Translation and cross-cultural adaptation into Brazilian Portuguese of the Mood and Feelings Questionnaire (MFQ) – Long Version

Tradução e adaptação transcultural para o português brasileiro do instrumento Mood and Feelings Questionnaire (MFQ) – Versão Longa

Abstract

Introduction

Major depressive disorder (MDD) is prevalent among young people, with a high incidence during adolescence. It is, therefore, important to have reliable instruments to capture the construct of depression in this population. The objective of the present work is to describe the process of translation and cultural adaptation of the Mood and Feelings Questionnaire (MFQ) – Long Version, into Brazilian Portuguese.

Method

We followed the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) guidelines for translation and cultural adaptation, including the steps of preparation, forward translation, reconciliation, back-translation, back-translation review, harmonization, cognitive debriefing, review of cognitive debriefing results and finalization, proofreading and final report. Cognitive debriefing was conducted in a sample of adolescent patients and their respective caregivers at mental health clinics affiliated with the Brazilian public health system.

Results

Results suggest that the items were well understood and that the MFQ seems to be an appropriate instrument for use with Brazilian adolescents and caregivers.

Conclusions

The Brazilian Portuguese MFQ – Long Version constitutes an adequate tool for the assessment of depression among adolescents. Future studies are required to evaluate psychometric properties of the instrument.

Translation; adaptation; adolescent; depression

Resumo

Introdução

O transtorno depressivo maior (TDM) é prevalente em jovens, com alta incidência durante a adolescência. Portanto, é importante que instrumentos confiáveis estejam disponíveis para avaliar o construto da depressão nessa população. O objetivo do presente trabalho é descrever o processo de tradução e adaptação cultural do Mood and Feelings Questionnaire (MFQ) – Versão Longa para o português brasileiro.

Método

Foram utilizadas as diretrizes da International Society for Pharmacoeconomics and Outcomes Research (ISPOR) para tradução e adaptação cultural, incluindo as etapas de preparação, tradução, reconciliação, retrotradução, revisão da retrotradução, harmonização, estudo piloto, revisão dos resultados do estudo piloto, revisão final e relato final. A etapa de estudo piloto foi conduzida em uma amostra de pacientes adolescentes e seus respectivos cuidadores em clínicas de saúde mental afiliadas ao Sistema Único de Saúde.

Resultados

Os resultados sugeriram que os itens foram bem compreendidos, e que o MFQ parece ser um instrumento apropriado para uso com adolescentes e cuidadores brasileiros.

Conclusões

A versão traduzida para o português brasileiro do MFQ – Versão Longa constitui um instrumento adequado para a avaliação da depressão em adolescentes. Futuros estudos são necessários para avaliar as propriedades psicométricas da escala.

Tradução; adaptação; adolescente; depressão

Introduction

Major depressive disorder (MDD) is prevalent among young people and represents a major cause of disease burden in this age group.¹ The impact imposed by MDD among youth contrasts with the limited availability of studies and resources in low- and middle-income countries, where most of children and adolescents live.² For this reason, it is crucial to have good and reliable measures to evaluate depressive symptomatology and to support clinical diagnoses and treatments in such contexts.

A number of self-report instruments are currently available for the assessment of children and adolescents.³ The Beck Depression Inventory (BDI) and Center for Epidemiologic Studies Depression Scale (CESD) were developed to evaluate depressive symptoms in adults, but are also validated for and used with the adolescent population.^4-6 Although these scales have proven to be reliable measures, none of them provides a parental version for depressive symptom assessment in the caregiver, a relevant factor in the analysis of reported depressive symptomatology for this age group.^3-6 Another widely used scale in this age group is the Children’s Depression Inventory (CDI). The CDI was adapted from the BDI for children and adolescents but, despite having versions for both parents and teachers, the instrument is not freely available, which hinders its use in low- and middle-income settings.⁷

The Mood and Feelings Questionnaire (MFQ) is one of the most widely used instruments to assess MDD in children/adolescents and has been shown to be a reliable and valid measure.⁸ The MFQ was initially developed as a tool to be used in epidemiological studies of MDD.^9,10 It was planned to cover not only Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria, but also clinically relevant additional symptoms, such as feelings of loneliness, not being loved or being ugly. The instrument has three versions that can capture different perspectives of the depressive phenomenology in the child/adolescent and parent/caregiver. The versions developed for children/adolescents (MFQ-C) and for adults (MFQ-A) in their full form have 33 items referring to the subject him/herself. Additionally, the MFQ has a parental version (MFQ-P), which makes the instrument even more relevant, as it also evaluates the children’s/adolescents’ depressive symptoms from the parent’s perspective. The parental version of the scale in its full form has 34 items. All three versions are self-report questionnaires, evaluating symptoms over the previous two weeks with three response options rated as true (score=2), sometimes true (score=1) and not true (score=0). In addition to the long version, the MFQ has also a short questionnaire (SMFQ) that includes only 13 of the original items. These shorter versions (SMFQ-C and SMFQ-P) have been already translated into Brazilian Portuguese.¹¹ Although the short form appears to be good in screening protocols, the long form includes a greater number of symptoms and provides a more comprehensive description of depressive symptoms, and it was adopted as the primary outcome measure in the largest randomized clinical trial so far conducted for this condition.¹²

Considering the high prevalence and the burden imposed by MDD across the lifespan, it is important to have adequate tools to capture this construct among children and adolescents. The translation and cultural adaptation processes of an instrument require a rigorous methodology, with the ultimate goal of maintaining the accuracy of the original scale. For this reason, the objective of this study is to describe the process of translation and cultural adaptation of MFQ-C and MFQ-P into Brazilian Portuguese using the procedures proposed by the Translation and Cultural Adaptation Group of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR).¹³

Method

We followed all ISPOR recommended procedures for the translation and cultural adaptation process for self-report measures, encompassing ten steps. In the first step (preparation), we asked for the authors’ permission to use the instrument, invited them to be involved in the process, and recruited translators. In the second step (forward translation), two independent translations were performed (by M.R. and V.M-.C. – the latter is listed in the Acknowledgments). In the third step (reconciliation), the forward translations were reconciled into a single forward translation (any discrepancies were discussed with T.B.M.R. and C.K.). In step four, a native speaker of English (E.M.) performed a back-translation of the instrument into the original language. In step five, a back-translation review was conducted to ensure the conceptual equivalence of the translation with the original instrument. The sixth step consisted of harmonization across different translations. In step seven (cognitive debriefing), the level of comprehensibility of the translation was assessed in a sample of adolescents. The sample group for this stage was composed of patients treated at mental health clinics at Hospital de Clínicas de Porto Alegre. Specifically, 14 adolescents and their 14 respective primary caregivers were selected to answer the questionnaires. We used a convenience sampling approach, recruiting two adolescents (one boy and one girl) per year of age (from 11 to 17). There was no restriction in terms of psychiatric diagnoses; the only exclusion criterion was clinical evidence of intellectual disability. In step eight (review of cognitive debriefing results and finalization), results were reviewed and the translation was finalized. In step nine (proofreading), an additional revision was performed to check for possible errors that might have been missed during the translation process. The last, tenth step was the elaboration of this final report, detailing the translation process. This project was approved by the research ethics committee of Hospital de Clínicas de Porto Alegre (50473015.9.0000.5327).

Results

The process of translation and cultural adaptation generated Brazilian Portuguese versions of the MFQ scales. Table 1 shows the steps that were followed in the translation and adaptation process of the MFQ-C with the respective results: original version, version 1 (first forward translation), version 2 (second forward translation), reconciliation, back-translation and final version. The MFQ-P was also translated and adapted, and the table with the steps and results is available as Online-Only Supplementary Material.

Table 1
Summary of results of translation and adaptation of MFQ into Brazilian Portuguese

Original	Version 1 (V1)	Version 2 (V2)	Reconciliation (V3)	Back translation	Final version
This form is about how you might have been feeling or acting recently.	Este questionário refere-se à forma que você vem se sentindo ou se comportando recentemente.	Esse formulário trata a respeito de como você pode estar agindo ou se sentindo recentemente.	Este questionário é sobre como você pode estar se sentindo ou agindo recentemente.	This questionnaire is about how you have been feeling or acting recently.	Este questionário é sobre como você pode estar se sentindo ou agindo recentemente.
For each question, please check (✓) how you have been feeling or acting in the past two weeks.	Para cada pergunta, por favor marque (✓) como você vem se sentindo ou se comportando nas últimas duas semanas.	Para cada pergunta, marque (v) como você tem se sentido ou agido nas últimas duas semanas.	Para cada pergunta, por favor marque (✓) como você esteve se sentindo ou agindo nas últimas duas semanas.	For each question, check (✓) how you have been feeling or acting over the past two weeks.	Para cada pergunta, por favor marque (✓) como você esteve se sentindo ou agindo nas últimas duas semanas.
If a sentence was not true about you, check NOT TRUE. If a sentence was only sometimes true, check SOMETIMES. If a sentence was true about you most of the time, check TRUE	Se a frase não é verdadeira sobre você, marque NÃO É VERDADEIRA. Se a frase é apenas às vezes verdadeira, marque ÀS VEZES. Se a frase é verdadeira sobre você na maioria do tempo, marque VERDADEIRA.	Se uma frase não condiz com você, marque Não é Verdade Se uma frase condiz com você somente às vezes, marque Ocasionalmente Verdade Se uma frase condiz com você na maior parte do tempo, marque Verdade	Se a frase não for verdadeira sobre você, marque NÃO É VERDADE. Se a frase for verdadeira apenas às vezes, marque ÀS VEZES. Se a frase for verdadeira sobre você na maior parte do tempo, marque VERDADE	If the phrase is not true about you, mark NOT TRUE. If the phrase is only true sometimes, mark SOMETIMES. If the phrase is true about you most of the time, mark TRUE.	Se a frase não for verdadeira sobre você, marque NÃO É VERDADE. Se a frase for verdadeira apenas às vezes, marque ÀS VEZES. Se a frase for verdadeira sobre você na maior parte do tempo, marque VERDADE.
Score the MFQ as follows: NOT TRUE = 0 SOMETIMES = 1 TRUE = 2	Pontue o MFQ da seguinte forma: NÃO É VERDADEIRA = 0 ÀS VEZES=1 VERDADEIRA = 2	Pontue o QHS da seguinte forma: Não é verdade = 0 Ocasionalmente Verdade = 1 Verdade = 2	Pontue o MFQ da seguinte forma: NÃO É VERDADE = 0 ÀS VEZES=1 VERDADE = 2	Scoring: NOT TRUE = 0 SOMETIMES = 1 TRUE = 2	Pontue o MFQ da seguinte forma: NÃO É VERDADE = 0 ÀS VEZES = 1 VERDADE = 2
To code, please use a checkmark (✓) for each statement.	Para preencher, por favor, use o sinal de “✓” para cada afirmação.	Para preencher, por favor, use o sinal de “✓” para cada afirmação.	Para preencher, por favor, use o sinal de “✓” para cada afirmação.	To code, please use a checkmark (✓) for each statement.	Para preencher, por favor use o sinal✓ para cada afirmação.
NOT TRUE	NÃO É VERDADEIRA	NÃO É VERDADEIRA	NÃO É VERDADEIRA	NOT TRUE	NÃO É VERDADE
SOMETIMES	ÀS VEZES	ÀS VEZES	ÀS VEZES	SOMETIMES	ÀS VEZES
TRUE	VERDADEIRA	VERDADEIRA	VERDADEIRA	TRUE	VERDADE
I felt miserable or unhappy.	Eu me senti muito triste ou infeliz.	Eu me sentia muito triste ou infeliz.	Eu me senti muito triste ou infeliz.	I have felt very sad or unhappy.	Eu me senti muito triste ou infeliz.
I didn’t enjoy anything at all.	Eu não consegui sentir prazer em nada.	Eu não conseguia apreciar/desfrutar de nada.	Eu não consegui me divertir com nada.	I haven’t been able to enjoy anything.	Eu não consegui me divertir com absolutamente nada.
I was less hungry than usual.	Eu estava com menos fome do que o usual.	Eu estava com menos fome do que usualmente.	Eu estive com menos fome do que normalmente.	I have been less hungry than usual.	Eu estive com menos fome do que normalmente.
I ate more than usual.	Eu comi mais do que o usual.	Eu comia mais do que usualmente.	Eu comi mais do que normalmente.	I have been eating more than usual.	Eu comi mais do que normalmente.
I felt so tired I just sat around and did nothing.	Eu me senti tão cansado (a) que apenas fiquei sentado (a) sem fazer nada.	Eu me sentia tão cansado que só ficava sentado e não fazia nada.	Eu me senti tão cansado(a) que apenas ficava sentado(a) sem fazer nada.	I have felt so tired all I can do is sit and do nothing.	Eu me senti tão cansado(a) que só ficava sentado(a) sem fazer nada.
I was moving and walking more slowly than usual.	Eu estava me movimentando e caminhando mais devagar do que o usual.	Eu estava me mexendo e caminhando mais lentamente que o usual.	Eu estive me movimentando e caminhando mais devagar do que normalmente.	I have been moving and walking more slowly than usual.	Eu estive me movimentando e caminhando mais devagar do que normalmente.
I was very restless.	Eu estava muito inquieto (a).	Eu me sentia muito inquieto/agitado.	Eu estive muito agitado(a).	I have felt really restless.	Eu estive muito agitado(a).
I felt I was no good anymore.	Eu senti que não tinha mais importância.	Eu sentia que não era mais uma pessoa boa.	Eu senti que eu não prestava mais.	I feel worthless.	Eu senti que eu não valia mais nada.
I blamed myself for things that weren’t my fault.	Eu me culpava por coisas que não eram minha culpa.	Eu me culpava por coisas pelas quais não tinha culpa.	Eu me culpei por coisas que não eram minha culpa.	I have blamed myself for things that aren’t my fault.	Eu me culpei por coisas que não eram minha culpa.
It was hard for me to make up my mind.	Era difícil para mim tomar decisões.	Era difícil para mim tomar uma decisão.	Foi difícil me decidir sobre as coisas.	I have had trouble making decisions.	Foi difícil me decidir sobre as coisas.
I felt grumpy and cross with my parents.	Eu me senti mal-humorado (a) e irritado (a) com meus pais.	Eu me sentia mal-humorado e irritado com meus pais.	Eu fiquei emburrado(a) e de mal com meus pais.	I have been irritated and crabby with my parents.	Eu fiquei emburrado(a) e de mal com meus pais.
I felt like talking less than usual.	Eu senti que eu estava menos disposto (a) a conversar do que o usual.	Eu me sentia menos a fim de conversar do que o usual.	Eu estive menos a fim de conversar do que normalmente.	I’ve been less talkative than usual.	Eu estive menos a fim de conversar do que normalmente.
I was talking more slowly than usual.	Eu estava falando mais devagar do que o usual.	Eu sentia que estava falando mais lentamente que o usual.	Minha fala esteve mais devagar do que normalmente.	I have been talking more slowly than usual.	Minha fala esteve mais devagar do que normalmente.
I cried a lot.	Eu chorava muito.	Eu chorava muito.	Eu chorei muito.	I have been crying a lot.	Eu chorei muito.
I thought there was nothing good for me in the future.	Eu pensava que nada de bom aconteceria comigo no futuro.	Eu pensava que não havia nada de bom para mim no futuro.	Eu pensei que nada de bom aconteceria comigo no futuro.	I think nothing good is ever going to happen to me.	Eu pensei que nada de bom aconteceria comigo no futuro.
I thought that life wasn’t worth living.	Eu pensei que a vida não valia a pena ser vivida.	Eu pensava que a vida não valia a pena ser vivida.	Eu pensei que a vida não valia a pena ser vivida.	I think life is not worth living.	Eu pensei que a vida não valia a pena ser vivida.
I thought about death or dying.	Eu pensei sobre morte ou morrer.	Eu pensava a respeito da morte ou de morrer	Eu pensei sobre morte ou morrer.	I have thought about death or dying.	Eu pensei sobre morte ou morrer.
I thought my family would be better off without me.	Eu pensei que a minha família poderia ser mais feliz sem a minha presença.	Eu pensava que minha família estaria melhor sem mim.	Eu pensei que minha família estaria melhor sem mim.	I have thought that my family would be better off without me.	Eu pensei que minha família estaria melhor sem mim.
I thought about killing myself.	Eu pensei em me matar.	Eu pensava em me matar.	Eu pensei em me matar.	I’ve thought about killing myself.	Eu pensei em me matar.
I didn’t want to see my friends.	Eu não queria ver meus amigos.	Eu não queria ver meus amigos.	Eu não queria ver meus amigos.	I haven’t wanted to see my friends.	Eu não queria ver meus amigos.
I found it hard to think properly or concentrate.	Eu achei difícil pensar corretamente ou me concentrar.	Eu achava difícil pensar corretamente e me concentrar.	Eu achei difícil raciocinar ou me concentrar.	I have had trouble thinking or concentrating.	Eu achei difícil raciocinar ou me concentrar.
I thought bad things would happen to me.	Eu pensei que coisas ruins aconteceriam comigo.	Eu achava que coisas ruins iriam acontecer comigo.	Eu pensei que coisas ruins aconteceriam comigo.	I think bad things will happen to me.	Eu pensei que coisas ruins aconteceriam comigo.
I hated myself.	Eu me odiei.	Eu me odiava.	Eu me odiei.	I hate myself.	Eu me odiei.
I felt I was a bad person.	Eu me senti uma pessoa ruim.	Eu sentia que era uma má pessoa.	Eu me senti uma pessoa ruim.	I feel like a bad person.	Eu me senti uma pessoa ruim.
I thought I looked ugly.	Eu pensei que era feio (a).	Eu pensava que era feio.	Eu me senti feio(a).	I feel ugly.	Eu me senti feio(a).
I worried about aches and pains.	Eu me preocupei com dores e sofrimentos.	Eu me preocupava com dores.	Eu me preocupei com dores no corpo.	I am worried about pain in my body.	Eu me preocupei com dores no corpo.
I felt lonely.	Eu me senti sozinho (a).	Eu me sentia sozinho.	Eu me senti sozinho(a).	I have felt alone.	Eu me senti sozinho(a).
I thought nobody really loved me.	Eu pensei que ninguém poderia realmente gostar de mim.	Eu acreditava que ninguém realmente me amava.	Eu pensei que ninguém me amava de verdade.	I feel like no one really loves me.	Eu pensei que ninguém me amava de verdade.
I didn’t have any fun in school.	Eu não me divertia na escola.	Eu não me divertia em nada na escola.	Eu não me diverti nem um pouco nas minhas atividades.	I haven’t had any fun with my usual activities.	Eu não me diverti nem um pouco nas minhas atividades.
I thought I could never be as good as other kids.	Eu pensei que eu jamais poderia ser bom como as outras crianças.	Eu achava que nunca seria tão bom quanto as outras crianças.	Eu pensei que eu nunca seria tão bom(boa) quanto os outros da minha idade.	I don’t think I’ll ever be as good as other kids my age.	Eu pensei que eu nunca seria tão bom(boa) quanto os outros da minha idade.
I did everything wrong.	Eu fazia tudo errado.	Eu fazia tudo errado.	Eu fiz tudo errado.	I do everything wrong.	Eu fiz tudo errado.
I didn’t sleep as well as I usually sleep.	Eu não dormi tão bem como eu usualmente durmo.	Eu não dormia tão bem quanto durmo usualmente.	Eu não dormi tão bem quanto eu normalmente durmo.	I haven’t been sleeping as well as usual.	Eu não dormi tão bem quanto eu normalmente durmo.
I slept a lot more than usual.	Eu dormi mais do que o usual.	Eu dormia muito mais que usualmente.	Eu dormi muito mais do que normalmente.	I have been sleeping much more than usual.	Eu dormi muito mais do que normalmente.

Following the steps in Table 1, between back-translation and final version, two versions of the instrument (MFQ-C and MFQ-P) were administered to 28 adolescents and primary caregivers whose native language was Brazilian Portuguese. For each item, patients answered the following questions: “Do you understand this instruction/item/rating scale? (If you do not understand, please, explain the difficulty)”; “If there are difficulties, how would you write this instruction/item/rating scale?”; “Could you explain what it means? (Ask the person to explain what they think that the instruction/item/rating scale means)”; “Are the response options appropriate? (If they aren’t, please explain the difficulty and how you would write it).” Adolescents and caregivers took an average of 30 to 45 minutes to respond to the questionnaire. All responses were assessed in detail by a decision committee, which consensually decided that no additional changes were required, as both MFQ versions were shown to be easily understood. The only issue that raised some questions by the adolescents was a possible overlap between the item on morbid thoughts (item 17 – “Eu pensei sobre morte ou morrer”) and the one on suicidal ideation (item 19 – “Eu pensei em me matar”).

Discussion

The MFQ is one of the most frequently used instruments to assess depressive symptoms in children and adolescents in the international literature.^12,14 The absence of a Brazilian Portuguese translation of its long version prevents its use in a country currently with a population of 63 million children and adolescents.¹⁵ We have described the process of translation and cultural adaptation of the MFQ using the methods recommended by the ISPOR. Both MFQ-C and MFQ-P, after rigorous procedures of translation and back-translation, were tested in a sample of adolescent patients and caregivers, who verified the comprehensibility of the scale. The Brazilian Portuguese translation of the long versions of the MFQ appeared to be acceptable and easy to understand.

Other instruments that evaluate the symptoms of MDD in this age group have also been translated and validated for Brazilian Portuguese. The CDI was initially translated and validated in 1995¹⁶ and, since then, it has been applied with the objective of verifying its psychometric properties.^17,18 The BDI was also translated and validated to Brazilian Portuguese,¹⁹ and several studies have evaluated the psychometric properties of this instrument among Brazilian adolescents.^20,21 The CESD has also been translated and validated into Brazilian Portuguese, and its psychometric properties have been verified in different populations, including adolescents.^22-27

Collecting information from multiple sources is essential in the assessment of psychiatric symptoms among children and adolescents.²⁸ As the MFQ also includes a version for parents, this allows the instrument to be even more informative. Although MDD is conceptualized as an internalizing disorder, the caregiver’s version helps to capture the construct of depression more comprehensively and seems to better predict a depressive episode when compared to the adolescent report in isolation.^8,14

The present study, however, is not without limitations: the sample for the cognitive debriefing step was very small and, despite trying to cover different ages and genders, we did not control for socioeconomic status or diagnostic categories. Also, the fact that all subjects were patients at mental health clinics limits the generalizability of findings to community settings. Additionally, although we also translated the MFQ-A, we did not include it in the cognitive debriefing for logistical reasons. Nevertheless, the MFQ-A is extremely similar to both MFQ-C and MFQ-P, which suggests that adults would not have difficulty understanding it.

Translation and cultural adaptation constitute a first step in the process of validation of an instrument in a different setting. The Brazilian Portuguese versions of the MFQ are now ready for use with adolescents and caregivers. Future studies should evaluate the psychometric properties of the questionnaires in order to gain insights into the reliability and validity of the instrument in a more diverse population.

Acknowledgments

Christian Kieling received grants from Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul (FAPERGS), and Fundo de Incentivo a Pesquisa e Eventos – Hospital de Clínicas de Porto Alegre (FIPE/HCPA).

The authors are grateful to Brian Small and Jane Costello for the authorization to translate the questionnaires and for the revision of the back-translated versions of MFQ. The authors also thank Cristiane Geyer, Dimas Gramz, Julia Bondar and Vinícius Martins-Costa for their assistance in the process of cognitive debriefing.

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Publication Dates

• Publication in this collection
  05 Apr 2018
• Date of issue
  Jan-Mar 2018

History

• Received
  14 Feb 2017
• Accepted
  08 June 2017