had a direct and positive effect on both PedsQL results – the better assessed this component, the better the self-reported and parent-reported quality of life tended to be. Diagnostic hypotheses of speech changes were also positively related to PedsQL child report outcome. The checklist proposed at the end has 34 categories. Conclusion: SLH diagnostic hypotheses were associated with Environmental Factors codes present in ICF chapters 3 and 4. Sociodemographic and clinical-assistance variables had direct and negative effects on the ICF as a single construct and its components. SEM indicated that Activities and Participation and diagnostic hypotheses of speech changes had a direct positive effect on the self-reported and parent-reported quality of life of children and adolescents in the assessment process. These results demonstrate the importance of a comprehensive approach to patients with communication changes; they also show the feasibility of using the ICF in SLH assessment and diagnosis. Factorial and SEM analyses were important and useful to analyze the classification of functioning and its components, SLH covariables, and the quality of life.