Psychometric properties of Malay obsessive-compulsive inventory-child version (OCI-CV) in Malaysian perspectives

Obsessive-Compulsive Disorder (OCD) is a mental disorder that consists of obsessive thoughts and compulsive behaviours. It is associated with impairments in social and occupational functioning and quality of life (1, 2). In addition, OCD is commonly comorbid with other psychiatric disorders which may hinder effective management (3, 4).

The prevalence rate of OCD is reported between 1% to 3% of children and adolescents internationally (5). In Malaysia, 1% to 2% of the population is affected by OCD, across ethnicity and males and females, including children and young adolescents (6). Although paediatric OCD is prevalent and causes impairment in daily functioning and social relationships, it is frequently misdiagnosed and undertreated, particularly in Malaysia (6). Because of the heterogeneous nature of paediatric OCD, a variety of potential comorbid conditions, and potentially limited, the development of valid paediatric OCD diagnostic criteria is challenging (7, 8). The availability of well-established instruments for assessing paediatric OCD symptoms is critical for developing and disseminating effective interventions and early detection and treatment initiatives.

A considerable amount of literature has been published on instruments or questionnaires used to assess OCD. The Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) a semi-structured interview has been widely used to measure OCD symptoms and assess the symptoms severity (9, 10). Despite the fact that this clinician rated interviews will accurately diagnosed individuals with OCD, this diagnostic instrument is only available to qualified clinician and requires a lengthy interview (11, 12). Due to the time costs of administering clinician-rated measures in research and clinical practice, several OCD self-report measures have been developed, such as the Children's Florida Obsessive-Compulsive Inventory (C-FOCI) (13), the Leyton Obsessional Inventory Child-Version, (LOI-CV; (14) and the Obsessive-Compulsive Inventory – Child Version (OCI-CV)(15). C-FOCI and LOI-CV self-report provides a fast assessment of both the presence and severity of OCD symptoms, it does not evaluate the severity of individual symptoms (16) and insensitivity to treatment changes (17, 18). Compared to other self-reports, OCI-CV is a well-established self-report measure that assesses the frequency and distress related to OCD based on dimensionality (19). This questionnaire is a shorter version of a self-instrument (21-items) developed for children and adolescents from the adult version of the OCI (42-items) inventory and is sensitive to treatment changes (18).

Both OCI-CV and OCI-R (Obsessive Compulsive Inventory-Revised) has been widely used to assess children and adults with OCD and has excellent psychometric qualities (15, 20). OCI-CV has 21 items and six domains: Doubting/Checking, Obsessing, Washing, Hoarding, Ordering, and Neutralizing. It is suitable for children aged 7 to 17, with strong internal consistency with Cronbach's .81 for the total and subscales (15). The overall test-retest reliability coefficient was .77, with subscales ranging from .68 to .85. This result of good psychometric of OCI-CV was supported by other findings using clinical samples of children and adolescents (19, 21) and non-clinical samples of children and adolescents (19, 22, 23, 24). A recent OCI-CV revised study was conducted where researchers omitted hoarding items and conducted a survey using 18 items. They found that OCI-CV revised showed a five factor model and good convergent and discriminant validity (9).

Due to the high usability of OCI-CV in screening for OCD, as well as sensitivity to treatment changes, this tool has been widely translated and validated. For example, the OCI-CV has been tested on clinical and non-clinical samples in Spain (23), Italy (22), Chile (19), Sweden (21), Nigeria (25) and Iran (19). All of these studies findings showed comparable results and confirmed the instrument's compatibility with non-Western cultures, as well as demonstrating it to be a valid and reliable technique to assess paediatric OCD.

The OCI-CV has not been validated for use in Malaysia. Therefore, the purpose of this study was to determine the psychometric properties of the Malay OCI-CV in healthy adolescents. Since Malaysia is a multicultural country (26), it is critical to use OCI-CV that has been modified and adapted to various populations to avoid assumptions based on race, ethnicity, and culture (27) and aid in the distribution of evidence-based assessment methods (23).

The main objective of this study was to examine the psychometric properties of the OCI-CV by applying it to a community sample of Malaysian children and adolescents from age 10 to 18 years old. The study found that Malay OCI-CV has multidimensional components, good internal consistency, and high reliability. These results are consistent with those of other studies that report that OCI-CV is a valid instrument for assessing OCD symptoms among children and adolescent populations (17, 18). Despite Malay OCI-CV demonstrating an appropriate level of internal consistency, factor structure and allocation of items for the domain are distinct from the English and other language versions. Based on the exploratory factor analysis finding with 21 items, we found that OCI-CV has five dimensions factors, namely, Ordering and Washing, Doubting, Obsessing, Checking, and Hoarding with neutralizing factor omitted. Contrary to expectations this finding did not derive a similar result with the original finding where they find a six-factor model presented by Foa et al. (2010). Surprisingly, we also found that items for each domain are not in a similar position with the original finding (15). Items 7, 3, and 16 indicating that Hoarding symptoms were retained in our sample. Items in the Neutralizing factor (items 6, 9, and 12) were grouped into checking as well as doubting domain, lowering the dimensions in the Malay version of the OCI-CV from six to five. These findings may be explained in part by respondents' perceptions of neutralising strategies (counting and repetition) as a behavioural response to verifying (checking) or doubting. The items from the original washing domain were grouped in the Ordering factor, therefore we have renamed it the Ordering/Washing domain. This result, may be related to the cultural implications of disclosing OCD symptoms (39) in the Malaysian population. Perhaps, from a Malaysian perspective, their insight into the questions assigned in the OCI-CV differs from the Western context and understanding of the questions (40, 41). Items in the Ordering domain were combined with compulsive cleaning behaviour, indicating symptoms of an individual who engaged in repetitive arranging and rearranging items until conditions of "feels right" were obtained. Another possible explanation for this due to Islamic and society influence, which values “purity” and specific orders for cleaning in general day to day life and to ensure prayers would be accepted by God and eliminated from sickness (39, 42). In a study by Cougle et al. (2012), which examined relationship between guilt and compulsive washing they found that, guilt increased if an individual did not follow certain washing or ordering criteria (43).

Factor 3 was similarly loaded with Obsessions items as in the original study, except for Item 1, which was grouped with the Doubting factor. This factor indicated that an individual has recurring or repeated intrusive thoughts, impulsive behaviours, or visuals that elicit distressing emotions, such as revulsion. While the hoarding items in factor 5 were the same as those created in the original study, data analysis revealed that factor 4 items included checking symptoms, which define a person who engages in repetitive checking-based obsessive behaviour out of dread that something awful may happen (items 6, 12, and 15). Furthermore, to gain perfect control, the hoarder must not trash anything that might be needed in the future, which necessitates checking rituals and mental compulsions before discarding any objects (44, 45).

Although these results differ from some published studies (46, 47) they are consistent with those in terms of psychometric results. The results show excellent and supportive reliability with high internal consistency (>.90) for the overall score of the OCI-CV in the youth community sample in Malaysia. These results were consistent with previous studies that reported estimates internal consistency that were greater than > 0.80 for the total score and > 0.75 for all of the six dimensions (15, 19, 21, 23, 25). Consequently, this indicates that the applications of the OCI-CV across culture and society provide good psychometric properties even if the factors in the Malaysian context are different from the original version.

Overall, the Malay version of OCI-CV has been proven to be an excellent instrument for assessing obsessive-compulsive symptoms in children and adolescents in Malaysia. The result of this study had shown good psychometric properties of the OCI-CV, similarly to the original study by Foa et al. (2010) when we administered it to the Malaysian community.

A major limitation of this study is its small sample size, which results in low statistical power to enable generalisation to the community population. In addition, the present study sample consists of a nonclinical sample from a single Malay ethnic community that practises Islam. Thus, future studies should examine the psychometric features of OCI-CV in the context of Malaysia's multi-ethnic (Malay, Chinese, Indian, etc.) and multi-religious (Islam, Buddhism, Hinduism, Christianity, etc.) contexts. The recruitment of samples was conducted during the COVID-19 pandemic which hindered the researcher’s ability to recruit a larger sample for running a good confirmatory analysis. Additionally, the samples were primarily drawn from a single school in Selangor, and the respondents were mostly secondary students. Another limitation is that the education levels of parents or their socioeconomic information are misreported by their children (48). This could be due to children's cognitive and social skills are still developing, may need parent confirmation especially for lower cognitive ability(49). Subsequent expected issues are response quality and cause differential measurement inaccuracy (50, 51). The present study also was unable to provide information about psychometric properties of OCI-CV among the clinical population. Validating this instrument among the clinical samples should be undertaken in future research to ensure the instrument is reliable for use in the Malaysian context.

The current study validating the Malaysian version of the OCI-CV revealed several promising findings, including the availability of assessments of OCD symptoms and severity based on the five supplied multidimensional criteria and appropriate reliability and validity to account for demographic differences as well as screen potential OCD symptoms among healthy adolescents. Additionally, the current data are compatible with the original version and past research on the structural models of OCD and its symptoms. Our study contributes to the growing body of knowledge and increased cross-cultural acceptance of OCI-CV as a self-report measure for identifying OCD symptoms in Malaysian society, particularly among children and adolescents.