A Brazilian version of the “ Children ’ s Interview for Psychiatric Syndromes ” ( ChIPS ) A versão brasileira do “ Childreń s Interview for Psychiatric Syndromes ” ( ChIPS )

Objective: The advance of research in child and adolescent psychiatry in Brazil heavily depends on the existence of instruments for the investigation of psychiatric syndromes adapted to Brazilian Portuguese. Methods: This article describes a careful process of translation of the Children’s Interview for Psychiatric Syndromes for the purpose of use in research in Brazil. The Children’s Interview for Psychiatric Syndromes has a version for parents (P-ChIPs) and a version for children (ChIPS). In this article, the sections of P-ChIPS referring to attention-deficit hyperactivity disorder, oppositional-defiant disorder, conduct disorder, mania/hypomania, anorexia nervosa, bulimia nervosa and psychotic disorders were translated to Brazilian Portuguese. The sections of the ChIPS referring to substance use disorders, social anxiety disorder, specific phobias, obsessive-compulsive disorder, generalized anxiety disoder, separation anxiety disorder, post-traumatic disorders OS 8649 J Bras Psiq 58_2.indd 115 23/07/2009 16:37:03 J Bras Psiquiatr. 2009;58(2):115-118. 116 Souza IGS et al. artigo original


artigo original introDuCtion
Psychiatric disorders in childhood and adolescence are often chronic and impairing.Accurate diagnoses are crucial for a correct approach to the treatment of these disorders.The field of child and adolescent psychiatry has evolved steadily in the last years based on research, with sound methods, including the use of structured or semi-structured psychiatric interviews for the definition of psychiatric diagnoses.In Brazil, there is also an increasing scientific production in the area of Child and Adolescent Psychiatry, with many University Centers dedicated to the study of conditions such as attention-deficit hyperactivity disorder (ADHD), obsessivecompulsive disorder (OCD) and mood disorders.
There is consensus on the fact that instruments developed for use in a certain country, language or culture should only be used in other cultures, once they have gone through a process, not only of translation, but also of cultural adaptation 7,8,14.The means for reaching this culturally adequate instrument, however, have been very discrepant.Translation followed by backtranslation, the use of multiple translations, multidisciplinary discussion groups, focus groups discussions, reevaluation of psychometric properties and formal evaluation of semantic equivalence are all examples of methods employed with the goal of achieving this culturally adapted instrument.
In this paper we will review the Brazilian research experience with psychiatric interviews in the area of Child and Adolescent Psychiatry and we will outline possible approaches to translation and adaptation processes.In addition, we will present information on the Child Inteview for Psychiatric Syndromes (ChIPS) 13 and we will describe the method we used for translating the interview to Brazilian Portuguese.The translation and adaptation processes were authorized by the authors.

Brazilian experience with interviews in the area of Child Psychiatry
Brazilian researchers have been using interviews created in the United States and England for their research projects, something that facilitates comparisons with results obtained worldwide.Psychiatric Interviews such as the Kiddie-Sads-E 6 and the Development and Well-Being Assessment (DAWBA) 4 have been used in research in Brazil 3 .These are time-consuming interviews and there is no published description of the process involved in the cultural adaptation of these instruments to Brazilian Portuguese.The Kiddie-Sads-PL has been subject to translation and validation in our country 5 .However, because of its length and because of the level of training expected of its interviewers, it is not frequently used.There might be also some problems, specifically concerning the ADHD diagnosis, as recently suggested 10 .The DAWBA has been translated and backtranslated but there is no data on the establishment of semantic equivalence and cultural adaptation.The Diagnostic Interview for Children and Adolescents (DICA) has been translated and backtranslated, but it is very lengthy and its free use is not authorized for research.The final version of the instruments currently in use, therefore, have restricted use, due to copyrights or application time, and have rarely been analyzed by committees of experts in Child Psychiatry and linguists, which could improve the quality of the final instruments.

Approaches to obtaining a culturally adaptated instrument
The valid use of mental health instruments across cultures requires a careful adaptation process which goes beyond mere language translation.Guarnaccia 8 and others authors defend the needs of a cross-cultural study of mental illness.The development of a culturally adapted instrument, however, is expensive, time-consuming and complex.That is why, despite the consensus for the need of cultural adaptation, many instruments are currently in use without having gone through rigorous adaptation processes.Cultural adaptation involves conceptual, semantic and technical aspects.Conceptual adaptation usually involves focus groups and it is more relevant in situation in which modifications of the original instrument would be more acceptable and in which the instrument has not been widely used 7 .In addition to that, instruments addressing issues such as quality of life are especially susceptible to cultural variations, and, therefore, more dependent of the use on conceptual adaptation.
The semantic aspects of cultural adaptation have been addressed in many ways.The method of translation and backtranslation has been commonly used to establish versions of instruments for the assessment of symptoms in languages that are different from the ones they were developed and depression/dysthimia were also adapted.Each section was translated by two independent translators and later discussed in a committee composed of experts in the field of Psychiatry and a professional of the field of linguistics.Result: A final version containing an interview for the main psychiatric syndromes was defined.Conclusion: The translated P-ChIPS is a helpful instrument in children and adolescent clinical evaluation.

P-ChIPS, translation, clinical interview.
A Brazilian version of the "Children's Interview for Psychiatric Syndromes" (ChIPS) artigo original is a version for interviewing the parents (P-ChIPS), comprising the same diagnoses assessed in the ChIPS.Neither the application, nor the training of the interviewers, is timeconsuming, as opposed to Kiddie-SADS.Questions are very specific and, in most cases, demand straight answers, such as "yes" or "no".Its items are very similar to DSM-IV criteria 1 .It is subject to copyright laws, but liberation for its use in research can be asked for from the editors.

ChIPS translation process
The structured interview was divided in sections to be assessed with children or their parents.Sections related to ADHD, ODD, CD, mania, eating disorders and psychotic disorders were translated from the P-ChiPs.Sections related to SUDs, SAD, SP, OCD, GAD, SepAD, Post-traumatic disorders and depression/dysthimia were translated from the ChIPS.Parents are usually considered the best informants for externalizing disorders, especially ADHD and ODD.There is evidence, however, suggesting that they are frequently not fully aware of anxious and depressive symptoms in their children 11 .Based on these assumptions, certain sections were adaptated from the children's interview and some were adaptated from the parents'.
The initial step was translation of all of these sections by a psychiatrist or speech therapist fluent in English.The next step was to gather three psychiatrists to discuss each part of the translation, based on the original version.Finally, a professional from the field of linguistics was given the version created by the psychiatric committee to correct and criticize.The linguistic field professional analyzed the translated instrument with the goal of achieving linguistic cultural equivalence and reducing ambiguity and misunderstandings.Another meeting was held, with both the linguistics professional and the child psychiatrists to discuss problematic items and define a final version.
The preference for this approach of using multiple translations and a multidisciplinary team, comprised of psychiatrists, child psychiatrists, and, later on, a linguist, to discuss the translations, was undertaken based on the work of Swaine-Verdier 12 .This author performed a critical review of the process of translation and backtranslation.This approach was also chosen based on the earlier experience we had with the translation of a scale for the evaluation of ADHD symptoms, in which it became clear that the most useful in.This method is labour intensive and its rationale has been subject to criticism, such as the ones discussed later on.The process involves a first approach, the translation of the instrument from the source language into the target language.Afterwards, a different professional than the one involved in the first step will backtranslate the instrument into the source language.The third step is a comparison, performed by an expert, which will provide a careful analysis of the differences between the original instrument and the backtranslated one.The backtranslation is a valid method, that has been established over the years on many studies.It is a very complex and time-consuming process, but it has some limitations.
Swaine-Verdier et al. 12 suggest that the traditional process of translation and backtranslation is based on a series of incorrect assumptions, such as, for example, the notion that the backtranslator is less subject to errors than the translator.Some mistakes could occur both in the translation and in the backtranslation process.Bad translations are easy to trace back to their original form, providing clues for the backtranslator to achieve a backtranslation very similar to the original, not withstanding the error in the translated version.The author continues saying that there is no reason for the process of translation-backtranslation being considered the goldstandard for the elaboration of a foreign language version of an instrument.In fact, based on earlier work from our group 9 , it became clear that in many circunstances in which semantic equivalence of the backtranslated instrument with the original instrument was not verified, that was due to errors in the backtranslation and not in the translation.Another important limitation of the translationbacktranslation approach is the fact that, very frequently, the versions are not entirely adequate to the sociocultural reality of the country where the translated version will be applied, because the versions of the translated instrument are frequently literally, but not culturally adequate, making backtranslation insufficient.Hence, the instrument should be subject to a pre-test to determinate its appropriateness.
The discussion of the translated versions of an instrument by experts in the field and linguists together has been described as a more productive way of obtaining a culturally adapted instrument than the method of translation and backtranslation.We used this combined discussion method to obtain an adequate version of a comprehensive, but not time-consuming, interview for Child Psychiatry.
Technical adaptation is reached through analysis referring to the length of the questions, the possibility of selfapplication, issues related to the socio-cultural aspects of the target culture.

ChIPS e P-ChIPS
The ChIPs is a structured interview, by which the most important diagnoses in Child Psychiatry are assessed.There artigo original step for the elaboration of the scale was the common discussion and analysis of the different candidate translations.

DisCussion
Children´s Interview for Psychiatric Syndromes (CHIPS) is a practical and reliable instrument to be used in children psychiatric assessment.Even though it is easy to use and not very time consuming, it provides a careful and meticulous interview, facilitating the approach to the patient and data-gathering both with children and parents.This instrument, however, has some limitations, as it does not assess pervasive disorders or tic disorders.Another relevant limitation is that both ChiPs and P-ChiPs do not provide a lifetime description of the symptoms, which is particularly important when investigating internalizing symptoms, such as anxiety and depression, or even bipolar disorder, especially in adolescents.
The translation process in this case was carefully performed and seems to better address both cultural and linguistic aspects of the socioeconomic and cultural varieties present in Brazil.The methodology adopted was performed by professionals with knowledge in children's development and who were involved in activities that put them in close contact with a variety of people and their language skills, enhancing the efficacy and acceptability of this process.It has been stated that translators should have good technical knowledge of the languages involved in the translation processes, should be deeply involved in the cultures in question and should be knowledgeable of the domains explored in the instrumen 7 .These criteria are difficult to meet, but were definitely addressed in the process employed herein.
The refusal to perform a backtranslation was bold.The process of translation and backtranslation has been sistematically employed for the use of psychiatric instruments from foreign countries 2,9 .Based on our previous experience and also theoretical perspectives, we chose not to incur in a time-consuming and expensive process, which is less relevant to obtaining a culturally adapted version of a psychiatric instrument than performing a detailed, multidisciplinary discussion of more than one translation and their possible caveats.
Even though it is widely recognized that instruments developed in one language should not be automatically considered suited for use in other countries, few instruments have gone through adaptation processes for use in other languages.This is probably due to the large expenditure of time and money and the complexities involved in the process of cultural adaptation.It is crucial to establish a cost-efficient process of adaptation of instruments develo-ped in other languages.In this work, we only approached semantic aspects.It has been acknowledged that, when major changes are considered less appropriate, the use of a conceptual adaptation is less useful 7 .Psychometric aspects of the instrument and its validation process will be addressed by our group in a future work.Research should concentrate on the real cost-effectiveness of backtranslation and on developing a standard ideal process for achieving sound, culturally adapted versions of instruments developed for use in other countries.
Souza IGS et al.