Translation and adaptation into Brazilian Portuguese of the Family Accommodation Scale for Obsessive-Compulsive Disorder - interviewer-Rated (FAS-IR)

Tradução e adaptação para o português do Brasil da Escala de Acomodação Familiar - Pontuado pelo Entrevistador (FAS-IR)

BRIEF COMMUNICATION

Translation and adaptation into Brazilian Portuguese of the Family Accommodation Scale for Obsessive-Compulsive Disorder – Interviewer-Rated (FAS-IR)

Tradução e adaptação para o português do Brasil da Escala de Acomodação Familiar – Pontuado pelo Entrevistador (FAS-IR)

Juliana Braga Gomes;^I Lisa Calvocoressi;^II Barbara Van Noppen;^III Michele Pato;^IV Elisabeth Meyer;^V Daniela Tusi Braga;^VI Christian Haag Kristensen;^VII Aristides Volpato Cordioli^VIII

^IMestranda em Ciências Médicas: Psiquiatria, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil

^IIPhD. Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT, USA

^IIIPhD. Keck School of Medicine, Department of Psychiatry, University of Southern California, Los Angeles, CA, USA

^IVMD. Keck School of Medicine, Department of Psychiatry, University of Southern California

^VDoutora em Psiquiatria, UFRGS

^VIDoutoranda em Ciências Médicas: Psiquiatria, UFRGS

^VIIDoutor. Professor, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil

^VIIIDoutor, Professor associado, Departamento de Psiquiatria e Medicina Legal, UFRGS

^{Correspondence}

ABSTRACT

OBJECTIVE: To describe the process of translation and adaptation into Brazilian Portuguese of the Family Accommodation Scale for Obsessive-Compulsive Disorder – Interviewer-Rated (FAS-IR).

METHOD: The process of translation and adaptation of the scale involved four bilingual health professionals. The scale was initially translated into Brazilian Portuguese independently by two professionals. Then, the two versions were compared, resulting in a preliminary Portuguese version that was administered to 15 relatives of patients diagnosed with obsessive-compulsive disorder (OCD) with different education levels, deliberately chosen to collect language adjustment suggestions. Subsequently, the scale was translated back into English independently by two other professionals. After comparing the two back translations, a new English version was generated. This version was reviewed and approved by the authors of the original scale.

RESULTS: The Brazilian Portuguese version of the FAS-IR proved to be easily understood and can be used in relatives of OCD patients from different socioeconomic backgrounds.

CONCLUSION: Adaptation of the FAS-IR into Brazilian Portuguese will enable health professionals to assess the level of accommodation in relatives of OCD patients and allows the development of future studies aimed at 1) studying the influence of family accommodation on maintaining and possibly facilitating OCD symptoms, and 2) assessing the effect of family accommodation on treatment outcomes in Portuguese-speaking populations.

Keywords: Obsessive-compulsive disorder, family relations, questionnaires, translation.

RESUMO

OBJETIVO: Descrever o processo de tradução e adaptação para o português do Brasil da Family Accommodation Scale for Obsessive-Compulsive Disorder – Interviewer-Rated (FAS-IR).

MÉTODO: O processo de tradução e adaptação da escala envolveu quatro profissionais de saúde bilíngues. A escala foi inicialmente traduzida de forma independente para o português do Brasil por dois profissionais. A seguir, as duas versões foram comparadas, resultando em uma versão inicial em português que foi aplicada a 15 familiares de pacientes com transtorno obsessivo-compulsivo (TOC), com diferentes níveis de instrução, deliberadamente escolhidos para coletar as sugestões de ajuste linguístico. Subsequentemente, a escala foi retrotraduzida independentemente por outros dois profissionais da saúde. Depois de comparar as duas retrotraduções, uma nova versão da escala foi gerada em inglês. Essa versão foi revisada e aprovada pelos autores da escala original.

RESULTADOS: A versão em português do Brasil da escala FAS-IR mostrou ser facilmente compreendida e pode ser usada em familiares de pacientes com TOC de diferentes níveis socioeconômicos.

CONCLUSÃO: A FAS-IR adaptada ao português do Brasil fará com que profissionais de saúde possam avaliar o nível de acomodação em familiares de pacientes com TOC e permitirá a realização de futuros estudos com os objetivos de 1) estudar a influência da acomodação familiar na manutenção e, possivelmente, na facilitação dos sintomas do TOC e 2) examinar o efeito da acomodação familiar sobre os resultados do tratamento em populações de países de língua portuguesa.

Descritores: Transtorno obsessivo-compulsivo, relações familiares, questionários, tradução (processo).

Introduction

Obsessive-compulsive disorder (OCD) is characterized by recurrent intrusive thoughts (obsessions) which increase the individual’s anxiety, typically accompanied by the urge to perform neutralizing overt or covert actions (compulsions), which are associated with decreased anxiety. These symptoms cause significant distress and interfere with the patient’s daily routine.¹ Questions have been asked about the family’s influence on obsessive-compulsive (OC) symptoms. In fact, studies have shown a 4-5 times greater incidence of OCD in relatives of OCD patients and a high concordance of the disorder in twins, pointing to the presence of genetic factors. Studies assessing twins and families have supported the hypothesis that OCD is a disorder of familial incidence, and genetic factors have been shown to play a significant role in the expression of the disorder.² A meta-analysis was conducted with a sample of 1.209 first-degree relatives of OCD patients and found that the risk of developing the disorder was four times higher than in relatives of controls (8.2 vs. 2%).³

Environmental factors, including family responses to the disorder, may contribute to maintaining or facilitating OCD symptoms. Family accommodation refers to the participation of family members in rituals, the modification of personal and family routines, facilitation of avoidance behavior, and taking on the patient’s responsibilities.⁴ Calvocoressi et al.⁵ reported that family accommodation behaviors were present in 88% of spouses or parents of patients with OCD and was significantly correlated with patient symptom severity, global functioning, family dysfunction, and relatives’ stress. Excessive accommodation of relatives to compulsions may undermine exposure-based therapy, perpetuate and reinforce symptoms, and increase the relatives’ distress feelings.⁶ However, little is known about how family accommodation affects the severity and maintenance of OCD symptoms, or how a change in family accommodating behaviors may contribute to the patient’s improvement or adherence to ongoing treatment. An instrument developed by Calvocoressi et al.,^4,5 namely, the Family Accommodation Scale for Obsessive-Compulsive Disorder – Interviewer Rated (FAS-IR), has been used in several clinical studies to assess family accommodation and improve our understanding of this topic.

In 1995, Calvocoressi et al.⁴ conducted an open trial with 34 relatives of OCD patients to analyze the frequency and nature of family accommodation and the consequences of family members refusing to participate in the patient’s rituals. The authors found that most families participated in compulsions and took on responsibilities that would be the patient’s, i.e., family members accommodated the patient’s symptoms. In that study, the authors developed a pilot questionnaire to assess the level of family accommodation among relatives of patients with OCD.

Later, in 1999, Calvocoressi et al.⁵ assessed the psychometric properties of a revised version of the same instrument. The results of this second study were consistent with those of the previous one⁴: of the 32 families whose members accommodated the patient’s symptoms, 84% reported patient anxiety, 66% indicated that the patients expressed anger, and 75% reported that the patients spent more time completing rituals whenever the relatives did not accommodate the patient’s demands. Most relatives did not associate accommodation with an improvement in symptoms or patient functioning; nevertheless, most of the relatives confirmed that they accommodated OCD-related demands, often compromising their own and the family’s functioning. These findings suggest that many relatives would probably be receptive to interventions specifically designed for relatives of OCD patients, such as psychoeducation, in order to reduce family stress and develop more functional ways of responding to OC symptoms.⁵

The FAS-IR is a clinician-administered, validated scale comprises two parts: the first part is a checklist which assesses the symptoms of OCD patients; the second part consists of 12 items that assess the level of family accommodation in different dimensions of accommodation. The scale should be administered by a trained professional to an identified relative of the OCD patient who spends at least one hour every day face to face with the patient.

Family accommodation has been identified as a robust contributor to predicting OCD symptom severity, as recently reported by Van Noppen & Steketee.⁷ In a series of pathway analyses, those authors identified that family accommodation made the largest, most significant contribution to OCD symptom severity in both patient-rated and relative-rated measures of perceptions of family responses. Accordingly, the strongest determinant of family accommodation was a relative’s assessment of the degree of control the patient had over their behavior. Although we are still trying to understand what exactly drives relatives to accommodate, it is clear that family accommodation has negative effects on OCD patients and their families.

In a study conducted in Brazil, Ferrão et al.⁸ evaluated the phenomenon of family accommodation and observed that relatives of refractory patients presented higher rates of accommodation and exhaustion when compared to relatives of patients who responded to treatment. These results demonstrate the relevance of the FAS-IR4,⁵ as a sensitive outcome measure.

However, in order to better and more consistently assess family accommodation in different populations, translation of the scale into different languages, including Brazilian Portuguese, is required. Therefore, the objective of our study was to describe the translation and adaptation into Brazilian Portuguese of the FAS-IR, developed by Calvocoressi et al.⁵

Methods

After receiving authorization from the authors of the original scale (Calvocoressi L, 2007, personal communication), two independent professionals translated and adapted the scale into Brazilian Portuguese. Based on the two translations, a preliminary version of the instrument was developed and administered to 15 relatives of OCD patients. Subjects were selected to represent different socioeconomic levels and cultural backgrounds. The aim of this pilot questionnaire administration was to assess the quality of the translation and to collect suggestions for language adjustments aimed at improving instrument clarity and ensuring that the items would be easily understood by groups from different cultural and socioeconomic backgrounds. The pilot questionnaire was administered at Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil. Each interview lasted for approximately 1 hour. Whenever the subject had difficulties understanding a question or a particular word, the interviewer reworded it until the respondent understood the meaning the interviewer wished to convey. The most frequent suggestions made by the interviewees were either added to the questionnaire in parentheses or used to rephrase the questions, to ensure their understanding in a definitive version.

Once the scale was considered to be appropriately translated into Portuguese, its back-translation into English was conducted independently by two other bilingual health professionals who had not seen the instrument in its original form. After comparing the two back-translations, a new English version of the scale was generated. This version was reviewed and approved by the authors of the original scale. The final translated version of the FAS-IR is presented in ^{Appendix 1}. Figure 1 presents a flowchart of the process of translation, adaptation and back-translation.

Results

Of the 15 relatives involved in the pilot questionnaire application, 93% were female and 53% were mothers of the patients; mean age was 55 ± 16.4 years. The participants had different education levels, ranging from 33% who had completed basic education to 7% with university degrees. As previously mentioned, some family members had questions about the wording of some questions; these subjects requested an explanation from the interviewer and made suggestions to improve the clarity and understanding of the instrument. The change made to the scale are listed in Table 1.

Discussion and conclusion

Throughout the process of adaptation of the FAS-IR into Brazilian Portuguese, we sought to achieve semantic equivalence between the original and the translated versions. This process involved using language with a focus on maintaining the meaning of the concepts contained in the original instrument so that it would have a similar effect on the respondents in both cultures.⁹ As a result, the interaction between subjects and interviewers was especially important, in the sense of enduring that the original meaning of the question would be conveyed. The process of adapting an instrument is thus a combination of literal word translation and careful fine-tuning that addresses the cultural context and lifestyle of the target population.⁹ Moreover, approval of the back-translated version by the original authors ensured that the original meanings were not lost. As a result, we strongly believe that the Brazilian version of FAS-IR can provide a baseline measure of accommodation and serve as a sensitive measure of changes obtained with cognitive-behavioral treatment approaches.

In sum, the availability of the FAS-IR in Brazilian Portuguese will allow Brazilian investigators to evaluate the participation of family members in rituals and changes in routine, as well as the influence of such participation on the maintenance of symptoms. Moreover, it can be used to assess whether family accommodation is a predictor of the treatment outcome. Finally, the translation of the FAS-IR will also enable comparisons between national and international studies on family accommodation.

Future studies are needed to assess the reliability and validity of the Brazilian version of the scale. Moreover, it would be interesting to add a family-based intervention, aimed at reducing family accommodation, to standard OCD treatments and examine whether this improves treatment outcomes.

Acknowledgments

The authors are grateful to health professionals Anna Williams, Patricia Pranke, Ygor Ferrão, and Rui Ramos Neto, and to all the patients and their relatives for their cooperation. Also our thanks to Esperança Moniz, at the University of Southern California, for her assistance with the back translation from Portuguese into English.

Submitted Jun 16, 2010

Accepted Jun 22, 2010

Financial support: Fundo de Incentivo a Pesquisa e Eventos (FIPE).

No conflicts of interest declared concerning the publication of this article.

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Appendix 1

Publication Dates

• Publication in this collection
  06 Jan 2011
• Date of issue
  2010

History

• Accepted
  22 June 2010
• Received
  16 June 2010