Development of a Tool for Early Referral of Children and Adolescents With Signs and Symptoms Suggestive of Chronic Arthropathy to Pediatric Rheumatology Centers CLAUDIO ARNALDO LEN, MARIA TERESA TERRERI, ROSANA F. PUCCINI, RUDOLF WECHSLER, EDINA KOGA SILVA, LEDA M. OLIVEIRA, CA ´ SSIA M. PASSARELLI BARBOSA, GLAURA CE ´ SAR PEDROSO, AND MARIA ODETE E. HILA ´ RIO Objective. To develop an easy, time-efficient tool to identify children and adolescents with signs and symptoms suggestive of chronic arthropathies, and to evaluate its interobserver reproducibility and reliability. Methods. The instrument used standardized techniques as required for the development of health-related instruments, targeting parents of apparently healthy children and adolescents ages 1–16 years. A multidisciplinary team was involved in the design of the instrument. Results. Each health professional generated 10 –15 questions addressing musculoskeletal complaints that they consid- ered to be the most relevant. A total of 60 questions were listed. During the reduction step, each health professional scored questions from 1 to 4 according to the question’s relevance. The tool comprised 12 questions and was administered to the parents of 3 groups: patients with juvenile idiopathic arthritis (JIA; n  48), children with diffuse musculoskeletal pain (n  39), and a healthy control group (n  42). The JIA group achieved the highest scores, followed by the diffuse musculoskeletal pain group and the control group. Nine (18.7%) of 48 patients with JIA and 2 (5.1%) of 39 children with musculoskeletal pain had a score of 5. The interobserver reproducibility was confirmed. All 12 questions were included in the final version of the instrument. We determined that children and adolescents with a score >5 should be referred for a rheumatologic evaluation (cluster analysis and logistic regression). Conclusion. Our questionnaire seems to be a useful tool for the early detection of musculoskeletal problems in children that may need a referral for a rheumatologic evaluation. KEY WORDS. Juvenile idiopathic arthritis; Juvenile rheumatoid arthritis; Arthritis; Questionnaire; Pain. INTRODUCTION Several factors contribute to delay in the diagnosis of juvenile idiopathic arthritis (JIA), a chronic and progres- sive disease, which has an important impact on long-term prognosis (Table 1) (1,2). A study conducted in Brazil (3), involving 8 specialized pediatric rheumatology centers, evaluated 111 children and adolescents with a definite diagnosis of JIA, 92% of whom were from urban areas. In 20% of the cases, the initial diagnosis was trauma, and in 15% acute rheumatic fever, a prevalent disease in devel- oping countries. The number of physicians consulted be- tween the onset of symptoms and the first consultation with the pediatric rheumatologist ranged from 1 to 20 (average of 3.6), and the time interval between the first medical visit and the consultation with the specialist ranged from a few days to 10 years (average of 1.4 years). The outcome of JIA is related to early diagnosis and to adequate referral to the specialist. However, the initial signs and symptoms can be nonspecific, and parents may initially be unaware of the severity of the problem. Also, the detection of arthritis in children requires a detailed joint examination, which is usually not performed in rou- tine or urgent clinical consults. This necessitates the de- Supported by Fundac ¸a ˜o de Amparo a ` Pesquisa do Estado de Sa ˜ o Paulo (Project 01/09022-0). Claudio Arnaldo Len, MD, Maria Teresa Terreri, MD, Rosana F. Puccini, MD, Rudolf Wechsler, MD, Edina Koga Silva, MD, Leda M. Oliveira, PT, Ca ´ ssia M. Passarelli Bar- bosa, MD, Glaura Ce ´sar Pedroso, MD, Maria Odete E. Hi- la ´ rio, MD: Universidade Federal de Sa ˜o Paulo, Escola Paulista de Medicina, Sa ˜ o Paulo, Brazil. Address correspondence to Claudio Arnaldo Len, MD, Avenida Brigadeiro Faria Lima 1826 cj 205, CEP 01451-001, Sa ˜ o Paulo, SP, Brazil. E-mail: len.cl@terra.com.br. Submitted for publication July 17, 2005; accepted in re- vised form September 15, 2005. Arthritis & Rheumatism (Arthritis Care & Research) Vol. 55, No. 3, June 15, 2006, pp 373–377 DOI 10.1002/art.21983 © 2006, American College of Rheumatology ORIGINAL ARTICLE 373