Translation and cross-cultural adaptation of the Motor Behavior Checklist ( MBC ) into Brazilian Portuguese

INTRODUCTION
There are only a few instruments available to assess behavioral problems in school-age children based on reports of physical education teachers. The Motor Behavior Checklist (MBC) was designed to be completed by this professional in free play-situations or during physical education classes to rate students' motor-related behavior using 5-point Likert scales. The MBC comprises 59 items distributed into two broadband factors (externalizing and internalizing) and seven behavior problem scales: rule breaking, hyperactivity/impulsivity, lack of attention, low energy, stereotyped behaviors, lack of social interaction, and lack of self-regulation. The objective of this study was to describe the translation and cross-cultural adaptation processes of the MBC into Brazilian Portuguese.


METHOD
The following procedures were conducted: forward translation of the original instrument, production of a synthesized version, back-translation, literal and semantic comparison, back-translator's evaluation of divergent items, synthesized version with back-translator's suggestions, clarity assessment of the synthesized version by professionals (physical education teachers), focus group to assess clarity indicators of the instrument, evaluation of adjustments by the author of the instrument, and production of the final version.


RESULTS
The results indicated a satisfactory level of agreement between the original and the back-translated versions, with 68% of exact equivalence between the translated items and 16% of terms requiring minor adjustments. In the draft version, 84% of the items were evaluated as clear by physical education teachers.


CONCLUSION
The translated version has compatible content with the original version. Future studies should be conducted to assess the psychometric properties of the Brazilian Portuguese version of the MBC.


Introduction
Neurodevelopmental disorders (NDD) are a group of disorders that typically manifest early in development, usually before the age at which children start school.
NDD are characterized by developmental deficits that range from specific limitations of learning or control of executive functions to global impairments of social skills or intelligence. 1Parents/teachers are often asked to answer questions about the behavior of their children/ students during the assessment of developmental impairments and/or behavioral problems.This approach allows the collection of standardized information about child behavior in different environments and in natural conditions.][4][5] Only a few studies have assessed instruments that rely on physical education teachers as a main source of information about emotional, behavioral, and/ or developmental problems in school-age children.
Although reports of physical education teachers could be used as a criterion to identify signs of NDD in children, the instruments aimed at these professionals are not considered as important sources of information for behavioral difficulties because they usually focus on movement and motor coordination problems. 6However, physical education classes and team games allow the naturalistic observation of several behavioral repertoires exhibited during social interactions, cooperative games, competitions, decision making and problem solving scenarios, and rule-following situations, among others. 7,8Therefore, physical education teachers could play a key role in assessing their students' behavior. 6tention deficit hyperactivity disorder (ADHD) is one among the NDD that physical education teachers could help identify by gathering information about student behavior.During physical education classes, students are required to behave in a variety of ways; in the presence of ADHD, a child usually exhibits problems in executive functioning areas such as turn-taking, motor movement at varying levels (depending on the type of activity), cooperation, decision-making, and focusing on the same task for an extended period.
The Sports Behavior Checklist is a 29-item informant report measure developed to assess behavioral difficulties in children with ADHD.The instrument evaluates involvement in individual and team sports, addressing the length of participation, types of sports played, and quality of involvement. 7The remaining 26 items assess frequency of aggression, emotional reactivity, injury, disqualification, adherence to rules, and sportsman-like conduct.A study with boys aged 6-17 years -34 with ADHD and 41 without ADHDshowed higher levels of aggression, emotional reactivity, and frequency of disqualification in children with ADHD when compared to those without the disorder.However, both groups presented high levels of aggression and emotional reactivity when playing team sports compared to individual sports. 7endenin et al. 8 verified the psychometric properties of the Sport Behavior Checklist in a sample of 5-13-yearold children composed of 58 boys and 34 girls, 49 with ADHD and 43 without ADHD.They also found higher levels of aggression, emotional reactivity, and frequency of disqualification in children with ADHD, similar to the results of the other study previously mentioned. 7though the Sports Behavior Checklist is widely used to assess the behavior of children in sports settings, the instrument was not designed as a screening tool to identify different disorders during sports practice.
In this scenario, the Motor Behavior Checklist (MBC) for Children In another study, Efstratopoulou et al. 10  In social interaction settings with multiple stimuli, the behavioral patterns of children with ADHD and ASD can be more clearly expressed than in a classroom environment, where stimuli are tightly controlled and students are supposed to follow more rigid rules of behavior.Therefore, the MBC is an important tool both to assist physical education teachers in the process of referring students for a more detailed evaluation and to collect information from children and adolescents as part of the process of clinical investigation.
Although no consensus can be found in the literature on the steps for a cross-cultural adaptation process, scholars agree that this process must go beyond a simple translation, 11,12 since a translation alone does not guarantee the reliability and construct validity of the instrument. 112][13] While the translation as the first step is common to all works, the subsequent steps may be diverse.
5][16] It is also recommended that more than one back-translator be used, which may increase financial costs. 125][16] Another possibility, as proposed by Borsa et al., 11 is that the evaluation by experts and later by target groups be done before the back-translation process.
5][16] Statistical analyses should be carried out in a complementary fashion to the cross-cultural adaptation process to evaluate the extent to which the instrument can, in fact, be considered valid for the setting to which it has been adapted. 11,13ondrzak et al. 14

Method
The translation and cross-cultural adaptation processes adopted in this study followed the main recommendations described in the works previously mentioned, [11][12][13][14] following 10 stages, which are described in sequential order in Figure 1 and Table 1.
The project was approved by the ethics committee of Universidade Presbiteriana Mackenzie (protocol 1886171, CAAE 61179416.8.0000.0084).We received the author's permission to translate and cross-culturally adapt the original version of the MBC into Brazilian Portuguese.

Table 1 -Description of the translation and cross-cultural adaptation stages
Stages Actions 1 Three professionals with proficiency in English independently translated the instrument into Portuguese.
-Translator 1: psychologist with expertise in cognitive neuropsychology and associated neurodevelopmental disorders.
-Translator 2: psychologist with expertise in applied behavior analysis and identification/management of behavioral problems in neurodevelopmental disorders.-Translator 3: physical education teacher with experience in neurodevelopmental disorders.

2
After completion of the individual translations, the translators compared the different versions of each item to reach a consensus, seeking the most appropriate cultural adjustment in case of discrepancies to facilitate understanding.

3
The instrument was back-translated into the source language by an English teacher with command of both English and Portuguese, an English native speaker living in Brazil.

4
The original document was compared with the back-translated version in order to find the best literal and semantic match between the words in the two versions.

5
The items that presented divergence in the back-translation in comparison with the original document were highlighted by the back-translator.

6
Based on the comments of the back-translator, the authors designed a new synthesized version.

7
Four physical education teachers who work with children evaluated the items for clarity.The following scores were assigned: 1 -not clear; 2 -partly clear; 3 -totally clear.A mean for each of the 59 items was calculated.For validation purposes, means between 2.75 and 3 were considered clear, between 2 and 2.5 partly clear, and below 2 not clear.

8
Partly clear items were analyzed by a focus group composed of three other physical education teachers.9 The suggestions of the focus group were sent for approval by the author of the original version. 10 The author's comments were analyzed to produce the final version.

Discussion
The cross-cultural adaptation and translation processes used in this article allowed the formulation Has difficulty in taking turns when executing tasks In "taking turns when executing tasks"/"waiting his turn to perform," "executar tarefas" could be translated as "perform" or "perform tasks"  The present study sought maximum equivalence between the original instrument and the translated version.Our results are in accordance with other studies that revealed that, based on the synthetized version, the translation and back-translation processes were adequate and without major distortions. 17,18After this adaptation stage with satisfactory results, assessment of the psychometric properties of the instrument can be conducted. 19A study currently in progress, by our group, has started to assess the psychometric The Brazilian Portuguese version of the MBC was produced following rigorous translation and cross-cultural adaptation procedures and is presented in Appendix 1.
Our instrument fills a gap in the evaluation process of students in sports and free-play situations.Moreover, it can help school teachers to better understand and effectively deal with their students' behavioral profiles, especially those with behavior problems compatible with NDD.
examined the agreement among different instruments by assessing a group of students as follows: the MBC completed by the physical education teacher; the Teacher Report Form (TRF) and the ADHD Rating Scale-IV completed by the classroom teacher; and the parent's version of the Child Behavior Checklist (CBCL) and the ADHD Rating Scale-IV completed by the parents.The authors found significant correlations with specific MBC subscales and the corresponding subscales of the TRF, CBCL, and ADHD Rating Scale-IV.In particular, they found significant correlations for the rule breaking, lack of attention, hyperactivity/impulsivity, and lack of social interaction problem scales, and for the internalizing, externalizing, and total scores.In relation to the ADHD scale -more specifically lack of attention and hyperactivity/impulsivity scales -, the MBC items demonstrated convergent relationships with the ADHD Rating Scale-IV (teachers and parents), with greater correlations between physical educators and teachers than between physical educators and parents for both scales.The MBC has also shown highly sensitive psychometric properties in the identification of ASD signs,9 a disorder characterized by persistent deficits in social communication and social interaction in multiple settings, including deficits in social reciprocity and nonverbal and verbal communication.In addition to deficits in social communication, the diagnosis of ASD requires the presence of restricted and repetitive patterns of behavior, interests, or activities.1 used the guidelines proposed by the Task Force for Translation and Cultural Adaptation of the International Society for Pharmacoeconomics and Outcomes Research, which divides the translation process into 10 steps: preparation, forward translation, reconciliation of different translations into a single version, back-translation, back-translation review, harmonization, cognitive debriefing, review of cognitive debriefing results and finalization, proofreading, and final report.Gjersing et al., 12 in turn, performed a careful process of cross-cultural adaptation of a research instrument following 12 steps: investigation of conceptual and item equivalence, original instrument translation (by two fluent translators), compilation of a synthesized translated version (by a third translator), backtranslation (by two fluent translators), compilation of a synthesized back-translated version (by a third backtranslator), expert committee judgment, instrument pretest, revision of the instrument, investigation of operational equivalence, main study conduction, exploratory and confirmatory analysis, and final instrument consolidation.Finally, Borsa et al. 11 suggest a six-step process of cross-cultural adaptation: 1) translation of the instrument from the source language into the target language; 2) synthesis of translated versions; 3) synthesis evaluation by expert judges; 4) evaluation of the instrument by the target groups; 5) back-translation; and 6) pilot study.In addition to these six steps, the authors emphasize the importance of an assessment of the factorial structure of the instrument to confirm its stability in relation to the original document.The objectives of the study were to describe the translation and cross-cultural adaptation processes of the MBC into Brazilian Portuguese and to present a validated version of the instrument in the target language.

Figure 1 -
Figure 1 -Stages involved in the translation and cross-cultural adaptation processes of the Motor Behavior Checklist of a Brazilian Portuguese version of the MBC that will enable physical education teachers to evaluate their student's behavioral aspects in sports and free-play situations.It will also contribute to the identification of emotional and behavioral problems related to some NDD highly prevalent among children and adolescents.Detailed assessment by a team of professionals with multiple instruments can benefit proper identification of behavior changes and/or developmental delays.Therefore, we highlight the importance of the crosscultural adaptation of instruments for use in different countries, as demonstrated by previous works and performed in our study.[11][12][13]In addition, evidence of validity should be demonstrated through multiple informants.The translated and culturally adapted version of the MBC, as described in this article, should contribute to the development of another instrument for the assessment of children by physical education teachers or classroom teachers.Supported by such instruments, these professionals can provide reports on children's behaviors observed in natural conditions of interaction and competition, which are rarely considered in evaluation protocols.Our results revealed a satisfactory level of agreement between the original and back-translated versions, with 68% of exact equivalence between the translated items and 16% of terms requiring minor adjustments.Clarity assessment using reports from physical education teachers revealed an 84% agreement with the draft version of the MBC.Consequently, the Brazilian Portuguese version of the instrument showed adequate indicators of semantic equivalence after the translation, back-translation, and clarity assessment by professionals and the focus group.The synthetized version of the instrument required a few modifications for semantic and cultural adequacy in relation to the original version.

Table 2 -
Comparison between the original version of the Motor Behavior Checklist and the translated and back-translated versions with semantic adaptation

Table 3 -
Modifications proposed by the focus group to the back-translated version of the Motor Behavior ChecklistThe aim of that study is to investigate whether the Brazilian Portuguese version of the MBC can be used as a valid and reliable assessment instrument by physical education teachers.