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Repeat upper limb botulinum toxin A injections: a reflection of clinical practice

paper the authors demonstrate the tool’s reliability and content validity. The final form of the tool showed high intrarater reliability for clinicians and parents, and good interrater reliability between clinicians when rating children’s current communication. The tool was completed in 10 minutes, suggesting that it will be easy to use in clinics. The authors suggest that the measure should be completed after children have been seen twice by a clinician. This would be supported by the lower interrater agreement on the amounts of help needed for children to reach capacity between clinicians who had differing amounts of knowledge of the children rated. As the authors previously acknowledged, distinguishing between activity and participation in the ICF can be problematic. For the development of the FOCUS they classified behaviours as activities if there is no mention of their use in a societal setting such as at nursery or home, and at the participation level if transfer of use to life settings was explicit. However, in the FOCUS as presented here, life situations are not specified and whether items relate to participation or activity is not yet confirmed. The authors determine the construct validity of the measure by correlating FOCUS scores with scores on the parent completed Pediatric Quality of Life Inventory (PedsQL). Although there was convergence between FOCUS and PedsQL scores, the argument for construct validity is less compelling than those for the test’s content validity and reliability. The PedsQL asks parents to rate their children’s function in different situations but may not capture parents’ feelings about the quality of their children’s lives. Furthermore, quality of life does not embody participation and may not represent the construct being measured by the FOCUS. It will be more illuminating to see the correlation between the FOCUS and wider measures of participation, such as the Children’s Assessment of Participation and Enjoyment and the forthcoming preschool version of that measure. The authors also suggest that the data presented show that the FOCUS is sensitive to communication change. However, as scores are not presented, the assessors were not blind to time of assessment, and a comparator measure other than the PedsQL has not been used, the tool’s sensitivity to change is yet to be established. Further work is currently being conducted to address the responsiveness to longer-term change, including blind assessment of children’s communication, and will undoubtedly address some of the questions above. It shall also be interesting to see the agreement between parents and clinicians on the FOCUS and if the tool can be used by other professionals such as preschool teachers and nursery workers. The results of the next phase of development are eagerly awaited by clinicians and researchers in a field where reliable and valid tools to measure generalized outcomes of therapy on children’s everyday life are desperately needed.