Psychometric properties of the Arabic version of the Alexithymia

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International Journal of Culture and Mental Health

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Psychometric properties of the Arabic version of the Alexithymia Questionnaire for Children (AQC) in children and adolescents Fares Zine El Abiddine & Gwenolé Loas To cite this article: Fares Zine El Abiddine & Gwenolé Loas (2018): Psychometric properties of the Arabic version of the Alexithymia Questionnaire for Children (AQC) in children and adolescents, International Journal of Culture and Mental Health, DOI: 10.1080/17542863.2018.1556716 To link to this article: https://doi.org/10.1080/17542863.2018.1556716

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INTERNATIONAL JOURNAL OF CULTURE AND MENTAL HEALTH https://doi.org/10.1080/17542863.2018.1556716

Psychometric properties of the Arabic version of the Alexithymia Questionnaire for Children (AQC) in children and adolescents Fares Zine El Abiddinea and Gwenolé Loasb a

Department of Psychology, Faculty of Social Sciences and Human Studies, University of Djillali Liabes Sidi Bel Abbes, Sidi Bel Abbes, Algeria; bDepartment of Psychiatry & Laboratory of Psychiatric Research (ULB 266), Cliniques universitaires de Bruxelles, Université Libre de Bruxelles (ULB), Bruxelles, Belgium ABSTRACT

ARTICLE HISTORY

This study had the aim to explore the psychometric properties of the Arabic version of the Alexithymia Questionnaire for Children (AQC) that measures the three dimensions of alexithymia (DIF, difficulty identifying feelings; DDF, difficulty describing feelings; EOT, externally oriented thinking). 817 healthy children or adolescents (407 girls, 410 boys) with a mean age of 12.10 years (SD = 1.91, range from 9 to 16 years) were included in the study. Confirmatory factor analyses (CFA) were done exploring seven-factor models and Cronbach’s alpha coefficients were calculated to rate reliability. The results showed that the one-factor model without EOT item and the two-factor model (DIF, DDF) provided acceptable fits and had significant advantages over the three-factor model (DIF, DDF, EOT). Based on the χ 2 differences, the two-factor model has been preferred. Low alpha coefficients for the EOT and DDF subscale were reported (.55 and .66, respectively). Satisfactory Cronbach’s alpha coefficients for the AQC or AQC without the EOT items were also found, the values were .83 and .79, respectively. Alexithymia can be reliably assessed in adolescents using the AQC without the 8 items rating the EOT dimension.

Received 21 March 2018 Accepted 2 December 2018 KEYWORDS

Alexithymia; adolescents; children; Alexithymia Questionnaire for Children (AQC); depression

Introduction Alexithymia is a multifaceted personality construct observed in various psychiatric disorders and described firstly in psychosomatic disorders. Alexithymia is characterized by four main features: difficulty identifying feelings (DIF) or difficulty describing feelings (DDF), externally oriented thinking (EOT) and diminished imaginal processes (Taylor, Bagby, & Parker, 1997). Since a decade, studies on alexithymia have explored the interest of the concept in child and adolescent populations. Prevalence of alexithymia have been found ranging from 7% (Joukamaa et al., 2007) to 21.1% (Säkkinen, Kaltiala-Heino, Ranta, Haataja, & Joukamaa, 2007) in various samples of children or adolescents. One of the main limitations of the study of alexithymia in children or adolescents is the use of instruments developed for adult populations without the control that the psychometric properties of the corresponding rating scales remained satisfactory in children or adolescents. Several rating scales have been developed for children or adolescents: the Alexithymia Scale for Children (Fukunishi, Yoshida, & Wogan, 1998), the Children’s alexithymia measure (Way et al., 2010), the Alexithymia Questionnaire for Children (AQC, Rieffe, Oosterveld, & Terwogt, 2006) and the Emotion Awareness Questionnaire (Rieffe et al., 2007). CONTACT Gwenolé Loas [email protected] Hôpital Erasme, 808 Route de Lennik, 1070 Bruxelles, Belgium © 2018 Informa UK Limited, trading as Taylor & Francis Group

Department of Psychiatry, Université Libre de Bruxelles (ULB),

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Among these rating scales one (AQC) was based of the most used questionnaire for adults, the 20item Toronto Alexithymia Questionnaire (TAS-20, Bagby, Parker, & Taylor, 1994). The AQC consisted of 20 items rating three dimensions: DIF (7 items), DDF (5 items) and EOT (8 items). Several authors (reviewed by Müller, Bühner, & Ellgring, 2003) exploring the factorial structure of the TAS20 in different samples has proposed that EOT could be split into two factors (pragmatic thinking or PR, lack of subjective significance of emotions or IM). Using the original version (in Dutch) of the AQC or the foreign versions (English, French, Farsi, Italian, Spanish), several studies have explored the factorial structure of the scale as well as its reliability using the Cronbach’s alpha coefficient (Cerutti et al., 2017; Delhaye, Orts, Bury & Loas, 2018; Loas et al., 2010; Loas, Braun, Delhaye, & Linkowski, 2017; Mishra, Maudgal, Theunissen, & Rieffe, 2012; Rieffe et al., 2010; Yearwood, Vliegen, Luyten, Chau, & Corveleyn, 2017). The results of these studies showed a low reliability of the EOT factor and the factorial analyses (exploratory or confirmatory) reported the superiority of a two-factor solution (DDF and DIF) comparatively to the three-factor solution (DDF, DIF and EOT). Among the seven previous studies, five (Delhaye et al., 2018; Loas et al., 2010, 2017; Rieffe et al., 2010; Yearwood et al., 2017) used confirmatory factor analysis (CFA) to compare the different factorial structures of the AQC and only one (Loas et al., 2017) has tested all the potential models of the item organization of the scale. Taking into account the work of Meganck, Markey, and Vanheule (2012), examining in an adolescent sample the five different models of the TAS-20 proposed by Müller et al. (2003) and the two possible models without EOT items (one-factor model and a two-factor model with DIF and DDF factors) seven potential models of the TAS-20 or AQC can be tested. The five different models proposed by Meganck et al. (2012) were: Model A: a one-factor model. Model B: a two-factor model with DIF–DDF forming one factor and EOT. Model C: the common three-factor solution with DIF, DDF and EOT. Model D: another three-factor solution with DIF–DDF forming one factor, PR (items 5, 8, 20) and importance of emotions (IM) (items 10, 15, 16, 18, 19). Model E: a four-factor solution with DIF, DDF, PR, and IM. The two other models without EOT items were: Model F: an one-factor model without EOT items. Model G: a two-factor solution with DIF and DDF. Only one study (Loas et al., 2017) has examined all these seven models and the aim of the present study was to replicate this previous work by examining the psychometric properties of the Arabic version of the AQC and notably to determine among the seven models what is the model having the best fit indices. CFA was used taking into account all the seven factorial structures of the scale.

Method Participants and procedure Eight hundred and seventeen children and adolescents (407 girls, 410 boys) with a mean age of 12.10 years (SD = 1.91, range from 9 to 16 years) were included in the study. Three hundred and fifty-eight subjects were in primary school and 459 in secondary school from Sidi Bel Abbes, a town of the northwestern of Algeria. The rationale for the sample size chosen is related to the minimum number of participants in CFA. For Everitt (1975), 10 participants for each parameter is recommended. Two hundred subjects were necessary and more subjects were recruited to allow analyses by gender and range of age. There were no exclusion criteria. The study has been approved by the Research Committee of the Faculty of Humanities and Social Sciences of the University of Djillali Liabes, Sidi Bel Abbes. Consent was obtained from the school principals, teachers and students whereas parents were not informed by schools about the study. The AQC was developed in 2006 by Rieffe using a careful adaptation of the items of the TAS-20. The original version of the AQC was in Dutch and an English version was also proposed. The AQC contains three subscales measuring: DIF (7 items: 1, 3, 6, 7, 9, 13, 14); DDF (5 items: 2, 4, 11, 12, 17); EOT (8 items: 5, 8, 10, 15, 16, 18, 19, 20). To simplify the response scale for children or adolescents,

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the AQC is rated using a three-point response Likert scale ranging from 0 (not true) to 2 (true). The total score ranges from 0 to 40. The AQC is appropriate for children having 9 years of age and older and has been translate into different languages (Farsi, French, Hindi, Italian, Spanish). The Arabic translation of the AQC was done using the following procedure. Firstly, the first author (Fares Zine El Abiddine) has obtained the agreement of Carolien Rieffe for the translation (23 November 2012). Secondly, using the English version of the AQC, the items were translated into Arabic by a team of English professors from university or secondary schools. Thirdly, back translation from Arabic to English was done by different professors, and problematic items were reviewed, discussed and modified by the team. Statistical analyses The assumption of univariate normality was not severely violated for the data of the present study. The skewness of the 20 variables ranged from 0.05 to 1.06 and the values of the kurtosis ranged from – 0.33 to −1.39. No outliers were detected as all the values of the variables were lower than the mean plus 2 times the standard deviation. The Sepath program of Statistica version 7.1 (StatSoft, 2004) was used for the CFA. Several fit indices were used to evaluate model fit: the ratio of the chi-square to its degrees of freedom (χ 2/df ratio), the goodness-of-fit index (GFI), the adjusted goodness-of-fit index (AGFI), the comparative fit index (CFI), the root mean square error of approximation (RMSEA) and the Akaike information criterion (AIC).The following values were required for adequate fits: χ 2/df ratio ≤ 5 and preferably ≤2; GFI ≥ .85; AGFI ≥ .80; CFI ≥ .90 (Bentler, 1990); RMSEA ≤ .08 (Bentler & Bonett, 1980). The model with the lowest AIC was retained (Tanaka, 1993). The different models were: Model A: a one-factor model. Model B: a two-factor model with DIF–DDF forming one factor and EOT. Model C: the common three-factor solution with DIF, DDF and EOT. Model D: another three-factor solution with DIF–DDF forming one factor, PR (items 5, 8, 20) and IM (items 10, 15, 16, 18, 19). Model E: a four-factor solution with DIF, DDF, PR, and IM. Model F: an one-factor model without EOT items. Model G: a two-factor solution with DIF and DDF. When the best factor model was found for the whole sample it was also tested by gender (410 boys, 407 girls) and by age (N = 233, 9–10 years; N = 226, 11–12 years; N = 263, 13–14 years; N = 95, 15–16 years). These additional analyses were done to allow comparison with the results of previous studies (Meganck et al., 2012; Parker, Eastabrook, Keefer, & Wood, 2010). Secondly, Cronbach’s alpha coefficients and mean inter-item correlations (MIIC) were computed for the full scale as well as for the subscales. A value ≥.70 for the Cronbach’s alpha coefficient and between .20 and .40 for the MIIC were requested (Briggs & Cheek, 1986). Reliabilities were explored not only for the whole group but also by gender and age.

Results Concerning the CFA, the fit indices for the seven models were presented in Table 1. The one-factor model (F) and the two-factor model (G) provided acceptable fit on all criteria. The one-factor (F) model was compared with the two-factor (G) model using the χ 2 differences tests. χ 2 difference between the one and two-factor model was 7.23 with Δdf = 1, p = 0.01.Thus, based on the χ 2 differences, the two-factor model (G) should be preferred. The factor loadings of the items on the two different subscales were higher than 0.30 for the DIF and DDF except the item # 4. The fit indices of the two-factor model (G) by gender and age were presented in Table 2. Regarding reliability, the values of the Cronbach’s alpha coefficients for the AQC, DIF, DDF, EOT subscales and AQC (without EOT items) were respectively, .83, .74, .55, .66 and .79. The corresponding MIIC were .20, .29, .20, .20 and .24. Low reliabilities were found for the DDF and EOT subscales and satisfactory reliabilities were reported for the AQC and the AQC without the EOT items. Moreover, AQC without EOT items has not higher value of the Cronbach’s alpha coefficient than the full scale.

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Table 1: Goodness-of-fit indices of the confirmatory factor analysis for different models. χ2

Indices model

χ 2/df

df

RSMEA

GFI

AGFI

CFI

AIC

A: One factor 635.64 170 3.74 .07 .91 .89 .83 .88 B: DIF–DDF, EOT 533.88 169 3.16 .05 .93 .92 .87 .75 C: DIF, DDF, EOT 495.31 167 2.97 .05 .94 .92 .88 .71 D: DIF–DDF, PR, IM 524.60 167 3.14 .05 .93 .92 .87 .75 E: DIF, DDF, PR, IM 485.87 164 2.96 .05 .94 .92 .88 .71 F: One factor without EOT 137.03 54 2.54 .04 .97 .96 .95 .23 G: DIF, DDF 129.80 53 2.45 .042 .97 .96 .95 .22 Note: AQC: Alexithymia Questionnaire for Children, DIF: difficulty identifying feelings subscale of the AQC; DDF: difficulty describing feelings of the AQC, EOT: externally oriented thinking of the AQC; PR: pragmatic thinking of the AQC, IM: lack of subjective significance or importance of emotions of the AQC. The ratio of the chi-square to its degrees of freedom (χ 2/df ratio), the goodness-of-fit index (GFI), the adjusted goodness-of-fit index (AGFI), the comparative fit index (CFI), the root mean square error of approximation (RMSEA) and the Akaike information criterion (AIC). The following values were required for adequate fits: In boldface: χ 2/df ratio ≤ 5 and preferably ≤2; GFI ≥ 0.85; AGFI ≥ 0.80; CFI ≥ 0.90; RMSEA ≤ 0.08.

Table 2: Goodness-of-fit indices of the Model G by gender and age. Indices samples 410 boys 407 girls 233 (9–10 years) 226 (11–12 years) 263 (13–14 years) 95 (15–16 years)

χ2

df

χ 2/df

RSMEA

GFI

AGFI

CFI

AIC

109.54 78.41 82.86 67.49 102.48 73.09

53 53 53 53 53 53

2.07 1.48 1.56 1.27 1.93 1.38

.05 .03 .05 .03 .06 .06

.96 .97 .95 .95 .94 .89

.94 .95 .92 .93 .91 .84

.93 .97 .92 .95 .94 .89

.39 .32 .57 .52 .58 1.31

Note: AQC: Alexithymia Questionnaire for Children, DIF: difficulty identifying feelings subscale of the AQC; DDF: difficulty describing feelings of the AQC, EOT: externally oriented thinking of the AQC; PR: pragmatic thinking of the AQC, IM: lack of subjective significance or importance of emotions of the AQC. The ratio of the chi-square to its degrees of freedom (χ 2/df ratio), the goodness-of-fit index (GFI), the adjusted goodness-of-fit index (AGFI), the comparative fit index (CFI), the root mean square error of approximation (RMSEA) and the Akaike information criterion (AIC). The following values were required for adequate fits: In boldface:χ 2/df ratio ≤ 5 and preferably ≤2; GFI ≥ 0.85; AGFI ≥ 0.80; CFI ≥ 0.90; RMSEA ≤ 0.08.

The Cronbach’s alpha coefficients and MIIC by gender and age were given in Table 3. Low reliabilities for the DDF and EOT subscales were found and satisfactory reliabilities for the AQC and the AQC without the EOT items were reported. However, the Cronbach’s alpha coefficients for the AQC without the EOT items were not higher than the values found for the full scale.

Discussion This study provides evidence of the validity and the reliability of the AQC without the EOT items, in an Arabic-speaking Moroccan population. Firstly, the validity of the AQC was examined and notably the results of the CFA. Secondly, the reliability and notably the values of the Cronbach’s alpha coefficient were discussed. Thirdly, the Table 3: Cronbach’s alpha and mean inter-item correlations (MIIC) by gender and age. Scales samples 410 boys 407 girls 233 (9–10 years) 226 (11–12 years) 263 (13–14 years) 95 (15–16 years)

DIF .74 (.30) .73 (.29) .7 (.19) .71 (.26) .79 (.36) .71 (.26)

DDF .54 (.19) .57 (.21) .54 (.19) .42 (.13) .65 (.28) .53 (.19)

EOT .68 (.21) .63 (.18) .67 (.21) .51 (.11) .72 (.24) .68 (.21)

AQC .83 (.20) .83 (.20) .83 (.20) .74 (.13) .87 (.26) .84 (.21)

AQC-EOT .79 (.24) .78 (.23) .76 (.21) .72 (.19) .84 (.31) .77 (.22)

Note: AQC: Alexithymia Questionnaire for Children, DIF: difficulty identifying feelings subscale of the AQC; DDF: difficulty describing feelings of the AQC, EOT: externally oriented thinking of the AQC. In boldface: alpha ≥ .70 and MIIC ranging from .20 to .40.

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limitations of the study were presented. Fourthly, the interest of the AQC was discussed as well as the interest of future research. Using CFA, the one-factor model without EOT items and the two-factor solution showed satisfactory model fit, whereas the three-factor solution showed poor model fit as well as the other models tested. Using chi-square difference the two-factor model was retained when the one and two-factor models were compared. To the best of our knowledge, five studies have explored, using CFA, the factorial structure of the AQC. Rieffe et al. (2006) using the original Dutch version of the AQC have tested the three-factor of the scale using two fit indices: the ratio of χ 2 and the RMSEA, the values must be lower than 5 (or 2) and .05. In their sample of 740 children, the ratio of χ 2 and the RMSEA were 2.44 and 0.0046, respectively. The factor loadings of the items on the different subscales were higher than .4 for the DIF and DDF but only 3 items of the EOT (#15, #16, #20) have satisfactory values. Loas et al. (2010) and Delhaye et al. (2018) using the French version of the AQC have used the same methodology than Rieffe et al. (2006) and reported that the three-factor structure of the AQC have good fit indices. For the Loas et al.’s (2010) study, the χ 2 ratio and RMSEA were respectively 1.27 and .039 and the factor loadings of the items were satisfactory for 3 items out of 7 for the DIF, 4 items out of 5 for the DDF and only 1 item (#19) for the EOT. For the Delhaye et al.’s (2018) study, the χ 2 ratio and RMSEA were 1.16 and .03, respectively and the factor loadings of the items were satisfactory for 6 items out 7 for the DIF, all the items of the DDF and 3 items (# 14, #15,# 20) of the EOT. In the Delhaye et al.’s (2018) study the two-factor structure of the AQC was also studied showing a good fit of the indices and a χ 2 difference test reported the superiority of the two-factor structure. The factor loadings of the items were satisfactory except the item # 7. In 2017, we have reanalysed our data (Delhaye et al., 2018; Loas et al., 2010) and tested the seven models as done in the present study. The results showed (Loas et al., 2017) that the one factor without EOT items was retained for the study of 80 healthy children (Loas et al., 2010) and the two-factor structure (DDF, DIF) for the study of 105 adolescents presenting various psychiatric disorders (Delhaye et al., 2018). The last study used the Spanish version of the AQC in a sample of 265 Peruvian adolescents aged 11–18 years (Yearwood et al., 2017). The authors tested the two (DDF, DIF) and three-factor (DDF, DIF, EOT) solutions using four indices of fit: RMSEA < .07; standardized root mean square residual (SRMR) < .08; CFI and Tucker–Lewis Index (TLI) > .9.The two-factor solution showed satisfactory fit indices whereas the three-factor solution had a poor model fit. In the two-factor solution 2 items (#4 and # 12) had factor loadings lower than .4. Unfortunately, the authors did not test the seven models as the present study or as done by Loas et al. (2017). Concerning the reliability, the EOT and DDF have low values (.2). Low values of the Cronbach’s alpha coefficients were found in the other studies for the EOT with values ranging from .18 to .47 (Delhaye et al., 2018; Loas et al., 2010; Rieffe et al., 2006). Using the Italian version of the AQC in 356 Italian school aged children (mean age 11.43, SD = 2.41), Cerutti et al. (2017) reported a value of .27. For the DDF, two studies reported satisfactory values (.75 for Rieffe et al., 2006 and Delhaye et al., 2018) whereas three studies reported low values (.67 for Loas et al., 2010; .55 for Yearwood et al., 2017; .62 for Cerutti et al., 2017). The Cronbach’s alpha of the AQC without the EOT items was satisfactory (.79) but the value was not higher than the value of the full scale (.83). Two studies reported higher value of the AQC without EOT items comparatively to the full scale. Loas et al. (2010) and Delhaye et al. (2018) reported values of .76 and .83 respectively whereas for the full scale the values were .64 and .71. Three other studies reported values of Cronbach’s alpha coefficient higher than .7 using Farsi, Spanish or Hindi versions of the AQC (without EOT items) (Mishra et al., 2012; Rieffe et al., 2010; Yearwood et al., 2017).

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Some limitations of the study must be noted. Alexithymia was rated using a self-report questionnaire and responses tendencies could be taken into account by the use of hetero-evaluation of alexithymia. The psychometric properties of the Arabic version of the AQC must be confirmed in other samples of children or adolescents. The present study demonstrated that the Arabic version of the AQC without the EOT items had statisfactory validity and reliability and that alexithymia can be reliability assessed in adolescents. The EOT factor demonstrated severe problems replicated in samples with children, adolescents or adults using the TAS-20 or the AQC. Modifications of the content of the scale should be considered. Moreover, one study (Gohm & Clore, 2000) has suggested that individual differences related to emotion can be structured into five categories including measures of absorption, attention, clarity, intensity and expression. Using a review of 18 rating scales including the TAS-20, the authors proposed that the DDF and DIF dimensions were related to the Clarity category whereas the EOT dimension was related to the Attention category. Using a sample of university students to test the coherence of the five categories by a hierarchical cluster analysis, Gohm and Clore (2000) have confirmed the proposed structure into five categories. Thus, in a theoretical point a view, the deletion of the EOT factor could be justified. The AQC or TAS-20 without EOT items have been found to be distinguishable from the related traits of self-esteem, hope, positive and negative affective states (Heaven, Ciarrochi, & Hurrell, 2010) as well as from depression (Loas et al., 2017). However, the TAS-20 or the AQC have been criticized as alexithymia involve more features than those measured by these rating scales. Fantasizing is considered as one of the main factors of the alexithymia concept and this dimension has been included in the original version of the TAS but not in the revised version (TAS-20) (Taylor et al., 1997). Other authors have included the lowered ability to be emotionally aroused as another feature of alexithymia (Vorst & Bermond, 2001). In children and adolescents, taking into account firstly the weakness of the EOT factor in the AQC and secondly that emotional awareness included more aspects than those reflected in the TAS-20 or the AQC, Rieffe et al. (2007) have developed a new questionnaire, the Emotion Awareness Questionnaire for Children, to broaden the alexithymia concept. This questionnaire evaluates six dimensions: differentiating emotions, verbal sharing of emotions, bodily awareness, acting about emotions, analyses of emotions and others’ emotions. Concerning the future directions of research, more longitudinal studies including alexithymia evaluation and also measure of emotion awareness, are needed to understand firstly how and why children or adolescents develop psychiatric disorders or social problems and secondly the specific effect of alexithymia comparatively to emotional awareness.

Conclusion The Arabic version of the AQC has satisfactory psychometric properties when the 8 items of the EOT subscale were omitted. The results of the present study suggest also to use the total score of the AQC without the EOT subscale and to avoid to take into account separately the DDF and DIF.

Disclosure statement No potential conflict of interest was reported by the authors.

References Bagby, R. M., Parker, J. D., & Taylor, G. J. (1994). The twenty-item Toronto Alexithymia Scale–I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research, 38, 23–32. Bentler, P. M. (1990). Comparative fit indexes in structural models. Psychological Bulletin, 107, 238–246. Bentler, P. M., & Bonett, D. G. (1980). Significance tests and goodness of fit in the analysis of covariance structures. Psychological Bulletin, 88, 588–606.

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