Validation of the

www.jped.com.br

ORIGINAL ARTICLE

Validation of the Inventaire du Milieu Familial

Questionnaire (French version of the Infant/Toddler HOME) into the Brazilian Portuguese language ^,

Simone Sudbrack

, Fernanda P. Barbosa

, Rita Mattiello

, Linda Booij

, Geovana R. Estorgato

, Moisés S. Dutra

, Fabiana D. de Assunc¸ão

,

Magda L. Nunes

aPontifíciaUniversidade Católica do Rio Grande do Sul (PUCRS), Escola de Medicina, Porto Alegre, RS, Brazil

bPontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Programa de Pós-Graduac¸ão em Pediatria e Saúde da Crianc¸a, Porto Alegre, RS, Brazil

cUniversity of Concordia, Department of Psychology and Psychiatry, Montreal, Canada

dUniversity of Montreal, Montreal, Canada

eFundac¸ão Getúlio Vargas (FGV), MBA em Gestão Financeira e Controladoria, Rio de Janeiro, RJ, Brazil

fPontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Escola de Medicina, Departamento de Neurologia, Porto Alegre, RS, Brazil

gInstituto do Cérebro do Rio Grande do Sul (InsCer, BraIns), Porto Alegre, RS, Brazil

Received 5 May 2017; accepted 23 January 2018 Available online 22 April 2018

KEYWORDS Validation studies;

Child development;

Family environment

Abstract

Objective: To validate the Brazilian Portuguese version of the Family Environment Assessment questionnaire (Inventaire du Milieu Familial).

Methods: The validation process was carried out in two stages. First, translation and back- translation were performed, and in the second phase, the questionnaire was applied in 72 families of children between 0 and 24 months for the validation process. The tool consists of the following domains: mother’s communication ability; behavior; organization of the physical and temporal environment; collection/quantity of toys; maternal attitude of constant attention toward her baby; diversification of stimuli; baby’s behavior. The following was performed for the scale validation: 1 --- content analysis (judgment); 2 --- construct analysis (factorial analysis --- Kaiser-Meyer-Olkin, Bartlett, and Pearson’s correlation tests); 3 --- criterion analysis (calculation of Cronbach’s alpha coefficient, intraclass correlations, and split-half correlations).

Please cite this article as: Sudbrack S, Barbosa FP, Mattiello R, Booij L, Estorgato GR, Dutra MS, et al. Validation of theInventaire du Milieu FamilialQuestionnaire (French version of the Infant/Toddler HOME) into the Brazilian Portuguese language. J Pediatr (Rio J).

2019;95:314---20.

Study carried out at Escola de Medicina, Programa de Pós-Graduac¸ão em Pediatria e Saúde da Crianc¸a of Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Instituto do Cérebro (InsCer-BraIns), Porto Alegre, RS, Brazil.

∗Corresponding author.

E-mail:simone.sudbrack@pucrs.br(S. Sudbrack).

https://doi.org/10.1016/j.jped.2018.02.008

0021-7557/©2018 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Pediatria. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

qPlease cite this article as: Sudbrack S, Barbosa FP, Mattiello R, Booij L, Estorgato GR, Dutra MS, et al. Validation of the Inventaire du Milieu Familial Questionnaire (French version of the Infant/Toddler HOME) into the Brazilian Portuguese language. J Pediatr (Rio J).

2019;95:314–20.

q qStudy carried out at Escola de Medicina, Programa de Pós-Graduação em Pediatria e Saúde da Criança of Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Instituto do Cérebro (InsCer-BraIns), Porto Alegre, RS, Brazil.

J Pediatr (Rio J). 2019;95(3):314---320

www.jped.com.br

ORIGINAL ARTICLE

Validation of the Inventaire du Milieu Familial

Questionnaire (French version of the Infant/Toddler HOME) into the Brazilian Portuguese language ^,

Simone Sudbrack

, Fernanda P. Barbosa

, Rita Mattiello

, Linda Booij

, Geovana R. Estorgato

, Moisés S. Dutra

, Fabiana D. de Assunc¸ão

,

Magda L. Nunes

aPontifíciaUniversidade Católica do Rio Grande do Sul (PUCRS), Escola de Medicina, Porto Alegre, RS, Brazil

bPontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Programa de Pós-Graduac¸ão em Pediatria e Saúde da Crianc¸a, Porto Alegre, RS, Brazil

cUniversity of Concordia, Department of Psychology and Psychiatry, Montreal, Canada

dUniversity of Montreal, Montreal, Canada

eFundac¸ão Getúlio Vargas (FGV), MBA em Gestão Financeira e Controladoria, Rio de Janeiro, RJ, Brazil

fPontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Escola de Medicina, Departamento de Neurologia, Porto Alegre, RS, Brazil

gInstituto do Cérebro do Rio Grande do Sul (InsCer, BraIns), Porto Alegre, RS, Brazil

Received 5 May 2017; accepted 23 January 2018 Available online 22 April 2018

KEYWORDS Validation studies;

Child development;

Family environment

Abstract

Objective: To validate the Brazilian Portuguese version of the Family Environment Assessment questionnaire (Inventaire du Milieu Familial).

Methods: The validation process was carried out in two stages. First, translation and back- translation were performed, and in the second phase, the questionnaire was applied in 72 families of children between 0 and 24 months for the validation process. The tool consists of the following domains: mother’s communication ability; behavior; organization of the physical and temporal environment; collection/quantity of toys; maternal attitude of constant attention toward her baby; diversification of stimuli; baby’s behavior. The following was performed for the scale validation: 1 --- content analysis (judgment); 2 --- construct analysis (factorial analysis --- Kaiser-Meyer-Olkin, Bartlett, and Pearson’s correlation tests); 3 --- criterion analysis (calculation of Cronbach’s alpha coefficient, intraclass correlations, and split-half correlations).

Please cite this article as: Sudbrack S, Barbosa FP, Mattiello R, Booij L, Estorgato GR, Dutra MS, et al. Validation of theInventaire du Milieu FamilialQuestionnaire (French version of the Infant/Toddler HOME) into the Brazilian Portuguese language. J Pediatr (Rio J).

2019;95:314---20.

Study carried out at Escola de Medicina, Programa de Pós-Graduac¸ão em Pediatria e Saúde da Crianc¸a of Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Instituto do Cérebro (InsCer-BraIns), Porto Alegre, RS, Brazil.

∗Corresponding author.

E-mail:simone.sudbrack@pucrs.br(S. Sudbrack).

https://doi.org/10.1016/j.jped.2018.02.008

0021-7557/©2018 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Pediatria. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

ValidationoftheIMF---InventaireduMilieuFamilial 315 Results: The mean ageof thechildren was 9±6.7 months, andofthese, 35 (48.6%)were males.Mostcorrelationsbetweenitemsanddomainsweresignificant.Inthefactorialanalysis ofthe scale, Kaiser-Meyer-Olkinvalueswere 0.76, Bartlett’s testshowed ap-value<0.001, andcorrelationbetweenitemsanddomainsshowedap-value<0.01.Regardingthevalidity, Cronbach’salphawas0.92(95%CI:0.89---0.94).Theintraclasscorrelationamongtheevaluators was0.97(0.96---0.98)andsplit-halfcorrelations,r:0.60,withp<0.01.

Conclusions: ThePortugueseversionoftheInventaireduMilieuFamilialshowedgoodtoexcel- lentperformanceregardingtheassessedpsychometricproperties.

©2018PublishedbyElsevierEditoraLtda.onbehalfofSociedadeBrasileiradePediatria.Thisis anopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/

by-nc-nd/4.0/).

PALAVRAS-CHAVE Estudosdevalidac¸ão;

Desenvolvimento infantil;

Ambientefamiliar

Validac¸ãodoquestionárioInventaireduMilieuFamilial(versãofrancesadoInfant ToddlerHome)paraalínguaportuguesa

Resumo

Objetivo: ValidaraversãoemportuguêsdoQuestionáriodeAvaliac¸ãodoAmbienteFamiliar (InventaireduMilieuFamilial).

Métodos: Oprocesso de validac¸ão foi feito em duas etapas. Primeiramente, realizou-se a traduc¸ão eretrotraduc¸ãoe,nasegundafase,oquestionáriofoiaplicadoem 72famíliasde crianc¸asentrezeroe24mesesparaoprocessodevalidac¸ão.Oinstrumentoéformadopelos seguintes domínios: Capacidadede comunicac¸ão da mãe; Comportamento; Organizac¸ãodo ambientefísico etemporal; Acervo/quantidade debrinquedos;Implicac¸ão damãecomseu bebê; Diversificac¸ãode estímulos;Comportamentodo bebê.Paraa validac¸ãodaescala foi realizada: 1- análise de conteúdo (julgamento); 2- análisede construto (análise fatorial - testes Kaiser-Meyer-Olkin, Bartlettecorrelac¸ão dePearson); 3- análisedecritério (cálculo docoeficientealfadecronbach,correlac¸õesintraclasseecorrelac¸õessplit-half).

Resultados: Amédiadeidadedascrianc¸asfoi9±6,7mesese,dessas,35(48,6%)eramdosexo masculino.Amaioriadascorrelac¸õesentreositenseosdomíniosfoisignificativa.Naanálise fatorialdaescala,osvaloresdeKaiser-Meyer-Olkinforam0,76,testedeBartlettcomp<0,001 ecorrelac¸ãoentreositensedomíniosp<0,01.Emrelac¸ãoàvalidade,oalfadeCronbachfoi de0,92(IC95%0,89-0,94).Acorrelac¸ãointraclasseentreosavaliadoresfoide0,97(0,96-0,98) ecorrelac¸õessplit-halfr:0,60p<0,01.

Conclusões: AversãoportuguesadoInventaireduMilieuFamilialapresentouumbomàexce- lentedesempenhonaspropriedadespsicométricasavaliadas.

©2018PublicadoporElsevierEditoraLtda.emnomedeSociedadeBrasileiradePediatria.Este

´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/licenses/

by-nc-nd/4.0/).

Introduction

Theimpactoftheenvironmentonthefirstyearsoflifehas been associatedtohuman development.Studiesin epige- neticshavedemonstratedanassociationbetweenprenatal andpostnataladversities,withthedevelopmentofdiseases in theadult phase, suchasdepression, diabetes, obesity, aggressiveness, drugabuse,andearly mortality.¹Studying theimpactofthefamilyenvironmentonchilddevelopment isof utmostimportance,sinceenvironmentalmechanisms canberapidlymodifiedandearlyinterventionshaveshown lastingbeneficialeffectsontheindividuals’health.^2,3

Exposure during childhood to stressor factors results in progressive changes in gene expression, knownas DNA methylation.^3---7DNAchangesareassociatedwithincreased risk of unfavorableoutcomesin childhoodandadulthood, andmaybemanifested bychanges inmental health,lan- guage, cognitive andbrain development,and behavior.^4---7 However,a favorable familyenvironment,where children

receiveadequatestimulitotheirdevelopmentinearlychild- hood,has shown areduction indeleterious effectsin the longterm.⁴

Severaltoolsthatusequantitativeandqualitativescales tomeasure the stimulus offeredto the child in the fam- ilyenvironment areavailable intheliterature^8,9 but have notyetbeen adaptedfor theBrazilianpopulation. Among the tools used internationally is the Family Environment Assessment --- (Inventaire du Milieu Familial [IMF]) ques- tionnaire, which was first used in Canada in 1998⁸ in its French-languageversion, validated and adapted fromthe AmericanHomeObservationforMeasurement oftheEnvi- ronment(HOME) questionnaire.⁹Thistoolhasbeenwidely usedbyresearchersworldwide,anditsassociationwithchild cognitiveandsocialdevelopmentiswelldocumented.¹⁰

InCanada,theIMF,inits2002updatedversion,hasbeen usedformorethanfifteenyearsinlongitudinalstudieswith emphasisonchilddevelopment,andhasbecomeanimpor- tanttool for analyzing the familyenvironment. In Brazil,

there are no validated questionnaires similar to the IMF toassess theinclusion ofinfants andchildrenin thiscon- text.Themainobjectiveofthisquestionnaireistoevaluate thequalityandquantityof stimulusprovidedbythecare- giverforthechild’sdevelopment.Moreover,itevaluatesthe appliedparentaltechniques, thefamilyenvironment,and thecaregiver’sbehaviortowardthechildathome.^8,11

Consideringthe need toprovide a tooladapted tothe particularitiesof theBrazilian population,that canassess childdevelopmentanditsinclusioninthe familycontext, themain objectiveof this study wasto validatethe Por- tugueseversionoftheIMF.Thechoiceofvalidationofthis questionnaireisduetothefactthattheauthorsaredevel- opingastudyinBrazilwithmonozygotictwinsinpartnership withCanada,whichusestheIMF.TheIMFisatoolequivalent totheHOMEquestionnaire.

Methods

Thiswasacross-sectionalstudyforthevalidationoftheIMF (FrenchversionoftheInfant/ToddlerHOME).Intheperiod fromJuly2015toMay2016,familiesofchildrenofdiffer- entsocialclasses,ranginginagefromzeroto24monthsof age,ofbothgenders,wereincludedfor convenience.The familiesparticipatedinthestudyaftersigningtheInformed Consent,and the research wascarried out throughhome visits.

TheIMFconsistsof32items,dividedintosevendomains.

Domain A (mother’s ability to communicate) consists of eleven questions that assess the development of the languageofferedtothe childand thecaregiver’s commu- nicationabilitywiththechildandtheinterviewer.Domain B(behavior)dealswithrestrictionorpunishmentduringthe interview,includingsix questionsabout possible verbalor physicalaggressions.Domain C(organizationofthe physi- calandtemporalenvironment)consistsoffivequestionsand dealswiththeorganizationofthephysicalenvironment,the presenceofpets,andthedegree ofactivityin thehouse- hold.IndomainD(collection/quantityofappropriatetoys), theinterviewer must inquire about the numberandqual- ity of the toys offered to the child. Domain E (mother’s fussy attitude toward her baby) includes questions about themother’sattitudestowardthebaby,thatis,ifthechild iskeptwithinthematernalfieldofvisionandwhetheritis stimulatedinitsdevelopmentprocess.IndomainF(stimu- lusdiversification),informationiscollectedonthenumber ofpeoplepresentinthehouseholdatthetimeofthetool application.Finally,indomainG(baby’sbehavior),theeval- uatorreportsonthechild’sbehaviorduringtheapplication ofthetool.

Mostitems(75%)areansweredsimilarly,usinga6-point Likertscale,inwhich1isnever,2israrely,3issometimes,4 isoften,5isalways,and6isbaby/twinisabsentorsleeping.

The validationprocess was carried out in two phases:

PhaseOne ---translation process of thetool. PhaseTwo --- fieldvalidation(testingofpsychometricproperties).

Phase One: This phase was carried out according to internationalrecommendationsfortoolvalidations,¹²which includesthefollowingsteps:1---translationbytwoFrench- Portuguesespeakingtranslators;2---Harmonizationbetween both versions, resulting in a single Portuguese version;

3 --- Back-translation of the harmonized version initially,

by two Portuguese-French translators;4 --- Harmonization between both translators, resulting in a single French version;5---Generalharmonization,wheretheresultingver- sionsofthefirstandsecondharmonizationarediscussedby thefourtranslators,aimingtoobtain aconsensusversion.

Thelaststageofthefirstphaseconsistedofapplicationof thescale.TheIMFscalewasappliedtotenparticipantsin ordertoevaluatetheirunderstandingandincludepossible participants’suggestions.

PhaseTwo---The validationoftheIMFtoolwascarried out,throughtheanalysisofcontent,construct,andcriteria.

Forcontentanalysis(judgment), ateamofhealth pro- fessionals analyzedtherepresentativenessof theitems in relationtocontentareasandtherelevanceoftheobjectives tobemeasuredinthescale.

Forthe constructanalysis,the factorialanalysisof the questionnaire was performed using the following tests:

Kaiser-Meyer-Olkin (KMO --- Table 1), Bartlett’s test, and Pearson’scorrelation.

Table1 Kaiser-Meyer-Olkin(KMO)test.

Rotatedcomponentmatrix Component

1 2 3 4 5 6 7

AQ1 0.48 0.39 0.40 −0.15 0.19 −0.18 0.13 AQ2 0.70 0.17 0.46 0.04 0.15 −0.01 0.02 AQ3 0.70 0.27 0.37 0.11 0.06 −0.01 0.00 AQ4 0.53 0.21 0.65 0.13 0.04 0.07 0.02 AQ5 0.08 0.24 0.65 −0.12 −0.48 0.19 −0.08 AQ30 0.88 0.18 0.15 −0.14 −0.00 0.20 −0.07 AQ10 0.67 0.19 0.19 0.18 0.23 −0.29 −0.06 AQ11 0.48 0.28 0.54 0.10 0.31 −0.18 −0.05 AQ12 0.26 0.90 −0.12 0.03 −0.04 0.07 −0.00 AQ13 0.35 0.91 0.02 0.01 0.00 0.09 0.00 AQ14 0.35 0.90 0.02 0.03 −0.02 0.09 0.03 AQ15 0.31 0.92 0.01 0.09 0.00 0.08 0.00 AQ16 0.22 0.89 0.01 0.10 −0.16 0.04 0.03 AQ18A −0.19 −0.04 0.18 0.26 −0.05 −0.58 −0.13 AQ18B 0.08 0.02 0.10 −0.07 −0.06 −0.00 0.81 AQ18C −0.14 0.06 0.06 0.02 0.10 −0.02 0.85 AQ19 0.15 0.23 0.15 0.16 −0.13 0.74 −0.22 AQ20 0.19 0.22 −0.05 0.14 −0.75 0.12 −0.02 AQ21 −0.12 −0.04 −0.39 0.45 −0.30 0.39 0.10 AQ22 0.29 −0.20 −0.36 0.03 −0.14 0.16 0.30 AQ23 −0.10 0.22 −0.22 0.52 0.20 0.50 0.09 AQ24 0.78 0.24 0.15 −0.18 −0.19 0.22 0.02 AQ25 0.35 0.06 0.19 −0.08 0.74 0.16 −0.06 AQ26 0.70 0.33 0.28 −0.03 0.07 −0.03 0.14 AQ27 0.89 0.18 0.11 −0.13 −0.04 0.09 −0.10 AQ28 0.89 0.18 0.15 −0.11 −0.00 0.13 0.02 AQ29 0.88 0.25 −0.02 −0.08 −0.00 −0.01 0.01 AQ31A −0.02 0.05 −0.18 0.87 −0.20 −0.03 −0.11 AQ31B −0.07 0.07 −0.08 0.81 −0.04 −0.05 0.01 AQ32 0.58 0.31 −0.26 0.03 0.26 0.15 −0.02 AQ6 0.24 −0.21 0.73 −0.18 0.06 0.11 0.06 AQ7 0.13 −0.16 0.75 −0.11 0.16 −0.10 0.21 AQ8 0.20 −0.09 0.74 −0.28 0.03 −0.21 −0.05 AQ9 0.26 0.01 0.50 −0.27 0.53 −0.02 0.13

ValidationoftheIMF---InventaireduMilieuFamilial 317 Forthe criterionanalysis, thecorrelation between the

observers,item-by-item correlation,andCronbach’salpha coefficientwereverified.

The socioeconomic level classification was measured usingBrazilCriterion,basedontheBrazilianAssociationof MarketResearchInstitutes(Associac¸ãoBrasileiradeEmpre- sasdePesquisa[ABEP]),version.¹³

Statisticalanalysis

Qualitativevariablesweredescribedasabsoluteorrelative frequencies,andquantitativevariablesthroughmeansand standard deviations. Forthevalidationprocess, theques- tionnaire factorial analysis was performed by calculating Spearman’scorrelation coefficient,consideringacceptable values> 0.2,and byapplyingthe KMO test andBartlett’s test.Toperformthecorrelationsbetweentheobserversand item-by-item correlations, Cronbach’s alpha coefficients were evaluated, considering adequate values ≥ 0.6 and split-halfcorrelations.

Dataanalysisand processingwereperformed usingthe SPSSprogram,version17.0(SPSSInc.---Chicago,IL,United States).Thelevelofsignificancewassetat5%.Thesample sizewasconsidered asaminimumnumber offivepartici- pantsforeachitemofthetool.

ThestudywasapprovedbytheResearchEthicsCommit- tee of Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), according toCAEE 1,087,639. The children’s parentsorguardianssignedaninformedconsent.

Results

Intotal,72familiesparticipatedinthestudy.Thechildren’s meanagewas9±6.7monthsandofthese,35(48.6%)were males.Thefamiliesthatparticipatedinthestudybelonged tosocialclassesA(9.68%),B(22.58%),C(33.87%),andDand E(33.87%)accordingtotheABEPcriterion,and50%ofthe familieshadlessthannineyearsofschooling.

TheacceptanceoftheIMFbytheparticipantswas100%;

i.e.,noindividualsabandonedthestudyafterthetoolbegan tobeapplied.

Validity

Most correlations between items and domains were sig- nificant. Questionsabout petsandelectronic devicesthat wereonduringtheinterviewwerenotsignificantwiththeir domains(Table 2).The Cronbach’salpha of thequestion- nairewas0.92(95%CI:0.89---0.95).Cronbach’salphavalues greaterthan0.8werefoundinalmostalldomains,except intheCdomain(C_␣ ---0.39(95%CI:0.16---0.58).Cronbach’s alphavaluesinthedomainsA,B,D,E,F,andGwere,respec- tively:A---C_␣0.96(95%CI:0.87---0.93);B---C_␣0.93(95%CI:

0.91---0.95);D---C_␣0.92(95%CI:0.89---0.95);E---C_␣0.92(95%

CI:0.89---0.95);F---C_␣0.83(95%CI:0.79---0.86),andintheG domain---C_␣0.92(95%CI:0.86---0.95).Afterexcludingeach one of the items, the Cronbach’s alpha value was higher than 0.9.The intraclass correlation amongthe evaluators was0.97(95%CI:0.96---0.98). Whensplit-half correlations wereanalyzed,theyshowedr:0.60,withp<0.001.

Inthefactorial scaleanalysis,theKMOvalues(Table1) were0.76,Bartlett’stestshowedp<0.001,andthecorrela- tionbetweenitemsanddomainshadp<0.01.Invariable17 oftheIMFquestionnaire,thecommunalitytestwasp<0.46.

When this variable was removed, the value increased to p>0.8. Variable 17 refers tothe presence of pets in the household.

Discussion

Theresults foundin thisstudy showtheexcellent perfor- manceoftheIMFquestionnaireregardingitsvalidityforuse intheBrazilianpopulation.

Whenevaluatingthepsychometricpropertiesofthetool, theBrazilianversionoftheIMFperformedwellregardingits validity,particularlyin thedomainsof mother’scommuni- cation;collection/quantityoftoys;mother’sfussyattitude towardherbaby;stimulusdiversification;andbaby’sbehav- ior.

Theresultsofthisstudyshowedagoodcorrelationwith mostoftheitemsanddomainsthatshowadirectassociation between the mother’s communication and the child. The itemsforwhichanadequateassociationwasnotshown,such asTV,dog,andtoys,arenotdirectlyrelatedtothechild’s bondwiththeparents.

Theimportanceofthefamilyenvironmentandparental relationships in child development has been widely described in the literature.^9,10,14 Studies show the impor- tance of environmental stimuli and family care in the child’sdevelopmentandcognitiveperformance.9,10,14---18The present results corroborate findingsfrom previous studies thatusedtheHOMEscale,^9,10,14bysuggestingthatcaregivers whogivethe mostattentiontothe bondmaintainedwith thechild(maternalattitudeofconstantattentionwithher baby),havebettercommunicationcapacityandalsoprovide agreater numberof stimuliappropriatetotheir develop- ment.

Theuseofscalesthatevaluatethefamilyenvironment indifferentsocial andculturalcontexts hasindicated the importanceofthesocioeconomiclevelandtheculturalcon- text as predictors of the quality of family environment.

Thehigherthesocioeconomiclevelandthelevelofschool- ing of the caregivers, the higher the quality of family environment.^14,19,20

Oneofthelimitationsofthisstudywastheinclusionof economicallydisadvantagedfamilies.Morethan60%ofthe studypopulation showedaneconomic classificationbelow the C1 level, according to the ABEP criteria, which cor- respondstothelowermiddle classinBrazil.Even so,the resultsdidnotshowanyharmtotheassessmentofthemain questionnairedomains.

Anotherlimitingfactorofthestudywastheapplicationof thetoolassociatedtothehomevisit,withdirectobservation ofthecaregiverbyprofessionals.Someofthesefamilieslive inanareamarkedbysocialvulnerabilityandarefollowedby thelocalcommunityhealthteam.Itwasobservedthatsome caregiversfeltintimidatedbytheevaluator’spresenceand attemptedto demonstrate a greatly increased bond with thechild.Manyofthesedisadvantagedfamiliesrelyonthe localhealthteam’s evaluationtoreceive thesocial bene- fits,which couldinfluence their attitude duringthe visit.

SudbrackSetal.

Table2 PsychometricpropertiesoftheFamilyEnvironmentAssessment.

DomainA DomainB DomainC DomainD DomainE DomainF DomainG

Q01 r(s)=0.78^a,b Q12 r(s)=0.95^a,b Q18A r(s)=0.08 Q24 r(s)=1.00^b,a Q25 r(s)=0.52^a,b Q31A r(s)=0.93^b,a Q32 r(s)=1.00^b,a

p<0.001 p<0.001 p=0.488 p=0.001 p<0.001 p<0.001 p<0.001

Q02 r(s)=0.86^a,b Q13 r(s)=0.98^a,b Q18B r(s)=0.02 Q26 r(s)=0.82^a,b Q31B r(s)=0.92^b,a

p<0.001 p<0.001 p=0.865 p<0.001 p<0.001

Q03 r(s)=0.80^a,b Q14 r(s)=0.97^a,b Q18C r(s)=0.07 Q27 r(s)=0.94^a,b

p<0.001 p<0.001 p=0.522 p<0.001

Q04 r(s)=0.85^a,b Q15 r(s)=0.98^a,b Q19 r(s)=0.64^a,b Q28 r(s)=0.94^a,b

p<0.001 p<0.001 p<0.001 p<0.001

Q05 r(s)=0.47^a,b Q16 r(s)=0.94^a,b Q20 r(s)=0.38^a,b Q29 r(s)=0.92^a,b

p<0.001 p<0.001 p=0.001 p<0.001

Q06 r(s)=0.66^a,b Q17 r(s)=0.01 Q21 r(s)=0.67^a,b Q30 r(s)=0.94^a,b

p<0.001 p=0.938 p<0.001 p<0.001

Q07 r(s)=0.63^a,b Q22 r(s)=0.47^a,b

p<0.001 p<0.001

Q08 r(s)=0.68^a,b Q23 r(s)=0.73^a

p<0.001 p<0.001

Q09 r(s)=0.66^a,b p<0.001 Q10 r(s)=0.65^a,b

p<0.001 Q11 r(s)=0.81^a,b

p<0.001

a Correlationissignificantatthe0.01level(twoextremities).

b Correlationissignificantatthe0.05level(twoextremities).

DomainA,Mother’scommunicationability.DomainB,Behavior.DomainC,Organizationofthephysicalandtemporalenvironment.DomainD,Collection/quantityofappropriatetoys.

DomainE,Maternalattitudeofconstantattentiontowardherbaby.DomainF,Diversificationofstimuli.DomainG,Baby’sbehavior.Q1,Themothervocalizes(producessounds)/speaks spontaneouslywithherbaby.Q2,Themotherrespondstothebaby’svocalizations/words.Q3,Themothergivesthebaby/twinthenameofanyobjectduringthevisitorgivesthename ofapersonorobjectinapedagogicalway.Q4,Themother’sspeechtothebaby/twinisdistinct,clear,audible(easilyintelligible).Q5,Duringtheinterviewthemother:speakslittle;has analmostunintelligiblelanguage;speaksmoderatelyandcoherently;speaksalmostconstantly.Q6,Themotherinitiatesverbalexchangeswiththeinterviewer,asksquestions,makes commentsspontaneously.Q7,Themotherexpressesherideasfreelyandeasilyhasanswersthatconstituteanappropriateextensiontotheconversation(i.e.,givesbriefanswers).Q8, Themotherspontaneouslypraisesthequalitiesorbehaviorofherbaby.Q9,Whenshetalksaboutherbabyorwithherbaby,themother’svoiceexpressespositivefeelings.Q10,The mothercaressesorhugsthebabyduringthevisit.Q11,Themotherexpressespositivefeelingswhentheinterviewercomplimentsherbaby.Q12,Themotheryellsatthebaby.Q13,The motherseemsclearlytroubledbyherbabyandshowshostilitytowardhim/her.Q14,Themotherhitsthebabyandslapshim/heronthebuttocksduringthevisit.Q15,Themotherscolds andcriticizesthebaby.Q16,Themotherintervenesinthebaby’sactionsandrestrictshis/hermovements.Q17,Thefamilyhasapet.Q18,Duringthevisit,thefollowingdevicesareon:

television;radio;Q20Duringthevisit,disturbingnoisesofhumanvoices,television,radioorothersourceswereheard.Q20,Thedegreeofactivityinthehouseduringtheinterviewmay beclassifiedas:slow;activebutnotturbulent;veryactiveandturbulent,butnotduringtheentirevisit;veryactiveandveryturbulentduringmostofthevisit.Q21,Doesthelayoutof thewindowsanddoorsofthehouseallowthebabytohaveaviewoftheoutsideenvironment?Q22,Theenvironmentwherethebabyplaysseemssafeandnotdangerous.Q23,Overall, theinsideofthehousewas:quiteinorderandclean;inorderandclean;alittlecluttered,butclean;alittleclutteredanddirty;quitecluttered,butclean;quiteclutteredanddirty.

Q24,Themotherprovidesinterestingtoysoractivitiestothebaby.Q25,Themothertendstokeepthebabyinherfieldofvisionandwatcheshim/heroften.Q26,Themothertalkstoher babywhileworkingordoingherchores.Q27,Themotherconsciouslyencouragesthebaby’sprogressinhis/herdevelopment.Q28,Themothervalueseducationaltoysfortheattention shededicatestothem.Q29,Themotherstructuresthebaby’speriodsofplayingtodevelopnewskills.Q30,Themotheroffersthebabystimulatingtoys.Q31A,Howmanypeoplewere presentatthehouseduringthevisit?Number.Q31B,Howmanyofthesepeopledonotliveregularlyinthehouse?(excludingtheinterviewer).Q32,Duringthevisitthebabywas:irritable;

awakeandactive;awakebutpassive;sleeping;absent.

ValidationoftheIMF---InventaireduMilieuFamilial 319 Tomaintainthetool’sreliability,familiesfromhighersocial

classesalsoparticipated.

The tool was applied even when the child remained asleepduringhomeobservation,sinceoneoftheresponses ofallitemsinthedomainscomprisestheAbsent/Sleeping Baby/Twinoption.Thisfactcoulddirectlyinterferewiththe observationofthebondestablishedbetweenthecaregiver andthechildand,similarly,withtheprogressofthefamily environment.However,thegoodperformanceoftheques- tionnaireindicatesthatthiswasnotarelevantlimitation.

Althoughtherearenootherscalessimilartothepresent scalesothatcomparisonscouldbemade,therearestudies thathaveanalyzedthereliabilityofHOME,suchastheone byElardoetal.in1975.Theauthorsfoundaninternalcon- sistencyrangingfrommoderatetostrong(0.44---0.89)²when analyzingthepsychometricpropertiesofthetool.Theuseof theHOMEquestionnaireindifferentpopulations(preterm, low-socialclassfamilies,familieswithlowlevelsofschool- ing)alsoshowedadequateinternalconsistency.^10,20---22

In 2000, Holditch-Davis and colleagues validated the HOMEquestionnaire in clinically-illchildren and found an internal consistencycoefficient of0.84at 6---12monthsof age.Theauthorsstudiedtheintraclasscorrelationindexes between thedifferent domainsof theHOME tooland the generalcorrelationindexofthequestionnaire,whichranged from0.6to0.8.²³

Inadditiontostudiesevaluatingthepsychometricprop- erties of the HOMEtool, several authorsfound a positive predictivevalueofthetoolindeterminingthechild’scog- nitive development, especially the verbalcommunication development. These studies show the importance of the HOME toolboth for use in clinical practice and in future childdevelopmentstudies.^19,21---29

The family is the first context of child socialization anddevelopment,andprobablytheonewiththegreatest significanceindeterminingthemoreorlessadaptivedevel- opmentaltrajectoriesofchildren.Thesystematizedanalysis ofthefamilyenvironmentallowsustostudytheinfluence ofthefamilyandtheparentalsystemonchildren’sdevel- opment.The HOME inventoryis the mostfrequently used familyenvironmentassessmentmeasureworldwide.TheIMF isascaleequivalenttotheHOMEquestionnaire.Thereare fourversionsofHOME,andtheoriginalversionsusedinsmall children(0---2yearsofage)wereadaptedin2003.¹³

Although both thenational andinternational literature showagrowinginterestintheinfluenceofthefamilyenvi- ronmentonchilddevelopment,researchinthisareaisstill scarce.InBrazil,therearenovalidatedscalesforthePor- tuguese language that allow such research to be carried out.

ThepresentstudyallowedthevalidationoftheIMFtool inBrazil,takingcaretoassessfamiliesfromdifferentsocial classes.Itisknownthatfamiliesdiffersubstantiallyinthe qualityoftheenvironmenttheyprovidetochildrenandthat differencesareevenhigherinothersocialclasses.^14,15

The validationintothePortuguese languageoftheIMF theFrenchversionoftheInfant/ToddlerHOME,willenable theuseofthistoolinBrazilianchildren,allowingtheassess- ment of the family environment and the quality of the stimuli offered to child development in new studies and clinicalpracticeBrazil.

In conclusion, the IMF showed good performance regardingtheassessedpsychometricproperties:validity.

Funding

Edital Pesquisador Gaúcho 2013 --- Fundo de Amparo à PesquisadoEstadodoRioGrandedoSul.

Conflicts of interest

Theauthorsdeclarenoconflictsofinterest.

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