Letter to “Cultural adaptation and reliability assessment of the Hammersmith neonatal neurological examination for Brazilian newborns at risk of cerebral palsy”

Sep 29, 2026

Uploaded by Jiven

Letter to the editors expressing interest in a reported translation of the Hammersmith Neonatal Neurological Examination (HNNE) for Brazilian newborns. The author raises concerns about methodological and content errors, including scale timing, incorrect publication dates for cited materials, figure mismatch, and inappropriate claims about cultural adaptation and psychometric validation. Further critiques address interexaminer agreement assessment via filming and outdated or unsuitable statistics for ordinal data, emphasizing risks of confusion and incorrect clinical use.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

Letter to the editors

Concerns about scale information and cited dates

Figure mismatch and interpretation of cultural adaptation

Interexaminer agreement, psychometric methods, and statistics

Clinical impact and call for scientific attention

Article published online: 2025-02-06 Letter 1 Letter to “Cultural adaptation and reliability assessment of the Hammersmith neonatal neurological examination for Brazilian newborns at risk of cerebral palsy” Tathiana Ghisi de Souza 1,2,3 1 Faculdade de Medicina de Jundiaí, Departamento de Pediatria, Jundiaí SP, Brazil. 2 Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas SP, Brazil. 3 Protocolos de Avaliação Neonatal e Infantil de Hammersmith (HNNEHINE), Campinas SP, Brazil. Address for correspondence Tathiana Ghisi de Souza,(e-mail: [tathi_neo@yahoo.com.br](tathi_neo@yahoo.com.br)). Arq. Neuro-Psiquiatr. 2025;83(1):s00451802309 . Dear Editors, It was with great interest and appreciation that I read the article by Correr and Pfeirfer,1 which reported the translation of the Hammersmith Neonatal Neurological Examination (HNNE) . I would like to express some considerations and my concerns regarding the article published on pages 47 to 54, volume 81, of the journal Arquivos de Neuro-Psiquiatria. While reading it, I have identiﬁed some signiﬁcant errors in its methodology and content. I have noted that the part that addresses the scales contains incorrect information. For example, the neonatal evaluation (HNNE) should be performed on babies from 0 to 1-month-old, and on premature babies from 40 weeks of gestational age up to the ﬁrst month, while the HINE evaluation is indicated for babies from 2 to 24 months.2,3 In addition, the dates of publication of the scales are not correct. The abridged version cited in the article is from a 2005 study by Mercuri et al.,4 and is not intended for screening purposes, like the 2012 check list published by Romeo et al.5 This mistake can lead to confusion and inappropriate use of the form. I would also like to point out that Fig. 11 does not correspond to the cited scale, but rather to the upper half of the complete HNNE front page. Furthermore, the assessment can be translated, but it does not require cultural adaptation, validation, or psychometric analysis, since it isnot a psychometric test but rather a neurological assessment. It is unclear why Brazilian babies would behave differently from babies from other countries. What do they mean by the received August 3, 2024 accepted October 6, 2024 DOI [https://doi.org/](https://doi.org/)[ ](https://doi.org/)10.1055/s-0045-1802309 . ISSN 0004-282X Editor-in-Chief: Hélio A. G. Teive. Associate Editor: Juliana GurgelGianetti. “cross-adaptation process”? And “adapting it to the Brazilian culture”? It is important to note that interexaminer agreement was partly assessed through ﬁlming. However, the HNNE should not be interpreted through ﬁlming, since it is essential for the evaluator to feel the baby’s response during the assessment. Furthermore, the methodology of psychometric analysis to obtain validity evidence is outdated and, sometimes, incorrect.6 One example is the statistical test used to determine interexaminer agreement. Since questionnaires or scales are ordinal variables and not continuous ones, the use of the intraclass correlation coefﬁcient (ICC) is not appropriate. The translation was not made available as supplementary material in the article, and the inconsistency in the explanations for application makes me question whether the exam was performed correctly, also considering the errors in the methodology and data analysis. These errors concern me, since the assessment in question is receiving some attention, and such errors can result in confusion and inappropriate use of the assessment, leading to incorrect prognoses. I acknowledge that the liability for the published articles’content lies with the authors themselves. However, in writing this letter, my goal is not to question the responsibility of the Journal or its editorial board, but to draw the attention of the scientiﬁc community to these issues. As an instructor and the ﬁrst Hammersmi

FAQs

What main issues does the author raise about the translated HNNE article?

The author reports significant errors in methodology and content, especially concerning scale information, cited publication dates, and inconsistencies in how the exam is applied.

Why does the author question the need for cultural adaptation and psychometric validation?

The letter states that the assessment can be translated but does not require cultural adaptation, validation, or psychometric analysis because it is described as a neurological assessment rather than a psychometric test.

What concern is raised regarding the statistical method used for interexaminer agreement?

The author argues that ordinal questionnaire/scale variables make intraclass correlation coefficient (ICC) inappropriate, since it is typically suited to continuous data.

Sep 29, 2026

Uploaded by Jiven