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Assessment of feeding and swallowing in children: Validity and reliability of the Ability for Basic Feeding and Swallowing Scale for Children (ABFS-C)
Brain & Development 37 (2015) 508–514 www.elsevier.com/locate/braindev
Original article
Assessment of feeding and swallowing in children: Validity and reliability of the Ability for Basic Feeding and Swallowing Scale for Children (ABFS-C) Anri Kamide a,⇑, Keiji Hashimoto a, Kohei Miyamura b, Manami Honda a a
Division of Rehabilitation Medicine and Developmental Evaluation Center, National Center for Child Health and Development, Japan b Tokyo Metropolitan Ohtsuka Hospital, Japan Received 21 April 2014; received in revised form 14 August 2014; accepted 18 August 2014
Abstract Objective: The purpose was to devise a dysphagia scale for disabled children that could be applied by various medical professionals, family members, and personnel in treatment and education institutions and facilities for disabled children and to assess the validity and reliability of that scale, “Ability for Basic Feeding and Swallowing Scale for Children” (ABFS-C). Methods: Subjects were 54 children (aged 2 months to 14 years and 7 months, median 14 months) who visited the National Center for Child Health and Development from January 2012 to December 2013. They were examined using the Fujishima’s Grade of Feeding and Swallowing Ability (Fujishima’s Grade), the Functional Independence Measure for Children (WeeFIM) and the ABFS-C composed of 5 items (wakefulness, head control, hypersensitivity, oral motor and saliva control). Validity was evaluated according to correlations of the ABFS-C with Fujishima’s Grade or WeeFIM. To assess interrater reliability, 17 children were assessed by a doctor and occupational therapist independently. Results: The ABFS-C scores and Fujishima’s Grade were correlated using Spearman rank correlation coefficients. Fujishima’s Grade was significantly correlated with saliva control (R = 0.470) and the total ABFS-C scores (R = 0.322) but not with wakefulness (R = 0.014), head control (R = 0.122), hypersensitivity (R = 0.009), or oral motor (R = 0.139). In addition, the total ABFS-C scores had a significant correlation with the total score of the WeeFIM (R = 0.562), motor WeeFIM (R = 0.451), cognitive WeeFIM (R = 0,478), and the eating subscore of the WeeFIM (R = 0.460). Interrater reliability was demonstrated for all items except hypersensitivity. Conclusions: There were significant correlations between the total ABFS-C scores and Fujishima’s Grade and WeeFIM, which suggested the need for comprehensive assessments rather than assessments of individual feeding and swallowing functions. To improve the reliability for hypersensitivity, the assessment process for hypersensitivity should be reviewed. Ó 2014 The Japanese Society of Child Neurology. Published by Elsevier B.V. All rights reserved.
Keywords: Dysphagia; Children; ABFS-C; Clinical assessment scale
1. Introduction Dysphagia rehabilitation in our country involves multiple professions engaged in the treatment of primar-
ily physically disabled children with cerebral palsy or neuromuscular disease. Recently, however, a wider range of conditions such as developmental disorders and tube-feeding dependency have to be addressed
⇑ Corresponding author. Address: National Center for Child Health and Development, 10-1, Okura 2-chome, Setagaya-ku, Tokyo 157-8535, Japan. Fax: +81 (3) 3416 2222, +81 (3) 3416 0181. E-mail address: [email protected] (A. Kamide).
http://dx.doi.org/10.1016/j.braindev.2014.08.005 0387-7604/Ó 2014 The Japanese Society of Child Neurology. Published by Elsevier B.V. All rights reserved.
A. Kamide et al. / Brain & Development 37 (2015) 508–514
[1,2]. Children’s feeding and swallowing function is developed not only through functional and morphological growth of oropharyngeal organs but also through the development of other organs and psychophysiological functions. Consequently, children with dysphagia can be pathogenetically classified into those affected by retardation of functional development and those affected by a reduction of acquired function. Features of disability are thus so complicated that multiple assessments not only limited to the disease have to be performed. Neither here nor abroad, no satisfactory assessment scale for childhood dysphagia has been established that applies a clinical assessment based on an interview and observation with an auxiliary diagnosis using imaging methods [3]. Items found in textbooks for clinical assessment are wide-ranging, specialized, and timeconsuming. It is, therefore, desirable to develop an assessment scale that would allow those with diverse roles, varying from family members to personnel in medical treatment institutions and welfare facilities such as those facilities serving disabled children to arrive at a shared understanding of dysphagia in disabled children. We developed a feeding and swallowing function version of the Ability for Basic Movement Scale for Children (ABMS-C) [4], which we had developed to briefly assess the ability for movement in children. In addition, we verified the validity and reliability of the new instrument. 2. Subjects and methods 2.1. Subjects From January 2012 to December 2013, 54 pediatric patients with dysphagia at the National Center for Child Health and Development newly received rehabilitation. There were 24 males and 30 females, and their median age was 14 months (aged 2 months to 14 years and 7 months). They were classified according to the primary pathogenesis as follows: organic, 17 (4, malignant disease; 3, laryngeal paralysis; 3, laryngomalacia; 2, cheilognathopalatoschisis; 2, gastroesophageal reflux; 1, cleft tongue; 1, multiple malformation; 1, esophageal atresia); neurological, 28 (6, chromosome or genetic abnormality; 3, cerebral palsy; 3, hydrocephalus; 3, history of living donor liver transplantation; 3, extremely low birth weight; 2, brain tumor; 2, epilepsy; 2, multiple malformation; 1, cerebrovascular disease; 1, encephalitis; 1, hypoxic-ischemic encephalopathy; 1, history of cardiac surgery); psychobehavioral, 5 (2, anorexia; 2, developmental disorder; 1 tube-feeding dependency after operations); and developmental, 4 (3, tube-feeding dependency due to inflammatory bowel disease; 1, history of cardiac surgery). They were classified by swallowing phases as follows: postural control
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preparation phase, 6; oral preparatory phase, 10; oral phase, 4; pharyngeal phase, 32; and esophageal phase, 2. This study was approved by the research ethics committee of the National Center for Child Health and Development. Informed consent was obtained from family members of all of the children. 2.2. Methods 2.2.1. Ability for Basic Feeding and Swallowing Scale (ABFS-C) The ABFS-C is composed of 5 items pertaining to a child’s feeding and swallowing ability, i.e. wakefulness, head control, hypersensitivity, oral motor ability, and saliva control. Each item was rated on a 4-point scale from 0 to 3. Fig. 1 shows assessment contents of the ABFS-C. “Wakefulness” is an index of food recognizability reflecting the patient’s general status prior to a feeding and swallowing act. It is rated according to the Glasgow Coma Scale as 0 in the case of failure to respond to pain stimulation, as 1 if the patient is awakened by swaying of the body, as 2 if the patient is awakened by speech, or as 3 if the patient is awake without any stimulation. “Head control” provides information on the patient’s development of motor activity in the feeding posture or the severity of neurological symptoms. As in the case of the Ability for Basic Movement Scale for Children, [4] head control is graded as 0 if the neck is completely unstable, as 1 if the neck follows when both shoulders are raised to 45 degrees, as 2 if the neck follows but stays fixed for less than 10 s when both shoulders are raised to 90 degrees, and as 3 if the neck is perfectly stable. “Hypersensitivity” is a type of pediatric-specific dysesthesia and is an index of the degree of lack of experience with feeding and swallowing. The patient is examined for such dysesthesia by slow movement of the examiner’s palm while touching the patient’s body surface in the order of the upper and lower limbs from the periphery to the center, the face, and around the lips and oral cavity. Observation of changes in the patient’s facial expression determines whether or not hypersensitivity is present. It is graded as 0 if hypersensitivity is present all over the body, as 1 if it is present around the lips, as 2 if it is present in the oral cavity, and as 3 if there is no hypersensitivity. “Oral motor ability” serves as an index of the developmental degree of tongue and lip motor function and the severity of neurological symptoms. Around the time that a child acquires food-holding ability, he/she can open or close the lips. Later, the child can move the tongue back and forth or up and down, and then from side to side. Subsequently, the child becomes able to voluntarily protrude the tongue beyond the lips. Consequently, 0 represents the inability to close the lips or move the tongue, 1 indicates lack of ability to move
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A. Kamide et al. / Brain & Development 37 (2015) 508–514
score no response
wakefulness
to pain
no head control
head control
whole body
hypersensitivity
hypersensitive to touch
oral motor
wakes up when shaken
stimulus
or move tongue
can hold head up in line with can hold head up but not for body when both 10 sec when shoulders are both shoulders raised 45 are raised degrees 90 degrees
does not like objects
does not like objects
touching lips
touching inside
or mouth area
the mouth
but cannot move tongue
saliva control constantly drooling
awake
when called to
can move lips cannot close lips
wakes up
constant throat
can hold head up for 10 sec when both shoulders are raised 90 degrees not hypersensitive
can close lips
can close lips
and can move
and can stick
tongue inside
tongue outside
the mouth only
the mouth
throat gurgling
no throat gurgling
after stimulation
after stimulation
inside the mouth
inside the mouth
gurgling
Fig. 1. ABFS-C: Ability for Basic Feeding and Swallowing Scale for Children.
the tongue but the ability to close the lips, 2 denotes that tongue movement is limited to the inside of the oral cavity, and 3 signifies voluntary movement of the tongue beyond the lips. “Saliva control” is a risk index for aspiration that is surmised from saliva control and the amount of food residue in the pharynx. It is graded as 0 if the child is always unable to swallow saliva, resulting in overflow of saliva that has pooled in the oral cavity from the lips; as 1 if pharyngeal secretions always make a gurgling sound, as 2 if pharyngeal secretions make a gurgling sound only after oral stimulation (stimulation is selected from gum rubbing, gustatory stimuli, presentation of usual food, etc. depending on the child’s condition), and as 3 if there are no gurgling sounds of pooled pharyngeal secretions after oral stimulation. 2.2.2. Validity To explore the validity of the ABFS-C, we assessed the patient’s feeding and swallowing ability, and which was scored according to the Fujishima’s Grade of Feeding and Swallowing Ability (Fujishima’s Grade) [5] and the Food Intake LEVEL Scale (FILS) [6]. These scales measure the severity of dysphagia by examining to what degree patients take food orally. They are primarily applied to adults and are used all over Japan. As these instruments did not include factors related to childhood growth and development, we modified them so that they described how the child took food in a form that corresponded to that by a normally developed child of the patient’s age. Fujishima’s Grade determines the severity of a swallowing disorder as necessary by using a videofluoroscopic swallow study (VFSS) or a fiberoptic endoscopic
evaluation of swallowing (FEES). Severity is rated as follows: Grade 1, difficulty in swallowing or inability to swallow, no indication for swallow training; Grade 2, indication only for basic swallow training; Grade 3, aspiration occurs less often when conditions are right, swallow training is feasible; Grade 4, feeding can be enjoyable; Grade 5, oral intake is partially possible (1 or 2 meals); Grade 6, oral intake of 3 meals is possible but alternative nutritional therapy is required; Grade 7, oral intake of easy-to-swallow food is possible at 3 meals; Grade 8, oral intake is possible at 3 meals unless food is particularly hard to swallow; Grade 9, oral intake of regular meals is possible under clinical watch and guidance; and Grade 10, normal feeding and swallowing ability. FILS determines the severity of dysphagia by judgment based on food forms and ratios of oral intakes on a daily basis. Ratings are as follows: Level 1, no swallowing training is performed except for oral care; Level 2, swallowing training not using food is performed; Level 3, swallowing training using a small quantity of food is performed; Level 4, easy-to-swallow food less than the quantity of a meal is ingested orally; Level 5, easy-to-swallow food is orally ingested in one to two meals, but alternative nutrition (non-oral nutrition such as tube feeding and drip infusion) is also given; Level 6, the patient is supported primarily by ingestion of easyto-swallow food in three meals, but alternative nutrition is used as a complement; Level 7, easy-to-swallow food is orally ingested in three meals and no alternative nutrition is given; Level 8, the patient eats three meals by excluding food that is particularly difficult to swallow; Level 9, there is no dietary restriction, and the patient ingests three meals orally, but medical considerations
A. Kamide et al. / Brain & Development 37 (2015) 508–514
are given; and Level 10, there is no dietary restriction, and the patient ingests three meals orally (normal). In the above assessment, we had the patient ingest regular food consumed by normally developed children of the same age (i.e. milk for a 3-mon-old baby, soft solid food for an 8-mon-old baby). In addition, we assessed the patients’ disability status using the Functional Independence Measure for Children (WeeFIM). It is an 18-item, 7-level ordinal scale instrument that measures a child’s consistent performance of essential daily functional skills. The 18 items are organized into 6 subscales of self-care (including eating), sphincter control, transfers, locomotion, communication, and social cognition. Total score of the motor WeeFIM consists of scores for the subscales of self-care, sphincter control, transfers, and locomotion. Total scores of the cognitive WeeFIM consist of scores for the subscales of communication and social cognition. The Spearman rank method was employed to explore correlations between items on the ABFS-C or total scores of the ABFS-C and Fujishima’s Grade or the FILS in 54 pediatric patients. We similarly examined the strength of the association between items on the ABFS-C or total scores of the ABFS-C and the total scores of WeeFIM, motor WeeFIM, and cognitive WeeFIM and the eating subscore in the motor WeeFIM in 31 children (12 boys, 19 girls; aged 2 months to 7 years and 8 months, median 11 months). Statistical software used was SPSS Statistics 20. 2.2.3. Interrater reliability Interrater reliability was evaluated employing examination of 17 of the above-mentioned children (8 boys, 9 girls; aged 3 months to 38 months, median 7 months). Assessment was made separately by a doctor and an occupational therapist using the ABFS-C at the first examination to seek weighted k coefficients of resultant data on individual items using the above-mentioned software. Assessment dates differed at most by 1 week
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between the doctor and occupational therapist involved in the assessment. They were kept unaware of their counterpart’s assessment scores during the study period. 2.2.4. Internal consistency Internal consistency of the 5 items comprising the ABFS-C was checked by Cronbach’s coefficient alpha (Cronbach’s A) in 54 pediatric patients. 3. Results 3.1. Validity Whereas there was a significant correlation between Fujishima’s Grade and saliva control (R = 0.470) or the total score of the ABFS-C (R = 0.322), no obvious correlation was found between Fujishima’s Grade and wakefulness (R = 0.014), head control (R = 0.122), hypersensitivity (R = 0.009) or oral motor (R = 0.134). Additionally, FILS had no significant correlation with total scores or each item of the ABFS-C (Table 1). Results of the correlation coefficient analysis that compared scores of the ABFS-C and WeeFIM are shown in Table 2. The total score of the ABFS-C significantly correlated with the total score of the WeeFIM (R = 0.562), motor WeeFIM (R = 0.451), cognitive WeeFIM (R = 0.478), and the eating subscore of WeeFIM (R = 0.460). In addition, the total score of the WeeFIM had a significant correlation with head control (R = 0.423) and oral motor (R = 0.440), and the eating subscore of WeeFIM had a significant correlation with oral motor (R = 0.373). 3.2. Interrater reliability Scores on wakefulness and head control indicated almost perfect interrater reliability (weighted k = 1.0, weighted k = 0.889) while oral motor and saliva control
Table 1 Correlations of total scores of the ABFS-C with Fujishima’s Grade or with FILS. N = 54
Wakefulness Head control Hypersensitivity Oral motor Saliva control Total score of ABFS-C Grade Level
Grade
Median
Range
3.00 3.00 3.00 0.00 2.00 11.00 4.00 5.00
0–3 0–3 0–3 0–3 0–3 0–15 1–10 1–10
ABFS-C: Ability for Basic Feeding and Swallowing Scale for Children. Fujishima’s Grade: Fujishima’s Grade of Feeding and Swallowing Ability. FILS: Food Intake LEVEL Scale. * p < 0.05. ** p < 0.01.
r
Level p
0.014 0.122 0.009 0.134 0.470** 0.322*
0.918 0.378 0.951 0.335 0.000 0.018
0.803**
0.000
r
p 0.225 0.001 0.086 0.043 0.331* 0.098 0.803**
0.102 0.992 0.535 0.760 0.014 0.480 0.000
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A. Kamide et al. / Brain & Development 37 (2015) 508–514
Table 2 Correlations of total scores of the ABFS-C with WeeFIM. N = 31
Wakefulness Head control Hypersensitivity Oral motor Saliva control Total score of ABFS-C
Wee FIM Total score
Motor WeeFIM r
Median
Range
r
p
3.00 3.00 3.00 2.00 2.00 11.00
0–3 0–3 0–3 0–3 0–3 0–15
0.106 0.423* 0.071 0.440* 0.222 0.562**
0.570 0.018 0.705 0.013 0.231 0.001
0.089 0.354 0.004 0.359* 0.281 0.451*
Cognitive WeeFIM
Eating subscore of motor WeeFIM
p
r
p
r
0.635 0.051 0.984 0.047 0.125 0.011
0.098 0.389* 0.029 0.375* 0.147 0.478**
0.601 0.031 0.878 0.038 0.429 0.007
p 0.089 0.354 0.009 0.373* 0.288 0.460**
0.634 0.051 0.964 0.039 0.116 0.009
ABFS-C: Ability for Basic Feeding and Swallowing Scale for Children. WeeFIM: Functional Independence Measure for Children. * p < 0.05. ** p < 0.01.
Table 3 Inter-rater reliability of each ABFS-C item by doctor and occupational therapist (OT). N = 17
Wakefulness Head control Hypersensitivity Oral motor Saliva control * **
Doctor OT Doctor OT Doctor OT Doctor OT Doctor OT
Reliability
Median
Range
Weighted j
P
3.00 3.00 3.00 3.00 3.00 0.00 3.00 3.00 1.00 1.00
0–3 0–3 0–3 0–3 0–3 0–3 0–3 0–3 0–3 0–3
1.0*
0.000
0.889**
0.000
0.016
0.879
0.500*
0.006
0.502*
0.001
p < 0.05. p < 0.01.
had moderate correlations (weighted k = 0.500, weighted k = 0.502). On the other hand, hypersensitivity showed no significant interrater reliability (weighted k = 0.016) (Table 3). 3.3. Internal consistency The 5 items on the ABFS-C had appropriate internal consistency (Cronbach’s A = 0.974). 4. Discussion The prevalence of childhood dysphagia is estimated to fall between 25% and 45% in typically developing children and between 33% and 80% of children with developmental disability, [7] with an upward trend currently in place. There are more than a few very complicated and diversified structural, neurological and psychobehavioral abnormalities that occur in the process of growth and development [8]. Moreover, close
collaboration is required among disciplines to manage disabled children since a variety of professions as well as facilities become engaged in their management in accordance with changes that take place from infancy/ childhood to school age/adulthood [1,2]. Consequently, an assessment scale is desired that can easily identify the whole picture of dysphagia in a child so that information can be shared among disciplines. At present, however, in our country, individual facilities or communities assess dysphagia in their own distinctive ways. Decision tables for dysphagia rehabilitation levels and aspiration risks, which are being used in some pediatric rehabilitation centers, are the easiest to use but they have not been satisfactorily verified for reliability and validity [9]. An assessment approach proposed by Murayama et al. [10] was aimed at detecting aspiration in children with cerebral palsy and is therefore inappropriate for assessment of children with other disabilities. A number of assessment methods for children have been reported abroad [3,11–15]. A systematic review of 27 papers published before 2012 [16] cited the Schedule for Oral Motor Assessment (SOMA) [17] as an excellent assessment method with regard to reliability, validity, and clinical usefulness. This method was aimed at assessing oral motor function and distinguishes between normal and abnormal function by determining whether feeding status for each of 5 food forms exceeded the minimum level. However, it is not commonly used in actual examinations because it is suitable only for dysphasic children with issues of the oral phase. Thus, the reality is that there is no assessment method that is standardized for comprehensive assessment and severity classification with substantiation of reliability and validity [11]. We therefore developed the ABFS-C to provide a simple scale that could easily assess pediatric dysphagia in daily life. One of the most useful points of the
A. Kamide et al. / Brain & Development 37 (2015) 508–514
ABFS-C in comparison with other scales is that we can easily record comprehensive ability regardless of different phases of feeding and swallowing, and then can monitor the progress of the child’s ability without a VFSS or FEES. Our results showed that total scores of the ABFS-C had a significant correlation with Fujishima’s Grade, total scores of the WeeFIM, motor WeeFIM, cognitive WeeFIM, and the eating subscore of the WeeFIM. The 5 items on the ABFS-C had also appropriate internal consistency. On the other hand, regarding items on the ABFS-C, saliva control had a significant correlation with Fujishima’s Grade but wakefulness, head control, hypersensitivity, and oral motor did not. In addition, there were significant correlations between total scores of the WeeFIM and head control and oral motor. Oral motor had the only significant correlation with the eating subscore of the WeeFIM. Consequently, it was suggested that severity assessment required a more comprehensive assessment including not only individual swallowing functions but also consciousness levels, sensation disorders and gross motor functions. FILS had no significant correlation with total scores of the ABFS-C or each of its items except saliva control. This difference from our findings with Fujishima’s Grade was because Fujishima’s Grade indicated how much the patient “can” do based on a VFSS or FEES whereas FILS reflected the patients’ “actual feeding action” according to the direction by their primary doctor [18]. Therefore, FILS was not always determined with food forms suitable to the patient’s feeding and swallowing ability probably resulting in a discrepancy between those levels and ABFS-C scores. Moreover, since subjects differed in the causes of dysphagia, including causative diseases and disorders of the swallowing stages, it was suggested that the ABFSC had the potential to be used to assess disabled children in general. Based on these results, we believe that the ABFS-C is an effective assessment scale that reflects the severity of pediatric dysphagia. Interrater reliability of the ABFS-C was verified in 4 items: wakefulness, head control, oral motor and saliva control. On the other hand, such reliability was not demonstrated in hypersensitivity, which may have been because we do not have a good scale for evaluating hypersensitivity in the body, lips and oral cavity. An examiner whom the patient doesn’t know has difficulty distinguishing between hypersensitivity and psychological refusal, so there might have been differences in rating between examiners. Since a past unpleasant experience, a fear of strangers, or emotional insecurity due to a long hospitalization may cause psychological refusal, it seemed necessary to revise results of the assessment after hearing about the patient’s responses when touched by a family member. In addition, since different sensory stimuli other than touching with the examiner’s fingers, including touching with a pacifier, toothbrush or cup,
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taste stimulus and thermal stimulus, may elicit different responses, examiners might have faced difficulty in decision making. We thought that there was yet room for improvement in the assessment procedure, including unification of kinds of sensory stimuli. Finally, several limitations of this study should be mentioned. First, it remains necessary to explore the clinical utility of each item of the ABFS-C. We would like to use the SOMA for validation in pediatric patients with oral phase problems, and explore whether or not scores are properly allocated to each item and whether or not developing processes are reflected in each age category using other international development evaluation scales such as the Ages & Stages Questionnaires (ASQ) or the Kinder Infant Development Scale (KIDs). Second, we have to revise the assessment procedure for hypersensitivity and its wording. Finally, it is necessary to evaluate interrater reliability between professionals and non-professionals. Then, we plan to accumulate further cases and further revise this assessment tool. References [1] Mukai Y. History of developmental studies on eating function [in Japanese]. Dental Med Res 2013;33:23–34. [2] Nagai S, Koike J. Rehabilitation for pediatric dysphagia. Sogo Rehabil 2011;39:231–7 [in Japanese]. [3] Arvedson JC, Brodsky L. Pediatric swallowing and feeding: assessment and management. 2nd ed. New York: Singular Pub Group Press; 2002. [4] Miyamura K, Hashimoto K, Honda M. Validity and reliability of Ability for Basic Movement Scale for Children (ABMS-C) in disabled pediatric patients. Brain Dev 2011;33: 508–11. [5] Fujishima I. Rehabilitation for swallowing disorders associated with stroke [in Japanese]. 2nd ed. Tokyo: Ishiyaku Publishers Inc.; 1998. [6] Kunieda K, Ohno T, Fujishima I, Hojo K, Morita T. Reliability and validity of a tool to measure the severity of dysphagia: the Food Intake LEVEL Scale. J Pain Symptom Manage 2013;46:201–6. [7] Lefton-Greif MA. Pediatric Dysphagia. Phys Med Rehabil Clin N Am 2008;19:837–51. [8] Groher ME, Crary MA. Dysphagia: clinical management in adults and children. 1st ed. St. Louis: Mosby Inc; 2009. [9] Yokoyama M. Risk of rehabilitation in patients with profound intellectual and multiple disease. Sogo Rehabil 2012;40:137–42 [in Japanese]. [10] Murayama K, Kanda T, Kondo I, Kitazumi E, Kodama K. Assessment of dysphagia in the patient with cerebral palsy – a chart to estimate the possibility of aspiration in patients with severe motor and intellectual disabilities. Jpn J Dysphagia Rehabil 2004;8:143–55 [in Japanese]. [11] Nishio M. Recent international trends in rehabilitation of pediatric dysphagia. Jpn J Dysphagia Rehabil 2008;12:11–9 [in Japanese]. [12] Stratton M. Behavioral assessment scale of oral functions in feeding. Am J Occup Ther 1981;35:719–21. [13] Ottenbacher K, Dauck BS, Gevelinger M, Grahn V, Hassett C. Reliability of the behavioral assessment scale of oral functions in feeding. Am J Occup Ther 1985;39:436–40. [14] Cintas HL, Parks R, Don S, Gerber L. Brief assessment of motor function: content validity and reliability of the upper
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extremity gross motor scale. Phys Occup Ther Pediatr 2011;31:440–50. [15] Sheppard JJ. Using motor learning approaches for treating swallowing and feeding disorders: a review. Lang Speech Hear Serv Sch 2008;39:227–36. [16] Benfer KA, Weir KA, Boyd RN. Clinimetrics of measures of oropharyngeal dysphagia for preschool children with cerebral palsy and neurodevelopmental disabilities: a systematic review. Dev MedChild Neurol 2012;54:784–95.
[17] Ko MJ, Kang MJ, Ko KJ, Ki YO, Chang HJ, Kwon JY. Clinical usefullness of schedule for oral-motor assessment (SOMA) in children with dysphagia. Ann Rehabil Med 2011;35:477–84. [18] Fujishima I, Oono T, Takahashi H, Katagiri H, Kuroda Y, Ishibashi A, et al. Development of the scale of feeding and swallowing: the Food Intake Level Scale. Jpn J Rehabil Med 2006;43:S249 [in Japanese].
Original article
Assessment of feeding and swallowing in children: Validity and reliability of the Ability for Basic Feeding and Swallowing Scale for Children (ABFS-C) Anri Kamide a,⇑, Keiji Hashimoto a, Kohei Miyamura b, Manami Honda a a
Division of Rehabilitation Medicine and Developmental Evaluation Center, National Center for Child Health and Development, Japan b Tokyo Metropolitan Ohtsuka Hospital, Japan Received 21 April 2014; received in revised form 14 August 2014; accepted 18 August 2014
Abstract Objective: The purpose was to devise a dysphagia scale for disabled children that could be applied by various medical professionals, family members, and personnel in treatment and education institutions and facilities for disabled children and to assess the validity and reliability of that scale, “Ability for Basic Feeding and Swallowing Scale for Children” (ABFS-C). Methods: Subjects were 54 children (aged 2 months to 14 years and 7 months, median 14 months) who visited the National Center for Child Health and Development from January 2012 to December 2013. They were examined using the Fujishima’s Grade of Feeding and Swallowing Ability (Fujishima’s Grade), the Functional Independence Measure for Children (WeeFIM) and the ABFS-C composed of 5 items (wakefulness, head control, hypersensitivity, oral motor and saliva control). Validity was evaluated according to correlations of the ABFS-C with Fujishima’s Grade or WeeFIM. To assess interrater reliability, 17 children were assessed by a doctor and occupational therapist independently. Results: The ABFS-C scores and Fujishima’s Grade were correlated using Spearman rank correlation coefficients. Fujishima’s Grade was significantly correlated with saliva control (R = 0.470) and the total ABFS-C scores (R = 0.322) but not with wakefulness (R = 0.014), head control (R = 0.122), hypersensitivity (R = 0.009), or oral motor (R = 0.139). In addition, the total ABFS-C scores had a significant correlation with the total score of the WeeFIM (R = 0.562), motor WeeFIM (R = 0.451), cognitive WeeFIM (R = 0,478), and the eating subscore of the WeeFIM (R = 0.460). Interrater reliability was demonstrated for all items except hypersensitivity. Conclusions: There were significant correlations between the total ABFS-C scores and Fujishima’s Grade and WeeFIM, which suggested the need for comprehensive assessments rather than assessments of individual feeding and swallowing functions. To improve the reliability for hypersensitivity, the assessment process for hypersensitivity should be reviewed. Ó 2014 The Japanese Society of Child Neurology. Published by Elsevier B.V. All rights reserved.
Keywords: Dysphagia; Children; ABFS-C; Clinical assessment scale
1. Introduction Dysphagia rehabilitation in our country involves multiple professions engaged in the treatment of primar-
ily physically disabled children with cerebral palsy or neuromuscular disease. Recently, however, a wider range of conditions such as developmental disorders and tube-feeding dependency have to be addressed
⇑ Corresponding author. Address: National Center for Child Health and Development, 10-1, Okura 2-chome, Setagaya-ku, Tokyo 157-8535, Japan. Fax: +81 (3) 3416 2222, +81 (3) 3416 0181. E-mail address: [email protected] (A. Kamide).
http://dx.doi.org/10.1016/j.braindev.2014.08.005 0387-7604/Ó 2014 The Japanese Society of Child Neurology. Published by Elsevier B.V. All rights reserved.
A. Kamide et al. / Brain & Development 37 (2015) 508–514
[1,2]. Children’s feeding and swallowing function is developed not only through functional and morphological growth of oropharyngeal organs but also through the development of other organs and psychophysiological functions. Consequently, children with dysphagia can be pathogenetically classified into those affected by retardation of functional development and those affected by a reduction of acquired function. Features of disability are thus so complicated that multiple assessments not only limited to the disease have to be performed. Neither here nor abroad, no satisfactory assessment scale for childhood dysphagia has been established that applies a clinical assessment based on an interview and observation with an auxiliary diagnosis using imaging methods [3]. Items found in textbooks for clinical assessment are wide-ranging, specialized, and timeconsuming. It is, therefore, desirable to develop an assessment scale that would allow those with diverse roles, varying from family members to personnel in medical treatment institutions and welfare facilities such as those facilities serving disabled children to arrive at a shared understanding of dysphagia in disabled children. We developed a feeding and swallowing function version of the Ability for Basic Movement Scale for Children (ABMS-C) [4], which we had developed to briefly assess the ability for movement in children. In addition, we verified the validity and reliability of the new instrument. 2. Subjects and methods 2.1. Subjects From January 2012 to December 2013, 54 pediatric patients with dysphagia at the National Center for Child Health and Development newly received rehabilitation. There were 24 males and 30 females, and their median age was 14 months (aged 2 months to 14 years and 7 months). They were classified according to the primary pathogenesis as follows: organic, 17 (4, malignant disease; 3, laryngeal paralysis; 3, laryngomalacia; 2, cheilognathopalatoschisis; 2, gastroesophageal reflux; 1, cleft tongue; 1, multiple malformation; 1, esophageal atresia); neurological, 28 (6, chromosome or genetic abnormality; 3, cerebral palsy; 3, hydrocephalus; 3, history of living donor liver transplantation; 3, extremely low birth weight; 2, brain tumor; 2, epilepsy; 2, multiple malformation; 1, cerebrovascular disease; 1, encephalitis; 1, hypoxic-ischemic encephalopathy; 1, history of cardiac surgery); psychobehavioral, 5 (2, anorexia; 2, developmental disorder; 1 tube-feeding dependency after operations); and developmental, 4 (3, tube-feeding dependency due to inflammatory bowel disease; 1, history of cardiac surgery). They were classified by swallowing phases as follows: postural control
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preparation phase, 6; oral preparatory phase, 10; oral phase, 4; pharyngeal phase, 32; and esophageal phase, 2. This study was approved by the research ethics committee of the National Center for Child Health and Development. Informed consent was obtained from family members of all of the children. 2.2. Methods 2.2.1. Ability for Basic Feeding and Swallowing Scale (ABFS-C) The ABFS-C is composed of 5 items pertaining to a child’s feeding and swallowing ability, i.e. wakefulness, head control, hypersensitivity, oral motor ability, and saliva control. Each item was rated on a 4-point scale from 0 to 3. Fig. 1 shows assessment contents of the ABFS-C. “Wakefulness” is an index of food recognizability reflecting the patient’s general status prior to a feeding and swallowing act. It is rated according to the Glasgow Coma Scale as 0 in the case of failure to respond to pain stimulation, as 1 if the patient is awakened by swaying of the body, as 2 if the patient is awakened by speech, or as 3 if the patient is awake without any stimulation. “Head control” provides information on the patient’s development of motor activity in the feeding posture or the severity of neurological symptoms. As in the case of the Ability for Basic Movement Scale for Children, [4] head control is graded as 0 if the neck is completely unstable, as 1 if the neck follows when both shoulders are raised to 45 degrees, as 2 if the neck follows but stays fixed for less than 10 s when both shoulders are raised to 90 degrees, and as 3 if the neck is perfectly stable. “Hypersensitivity” is a type of pediatric-specific dysesthesia and is an index of the degree of lack of experience with feeding and swallowing. The patient is examined for such dysesthesia by slow movement of the examiner’s palm while touching the patient’s body surface in the order of the upper and lower limbs from the periphery to the center, the face, and around the lips and oral cavity. Observation of changes in the patient’s facial expression determines whether or not hypersensitivity is present. It is graded as 0 if hypersensitivity is present all over the body, as 1 if it is present around the lips, as 2 if it is present in the oral cavity, and as 3 if there is no hypersensitivity. “Oral motor ability” serves as an index of the developmental degree of tongue and lip motor function and the severity of neurological symptoms. Around the time that a child acquires food-holding ability, he/she can open or close the lips. Later, the child can move the tongue back and forth or up and down, and then from side to side. Subsequently, the child becomes able to voluntarily protrude the tongue beyond the lips. Consequently, 0 represents the inability to close the lips or move the tongue, 1 indicates lack of ability to move
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score no response
wakefulness
to pain
no head control
head control
whole body
hypersensitivity
hypersensitive to touch
oral motor
wakes up when shaken
stimulus
or move tongue
can hold head up in line with can hold head up but not for body when both 10 sec when shoulders are both shoulders raised 45 are raised degrees 90 degrees
does not like objects
does not like objects
touching lips
touching inside
or mouth area
the mouth
but cannot move tongue
saliva control constantly drooling
awake
when called to
can move lips cannot close lips
wakes up
constant throat
can hold head up for 10 sec when both shoulders are raised 90 degrees not hypersensitive
can close lips
can close lips
and can move
and can stick
tongue inside
tongue outside
the mouth only
the mouth
throat gurgling
no throat gurgling
after stimulation
after stimulation
inside the mouth
inside the mouth
gurgling
Fig. 1. ABFS-C: Ability for Basic Feeding and Swallowing Scale for Children.
the tongue but the ability to close the lips, 2 denotes that tongue movement is limited to the inside of the oral cavity, and 3 signifies voluntary movement of the tongue beyond the lips. “Saliva control” is a risk index for aspiration that is surmised from saliva control and the amount of food residue in the pharynx. It is graded as 0 if the child is always unable to swallow saliva, resulting in overflow of saliva that has pooled in the oral cavity from the lips; as 1 if pharyngeal secretions always make a gurgling sound, as 2 if pharyngeal secretions make a gurgling sound only after oral stimulation (stimulation is selected from gum rubbing, gustatory stimuli, presentation of usual food, etc. depending on the child’s condition), and as 3 if there are no gurgling sounds of pooled pharyngeal secretions after oral stimulation. 2.2.2. Validity To explore the validity of the ABFS-C, we assessed the patient’s feeding and swallowing ability, and which was scored according to the Fujishima’s Grade of Feeding and Swallowing Ability (Fujishima’s Grade) [5] and the Food Intake LEVEL Scale (FILS) [6]. These scales measure the severity of dysphagia by examining to what degree patients take food orally. They are primarily applied to adults and are used all over Japan. As these instruments did not include factors related to childhood growth and development, we modified them so that they described how the child took food in a form that corresponded to that by a normally developed child of the patient’s age. Fujishima’s Grade determines the severity of a swallowing disorder as necessary by using a videofluoroscopic swallow study (VFSS) or a fiberoptic endoscopic
evaluation of swallowing (FEES). Severity is rated as follows: Grade 1, difficulty in swallowing or inability to swallow, no indication for swallow training; Grade 2, indication only for basic swallow training; Grade 3, aspiration occurs less often when conditions are right, swallow training is feasible; Grade 4, feeding can be enjoyable; Grade 5, oral intake is partially possible (1 or 2 meals); Grade 6, oral intake of 3 meals is possible but alternative nutritional therapy is required; Grade 7, oral intake of easy-to-swallow food is possible at 3 meals; Grade 8, oral intake is possible at 3 meals unless food is particularly hard to swallow; Grade 9, oral intake of regular meals is possible under clinical watch and guidance; and Grade 10, normal feeding and swallowing ability. FILS determines the severity of dysphagia by judgment based on food forms and ratios of oral intakes on a daily basis. Ratings are as follows: Level 1, no swallowing training is performed except for oral care; Level 2, swallowing training not using food is performed; Level 3, swallowing training using a small quantity of food is performed; Level 4, easy-to-swallow food less than the quantity of a meal is ingested orally; Level 5, easy-to-swallow food is orally ingested in one to two meals, but alternative nutrition (non-oral nutrition such as tube feeding and drip infusion) is also given; Level 6, the patient is supported primarily by ingestion of easyto-swallow food in three meals, but alternative nutrition is used as a complement; Level 7, easy-to-swallow food is orally ingested in three meals and no alternative nutrition is given; Level 8, the patient eats three meals by excluding food that is particularly difficult to swallow; Level 9, there is no dietary restriction, and the patient ingests three meals orally, but medical considerations
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are given; and Level 10, there is no dietary restriction, and the patient ingests three meals orally (normal). In the above assessment, we had the patient ingest regular food consumed by normally developed children of the same age (i.e. milk for a 3-mon-old baby, soft solid food for an 8-mon-old baby). In addition, we assessed the patients’ disability status using the Functional Independence Measure for Children (WeeFIM). It is an 18-item, 7-level ordinal scale instrument that measures a child’s consistent performance of essential daily functional skills. The 18 items are organized into 6 subscales of self-care (including eating), sphincter control, transfers, locomotion, communication, and social cognition. Total score of the motor WeeFIM consists of scores for the subscales of self-care, sphincter control, transfers, and locomotion. Total scores of the cognitive WeeFIM consist of scores for the subscales of communication and social cognition. The Spearman rank method was employed to explore correlations between items on the ABFS-C or total scores of the ABFS-C and Fujishima’s Grade or the FILS in 54 pediatric patients. We similarly examined the strength of the association between items on the ABFS-C or total scores of the ABFS-C and the total scores of WeeFIM, motor WeeFIM, and cognitive WeeFIM and the eating subscore in the motor WeeFIM in 31 children (12 boys, 19 girls; aged 2 months to 7 years and 8 months, median 11 months). Statistical software used was SPSS Statistics 20. 2.2.3. Interrater reliability Interrater reliability was evaluated employing examination of 17 of the above-mentioned children (8 boys, 9 girls; aged 3 months to 38 months, median 7 months). Assessment was made separately by a doctor and an occupational therapist using the ABFS-C at the first examination to seek weighted k coefficients of resultant data on individual items using the above-mentioned software. Assessment dates differed at most by 1 week
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between the doctor and occupational therapist involved in the assessment. They were kept unaware of their counterpart’s assessment scores during the study period. 2.2.4. Internal consistency Internal consistency of the 5 items comprising the ABFS-C was checked by Cronbach’s coefficient alpha (Cronbach’s A) in 54 pediatric patients. 3. Results 3.1. Validity Whereas there was a significant correlation between Fujishima’s Grade and saliva control (R = 0.470) or the total score of the ABFS-C (R = 0.322), no obvious correlation was found between Fujishima’s Grade and wakefulness (R = 0.014), head control (R = 0.122), hypersensitivity (R = 0.009) or oral motor (R = 0.134). Additionally, FILS had no significant correlation with total scores or each item of the ABFS-C (Table 1). Results of the correlation coefficient analysis that compared scores of the ABFS-C and WeeFIM are shown in Table 2. The total score of the ABFS-C significantly correlated with the total score of the WeeFIM (R = 0.562), motor WeeFIM (R = 0.451), cognitive WeeFIM (R = 0.478), and the eating subscore of WeeFIM (R = 0.460). In addition, the total score of the WeeFIM had a significant correlation with head control (R = 0.423) and oral motor (R = 0.440), and the eating subscore of WeeFIM had a significant correlation with oral motor (R = 0.373). 3.2. Interrater reliability Scores on wakefulness and head control indicated almost perfect interrater reliability (weighted k = 1.0, weighted k = 0.889) while oral motor and saliva control
Table 1 Correlations of total scores of the ABFS-C with Fujishima’s Grade or with FILS. N = 54
Wakefulness Head control Hypersensitivity Oral motor Saliva control Total score of ABFS-C Grade Level
Grade
Median
Range
3.00 3.00 3.00 0.00 2.00 11.00 4.00 5.00
0–3 0–3 0–3 0–3 0–3 0–15 1–10 1–10
ABFS-C: Ability for Basic Feeding and Swallowing Scale for Children. Fujishima’s Grade: Fujishima’s Grade of Feeding and Swallowing Ability. FILS: Food Intake LEVEL Scale. * p < 0.05. ** p < 0.01.
r
Level p
0.014 0.122 0.009 0.134 0.470** 0.322*
0.918 0.378 0.951 0.335 0.000 0.018
0.803**
0.000
r
p 0.225 0.001 0.086 0.043 0.331* 0.098 0.803**
0.102 0.992 0.535 0.760 0.014 0.480 0.000
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Table 2 Correlations of total scores of the ABFS-C with WeeFIM. N = 31
Wakefulness Head control Hypersensitivity Oral motor Saliva control Total score of ABFS-C
Wee FIM Total score
Motor WeeFIM r
Median
Range
r
p
3.00 3.00 3.00 2.00 2.00 11.00
0–3 0–3 0–3 0–3 0–3 0–15
0.106 0.423* 0.071 0.440* 0.222 0.562**
0.570 0.018 0.705 0.013 0.231 0.001
0.089 0.354 0.004 0.359* 0.281 0.451*
Cognitive WeeFIM
Eating subscore of motor WeeFIM
p
r
p
r
0.635 0.051 0.984 0.047 0.125 0.011
0.098 0.389* 0.029 0.375* 0.147 0.478**
0.601 0.031 0.878 0.038 0.429 0.007
p 0.089 0.354 0.009 0.373* 0.288 0.460**
0.634 0.051 0.964 0.039 0.116 0.009
ABFS-C: Ability for Basic Feeding and Swallowing Scale for Children. WeeFIM: Functional Independence Measure for Children. * p < 0.05. ** p < 0.01.
Table 3 Inter-rater reliability of each ABFS-C item by doctor and occupational therapist (OT). N = 17
Wakefulness Head control Hypersensitivity Oral motor Saliva control * **
Doctor OT Doctor OT Doctor OT Doctor OT Doctor OT
Reliability
Median
Range
Weighted j
P
3.00 3.00 3.00 3.00 3.00 0.00 3.00 3.00 1.00 1.00
0–3 0–3 0–3 0–3 0–3 0–3 0–3 0–3 0–3 0–3
1.0*
0.000
0.889**
0.000
0.016
0.879
0.500*
0.006
0.502*
0.001
p < 0.05. p < 0.01.
had moderate correlations (weighted k = 0.500, weighted k = 0.502). On the other hand, hypersensitivity showed no significant interrater reliability (weighted k = 0.016) (Table 3). 3.3. Internal consistency The 5 items on the ABFS-C had appropriate internal consistency (Cronbach’s A = 0.974). 4. Discussion The prevalence of childhood dysphagia is estimated to fall between 25% and 45% in typically developing children and between 33% and 80% of children with developmental disability, [7] with an upward trend currently in place. There are more than a few very complicated and diversified structural, neurological and psychobehavioral abnormalities that occur in the process of growth and development [8]. Moreover, close
collaboration is required among disciplines to manage disabled children since a variety of professions as well as facilities become engaged in their management in accordance with changes that take place from infancy/ childhood to school age/adulthood [1,2]. Consequently, an assessment scale is desired that can easily identify the whole picture of dysphagia in a child so that information can be shared among disciplines. At present, however, in our country, individual facilities or communities assess dysphagia in their own distinctive ways. Decision tables for dysphagia rehabilitation levels and aspiration risks, which are being used in some pediatric rehabilitation centers, are the easiest to use but they have not been satisfactorily verified for reliability and validity [9]. An assessment approach proposed by Murayama et al. [10] was aimed at detecting aspiration in children with cerebral palsy and is therefore inappropriate for assessment of children with other disabilities. A number of assessment methods for children have been reported abroad [3,11–15]. A systematic review of 27 papers published before 2012 [16] cited the Schedule for Oral Motor Assessment (SOMA) [17] as an excellent assessment method with regard to reliability, validity, and clinical usefulness. This method was aimed at assessing oral motor function and distinguishes between normal and abnormal function by determining whether feeding status for each of 5 food forms exceeded the minimum level. However, it is not commonly used in actual examinations because it is suitable only for dysphasic children with issues of the oral phase. Thus, the reality is that there is no assessment method that is standardized for comprehensive assessment and severity classification with substantiation of reliability and validity [11]. We therefore developed the ABFS-C to provide a simple scale that could easily assess pediatric dysphagia in daily life. One of the most useful points of the
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ABFS-C in comparison with other scales is that we can easily record comprehensive ability regardless of different phases of feeding and swallowing, and then can monitor the progress of the child’s ability without a VFSS or FEES. Our results showed that total scores of the ABFS-C had a significant correlation with Fujishima’s Grade, total scores of the WeeFIM, motor WeeFIM, cognitive WeeFIM, and the eating subscore of the WeeFIM. The 5 items on the ABFS-C had also appropriate internal consistency. On the other hand, regarding items on the ABFS-C, saliva control had a significant correlation with Fujishima’s Grade but wakefulness, head control, hypersensitivity, and oral motor did not. In addition, there were significant correlations between total scores of the WeeFIM and head control and oral motor. Oral motor had the only significant correlation with the eating subscore of the WeeFIM. Consequently, it was suggested that severity assessment required a more comprehensive assessment including not only individual swallowing functions but also consciousness levels, sensation disorders and gross motor functions. FILS had no significant correlation with total scores of the ABFS-C or each of its items except saliva control. This difference from our findings with Fujishima’s Grade was because Fujishima’s Grade indicated how much the patient “can” do based on a VFSS or FEES whereas FILS reflected the patients’ “actual feeding action” according to the direction by their primary doctor [18]. Therefore, FILS was not always determined with food forms suitable to the patient’s feeding and swallowing ability probably resulting in a discrepancy between those levels and ABFS-C scores. Moreover, since subjects differed in the causes of dysphagia, including causative diseases and disorders of the swallowing stages, it was suggested that the ABFSC had the potential to be used to assess disabled children in general. Based on these results, we believe that the ABFS-C is an effective assessment scale that reflects the severity of pediatric dysphagia. Interrater reliability of the ABFS-C was verified in 4 items: wakefulness, head control, oral motor and saliva control. On the other hand, such reliability was not demonstrated in hypersensitivity, which may have been because we do not have a good scale for evaluating hypersensitivity in the body, lips and oral cavity. An examiner whom the patient doesn’t know has difficulty distinguishing between hypersensitivity and psychological refusal, so there might have been differences in rating between examiners. Since a past unpleasant experience, a fear of strangers, or emotional insecurity due to a long hospitalization may cause psychological refusal, it seemed necessary to revise results of the assessment after hearing about the patient’s responses when touched by a family member. In addition, since different sensory stimuli other than touching with the examiner’s fingers, including touching with a pacifier, toothbrush or cup,
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taste stimulus and thermal stimulus, may elicit different responses, examiners might have faced difficulty in decision making. We thought that there was yet room for improvement in the assessment procedure, including unification of kinds of sensory stimuli. Finally, several limitations of this study should be mentioned. First, it remains necessary to explore the clinical utility of each item of the ABFS-C. We would like to use the SOMA for validation in pediatric patients with oral phase problems, and explore whether or not scores are properly allocated to each item and whether or not developing processes are reflected in each age category using other international development evaluation scales such as the Ages & Stages Questionnaires (ASQ) or the Kinder Infant Development Scale (KIDs). Second, we have to revise the assessment procedure for hypersensitivity and its wording. Finally, it is necessary to evaluate interrater reliability between professionals and non-professionals. Then, we plan to accumulate further cases and further revise this assessment tool. References [1] Mukai Y. History of developmental studies on eating function [in Japanese]. Dental Med Res 2013;33:23–34. [2] Nagai S, Koike J. Rehabilitation for pediatric dysphagia. Sogo Rehabil 2011;39:231–7 [in Japanese]. [3] Arvedson JC, Brodsky L. Pediatric swallowing and feeding: assessment and management. 2nd ed. New York: Singular Pub Group Press; 2002. [4] Miyamura K, Hashimoto K, Honda M. Validity and reliability of Ability for Basic Movement Scale for Children (ABMS-C) in disabled pediatric patients. Brain Dev 2011;33: 508–11. [5] Fujishima I. Rehabilitation for swallowing disorders associated with stroke [in Japanese]. 2nd ed. Tokyo: Ishiyaku Publishers Inc.; 1998. [6] Kunieda K, Ohno T, Fujishima I, Hojo K, Morita T. Reliability and validity of a tool to measure the severity of dysphagia: the Food Intake LEVEL Scale. J Pain Symptom Manage 2013;46:201–6. [7] Lefton-Greif MA. Pediatric Dysphagia. Phys Med Rehabil Clin N Am 2008;19:837–51. [8] Groher ME, Crary MA. Dysphagia: clinical management in adults and children. 1st ed. St. Louis: Mosby Inc; 2009. [9] Yokoyama M. Risk of rehabilitation in patients with profound intellectual and multiple disease. Sogo Rehabil 2012;40:137–42 [in Japanese]. [10] Murayama K, Kanda T, Kondo I, Kitazumi E, Kodama K. Assessment of dysphagia in the patient with cerebral palsy – a chart to estimate the possibility of aspiration in patients with severe motor and intellectual disabilities. Jpn J Dysphagia Rehabil 2004;8:143–55 [in Japanese]. [11] Nishio M. Recent international trends in rehabilitation of pediatric dysphagia. Jpn J Dysphagia Rehabil 2008;12:11–9 [in Japanese]. [12] Stratton M. Behavioral assessment scale of oral functions in feeding. Am J Occup Ther 1981;35:719–21. [13] Ottenbacher K, Dauck BS, Gevelinger M, Grahn V, Hassett C. Reliability of the behavioral assessment scale of oral functions in feeding. Am J Occup Ther 1985;39:436–40. [14] Cintas HL, Parks R, Don S, Gerber L. Brief assessment of motor function: content validity and reliability of the upper
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extremity gross motor scale. Phys Occup Ther Pediatr 2011;31:440–50. [15] Sheppard JJ. Using motor learning approaches for treating swallowing and feeding disorders: a review. Lang Speech Hear Serv Sch 2008;39:227–36. [16] Benfer KA, Weir KA, Boyd RN. Clinimetrics of measures of oropharyngeal dysphagia for preschool children with cerebral palsy and neurodevelopmental disabilities: a systematic review. Dev MedChild Neurol 2012;54:784–95.
[17] Ko MJ, Kang MJ, Ko KJ, Ki YO, Chang HJ, Kwon JY. Clinical usefullness of schedule for oral-motor assessment (SOMA) in children with dysphagia. Ann Rehabil Med 2011;35:477–84. [18] Fujishima I, Oono T, Takahashi H, Katagiri H, Kuroda Y, Ishibashi A, et al. Development of the scale of feeding and swallowing: the Food Intake Level Scale. Jpn J Rehabil Med 2006;43:S249 [in Japanese].