Temporal evolution of the approach to functioning in early intervention under the perspective of the international classification of functioning, disability, and health: a systematic review

Evolução temporal da abordagem da funcionalidade na intervenção precoce sob a perspectiva da classificação internacional de funcionalidade, incapacidade e saúde: uma revisão sistemática

Evolución temporal del enfoque de la funcionalidad en la intervención temprana desde la perspectiva de la Clasificación Internacional de la Funcionalidad, la Discapacidad y la Salud: una revisión sistemática

ABSTRACT

Effective early interventions must guarantee child development in natural environments and improve their functioning. This study aimed to analyze the temporal evolution of the approach to functioning in early intervention programs using the international classification of functioning, disability, and health (ICF) as a reference. We included randomized clinical trials that studied early intervention programs in children aged from zero to six years. The significant concepts in the outcomes of interventions were linked to the ICF. This review included 56 articles and evaluated 74 outcomes. It generated 82 ICF codes, which encompassed the ICF domains of body functions, activities, participation, and environmental factors. The included early intervention programs partially addressed functioning over the years.

Keywords:
Child Development; Psychosocial functioning; Early intervention

RESUMO

Estratégias eficazes de intervenção precoce devem garantir o desenvolvimento infantil em ambientes naturais e melhorar a funcionalidade das crianças. Este estudo teve como objetivo analisar a evolução temporal da abordagem do funcionamento dos programas de intervenção precoce tendo como referência a CIF. Foram incluídos ensaios clínicos randomizados que estudaram programas de intervenção precoce em crianças de 0 a 6 anos. Os conceitos significativos contidos nos resultados das intervenções foram vinculados à CIF. Este artigo incluiu 56 artigos e avaliou 74 resultados de intervenções. Foram gerados 82 códigos diferentes da CIF, os quais contemplaram os domínios funções corporais, atividades e participação da CIF e fatores ambientais. A funcionalidade foi abordada parcialmente ao longo dos anos pelos programas de intervenção precoce incluídos.

Descritores:
Desenvolvimento infantil; Funcionamento psicossocial; Intervenção precoce

RESUMEN

Las estrategias efectivas de intervención temprana deben garantizar el desarrollo infantil en entornos naturales y mejorar la funcionalidad de los niños. Este estudio tuvo por objetivo analizar la evolución temporal del enfoque del funcionamiento de los programas de intervención temprana con referencia a la CIF. Se incluyeron ensayos clínicos aleatorizados que evaluaron programas de intervención temprana en niños de 0 a 6 años de edad. Los conceptos significativos que constan en los resultados de las intervenciones se vincularon a la CIF. Este estudio incluyó 56 artículos y evaluó 74 resultados de intervenciones. Se generaron 82 códigos diferentes de la CIF, que incluían los dominios de las funciones corporales, las actividades y la participación de la CIF y los factores ambientales. La funcionalidad ha sido abordada parcialmente a lo largo de los años por los programas de intervención temprana incluidos.

Palabras clave:
Desarrollo infantil; Funcionamiento psicosocial; Intervención temprana

INTRODUCTION

The biopsychosocial perspective understands child development as a complex and multifactorial phenomenon that depends on individuals’ relationship with their environment and received stimuli¹. Optimal early childhood development lays the groundwork for long-term academic, behavioral, socio-emotional, and economic achievements^2,3.

The early recognition of developmental difficulties in early childhood is essential for children to reach their developmental potential⁴. For this, early interdisciplinary intervention programs have largely targeted at-risk children with established risk or atypical development and their families^1,5.

These programs have undergone different stages and theoretical influences over the years, including child-centered practices that rehabilitate their mental, physical, or sensory disabilities⁶. By considering development in its complexity of factors, programs shifted their focus to current ecological models of service delivery, with the influence of equally recognized environmental, family, and child factors^6-8.

Based on biopsychosocial theoretical arguments, the International Classification of Functioning, Disability, and Health (ICF) reflects the approach that moved away from focusing on the consequences of diseases to highlight functioning as a fundamental component of health^9,10. The ICF describes functioning as a complex interaction of body functions and structures, activities, participation, and contextual factors^11,12.

Thus, under the influence of the biopsychosocial model, effective early intervention strategies must include elements to improve body functions and increase activity, ensuring full participation and development in natural environments and improving children’s functioning^6,13. For this, they must cover all the ICF domains to respond to the results and promote child development¹⁴.

Contributing to the planning of early intervention programs in line with the ICF recommendations requires a systematic review that provides an overview of early intervention programs in the literature based on the perspective of the broad ICF model of functioning. This will show the domains that require reinforcement and subsidize research, teaching, and health management. Thus, this study analyzed the temporal evolution of the functioning approach in early intervention programs using the ICF as a reference.

METHODOLOGY

A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement¹⁵. The methods are reported in the following sections. All steps were performed by two independent reviewers. In cases of disagreement, a third reviewer was consulted until a consensus was reached via discussion or arbitration.

Registration and protocol

The protocol of this systematic review was registered on the international prospective register of systematic reviews under number CRD42020221106.

Eligibility criteria

Randomized clinical trials (RCTs) on early intervention programs, children aged from zero to six years that had been published in English or Portuguese were included in this review. Search periods were ignored as this research focused on mapping the temporal evolution of scientific production on the subject. Only RCTs were considered since this study design provides strong evidence for interventions. RCT protocols or follow-ups were excluded.

Data sources

A comprehensive search was carried out on four electronic databases: PubMed (09/02/2021), CINAHL (via EBSCO Host [15/01/2021]), Embase (via CAPES Portal of Journals [09/02/2021]), and Central (09/02/2021).

Search strategies

Advanced search strategies were adopted on each database. A combination of the terms child development, early intervention, functioning, disability, and disabilities was used based on the PICOT strategy: (P) population - children, (I) intervention - early intervention, (C) comparison - over time, (O) outcome - functioning, disability, or incapacity, and (T) time - indefinite.

Initially, the authors conducted a pilot study by reading 10% of the retrieved abstracts to adjust the chosen descriptors and inclusion and exclusion criteria.

The possibilities of descriptors crossing were: “child development” AND “early intervention” AND functioning; “child development” AND “early intervention” AND disability; “child development” AND “early intervention” AND disabilities.

An additional manual search was performed 1) in the references of excluded follow-up articles to locate the original RCTs and 2) in the records of excluded RCT protocols to find studies derived from these protocols. The articles obtained by such manual search that met the inclusion criteria were added to the sample of this review.

Selection process

Articles were selected according to the following steps: title screening, abstract screening, and full-text screening. The variables of interest (first author, year of publication, sample size, population, intervention and control description, intervention outcomes, and study findings) were exported by one of the authors to an Excel spreadsheet.

Link with the ICF

Linking was conducted using Microsoft Excel^® 2019. The significant concepts in the intervention outcomes were extracted and linked to the most specific ICF categories by two independent healthcare providers according to the set of 10 linking rules in Cieza et al¹⁶. Following the proposed protocol, the significant concepts were organized according to the ICF domains.

The degree of agreement between the two authors regarding the connection of concepts to the ICF was calculated using the Kappa coefficient. The variable was nominal (ICF domains) and included no missing data. Kappa coefficient values range from zero to one, in which one indicates perfect agreement and zero, no additional agreement beyond what is expected by chance. Values from 0.61 and 0.80 mean substantial agreement, whereas those from 0.81 to 1 represent excellent agreement between researchers¹⁷. In the case of disagreements, a third reviewer was consulted until a consensus was reached.

Data analysis

A table was created to analyze the characteristics of the included articles with the following variables: author and year of publication of the studies, sample characteristics, intervention outcomes, and the characteristics of early intervention programs.

Descriptive statistics were used to examine the relative frequency of the ICF categories linked to the concepts in the intervention outcomes. Data analysis comprised tables with the binding frequency of each category and their respective ICF domains.

The ICF categories are described at the second, third, or fourth levels. The data are descriptively described and discussed.

Methodological quality assessment

The quality of reporting of the selected articles was assessed by physiotherapy evidence database (PEDro) criteria. The scoring system in the PEDro scale was used. When the score was unavailable, the assessments were performed by the authors of this study.

The PEDro scale aims to quickly find which randomized controlled trials may have internal validity and sufficient statistical information for result interpretation.

For this review, the following strength rating conventions were applied: 9-10 (excellent), 6-8 (good), 4-5 (fair), and <4 (poor). Similar conventions have been applied in published systematic reviews⁶.

RESULTS

Flowchart of the reviewed studies

This study found 1,564 studies in the accessed databases, of which 249 were duplicates. Thus, it analyzed 1,315 articles by title and abstract screening and selected 228 for full-text screening. Among these, 40 met the inclusion criteria of this study. This review included 16 articles after the manual search described above. Thus, its final sample consisted of 56 articles (Figure 1). This study included articles that had been published from 1980 to 2020; most of which were carried out from 2010 to 2020.

Figure 1
Search flowchart adapted from the preferred reporting items for systematic reviews and meta-analyses 2020.

Methodological quality

The mean score according to the PEDro scale totaled 5.9 points, ranging from four to nine points. Random allocation occurred in 88% of studies. Most studies included a blind allocation of their samples (71%) and similar groups (88%). Half of the chosen studies blinded their therapists and evaluators (50%).

Participants

The 56 articles included 9,645 participants. The target audiences in most studies (35.7%; n=20) referred to preterm and/or low birth weight infants. This review found that 12.5% (n=7) of its studies evaluated children at socioeconomic risk; that 8.9% of them (n=5) studied children with autism spectrum disorder (ASD), that 7.1% of them (n=4) included children with intellectual disability; that 3.6% of them (n=2) focused on children at risk for brain injuries, that 3.6% of them (n=2) included children with neonatal asphyxia, that 3.6% of them (n=2) studied children with language delay, that 3.6% of them (n=2) included children with organic or non-organic growth failure, that 3.6% of them (n=2) focused on children with Down syndrome, that 1.8% of them (n=1) assessed institutionalized children, that 1.8% (n=1) investigated children with brain damage syndrome, and that 1.8% of them (n=1) researched children with cerebral palsy.

In total, four studies (7.0%) specified their target audience as only children with or at risk of developmental delay. A study (1.8%) evaluated the results of an intervention in early childhood education in school-age children, one study (1.8%) failed to specify its participants’ disability, and one article (1.8%) investigated the results of an intervention in children with parents with mental health problems.

Characteristics of the interventions

Chart 1 summarizes the general characteristics and outcomes of the interventions.

Chart 1
Characteristics of the included articles

STUDY	TARGET AUDIENCE	OUTCOMES	INTERVENTION
Rose et al.18	60 premature babies	Sleep state	A multimodal stimulation performed by an interventionist during the hospital stay with emphasized tactile components.
		Eye movements
		Irregular breathing
		Motor activity
		Heart rate
Cappleman et al.19	37 babies from families with low socioeconomic status	Physical development	Carolina infant curriculum: a series of activities for mothers and children aged up to 24 months. Nurses carried out home visits once a month and trained the mothers.
		Cognition
		Motor skills
		Language
		Sociability
Ramey et al.20	64 high-risk children up to age three years	Cognition	Project care: In addition to a daycare educational experience, children and parents also received the home visitor family education curriculum (designed to teach parents problem-solving skills).
		Language
		Social behavior
		Adaptive skills
Palmer et al.21	48 infants (aged from 12 to 19 months) with mild to severe spastic diplegia	Motor skills	A physiotherapy program to stimulate child development including motor, sensory, language, and cognitive activities of increasing complexity.
		Balance
		Posture
Rauh et al.22	78 mother-newborn dyads	Maternal self-confidence	Mother-infant transaction program: maternity and home sessions to find mothers’ strengths, support their self-confidence, and familiarize them with their babies in domains such as self-regulation, behavioral signs of infant distress/disorganization, daily care routines, and playful experiences.
		Affection
		Maternal perception
		Cognition
		Adaptive skills
Živković 23	985 preterm infants with low birth weight	Cognition	The infant health and development program: home visits during children’s first three years of age at a child development center and parent group meetings. The visits provided parents with information on child health and development.
		Language
		Sociability
		Interaction with parents
		Maternal perception
Eiserman et al.24	45 children aged from three to five years with moderate speech disorders	Speech articulation	A phonetic approach including auditory training and word production, offered by a speech therapist in a clinic and home parenting training in which children received services directly from their parents by a program of games and activities for language skills and in other areas of development that showed delays.
		Language
		Sociability
		Cognition
		Motor skills
		Adaptive skills
Black et al.25	130 children, (mean age 12.7 months) with non-organic growth failure	Development/growth	A home visiting program developed as a partnership between families and interventionists. Visitors asked families about their strengths, needs, and priorities and worked with them to develop a family service plan with specific goals and objectives. Family-centered practice.
		Parent-Child interaction
		Behavior Troubleshooting
		Motor skills
		Language
Bao et al.26	64 babies asphyxiated at term	Cognition	During the neonatal period, home visits were carried out, showing parents how to stimulate the baby’s visual and hearing skills.
		Motor skills
		Speech articulation
		Sociability
Avon Premature Infant Project27	309 very premature children	Improvement of developmental scores at two years of age (motor skills, autonomy for activities of daily living, sociability, hearing, language, fine motor skills) and parental education	A parent counseling program including parent support interventions. Training comprised a series of seminars and individual and group work using a supportive counseling model.
Bao et al.28	103 preterm infants with a gestational age of 28-36.9 weeks	Motor skills	Parents were taught to carry out the intervention program from age zero to two years. Follow-up included checking the babies’ developmental status, instructing parents on how to carry out the program for the upcoming period and suggesting age-appropriate toys, books, and illustrations.
		Cognition
		Speech articulation
		Sociability
		Practical reasoning
Smith et al.29	28 children aged from 18 to 42 months	Higher brain functions	Each child’s primary caregiver was asked to perform five hours per week of treatment at home alongside a therapist. As they acquired some skills, such as verbal requests, proper play, dressing, and toileting, the focus shifted to more naturalistic instruction in group settings such as classrooms.
		Adaptive skills
		Sociability
		Language
		Academic achievement
Thomaidis et al.30	24 children aged from eight months to five years with developmental delay due to organic causes	Gross and fine motor skills	Portage early intervention: a weekly educational visit from early intervention advisors for two years aimed to help families achieve a good quality of life for themselves and their young children, learning and playing together and participating and being in the community.
		Sociability
		Copying
		Daily living skills
		Pre-academic skills
		Language
		Parent participation
Zeanah et al.31	136 institutionalized children aged from five to 31 months	Caregiving environment	A foster care intervention was designed to represent the home experience of children who have never been institutionalized and provide a replicable, accessible, and culturally relevant alternative to institutionalization.
		Physical growth
		Cognition
		Language
		Behavior/temperament
		Emotion
		Attention
		Brain electrophysiology
Als et al.32	30 premature infants from a neonatal intensive care unit (NICU)	Autonomic functions	Observations and assessments of infant behavior, with suggestions for parents and NICU staff on ways to support each infant’s development. A developmental intervention emphasized each baby’s behavioral individuality
		Motor skills
		Behavior state organization
		Sleep-wake cycle
Ohgi et al.33	23 low birth weight newborns who had been admitted to a NICU	Mother-child interaction	The intervention strategy had two main components: the first was designed to facilitate mother-infant interaction in the NICU using a neonatal behavioral assessment-based intervention. Then, a specialist commented and discussed the baby’s behavior and showed the parents the intervention method from which the baby would benefit.
		Sleep-wake cycle
		Sensory development
		Tone and posture
Olafsen et al.34	140 babies weighing less than 2000g from a geographically defined area	Parent-child interaction Joint attention	A modified version of the Vermont intervention program for low birthweight infants. In an initial session, parents shared their experiences of hospitalization and their feelings of grief. A logbook was written for each intervention session. The logbook was reviewed by the coordinating nurse and a clinical professor of child psychology to maintain the consistency of the intervention. Second, an attempt was made to adopt more active participation from the parents in the assessment and management of babies.
Giudice et al.35	47 children living with Down syndrome with a mean age of 4.5 and 5.9 months	Cognition	Carolina curriculum for infants and toddlers with special needs: Parents were instructed to incorporate therapeutic activities into their children’s daily care routines. The curriculum consists of 26 areas or developmental sequences representing cognition, language, social skills, and fine and gross motor skills.
		Language
		Sociability
		Adaptive skills
		Fine and gross motor skills
Kaaresen et al.36	140 babies with a birth weight of 2,000 g	Parent-child interaction Cognition Behavior	A modified version of the mother-infant transaction program. The intervention attempted to sensitize parents to notice their infants’ cues (especially those that signal stimulus overload, distress, and readiness for interaction) and to respond appropriately to these cues, facilitating mutually satisfying interactions.
Rickards et al.37	59 children aged from three to five years with disabilities but no cerebral palsy	Cognition	A home program based on the child’s needs and carried out at home to continue school learning and generalize skills across the child’s environments. The multidisciplinary team and the parents formulated an individual program determined by the child’s developmental level, learning style, and interests and covered all areas of development.
		Confrontation
		Family stress
		Parent empowerment
		Behavior
Bierman et al.38	356 four-year-old children in 44 classrooms	Socio-emotional development	Head Start REDI: the intervention involved short classes, “practical” extension activities, and specific empirically linked teaching strategies. Take-home materials were provided to parents to enhance skill development at home. The intervention was delivered by classroom teachers and integrated into their ongoing classroom programs.
		Language Literacy
		Learning
		Aggressiveness
Koldewijn et al.39	86 babies at 32 weeks of gestational age or birth and with a weight of 1500 g	Motor skills	Behavioral assessment and intervention program: a program for building infants and parents’ strengths, enhancing mutually satisfying interactions and parent empowerment. The interventionist assists parents in everyday life to adjust the environment to their infant’s neurobehavioral needs and provide co-regulatory support during infant interactions.
		Mental functions
		Behavior
		Regulatory competence
		Social interactions
Shin et al.40	30 preschool-age children aged from three to six years who lived with intellectual disabilities	Adaptive behavior	Based on the portage curriculum, teachers with a coaching strategy trained parents to work with their children during weekly home visits. First, they reviewed the homework by having the parents show the previously assigned task with their children. Then, teachers would review one or two new teaching objectives they had written with parents and show the steps to achieve the desired behavior. These new goals become assigned homework for parents, who would try to perform the activities with their children and receive guidance and feedback.
		Communication
		Daily living skills
		Social skills
		Motor skills
Heathcock et al.41	27 premature babies	Feet reaching	The movement training activities were divided into three categories: general, midline, and distinct movements. Families were asked to provide 10 minutes of training with their babies at home five days a week for eight weeks.
		Feet movements
Nair et al.42	A consecutive sample of 800 babies discharged alive	Tone	Child development center: the four main sensory modalities used are visual, auditory, tactile, and vestibulo-kinesthetic stimulation. A center occupational therapist trained mothers individually and in groups to give early center stimulation. Mothers were to continue to do the same at home.
		Sensory asymmetries (visual, auditory, tactile, and vestibulo-kinesthetic)
Latha et al.43	75 children aged from four to 33 months with developmental delay	Problem-solving	The experimental group received general cognitive stimulation and the early intervention model designed exclusively for the research, consisting of problem-solving tasks and mother-child interaction, enabling mothers to understand the child’s development, involving them as facilitators.
		Parent-child interaction
		Environmental arrangement
Dawson et al.44	48 children aged from 18 to 30 months who had been diagnosed with ASD	Cognition	Early start Denver model: teaching strategies that involve interpersonal exchange, positive affect, shared engagement with real-life materials and activities, adult responsiveness and sensitivity to child cues, and a focus on verbal and non-verbal communication based on an informed curriculum about all domains of development.
		Adaptive skills
		Affect
		Verbal and non-verbal communication
		Activities of daily living
Spittle et al.45	120 extremely premature babies	Posture	Preventative care program for the first 12 months of life: (1) generic content to all families, including strategies to promote an enriched environment, positive playing, general developmental milestones, eating, sleep, and parental well-being and (2) baby- and family-specific content based on parent-identified goals or concerns identified by parents.
		Coordination/Strength Parents’ mental health Parent-child relationship
		Cognition
		Language
		Motor skills
		Behavior
		Emotional regulation
Blauw-Hospers et al.46	46 babies aged from three to six months of corrected age at high risk for developmental disorders	Motor behavior	Coping with and caring for infants with special needs: a family-centered program with three components: (1) parental coaching, (2) challenging infants to produce motor behavior by themselves, and (3) stimulation of motor behavior at the limit of the infant’s capabilities.
		Playing
		Autonomy
		Family involvement
Mendelsohn et al.47	410 mother-newborn dyads	Parent-child interaction Playing	Video interaction project from birth to three years. A child development specialist met one-on-one with families, providing an individualized, relationship-based intervention that offered a curriculum focused on supporting verbal interactions in make-believe play, shared reading, and daily routines.
		Reading
		Daily routines
		Cognition
		Literacy
Ravn et al.48	93 mothers of premature babies	Parent-child interaction Parent-child relationship	Mother infant transaction program: aimed to teach parents to understand the individuality of an atypical child, establish a good pattern of interaction, and encourage parents to enjoy their babies.
Carlo et al.49	40 babies who showed no response to bag and mask ventilation as part of their birth resuscitation	Parent-child interaction Cognition	During home visits, the trainer presented one or two playful interactive learning activities that targeted a developmentally appropriate competency. The parent practiced the activity in the presence of the trainer, who provided them feedback. Activity cards were left with the parents, who were encouraged to apply the targeted activities, integrating them into daily life with the child until the next home visit.
		Fine motor skills
		Sociability
		Self-help
		Gross motor language
Kaiser et al.50	77 children with intellectual disabilities and their primary caregivers	Language	Enhanced milieu teaching: a naturalistic model of early language intervention that uses the child’s interest and initiations as opportunities to model and encourage language use in everyday contexts. It combines developmentally appropriate responsive interaction strategies (contingent responsiveness, language modeling, expansions of child utterances) with behavioral teaching strategies to increase the frequency and complexity of language.
		Vocabulary
		Cognition
		Nonverbal communication
		Quality home support
		Stress
		Playing
Karaaslan et al.51	15 Turkish preschool children (aged from two to six years) living with DS and their mothers	Cognition	Individualized intervention sessions between parents and children once a week. The interventionist explained how the behavior was associated with the child’s developmental concerns, coached the mothers, and helped them to develop a plan to advance the core goals of their child’s behavioral intervention into their routine activities and interactions with their child.
		Communication Sociability
		Emotional skills
		Child development
		Maternal behavior
Favazza et al.52	233 children aged from three to five years living with intellectual disabilities	Walking/Running Motor Skills	Young athletes program: 24 comprehensive lessons that included motor activities for basic skills (visual tracking, motor imitation), walking, running, balance, jumping, trapping, catching, throwing, striking, and kicking. Each class included an opening motor movement song, motor games, and activities. A home component was developed to complement the classes presented by teachers at the school.
		Balance
		Jumping
		Kicking
		Fine motor skills
Hwang et al.53	45 families of children with or at risk of developmental delay who were aged under 36 months	Participation in family routines	Routines-based early intervention: strategies were incorporated into family routines and procedures were written with objectives selected by the families.
		Child independence
		Parents and children’s relationship
		Cognition
		Language
		Gross and fine motor skills
Milgrom et al.54	109 women with 123 babies born <30 weeks’ gestation	Stress reduction	Enhanced mother infant transaction program: Mothers were encouraged to implement stress-reduction strategies while their babies were still in the NICU. Mothers were trained to increase their sensitivity in recognizing signs of stress (including “shutdown” mechanisms, alert-available behavior, facial expressions, quality of motor behaviors, posture, and muscle tone), provide graded stimulation, and avoid overwhelming infants.
		Cognition behavior
Kaminski et al.55	574 low-income mother-child dyads	Parent-child interaction Affection	Legacy for children: Weekly group meetings at a community or university, occasional one-on-one sessions, and group outings in the community providing a forum for discussing and testing parenting strategies and a community of support for mothers’ parenting choices.
		Parental effectiveness
		Community support for the mother
		Socio-emotional behavior
		Cognition
		Language
		Playing routines/discipline
		School readiness
Chen et al.56	178 premature babies with very low birth weight	Morbidity	Two interventions: clinic- or home-based intervention program. Specific care included teaching of child developmental skills, feeding support, massage, parent support, and education. Post-discharge interventions were performed at the same time as the neonatal follow-up visits. A booklet and a CD containing information on age-appropriate intervention activities were also provided.
		Growth
		Neurological development
		Parental education
Kasari et al.57	112 Families of children aged from two to five years with ASD	Parent-child interaction Joint attention	Two intervention groups: caregiver-mediated module or caregiver education module. The interventionists in the former followed an intervention that focused on establishing dyadic engagement during three routines at home (one routine involved play and two other “everyday activities” such as housework and hygiene). The latter group involved training caregivers in small groups without the presence of the child.
		Playing
Wake et al.58	200 children with language delay at the age of four years	Speech articulation	Language for learning: standardized activities covering the four domains of language development: vocabulary and grammar, narrative skills, comprehension, and phonological awareness. A trained “language assistant” visited the child and trained at least one caregiver at home for weekly one-on-one sessions.
		Vocabulary
		Grammar
		Pre-literacy
		Language
		Behavior
		Quality of life
		Sociability
		Education
Yousafzai et al.59	1,489 mother-infant dyads of families with children aged up to 24 months	Nutrition	Lady health worker program: Routine monthly group sessions and home visits that included, among other topics, health and hygiene education, nutrition education for infants and young children, breastfeeding and complementary feeding practices, and child growth monitoring.
		Growth
		Morbidity
		Cognition
		Language
		Social-emotional skills
		Motor skills
Ma et al.60	285 premature babies	Motor skills	Hospital and family intervention. Infants admitted to the NICU received auditory, visual, and tactile stimulation. At the children’s rehabilitation outpatient clinic, parents were also taught to perform vestibular stimulation, pediatric gymnastics, and hydrotherapy.
		Skeletal and muscular development
		Sensory function
Bierman et al.38	200 families with four-year-old children	Literacy	Research-based developmentally informed parent program: During home visits, activity boxes with play materials and stories were designed to promote the development of the child’s cognitive skills and socio-emotional skills. Parents watched videotapes illustrating the use of the material, featuring interactive reading and positive parenting strategies. On three occasions, home visitors reviewed videos of parents interacting with their children to provide feedback and individualize the program.
		Sociability
		Language
		Parent-child interaction Parental support
Doyle et al.61	233 pregnant women from a community at social risk	General health	A series of tip sheets delivered during home visits encouraged awareness of children’s physical health (example: tip sheets on immunization, childhood illnesses, smoking, keeping a safe home, etc.). An additional parenting class was also offered.
		Reduction of hospital admissions and illnesses
Castel et al.62	Of the 89 families in this study, 65 had premature babies and 24, full-term newborns.	Parental stress	A psychological intervention based on the attachment theory, organized in three steps: (1) to facilitate parent-infant and mother-infant interactions, improve emotional sharing within the mother-father-child triad, and improve the mental health of parents, (2) promote understanding of child development to reduce stress and strengthen parents’ appropriate perceptions of their baby’s behavior, and (3) to promote parent-infant triadic relationships to favor infants’ cognitive, motor, socio-emotional, and behavioral development.
		Mental health
		Posture
		Language
		Sociability Coordination
Liu et al.63	64 babies with brain damage syndrome	Posture	Intelligence seven needle therapy associated with the early routine intervention, involving physiotherapy, massage, positioning, strengthening, and relaxation.
		Postural reflexes Balance
Fonagy et al.64	76 dyads of parents with mental health issues who were experiencing high levels of social adversity and their babies (<12 months)	Cognition	Psychoanalytic parent-infant psychotherapy: Parents, babies, and a therapist would sit on the floor to produce smooth transactions with the baby. Parents would talk about their mental state/feelings, the factors affecting them, their relationship with their baby, and issues about the baby. The therapist would observe the interactions in the room and try to understand and give them meaning considering the parents’ concerns in the room and their knowledge of current and past experiences and relational models. Interactions that support child development were observed and reinforced and affective and behavioral impacts were addressed.
		Language
		Motor skills
		Parent-child interaction Mother’s stress Emotions
Sgandurra et al.65	41 premature babies (age range: 3.0-5.9 months corrected age)	Motor skills	CareToy intervention: This intensive, home-based, family-centered training program consisted of activities aimed at specific goals, called scenarios, planned remotely by the clinical/rehabilitation team according to the specific needs and capabilities of the baby. The multiaxial training had a high degree of variability and complexity.
		Visual acuity
		Activities of daily living
Yazejian et al.66	239 infants and children aged below 19 months from low-income families	Language	Educare: A high-quality school early childhood education program, with a strong curriculum focusing on language and literacy, development, problem-solving, arts, and more.
		Sociability
		Parent-child interactions
		Family well-being
Schertz et al.67	144 children and their parents aged from 16 to 30 months who lived with autism	Nonverbal communication	Joint attention mediated learning: An early intervention home program implemented by parents was designed to promote pre-verbal social communication. It aimed to acquire three developmentally sequenced social communicative competencies: focusing on faces, turn taking, and joint attention.
		Parent-child interaction
Platje et al.68	86 parents of young children aged from one to five years with visual or visual and intellectual impairments	Parent-child interaction Parent autonomy	Video-feedback intervention to promote positive parenting-visual: an intervention focused on parent-child relationship and interactions. Components: predictability, safety, independence, dealing with changes and frustration, sharing of attention, joint attention, recognizing and naming emotions, and empathy.
		Caring for children Stress
Nascimento et al.69	24 children who were born five months premature	Grabbing	A stimulation program to improve grabbing and catching skills. Velcro-covered toys were used to encourage catching, and babies wore Velcro-covered gloves on both hands during training.
		Catching up
		Adjustments with limbs
Hielkema et al.70	43 babies whose corrected age ranged from zero to nine months at very high risk of cerebral palsy	Motor skills	Coping with and caring for infants with special needs: a family-centered program with three components: (1) parental coaching, (2) challenging infants to produce motor behavior by themselves, and (3) stimulation of motor behavior at the limit of the infant’s capabilities.
		Cognition
		Behavior
		Parent-child interaction
Colditz et al.71	323 families with premature babies	Behavior	Baby triple p. Intervention guides for parents to improve coping skills, the ability to recognize the baby’s needs, promote a safe, engaging, stimulating, and positive learning environment, teach the baby new skills, and develop a relationship with the baby.
		Emotion
		Cognition
		Language
		Motor skills
		Parent-child interaction
Armstrong et al.72	71 children aged from 18 to 36 months with developmental delay	Parent-child relationship	Learn, engage and play. Indoor games and outdoor activities, group music, singing, story time, snack, and farewell activities. The theoretical framework of the service model was used based on family-centered practices.
		Language

The 56 selected studies used three strategies to facilitate early intervention: in 75% of them (n=42), parents or caregivers implemented interventions trained by healthcare providers or teachers, functioning as facilitators or co-therapists. In 9% of studies (n=5), early intervention specialists configured the only facilitators of the interventions. Interventionists used coaching in the remaining 16% of studies (n=9).

The interventions reported by the 56 studies occurred in varying scenarios: 42.9% (n=24) took place in homes; 8.9% (n=5), in reference services for early intervention; 5.4% (n=3), in hospitals; 3.6% (n=2), in schools; and the remaining 39.2% (n=22) in two scenarios that complemented the intervention: hospitals and homes after discharge, schools and homes, early intervention services and homes, or hospitals and follow-up outpatient clinics.

The chosen studies assessed 74 outcomes, including traditional child-focused and multidimensional outcomes, which reflect the child’s needs and the family context. In some cases, more than one study mentioned the same outcome, generating 267 instances.

Motor, cognitive, and language outcomes, considered traditional outcomes, constituted the three most prevalent results (26.2%; n=70). Family-child interaction was the fourth most evaluated outcome in the reviewed studies (7.9%; n=21), followed by social interaction (6.7%; n=18), behavior organization (4,9%; n=13), autonomy to perform activities of daily living (3.4%; n=9), and adaptive skills (2.6%; n=7). Studies also analyzed adjustment to the home, including reducing parental stress (2.2%; n=6) and parent empowerment (1,1%; n=3). Table 1 shows other analyzed outcomes.

This review found that 91% (n=51) of the chosen studies evaluated early intervention strategies with effective child and family participation. Among them, home visits constituted the most used modality. Parental guidance/education was the second most frequent intervention, addressing the participation of the family at home (via home visits) and at NICUs. In this last scenario, the intervention supported mothers’ self-confidence and promoted the attachment bond between mothers and infants.

Other intervention modalities with family participation included support for the relationship between parents and their children, psychosocial support for caregivers, family-centered practices, strategies to promote an enriched environment, and incorporation of therapeutic activities into daily routines. A study used the home care of institutionalized children to represent the domestic experience as an intervention.

The remaining 9% of studies (n=5) used clinical-therapeutic services, such as physiotherapy and acupuncture, and school education as interventions. These studies ignored the family in their interventions. Among them, four only evaluated traditional developmental outcomes. The remaining article assessed multidimensional outcomes in addition to the above.

Link with the ICF

The result of the Kappa statistic for agreement between the two investigators totaled 0.62. Thus, the coefficient exceeded 0.61, which this review considered as substantial agreement.

The 56 chosen articles extracted significant concepts coded according to the ICF in Cieza et al.¹⁶, resulting in 82 ICF codes. Some concepts occurred in multiple studies, generating the same code more than once. Thus, this review classified some such codes as not addressed or not defined, totaling 427 codes.

Studies addressed the body functions domain the most (45.9%; n=196 concepts), followed by activities and participation (42.2%; n=180 concepts), and environmental factors (8.0%; n=34 concepts). In addition to these ICF concepts, this review classified seven concepts as not addressed (1.6%) and 10 as not defined (2.3%). No concepts showed an association to the Body structures and personal factors categories.

Table 1 shows the relative frequency of the ICF domains and the significant concepts classified as not addressed or not defined by the 56 chosen articles. In total, 26 articles (46.4%), that is, most, addressed three ICF domains: body functions, activities and participation, and environmental factors. Also, 21 articles (37.5%) addressed two domains, and eight (14.3%), only one domain. Only one article had all its outcomes rated as not addressed considering the ICF framework⁶¹.

Table 1
Relative frequency in the percentage of International Classification of Functioning, Disability, and Health domains in each article.

Study	NUMBER OF CATEGORIES COVERED	LINKAGES
		ICF DOMAIN					OTHER
		BF	AP	EF	BS	PF	NA	ND
Rose et al.18	5	100%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%
Cappleman et al.19	9	66.7%	22.2%	0.0%	0.0%	0.0%	0.0%	11.1%
Ramey et al.20	9	33.3%	66.7%	0.0%	0.0%	0.0%	0.0%	0.0%
Palmer et al.21	5	100.0%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%
Rauh et al.22	7	28.6%	57.1%	14.3%	0.0%	0.0%	0.0%	0.0%
Živković 23	7	42.9%	42.9%	14.3%	0.0%	0.0%	0.0%	0.0%
Eiserman et al.24	11	54.5%	45.5%	0.0%	0.0%	0.0%	0.0%	0.0%
Black et al.25	11	36.4%	36.4%	9.1%	0.0%	0.0%	9.1%	9.1%
Bao et al.26	6	66.7%	33.3%	0.0%	0.0%	0.0%	0.0%	0.0%
Avon Premature Infant Project27	13	46.2%	46.2%	7.7%	0.0%	0.0%	0.0%	0.0%
Bao et al.28	8	62.5%	37.5%	0.0%	0.0%	0.0%	0.0%	0.0%
Smith et al.29	9	44.4%	55.6%	0.0%	0.0%	0.0%	0.0%	0.0%
Thomaidis et al.30	13	46.2%	46.2%	7.7%	0.0%	0.0%	0.0%	0.0%
Zeanah et al.31	10	60.0%	10.0%	10.0%	0.0%	0.0%	10.0%	10.0%
Als et al.32	6	100.0%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%
Ohgi et al.33	8	50.0%	37.5%	12.5%	0.0%	0.0%	0.0%	0.0%
Olafsen et al.34	5	20.0%	60.0%	20.0%	0.0%	0.0%	0.0%	0.0%
Giudice et al.35	12	50.0%	50.0%	0.0%	0.0%	0.0%	0.0%	0.0%
Kaaresen et al.36	6	33.3%	50.0%	16.7%	0.0%	0.0%	0.0%	0.0%
Rickards et al.37	6	33.3%	50.0%	16.7%	0.0%	0.0%	0.0%	0.0%
Bierman et al.38	9	33.3%	66.7%	0.0%	0.0%	0.0%	0.0%	0.0%
Koldewijn et al.39	7	57.1%	14.3%	14.3%	0.0%	0.0%	14.3%	0.0%
Shin et al.40	7	28.6%	57.1%	14.3%	0.0%	0.0%	0.0%	0.0%
Heathcock et al.41	1	0.0%	100.0%	0.0%	0.0%	0.0%	0.0%	0.0%
Nair et al.42	6	100.0%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%
Latha et al.43	5	0.0%	80.0%	20.0%	0.0%	0.0%	0.0%	0.0%
Dawson et al.44	10	30.0%	60.0%	10.0%	0.0%	0.0%	0.0%	0.0%
Spittle et al.45	14	78.6%	7.1%	7.1%	0.0%	0.0%	0.0%	7.1%
Blauw-Hospers et al.46	5	40.0%	40.0%	20.0%	0.0%	0.0%	0.0%	0.0%
Mendelsohn et al.47	13	15.4%	76.9%	7.7%	0.0%	0.0%	0.0%	0.0%
Ravn et al.48	4	0.0%	75.0%	25.0%	0.0%	0.0%	0.0%	0.0%
Carlo et al.49	13	46.2%	53.8%	0.0%	0.0%	0.0%	0.0%	0.0%
Kaiser et al.50	9	33.3%	55.6%	11.1%	0.0%	0.0%	0.0%	0.0%
Karaaslan et al.51	9	33.3%	44.4%	11.1%	0.0%	0.0%	11.1%	0.0%
Favazza et al.52	9	44.4%	55.6%	0.0%	0.0%	0.0%	0.0%	0.0%
Hwang et al.53	12	50.0%	41.7%	8.3%	0.0%	0.0%	0.0%	0.0%
Milgrom et al.54	3	66.7%	33.3%	0.0%	0.0%	0.0%	0.0%	0.0%
Kaminski et al.55	15	33.3%	46.7%	13.3%	0.0%	0.0%	0.0%	6.7%
Chen et al.56	3	0.0%	0.0%	33.3%	0.0%	0.0%	0.0%	66.7%
Kasari et al.57	6	16.7%	66.7%	16.7%	0.0%	0.0%	0.0%	0.0%
Wake et al.58	9	33.3%	55.6%	0.0%	0.0%	0.0%	11.1%	0.0%
Yousafzai et al.59	10	70.0%	10.0%	0.0%	0.0%	0.0%	0.0%	20.0%
Ma et al.60	5	60.0%	20.0%	0.0%	0.0%	0.0%	0.0%	20.0%
Bierman et al.38	11	18.2%	72.7%	9.1%	0.0%	0.0%	0.0%	0.0%
Doyle et al.61	1	0.0%	0.0%	0.0%	0.0%	0.0%	100.0%	0.0%
Castel et al.62	10	50.0%	30.0%	10.0%	0.0%	0.0%	10.0%	0.0%
Liu et al.63	3	100.0%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%
Fonagy et al.64	11	54.5%	36.4%	9.1%	0.0%	0.0%	0.0%	0.0%
Sgandurra et al.65	4	75.0%	25.0%	0.0%	0.0%	0.0%	0.0%	0.0%
Yazejian et al.66	8	25.0%	62.5%	12.5%	0.0%	0.0%	0.0%	0.0%
Schertz et al.67	4	0.0%	75.0%	25.0%	0.0%	0.0%	0.0%	0.0%
Platje et al.68	4	0.0%	75.0%	25.0%	0.0%	0.0%	0.0%	0.0%
Nascimento et al.69	3	0.0%	100.0%	0.0%	0.0%	0.0%	0.0%	0.0%
Hielkema et al.70	5	80.0%	0.0%	20.0%	0.0%	0.0%	0.0%	0.0%
Colditz et al.71	8	87.5%	0.0%	12.5%	0.0%	0.0%	0.0%	0.0%
Armstrong et al.72	5	40.0%	40.0%	20.0%	0.0%	0.0%	0.0%	0.0%

• Caption: BF: body functions; AP: activities and participation; EF: environmental factors; BS: body structures; PF: personal factors; NA: not addressed; ND: not defined.

Figure 2 depicts an overview of the distribution of the number of ICF domains in the studies in this review over the years.

Figure 2
Distribution of the number of International Classification of Functioning, Disability, and Health domains in the studies in this review over the years.

DISCUSSION

This systematic review included 56 RCTs on early intervention programs, which were published from 1980 to 2020. Most had a moderate methodological quality according to the PEDro scale. The significant concepts in the outcomes of their interventions predominantly addressed three ICF domains: body functions, activities and participation, and environmental factors. No concepts were linked to body structures and personal factors.

´No systematization from the year of publication of the included studies and the approach to the ICF domains occurred. The number of domains showed a non-homogeneous variation over the years (Figure 2). All cases addressed one domain more than others (in percentages) (Table 2).

Based on the analysis above, the assessed interventions failed to fully address functioning since the ICF considers that a child’s functioning is determined by the multidirectional relationship between body functions and structures, activity and participation, and contextual factors, such as environmental and personal ones⁷³. Thus, interventions must involve all ICF domains to improve functioning⁷⁴.

Studies that addressed only one domain or none were mostly published after 2000. Thus, some early intervention programs that preceded the publication of the ICF in 2000 had no structure based on the expanded perception of health advocated by that classification.

The samples of the included studies mainly consisted of children at biological risk (prematurity, low birth weight, ASD, among others), characterizing a target population with predominantly limited health conditions or associated disabilities. Moreover, child-focused outcomes occurred the most, with gross and fine motor, cognitive, and language skills being the three most mentioned.

The body’s health condition, functions, and structures encompass most of the biological determinants for early childhood. Thus, programs have traditionally focused on stimulating motor, cognitive, and language skills^75,76. Corroborating this statement, the body functions domain composed most categories in this study.

Thus, the biomedical model, which focuses on mental, physical, or sensory disabilities and which strongly contributed to structuring interventions in early childhood in the 1960s⁸, influences programs up to the present time.

The interventions of the included studies also suffered the influence of theoretical perspectives such as Sameroff and Chandler’s (1975) transactional model, Bronfenbrenner’s (1979) model of human development ecology, and Leal’s (1999) family systems theory⁸, which understands the family as the first context of socialization and development of human beings, favoring their insertion in healthcare.

Emphasizing the influence of the environment in which the individual is inserted in the child development results, some interventions evaluated their effects on children at socioeconomic risk and in institutions. In these cases, interventionists sought to adjust the early home environment, providing social and physical stimulation in childhood and thus causing variations in later developmental outcomes.

This review also highlights the reduction of parental stress as an analyzed outcome. Reduced stress, increased maternal self-efficacy, and an enhanced ability to respond in interactions with the baby are linked to a positive environment for child development, contributing to improving developmental outcomes⁷⁷.

Most interventions also aimed to improve the child’s activities and participation considering their family, such as family-child and social interactions, behavior organization, autonomy for activities of daily living, and adaptive skills, even associated with health conditions. This finding reflects a feature of the biopsychosocial perspective in recognizing the interaction of health conditions (diseases or disorders in the international statistical classification of diseases and related health problems) with environmental factors, body functions, and activities and participation⁷⁶.

Thus, this review found a search for interventions that break with the historical influence of the biomedical model. Family and environmental-focused strategies to improve children’s activities and participation have aimed at results with an approach to child development and its complex factors.

The family, represented by the father and mother, configured the main facilitator of most interventions, either acting as co-therapists or in an equal partnership with the interventionists through coaching techniques. The family provides the immediate environment in the early years of a child’s life, thus constituting the gateway to many child development interventions³. The included studies addressed a wide range of multidisciplinary services involving the effective participation of children and their families.

Home visits occurred the most among the interventions, facilitated by parents as co-therapists. Via home visits to participating families, early intervention specialists found parents’ or caregivers’ strengths and trained them to carry out developmentally appropriate activities for the child, providing a more personalized approach to service delivery⁷⁸.

The coaching facilitation strategy is associated with greater family empowerment. Early intervention specialists formally support families, empowering and encouraging them to find their children’s problems according to their upbringing perspectives and make strategical decisions⁵³.

Studies with the type of strategy above have evaluated family-centered practices, currently considered the best practice in early interventions as they aim to promote family and child competencies and strengthen existing capacities, with healthcare actions being included in the family’s daily routine⁶. The family-centered practice is in line with the biopsychosocial perspective, and the family, being fundamental in the child’s life, is an important environmental/contextual factor to be considered⁷⁹.

Still, this review linked the outcomes of two studies on family-centered practices to only two ICF domains and those of one to no domain. Placing the family at the center of the decision-making process failed to necessarily reached outcomes in all functioning domains. Based on a biopsychosocial approach, caregivers and interventionists must be aware of all factors as part of their interventions⁶.

Home s configured the main scenario to implement interventions, combined with facilitation strategies and family participation. In some studies, the intervention in this scenario complemented actions in maternity wards, schools, or clinical-therapeutic environments, seeking the participation and development of children in their natural environments. The home is a very influential element in child development based on the bioecological model, the perspective of the family system, and empirical evidence, characterizing an environmental factor variable⁷⁶.

Children’s main daily routines occur at home, enabling families to maximize teaching moments for their children. such active involvement configures a key element of early intervention services to empower families and influence positive child-family outcomes⁶.

Other prevalent intervention approaches included parental education, support for the relationship between parents and children, and psychosocial support for caregivers, which seek to positively impact the child’s development by structuring the bond between parents and children, welcoming these children, and promoting the care and stimuli offered daily by the family⁷⁷. These studies reinforce that considering nurturing care elements in interventions improves child development and leads to beneficial results in adult life⁸⁰.

We emphasize that no included studies mentioned the ICF or the term “functioning” to support their methodology or results. The results in this review fully stem from the rules for linking the outcomes of interventions with the ICF.

Based on the analysis of the link to the ICF, most early intervention programs have considered, since the 1980s, the systemic and multifactorial nature of child development, but to date, they still fail to address all ICF domains. Using the ICF theoretical framework for clinical reasoning broadly understands functioning and enables therapeutic interventions to better target the real factors that compromise functioning⁷⁴.

Thus, this review suggests that early intervention programs include outcomes such as physical, social, and environmental factors and personal characteristics such as psychological and gender-related specificities.

The main limitations of this study include the temporal inhomogeneity of its articles since most were published after 2000 and the moderate methodological quality of chosen studies. Moreover, searching for references beyond the article format and in other languages could expand or confirm the results.

This review brings innovation due to its use of the ICF binding rules, offering the opportunity to plan interventions based on a biopsychosocial perspective and fully addressing functioning.

CONCLUSION

The linking of intervention outcomes to the ICF showed that early intervention programs partially addressed functioning over the years since no study fully encompassed all ICF domains.

Still, most intervention programs in this review went beyond body functions and sought to stimulate child development and improve their activity and participation in their natural life contexts, involving the family in the process.

The implementation of interventions in line with what is proposed by the ICF remains a challenge. However, interventions stand closer to fully addressing functioning. An interdisciplinary approach centered on the child and the family in which professionals provide proper support to promote child development with practices that systematically consider all ICF domains seems the way to address all aspects of functioning.

This study will hopefully contribute to discussions about functioning in early intervention, subsidize research, teaching, and management in health, and favor the promotion of child development.

DATA AVAILABILITY

The data underlying this study are available in the published article.

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• 1
  Study carried out at the Federal Univeristy of Ceará (UFC) -- Fortaleza (CE), Brasil. This study derived from the thesis by Letícia Helene Mendes Ferreira, titled “Abordagem da funcionalidade na intervenção precoce segundo a perspectiva da Classificação Internacional de Funcionalidade, Incapacidade e Saúde.” The study was carried out within the Graduation Program of Physical Therapy and Functioning of the Department of Physical Therapy at the Federal Univeristy of Ceará.
• Financing sources:
  nothing to declare

Edited by

• Responsible editor:
  Sônia LP Pacheco de Toledo

Publication Dates

• Publication in this collection
  26 June 2026
• Date of issue
  2026

History

• Received
  02 June 2023
• Accepted
  02 May 2024