Original ArticleTuCASA questionnaire for assessment of children with obstructive sleep apnea: validation
Introduction
The term sleep-disordered breathing (SDB) describes the clinical spectrum of a condition that includes primary snoring, upper airway resistance syndrome (UARS), and obstructive sleep apnea syndrome (OSAS) [1]. The prevalence of OSAS in children is estimated to range between 1% and 3%, with equal distribution between the genders and peak prevalence in preschoolers [2], [3], [4], [5], [6].
Unlike adults, children with SDB do not have excessive daytime sleepiness, but rather have symptoms such as: behavioral changes, cognitive dysfunction [3], [4], impulsivity [7], impaired balance [8], impaired concentration and learning difficulties, facial growth abnormalities, growth retardation, and hyperactivity [9], [10], [11], [12], [13]. Thus, pediatric SDB may lead to major complications such as delayed growth and development, mental retardation, and pulmonary heart disease (cor pulmonale).
The pathophysiology of SDB in childhood is not yet understood, although adenotonsillar hypertrophy, obesity, muscle weakness, and craniofacial dismorphism are factors that may contribute [12], [13], [14].
Polysomnography (PSG), the standard for the diagnosis of SDB, is the most accurate method for determining its presence and severity, but is costly and has limited availability [12], [15]. In Brazil, the demand for PSG in children far exceeds the number of facilities qualified to perform it, which forces the children and their parents to seek care at major centers, where they are usually placed on a waiting list [13]. The need for expert technicians is a further hindrance to wider access to this diagnostic test.
Questionnaires are very useful tools for the assessment of sleep in children; however, these instruments must be clear, simple, brief, and easy to understand and administer. Several different questionnaires may be used for diagnostic purposes in routine clinical practice. Most instruments used for this purpose in Brazil were developed in other countries, and few have been adapted and validated for Portuguese-speaking populations; therefore, it is believed that misinterpretations and certain cultural aspects may influence the specificity and sensitivity of these methods. The need for visual adaptation of instruments should also be taken into account [16]. The use of questionnaires as evaluation parameters is useful, because they can allow standardization, consistency, and reproducibility of the proposed measures. When translating a questionnaire, its measurement properties need to be tested and validated in a pilot group, to enable later use in population studies. Thus, established methods for translation and cross-cultural adaptation allow instruments to be used in a given language and culture.
The Tucson Children's Assessment of Sleep Apnea Study (TuCASA) questionnaire is intended for children aged 4 years to 11 years and comprises 13 items about the symptoms of SBD [12]. This questionnaire has proven to be relevant and reproducible, as demonstrated in several studies [12], [17], [18], [19], [20], is easy to administer in a clinical setting, and can help determine the symptoms of SDB in Brazilian children. The aim of the present study was to validate a version of the TuCASA questionnaire that had been translated and adapted for use in Brazil [21].
Section snippets
Sample
A total of 62 children (27 girls), aged 4 years to 11 years, participated in the present study; all were chaperoned by their parents and/or guardians. The translation, back-translation, and pretesting, according to the methodology proposed by Guillemin et al. [22] and Beaton et al. [23], was previously performed with the permission of the authors of the original English-language questionnaire [12], yielding a version of the instrument adapted culturally for the Brazilian population (Appendix S1
Analysis of respondents
The validation sample consisted of 35 boys (56.5%) and 27 girls (43.5%), with a mean age of 8.63 ± 1.85 years (Table 1, p = 0.306). There was no difference among TuCASA scores and presence of SDB with either gender or age (Table 2).
Analysis of reliability
The TuCASA scale exhibited a Cronbach's alpha coefficient of 0.726 (95% CI 0.614 to 0.817), which denotes satisfactory internal consistency (Table 3). This was reinforced by evaluation of the effect of the exclusion of each item on the questionnaire.
Analysis of validity
Of the 34
Discussion
The present study validated an instrument for assessment of symptoms of SDB – the TuCASA questionnaire – in Brazilian children. This instrument proved to be effective for use in research and clinical settings, in that it aids the assessment of SDB symptoms and can thus be used to support the decision to refer children for PSG.
The TuCASA is a clinical evaluation questionnaire that was developed to assess symptoms of SDB in children; it was originally created in English. The instrument was
Conclusion
The version of the TuCASA questionnaire translated into Portuguese and adapted culturally for the Brazilian population was validated and proved to be a reliable, valid instrument that can be used in clinical practice for evaluation of children with symptoms of SDB. It can also be used to increase accuracy when choosing whether to refer children for overnight PSG in a sleep laboratory, which is the standard for diagnosis of SDB.
Conflict of interest
The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2014.09.013.
Acknowledgments
This research was supported by Capes e CNPq.
References (41)
- et al.
Pediatric sleep-related breathing disorders
Am J Otolaryngol
(2000) - et al.
Pediatric Sleep Questionnaire (PSQ): validity and reliability of scale for sleep-disordered breathing, snoring, sleepiness, and behavioral problems
Sleep Med
(2000) - et al.
Update in obstructive sleep apnea syndrome in children
Rev Bras Otorrinolaringol
(2005) - et al.
Symptoms related to sleep-disordered breathing in white and Hispanic children – the Tucson Children's Assessment of Sleep Apnea study
Chest
(2003) - et al.
Pediatric obstructive sleep apnea syndrome
Clin Chest Med
(2010) - et al.
Sleep disturbance scale for children: translation, cultural adaptation, and validation
Sleep Med
(2009) - et al.
Incidence and remission of sleep-disordered breathing and related symptoms in 6- to 17-year old children – the Tucson Children's Assessment of Sleep Apnea study
J Pediatr
(2010) - et al.
Cross-cultural adaptation of healthy-related quality of life measures: literature review and proposed guidelines
J Clin Epidemiol
(1993) - et al.
Methods for validating and norming translations of healthy status questionnaires: the IQOLA project approach
J Clin Epidemiol
(1998) - et al.
Cognitive dysfunction in children with sleep-disordered breathing
J Child Neurol
(2005)
Cognitive dysfunction in children with sleep-disordered
Arq Neuropsiquiatr
The prevalence of symptons of sleep-disordered-breathing in Brazilian school children
J Pediatr (Rio de Janeiro)
Sleep disorders are associated with impulsivity in school children aged 8 to 10 years
Arq Neuropsiquiatr
Sleep disorders and starting time to school impair balance in 5-year-old children
Arq Neuropsiquiatr
Symptoms of sleep disorders and objective academic performance
Sleep Med
Mouth breathing children have cephalometric patterns similar to those of adult patients with obstructive sleep apnea syndrome
Arq Neuropsiquiatr
Polysomnographic findings are associated with cephalometric measurements in mouth-breathing children
J Clin Sleep Med
Obstructive Sleep Apnea Syndrome (OSAS) in mouth breathing children
Braz J Otorhinolaryngol
Questionnaire validation: a brief guide for readers of the research literature
Clin J Pain
Clinical outcomes associated with sleep-disordered breathing in Caucasian and Hispanic children – the Tucson Children's Assessment of Sleep Apnea study (TuCASA)
Sleep
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