Translation and cross-cultural adaptation of the anchor points of the Cornell Assessment of Pediatric Delirium scale into Portuguese

Objective To translate and cross-culturally adapt the Cornell Assessment of Pediatric Delirium anchor points from English to Brazilian Portuguese. Methods For the translation and cross-cultural adaptation of the anchor points, all steps recommended internationally were followed after authorization for use by the lead author. The stages were as follows: translation of the original version into Portuguese by two bilingual translators who were native speakers of the target language, synthesis of the versions, reverse translation by two translators who were native speakers of the source language, review and synthesis of the back-translation, review by a committee of experts and preparation of the final version. Results The translation and cross-cultural adaptation of the anchor points was conducted in accordance with recommendations. The linguistic and semantic issues that arose were discussed by a committee of judges, with 91.8% agreement, as determined using a Likert scale, after changes by consensus. After reanalysis by the authors, there were no changes, resulting in the final version, which was easy to understand and administer. Conclusion The translation and cross-cultural adaptation of the anchor points of the Cornell Assessment of Pediatric Delirium scale into Portuguese spoken in Brazil were successful, maintaining the linguistic and semantic properties of the original instrument. The table of anchor points is easy to understand and will be helpful during the assessment of children younger than 24 months using the Cornell Assessment of Pediatric Delirium scale.


INTRODUCTION
7)(8)(9)(10) These findings were confirmed in a systematic review of the analysis of the prevalence of pediatric delirium using validated tools; the conclusion of the review was that pediatric delirium occurs in approximately 34% of children admitted to pediatric Marina dos Santos Ramos Barbosa 1 , Lívia Barboza Andrade 1 , Maria do Carmo Menezes Bezerra Duarte 1 , Roberta Esteves Vieira de Castro 2 intensive care units, with the hypoactive subtype being the most prevalent. (11)he most cited risk factors associated with pediatric delirium are pain, separation anxiety, absence of a caregiver, admission to the pediatric ICU, mechanical ventilation, anticholinergic medications, sleep deprivation (noise, cold and light), mechanical restraint, number of procedures (placement and removal of devices), and use of sedatives and analgesics. (7,12,13)Among the most cited causes for the development of pediatric delirium are cumulative doses of benzodiazepines, opioids, number of sedative classes used, deep sedation and chest surgery. (7)n recent years, several screening tools for use in children in the PICU have been proposed and validated.Among such tools is the Cornell Assessment of Pediatric Delirium (CAPD) scale, a promising clinical triage tool designed and validated for use in the pediatric ICU that is easy to use, allows fast observation, is applicable by a multidisciplinary team and can detect all types of delirium in all pediatric age groups. (13)lthough it has been translated into Portuguese and culturally adapted for use in the pediatric population of Brazil, (14) the CAPD has not yet been validated for use in the Brazilian population, nor have the anchor points table been translated and cross-culturally adapted, which would aid in the evaluation of children under 2 years of age. (13)17) The process required for the cross-cultural adaptation of instruments into new languages/cultures involves more than the simple translation of the original and literal comparison with a back-translation.There is no consensus regarding execution strategies, but it is recommended that the process should be meticulous and consider the cultural context and lifestyle of the target population.This process has several advantages compared to the development of a new instrument with the same purpose.20) In this context, the objective of this study was to translate and cross-culturally adapt the table of CAPD anchor points into Portuguese for use in Brazil.

METHODS
This was a methodological study involving the translation and cross-cultural adaptation of the CAPD anchor points into Brazilian Portuguese.(16)(17) In addition to the scale, the author of the CAPD developed a table with anchor points to aid in the evaluation of delirium in children under 24 months of age. (13)The translation and cross-cultural adaptation of the table into Brazilian Portuguese is important and necessary.Although it was translated into Portuguese and culturally adapted for use in the pediatric population of Brazil, the table of anchor points was not translated and cross-culturally adapted (Table 1). (14)he study was initiated after authorization of use by the original author, Dr. Chane Traube, Weil Cornell Medical College, New York, United States, and approval of the study by the Ethics Committee in Research Involving Human Beings of Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife (PE), under process 5,882.615.The procedures adopted in this study followed the model proposed by Reichenheim & Moraes and involved the following steps: permission from the lead author; translation and concordance; back translation and concordance; analysis by a committee of judges; and review and construction of the final version. (20)

Description of the Cornell Assessment of Pediatric Delirium and table of anchor points
The CAPD is composed of eight items to be observed.Each of the eight items is scored from zero to four, and a total score equal to or greater than nine points indicates the presence of delirium.To aid in the evaluation of children younger than 24 months, the author developed a table of anchor points, which are the main developmental milestones, divided into seven columns (newborn, 4 weeks, 6 weeks, 8 weeks, 28 weeks, 1 year and 2 years). (13)

Translation and cross-cultural adaptation
The table of anchor points was translated by experienced bilingual translators.All translators produced independent translations.
The steps for the translation and cultural adaptation process were conducted in accordance with internationally accepted recommendations, namely, authorization from the author of the original version for the translation and cultural adaptation of the anchor points; translation from English into Portuguese by two Brazilian translators fluent in English; synthesis of the translated versions (to evaluate the linguistic, semantic, idiomatic, conceptual and contextual discrepancies, to obtain a single version); back-translation (back-translation of the summary version in Portuguese into the target language -English -by two bilingual translators who are native English speakers and fluent in Portuguese); review and harmonization of the back-translation to produce a single version; meeting with the committee of judges formed by experts with practical experience in the area in question; and after making necessary corrections and adaptations based on feedback from the committee of judges, reconciliation and preparation of the final version.

Translation into Portuguese and synthesis of the translated versions
The table was translated by two native Portuguese translators with command of English, resulting in two versions.The two versions, which were independently translated, were analyzed and compared during a meeting between the translators and the lead author.A consensus approach was used to resolve any differences, resulting in a single version of the scale in Portuguese.

Back-translation into English and synthesis of the back-translated versions
The synthesized Portuguese version was translated back into English by two independent translators who were native speakers of English and fluent in Portuguese.The translators were not familiar with the concepts explored in the table, nor were they aware of the original English version.The two versions, which were independently translated, was performed, were synthesized, resulting in a single version of the scale in English.

Committee of judges
The versions were reviewed and evaluated by a committee of judges composed of 13 professionals who specialized in the content addressed (physical therapists, pediatric intensivists, nurses and neurologists).20) After the meeting of the committee of judges, a prefinal version of the table of anchor points was produced.Each item was revised, and relevant modifications suggested by the experts were incorporated, producing the final version of the table of anchor points.Thus, the final version of the CAPD anchor points table adapted to Brazilian Portuguese was prepared.

RESULTS
After the first stage (translation), two Portuguese versions of the table of anchor points were obtained.In the synthesis of the versions, the authors considered a combination of the versions because the translations were similar and different terms were synonyms.In the back-translation of the Portuguese version into English, no changes were made to the words suggested by the translators because there was no discrepancy between the items in the original scale and those in the back-translated version.
The items evaluated and altered, by consensus, by the lead author during the meeting of the expert committee are shown in boldface in table 2. Some words were removed or added to improve agreement and facilitate understanding.Specific terms in the last row of the table underwent the most changes when compared with the terms in the translated version of the original table, but the semantics did not change because the terms (suck/suction), (grasp/ grab), and (disturbing/uncomfortable) were considered synonyms.In the elaboration of the final version (Table 3), although the items were considered little changed compared to the items in the original version, these terms were synonymous and, when back-translated into English, were identical to the original (grasp, suck, noxious stimuli) and did not change the semantics of the items.
During the expert committee meeting, the participants were invited to fill out a form to assess the degree of agreement.After analyzing the results, agreement was 91.8% (Likert scale).

DISCUSSION
Herein, the process of the translation and cross-cultural adaptation of the CAPD anchor points table from English to Brazilian Portuguese is described.The steps were performed in accordance with the recommendations found in the literature.The linguistic and semantic equivalences between the original table and the Brazilian Portuguese version were satisfactory, as there was no divergence.
The translation and cross-cultural adaptation process is meticulous and necessary, and characteristics of the original version must be preserved.Such adaptation is important due to the heterogeneity of the population and the use of several regional terms. (20)The Portuguese version of the CAPD anchor points table produced in this study is technically and semantically equivalent to the original version.The evaluation of equivalence between the items in the original scale, the syntheses of the versions translated into Portuguese and the synthesis of the back-translations allow confirmation that most of the items, both in the translation and in the back-translation, are similar to the original version, with small changes.The fact that there were no completely altered terms in the analysis of item equivalences is due, in our opinion, to the simplicity of the instrument, which contains practical terms and uses simple language.
During the evaluation by the committee of multidisciplinary experts, there were some questions about agreement and some specific terms, which were changed by consensus, maintaining the semantic characteristics of the original version.The main changes were made in the last row of the first column (NB) and in the second column (4 weeks), and the term "suck" was replaced with "suction", and "grab" was replaced with "grasp" because they are usually considered more common terms used in daily practice.In the other columns, some words were modified to improve agreement and understanding; for example, "perturbam" ("perturb") was replaced with "incomodam" ("annoy"); "disturbing" was replaced with "uncomfortable"; "mantém" was replaced with "fixed"; "lack of coordination" was replaced with "incoordination"; and "moves" was replaced with "mobile".The changes were made by consensus, taking into account the opinion of the experts and the goal of maintaining the semantic characteristics of the original instrument.
Although there is no gold standard to be strictly followed in the transcultural translation and adaptation process, some guidelines are recommended as essential steps to be followed for such studies. (20)After the small adjustments suggested by consensus during the meeting of the committee of experts and the final meeting with the translators and authors, the final version of the table of CAPD anchor points for Brazilian Portuguese was created.

CONCLUSION
The table of anchor points within the Cornell Assessment of Pediatric Delirium was translated and cross-culturally adapted to Brazilian Portuguese and is ready to be tested on a larger scale.To this end, further studies are needed to evaluate the psychometric properties of the Cornell Assessment of Pediatric Delirium, making its use possible in all regions of Brazil.

Table 1 -
Original version

Table 2 -
Version with adjustments after suggestions by the committee of judges Continue...

Table 3 -
Final version