Abstract
<title>Abstract</title> <p>Background: Childhood disability in low-resource settings is primarily identified through impairment-based clinical certification, which may not adequately capture functional limitations. Evidence comparing functional assessment tools with certification-based identification in community settings in India remains limited. Methods: A nested case–control study was conducted in three blocks of Chitrakoot district, Uttar Pradesh. A total of 2,295 children aged 2–17 years were included, comprising 605 clinically certified cases and 1,690 controls. Functional difficulties were assessed using the Washington Group/UNICEF Child Functioning Module (WG-CFM). Descriptive statistics, chi-square tests, and age- and sex-adjusted logistic regression analyses were performed. Results: Among children aged 5–17 years (n = 2,060), 92.6% of clinically certified children reported ≥ 1 functional difficulty compared with 52.8% of controls (p < 0.0001; AOR 9.79, 95% CI: 7.04–13.63). Cognitive and psychosocial difficulties were most common among cases, including learning (77.5%), remembering (77.2%), concentration (75.9%), and behaviour (75.3%). Daily anxiety and depressive symptoms were reported in 34.8% of cases versus ~ 2.8% of controls (AOR ~ 19). Sensory difficulties were lower but significant (hearing: 12.8% vs 3.9%; seeing: 8.3% vs 3.4%). In children aged 2–4 years (n = 235), functional difficulty was higher among cases (77.8% vs 64.9%) but not statistically significant; only seeing and hearing showed significant associations. Conclusion: Functional difficulties were substantially higher among clinically certified children, particularly in cognitive and psychosocial domains. The WG-CFM captured a broader spectrum of functional limitations beyond sensory impairments, indicating its value as a complementary tool to clinical certification for identifying childhood disability in community settings.</p>