Translation and preliminary validation of the Italian version of the Family Impact of Assistive Technology Scale for Augmentative and Alternative communication (FIATS-AAC.it)

Abstract

BACKGROUND:

The Family Impact of Assistive Technology Scale for Augmentative and Alternative Communication (FIATS-AAC) is an emerging parent-reported outcome measure designed to detect the functional impact of augmentative and alternative communication (AAC) interventions on family systems.

OBJECTIVE:

The present contribution reports on the adaptation of the FIATS-AAC into the Italian language.

METHOD:

The original FIATS-AAC was first translated in Italian by following a standard linguistic validation protocol that employed a translation-back-translation technique. To assess its preliminary measurement properties empirically, the initial Italian FIATS-AAC was then administered by either phone or face-to-face encounters to 30 parents or primary caregivers of children with AAC needs who were aged four to 18 years. Parents completed the scale twice with a one-week interval. During the first administration, parents also completed the standardized Impact on Family Scale as a comparative measure to assess convergent validity.

RESULTS:

Overall, the interpretation of results from internal consistency, test-retest reliability, and convergent validity suggest that the Italian FIATS-AAC is a promising tool to assess child and family functioning in areas that may be impacted by the introduction of AAC interventions.

CONCLUSIONS:

Recommendations for further study include confirmation of its responsiveness to detect meaningful functional change following the introduction of AAC interventions and the utility of a shortened version.

Keywords

AAC communication outcome children

1. Introduction

Developing effective communication skills is crucial for social and cognitive development, everyday functioning and inclusion in society. Interventions to improve communication skills of children and adolescents with disabilities who have difficulty in speaking or whose speech is unintelligible include alternative and augmentative communication (AAC). AAC refers to all types of communication other than oral speech (e.g., pictures, symbols, writing, hand gestures; [1]). AAC systems may be ‘unaided’ (e.g., signing, gestures) or ‘aided’ [2]. Aided AAC systems may include low-tech assistive products (e.g., communication boards, books) and high-tech products (e.g., speech-generating devices, mobile technologies, eye trackers).

Overall, research evidence indicates that aided AAC interventions are in general effective in supporting and developing comprehension and expression skills across participants of various ages, disabilities, and language abilities (for recent systematic reviews on aided AAC interventions see [3, 4]). Less clear, however, is whether benefits from AAC interventions extend also to children’s families. As pointed out in a seminal paper by Angelo [5], understanding the impact of AAC interventions on families is important as parents are instrumental in shaping outcomes in AAC [5]. Specifically, family attitudes towards AAC play a key role in AAC acceptance, adoption and use. Research has shown that parents who actively partici-pate in AAC interventions may yield greater numbers of child initiations [6], child communicative turns, and use of different language concepts [7]. In contrast, if the family perceives that the intervention is not effective, this may contribute to AAC system underuse or abandonment [8, 9]. Compared to their peers, children and adolescents with complex communication needs are at increased risk of being marginalized [10], presenting behavioral, emotional or psychiatric disorders [11, 12], and in general reporting lower levels of quality of life [13, 14]. These factors are often associated to heightened familial burden [15], stress and frustration, which in turn may further exacerbate the family’s negative perceptions of AAC interventions and hence abandonment [16].

In light of the above, it emerges the need for professionals in the field of assistive technology (AT) to consider the monitoring of the interplay of AAC and family functioning as a fundamental consideration for the development and evaluation of AAC solutions. To date, the only reliable parent-reported outcome measure designed to detect functional change following an AAC intervention in children and youth is the Family Impact of Assistive Technology Scale for Augmentative and Alternative Communication (hereafter, FIATS-AAC; [17]). The FIATS-AAC was developed in English and is intended to measure the everyday functional outcomes of AAC interventions in children and youths ranging from three to 18 years of age and their families [17]. Its development is conceptually grounded in the domains of the International Classification of Functioning [18] related to both child and family functioning [19, 20, 21]. Investigations involving more than 250 parents of children with AAC needs provide empirical support for its reliability and validity in its original English form [19, 20, 21].

At present, a validated version of the FIATS-AAC for its use in the Italian context is not available. AT service delivery in Italy is generally organized at regional level and delivered via local health authorities usually in collaboration with specialized AT centres [22, 23]. The acronym GLIC refers to the Italian association of independent AT centres which specialize in the provision AT devices and services for people with disabilities. The GLIC network was founded in 1997 and now includes almost all the active independent centres for AT in Italy (30 at present). From the perspective of the GLIC network, a centre for AT is an organization that presents the following characteristics: (1) it has no commercial interest; (2) it provides information, eva-luation, assessment, support, training and research; (3) it draws on the services of a multi-disciplinary team of highly specialized professionals; (4) it possesses its own AT resources.

As GLIC centres constitute a point of reference for professional operators and for people with disabilities in Italy, a common strategy to evaluate outcomes of the proposed AT interventions is needed. As part of a wider project aimed at providing such centres with a core set of outcome measures to evaluate effects of their service delivery practices (for more information see [24]), we developed and studied the preliminary measurement properties of the Italian version of the FIATS-AAC. Specifically, the primary objectives of the present study were to determine and assess support for its internal consistency, test-retest reliability, and convergent validity.

2. Method

The FIATS-AAC is a parent-reported questionnaire designed to detect child and family functioning in domains that may be influenced by the introduction of AAC interventions for children aged between three to 18 years. It is composed of 89 items grouped according to 13 dimensions. The dimensions include seven child-related factors (behavior, face-to-face communication, contentment, doing activities, education, self-reliance, social versatility) and six parent- and family-related factors (caregiver relief, energy, family roles, finances, security, supervision). Responders complete the questionnaire by indicating the extent to which they agreed or disagreed with each of 89 statements using a seven-point Likert scale (1 $=$ strongly disagree; 7 $=$ strongly agree). Item ratings within each dimension are summed and divided by the number of valid item ratings to create a mean domain score with a range of 1 (lowest level) to 7 (highest level). Higher scores suggest higher (positive) functional levels within a specific domain. A composite total score is derived by summing the mean domain scores for all 13 dimensions. Total scores range from 13 to 91, where higher scores indicate higher levels of child and family functioning.

2.1 Translation and adaptation

The original FIATS-AAC scale was translated and adapted to the Italian context following the translation policy and guidelines contained in copyright license and already used to translate a companion version of the FIATS-AAC for other contexts [17, 25]. In brief, a translator (no AT expertise) whose native language was Italian produced an Italian forward translation from the English source version. Four authors who are AT/AAC professionals (RM, JC, LD, EV) reviewed this preliminary translation. After the reviewers reached full consensus on the adequacy of the initial Italian version, five parents of children with AAC needs reviewed the translation to assess its comprehensibility. Since parents considered all 89 items fully comprehensible, a native English speaker who was naive on the content area back translated the Italian version to produce an alternative English version. This back translation was reviewed and approved by the original author of the FIATS-AAC (SR).

2.2 Participants

The approved Italian version of the FIATS-AAC (hereafter, FIATS-AAC.it) was completed by 30 parents or primary caregivers of children with complex communication needs aged between 4 and 18 years ( $M_{\textit{age}}=$ 7.8; SD ${}_{\textit{age}}=$ 4.6). Participants were recruited from one specialized centre for assistive technology and one association of parents of children with disabilities located in central and north-central Italy. Eligible parents had a child with a chronic disability who used at least one assistive device for communication (Table 1). The study received ethical clearance from the corresponding author’s institutional review committee and was carried out in accordance with the principles of the Declaration of Helsinki.

Table 1
Demographic information of children with complex communication needs and their parent participants

Characteristics	Number	%
Sex of child
Male	16	53
Female	14	47
Primary diagnosis of child
Cerebral palsy	9	30
Genetic syndrome	9	30
Developmental delay	7	23
Autism	3	10
Intellectual disability	2	7
Survey respondent
Mother	21	70
Father	7	23
Both	2	6

2.3 Protocol

A principal investigator met with each participant twice over a one-week interval to administer the questionnaires by either phone ( $n=$ 22) or face-to-face interviews ( $n=$ 8). For the first administration, parents completed the FIATS-AAC.it, a child and family demographic measure, and the Italian version of the Impact on Family Scale (IFS) [26, 27]. The IFS is a standardized, parent-reported measure designed to assess the psychological and social consequences of having a child with a disability [26]. Respondents rate their degree of agreement with each of 24 statements using a 4-point Likert scale (strongly agree to strongly disagree). Lower IFS scores indicated lesser parent-perceived psychosocial consequences of having a child with a disability. Other investigators provide empirical support for the reliability and validity of the Italian IFS [27, 28]. For the second administration, parents completed only the FIATS-AAC.it following the same administration procedure (i.e. phone or face-to-face) as in the first administration.

2.4 Data analyses

We calculated Cronbach’s alpha using ratings from the first administration to evaluate the internal consistencies of the FIATS-AAC.it total scale and subscales. Internal consistency was deemed adequate if the alpha coefficient was between 0.7 and 0.9 [29].

Intra-class coefficients (ICC; mixed effects model for absolute agreement) and 95% confidence intervals for the total scale and 13 subscales provided estimates of test-retest reliability. ICC results were interpreted according to the guidelines proposed by measurement experts [30], with ICC values of $>$ 0.75, 0.4–0.75, and $<$ 0.4 interpreted as ‘excellent,’ ‘fair-to-good,’ and ‘poor’, respectively.

To assess the convergent construct validity, a Pearson correlation coefficient was calculated to determine the strength of association between FIATS-AAC.it and IFS. In other words, the higher the levels of child and family functioning scores (i.e., FIATS-AAC.it) would generally be associated with the lower the family burden scores (i.e., IFS). We hypothesized a medium, negative correlation between the FIATS-AAC.it scores and IFS based on their measurement of common constructs and as reported in the original FIATS-AAC development study [19]. Power analysis conducted using G*Power [31] confirmed that a sample size of 30 participants was large enough to detect a correlation as large as 0.50 for a power of 80%.

3. Results

3.1 Internal consistency and test-retest reliability

Internal consistency for the total FIATS-AAC.it scale resulted in a level slightly higher than the upper threshold for internal consistency ( $\alpha=$ 0.92). Analyses of the 13 dimensions yielded nine subscales with alphas between 0.7 and 0.87 and four subscales (contentment; energy; family roles; security) below the targeted lower threshold of 0.7 (Table 2).

Table 2
Internal consistencies (Cronbach’s alpha) of the subscales of the FIATS-AAC.it ( $n=$ 30)

Subscale	Cronbach’s $\alpha$
Behavior	0.78
Caregiver relief	0.82
Contentment	0.19
Doing activities	0.77
Education	0.87
Energy	0.55
Face-to-face communication	0.83
Family Roles	0.57
Finances	0.84
Security	0.39
Self-reliance	0.70
Social versatility	0.81
Supervision	0.80

Point estimates for ICC indicate excellent test-retest reliability for the total FIATS-AAC.it (ICC $=$ 0.98; 95% CI $=$ 0.96–0.99). Point estimates for ICC were excellent for 12 subscales and fair-to-good for one subscale (Contentment) (Table 3). Further, lower 95% confidence limits for each subscale was at least fair-to-good (ICC $>$ 0.4), and 9 of these subscales had lower limit statistics that were excellent (ICC $>$ 0.75).

Table 3

Test-retest reliability of the FIATS-AAC.it dimensions ( $n=$ 30).

	Time 1		Time 2		Test-retest
	$M$	SD	$M$	SD	ICC ${}^{*}$	95% CI
Behavior	5.24	1.09	5.29	1.18	0.90	0.80–0.95
Caregiver relief	4.15	1.28	4.17	1.43	0.93	0.86–0.96
Contentment	4.42	0.67	4.42	0.66	0.68	0.43–0.83
Doing activities	5.09	1.26	5.22	1.21	0.93	0.86–0.96
Education	5.14	1.33	5.10	1.27	0.96	0.91–0.98
Energy	3.83	0.96	3.75	0.89	0.92	0.85–0.96
Face-to-face communication	4.03	1.11	4.17	1.06	0.88	0.77–0.94
Family roles	4.18	1.07	4.09	1.08	0.87	0.75–0.93
Finances	4.83	1.39	4.97	1.27	0.92	0.85–0.96
Security	3.95	0.47	3.93	0.58	0.75	0.54–0.87
Self-reliance	4.46	1.01	4.56	0.94	0.83	0.67–0.91
Social versatility	4.26	1.36	4.36	1.27	0.95	0.90–0.97
Supervision	3.15	1.29	3.10	1.05	0.84	0.70–0.92

3.2 Convergent validity

As hypothesized, correlational analyses revealed a medium, negative correlation between FIATS-AAC.it and IFS ( $r=$ $-$ 0.73; $p<$ 0.01). Significant medium-level associations were found between IFS total scores and 10 out of 13 FIATS-AAC.it subscales at a significance level of $p<$ 0.01 (Table 4). No significant correlations were estimated for two child-related dimensions (face-to-face communication, contentment) and one parent-related dimension (security).

Table 4
FIATS-AAC.it correlations with the impact on family scale ( $n=$ 30)

Domain	Total IFS
Behavior	$-$ 0.44 ${}^{**}$
Caregiver relief	$-$ 0.62 ${}^{**}$
Contentment	$-$ 0.35
Doing activities	$-$ 0.46 ${}^{**}$
Education	$-$ 0.52 ${}^{**}$
Energy	$-$ 0.44 ${}^{**}$
Face-to-face communication	$-$ 0.30
Family roles	$-$ 0.48 ${}^{**}$
Finances	$-$ 0.62 ${}^{**}$
Security	$-$ 0.12
Self-reliance	$-$ 0.54 ${}^{**}$
Social versatility	$-$ 0.65 ${}^{**}$
Supervision	$-$ 0.65 ${}^{**}$

${}^{**}p<$ 0.01.

With respect to other findings, many parents suggested anecdotally that a shorter version of the FIATS-AAC.it would be welcomed to reduce response burden.

4. Discussion

This study reported on a preliminary investigation of the measurement properties of the FIATS-AAC.it to assess child and family functioning in the Italian context. Results suggest that the scale may be a promising tool to assess functioning in areas that may be impacted by the introduction of AAC interventions. However, this is the first study to explore the measurement properties of the new FIATS-AAC.it, our results should be interpreted with caution. Application of the FIATS-AAC.it tool in research and everyday clinical practice should include additional empirical support for its validity and reliability and practical guidelines for its administration. Accordingly, we discuss the results and recommend future studies for each study objective.

Firstly, the internal consistency of the total FIATS-AAC.it generally aligns with that reported for the original English version. In early study of the original scale [19], internal consistency for the total scale resulted $\alpha=$ 0.91, thus very close to our findings for the Italian version. Similarly, alphas for 9 subscales exceeded the traditional threshold of alpha $=$ 0.7. Interestingly, the alpha for one subscale (contentment) was below this lower threshold in both the original and the present study with the latter being very low ( $\alpha=$ 0.19). The alpha statistics for three other subscales (energy, family roles, security) were also somewhat below the recommended threshold. We recommend that these four subscales be retained to re-estimate their internal consistencies and evaluate their importance for assessing family functioning in the Italian context. Further studies involving larger, diverse samples may provide insights as to whether these results were random, related to the heterogeneity of the current participants, or actually reflected that the items within these subscales tap into different constructs.

Secondly, the present study provides compelling support for the stability of the FIATS-AAC.it. ICC point estimates for the total scale and 12 of the 13 subscales exceeded the level for excellent test-retest reliability. One subscale (contentment) had acceptable, but the lowest ICC statistic compared to the others. The low internal consistency for the same subscale noted above may have been a contributing factor to the lower stability statistic. Replication of our study to re-estimate test-retest reliabilities using a variety of administration methods is recommended to confirm these findings and maximize flexibility of use of the FIATS-AAC.it for research and service applications.

Thirdly, ours is the second study to assess convergent validity of the FIATS-AAC/AAC.it using the IFS as a comparative measure. Our findings support our hypothesis that the FIATS-AAC.it seems to measure a construct related to the psychosocial impact of having a child with a communication-related disability. Our findings are consistent with the results from convergent validity analysis of the original FIATS-AAC where investigators also reported a medium, negative correlation between the two measures [19]. Yet, the magnitude of the correlation in the present study explains only 53% of the variance.

In a recent investigation of the convergent validity of the original FIATS-AAC [20], a significant medium-level correlation was reported with a standardized measure of child-related quality-of life, but no significant association with a second standardized measure of child participation in the community. These findings provide guidance to identify possible sources of unexplained variance in the present study. It would be useful to investigate if such patterns of association (or lack thereof) would emerge also in the FIATS-AAC.it to provide additional empirical support for validity of the FIATS-AAC.it.

Higher significant correlations were found between the IFS and several parent-related dimensions (supervision, caregiver relief, finances) and child-related dimensions (social versatility, self-reliance). This was expected in consideration of the family-related construct of the IFS and is generally consistent with the results of the original FIATS-AAC study [19].

The FIATS-AAC was developed as a tool to evaluate the effectiveness of AAC interventions; that is, to detect change in the lives of children/youth and their families as a consequence of AAC use. In this view, future administration of the FIATS-AAC.it should include an assessment of scale responsiveness as a key measurement property: the degree to which an instrument is able to detect important functional change.

Encouraging results from a recent responsiveness study found that the English FIATS-AAC could detect statistically significant gains in overall scores six and 12 weeks after children received a new graphic-based speech-generating device [21]. This evidence provides important support for the FIATS-AAC as a reliable, parent-reported questionnaire that is sensitive to short-term functional change after children and youth with complex communication needs [21]. Future investigations in the Italian context should aim to replicate these results for different AAC interventions (both low-tech and high-tech). Doing so would further support its application and utility in different AAC service settings.

In light of comments from parents regarding the lengthy completion time for the FIATS-AAC.it (i.e., about 20 minutes), future studies should include an examination of the comparative utility of a new 38-item (shorter) version of the FIATS-AAC (FIATS-AAC38; [17]).

5. Conclusions

Measuring AT outcomes is a crucial aspect of any AT intervention and may fulfil a number of purposes at individual, service and system levels [24]. At the individual level, it allows AT and rehabilitation professionals to constantly monitor the effectiveness of their interventions and make corrective actions when nece-ssary. At service level, it facilitates assessment and monitoring of the overall functioning of a specific service delivery process over time. At a system level, outcome assessment allows the identification of the differences in service delivery practices and processes, programs and policies, as well as the consequences associated with these differences.

Despite its importance for AT practice and research, however, evaluating the outcomes of AT is still perceived as a challenging task by AT and rehabilitation professionals worldwide, mainly because the AT field is chronically lacking evidence-based procedures to evaluate outcomes of AT service delivery reliably [32]. Future investigations are warranted to understand whether AT outcome measures may be implemented in research and service delivery daily practices to promote more evidence-based AT services. In the light of this laudable goal, the present study provides emerging support for the FIATS-AAC.it for AAC research and service applications in the Italian context.

Footnotes

Conflict of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

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Translation and preliminary validation of the Italian version of the Family Impact of Assistive Technology Scale for Augmentative and Alternative communication (FIATS-AAC.it)

Abstract

BACKGROUND:

OBJECTIVE:

METHOD:

RESULTS:

CONCLUSIONS:

Keywords

1. Introduction

2. Method

2.1 Translation and adaptation

2.2 Participants

Table 1 Demographic information of children with complex communication needs and their parent participants

2.4 Data analyses

3. Results

3.1 Internal consistency and test-retest reliability

Table 2 Internal consistencies (Cronbach’s alpha) of the subscales of the FIATS-AAC.it ( n = 30)

Table 4 FIATS-AAC.it correlations with the impact on family scale ( n = 30)

5. Conclusions

Footnotes

Conflict of interest

References

Table 1
Demographic information of children with complex communication needs and their parent participants

Table 2
Internal consistencies (Cronbach’s alpha) of the subscales of the FIATS-AAC.it ( $n=$ 30)

Table 4
FIATS-AAC.it correlations with the impact on family scale ( $n=$ 30)