due is 24 hours

O R I G I N A L A R T I C L E

Factor Structure, Reliability, and Validity of the Spanish Version of the Children’s Florida Obsessive Compulsive Inventory (C- FOCI)

José A. Piqueras1 • Tı́scar Rodrı́guez-Jiménez1 • Ana G. Ortiz2 • Elena Moreno2 •

Luisa Lázaro3 • Eric A. Storch4,5,6

Published online: 9 June 2016

� Springer Science+Business Media New York 2016

Abstract The Children’s Florida Obsessive Compulsive

Inventory (C-FOCI) is a promising self-report measure of

the presence and severity of obsessive–compulsive symp-

toms in children and adolescents. Although initial research

showed it to have adequate psychometric properties, only

one study has been published to date, which dealt exclu-

sively with children. The aim of this report was to examine

the psychometric properties of the C-FOCI across clinical

and community samples of children and adolescents. The

sample consisted of 94 Spanish-speaking patients with

obsessive–compulsive disorder (OCD) and 1068 healthy

community controls, aged 8–19 years. Factor analysis

supported two single and independent factors (severity and

symptoms), as well as metric invariance across groups for

the symptom checklist and the Severity Scale. Results also

indicated good reliability in terms of internal consistency

and temporal stability, significant and high correlations

with other OCD measures, and acceptable sensitivity and

specificity for detect OCD. In summary, the C-FOCI is a

promising, brief measure of 22 items for screening OCD

symptoms and severity in children and adolescents.

Keywords Obsessive–compulsive disorder � Children � Adolescents � Assessment � Validity � Reliability

Introduction

Obsessive–compulsive disorder (OCD) is characterized by

the presence of obsessions and/or compulsions that produce

distress and disability [1]. At least 50 % of obsessive–

compulsive symptoms begin during childhood [2]; as many

as 2 % of youth meet diagnostic criteria for OCD [3], with

up to 19 % presenting subclinical symptoms [4–6].

Given the incidence of the disorder and its associated

deleterious consequences [7], instruments have been

developed to assess obsessive–compulsive symptomatol-

ogy in children and adolescents [8]. International mental

health organizations such as the National Institute for

Health and Clinical Excellence (NICE) [9] and the Amer-

ican Academy of Child and Adolescent Psychiatry [3]

recommend routine screening of young people at risk,

either in general practice or in other settings where they

may present for help. This screening requires short, easy-

to-use, sensitive, inexpensive, and widely available mea-

sures. Clinical trials, especially those documenting real-

world efficacy, also require brief, focused measures that

can detect changes in core symptomatology.

The existence of well-validated instruments to assess

childhood obsessive–compulsive symptoms is critically

important for the development and dissemination of

effective interventions, as well as for initiatives aimed at

early detection and treatment. The evidence-based assess-

ment (EBA) classification [10] defines the evidence base of

& José A. Piqueras [email protected]

1 Department of Health Psychology, University Miguel

Hernández of Elche, Avda. de la Universidad, s/n,

03202 Elche, Alicante, Spain

2 Department of Child and Adolescent Psychiatry and

Psychology, Hospital Clı́nic Barcelona, Barcelona, Spain

3 Department of Child and Adolescent Psychiatry and

Psychology, Hospital Clı́nic Barcelona, IDIBAPS.

CIBERSAM, University of Barcelona, Barcelona, Spain

4 University of South Florida, Tampa, FL, USA

5 Rogers Behavioral Health – Tampa Bay, Tampa, FL, USA

6 All Children’s Hospital – Johns Hopkins Medicine,

St. Petersburg, FL, USA

123

Child Psychiatry Hum Dev (2017) 48:166–179

DOI 10.1007/s10578-016-0661-4

a measure according to three levels of empirical support:

(1) well-established assessment (i.e., reliability and validity

have been demonstrated in at least two published studies by

two research teams); (2) approaching well-established

assessment (i.e., reliability and validity have been

demonstrated in at least two published studies by one

research team; or two research teams published studies

offering mixed psychometric results); and (3) promising

assessment (i.e., reliability and validity have been

demonstrated in at least one published study).

Currently, the clinician-administered Children’s Yale-

Brown Obsessive–Compulsive Scale (CY-BOCS; [11]) is

the gold standard for the assessment of OCD symptom

presence and severity given its excellent psychometric

properties and treatment sensitivity [12]. However, the

clinician-administered format is lengthy, requires extensive

training, and is not well suited to community settings. The

self-report format [13, 14] is also too long for screening

purposes outside clinical settings, and certain questions

(e.g., resistance) may be difficult for youth to understand.

There are six child-report instruments designed to assess

pediatric OCD symptoms and severity that have received

empirical support. Among these, the Obsessive Compul-

sive Inventory-Child Version (OCI-CV) [15] is a well-

established assessment tool that assesses the frequency of,

and distress associated with, obsessive–compulsive symp-

toms. The other five instruments can be regarded as

approaching well-established or promising assessment

tools: examples are the Children’s Obsessional Compulsive

Inventory (CHOCI) [16], the Short OCD Screener (SOCS)

[9, 17], and the Leyton Obsessional Inventory Child-Ver-

sion (LOI-CV) [18], although the psychometric properties

of the LOI-CV are poor [12]. All of these tools, however,

have limitations for screening purposes, whether due to

their length, their ease of use, or availability (for further

details, see [12]).

The Children’s Florida Obsessive–Compulsive Inven-

tory (C-FOCI) [19] was developed in an attempt to remedy

this situation. The C-FOCI is a brief self-report question-

naire that assesses the presence of obsessive–compulsive

symptoms and their associated severity in a manner that

parallels the CY-BOCS. What distinguishes the C-FOCI,

however, is that it is easy to comprehend, provides a uni-

tary severity scale, and removes the ‘‘resistance against

symptoms’’ item which many patients have difficulty

understanding. It was developed for its use as a screening

instrument for community and general clinical populations.

A primary difference from other pediatric OCD self-report

measures is that the C-FOCI items are divided into two

parts: the symptom checklist and the Severity Scale (see

[19] for a further description of the C-FOCI development).

The symptom checklist enquires about the presence of 17

obsessions and compulsions that have been endorsed with

relative frequency among youth with OCD. The Severity

Scale is a unitary scale of five items that collectively assess

the severity of all obsessive–compulsive symptoms without

artificially dividing them into obsessions and compulsions.

The psychometric properties of the C-FOCI have been

validated in one publication involving two samples (clini-

cal and community groups) [19]. Results for the clinical

sample (n = 82 OCD participants aged 7–20 years)

showed that internal consistency was adequate for both the

Severity Scale (a = .79) and the symptom checklist (KR- 20 = .76). The most frequent symptoms, endorsed by over

50 % of the clinical sample, were: contamination concerns;

ritualized handwashing, cleaning, or grooming; symmetry

and ordering compulsions; and reassurance seeking and

confessing. Convergent validity was demonstrated through

significant relationships with the CY-BOCS (r = .50) and

Child Obsessive–Compulsive Impact Scale-Child and

Parent Versions (COIS-C/P; r = .42–.49) [20]. In addition,

C-FOCI symptom dimensions were significantly related to

the corresponding CY-BOCS symptom domains (r = .25–

.33). The C-FOCI Severity Scale and symptom checklist

correlated significantly and moderately with several mea-

sures of depressive and anxiety symptoms (Multidimen-

sional Anxiety Scale for Children, MASC [21]; Children’s

Depression Inventory, CDI [22]; and the Internalizing

score of the Child Behavior Checklist, CBCL [23];

r = .40–.48, and r = .35–.61, respectively), although not

with the Externalizing score of the Child Behavior

Checklist (r = .11 and r = .13, respectively). Finally, the

C-FOCI was sensitive to changes after cognitive-behav-

ioral treatment [19].

Despite the strengths of the C-FOCI, several psycho-

metric issues have yet to be addressed, including the

investigation of its factor structure and its invariance, test–

retest reliability estimations, the lack of other evidence of

convergent–divergent validity, and specificity and sensi-

tivity data. The importance of sensitivity and specificity

data analysis for screening purposes is worth mentioning

here; specificity and sensitivity are key indices of a mea-

sure’s value for screening children who may require a more

comprehensive assessment for OCD.

Consequently, the main objective of the present study

was to extend the validation of the C-FOCI with the par-

ticipation of a second research group who carried out an

empirical examination of the tool’s utility for assessing

obsessive–compulsive symptoms across a wide age range

in clinical and community samples of children and ado-

lescents, as well as to provide for a psychometrically sound

measure of obsessive–compulsive symptoms for use in

Spanish youth. There were seven research questions: (1)

What symptoms are frequently endorsed by clinical and

community samples?; (2) Which factor structure best

reflects the construct(s) measured by the scale, and do

Child Psychiatry Hum Dev (2017) 48:166–179 167

123

respondents across clinical and community groups attribute

the same meaning to the latent constructs under study

(metric invariance); (3) What is the internal consistency

and temporal stability of the C-FOCI?; (4) Is the C-FOCI

useful for discriminating between clinical and community

groups?; (5) Does the C-FOCI Severity Scale correlate with

measures of obsessive–compulsive symptoms and severity,

and of anxiety and depressive symptomatology?; (6) Is the

C-FOCI a diagnostically accurate measure, in terms of

sensitivity and specificity, for detecting pediatric OCD?;

and (7) Is the C-FOCI a good measure for predicting the

presence of pediatric OCD? We hypothesized that C-FOCI

scores would show: (1) different OCD manifestations

according to clinical and community samples; (2) the

metric invariance of a bi-factor structure across samples;

(3) high reliability in terms of internal consistency and

temporal stability; (4) known-group validity; (5) concur-

rent validity, with a higher correlation of C-FOCI scores

with OCD symptoms than with anxiety and depressive

measures; (6) acceptable accuracy for screening purposes;

and (7) acceptable predictive validity to identify the pres-

ence of childhood OCD.

Methods

Participants

The clinical sample consisted of 94 (female = 48) child

and adolescent patients who had a current primary diag-

nosis of OCD according to DSM-IV-TR criteria [24]. Their

mean age was 14.62 years (SD = 2.65; range = 8–19 -

years). All clinical participants were recruited from the

Child and Adolescent Psychiatry and Psychology Unit of

the Hospital Clinic in Barcelona and the Child and Ado-

lescent Clinical Psychology Unit of the University Miguel

Hernández of Elche. Axis I diagnoses were made by

trained professionals (a psychologist and psychiatrist)

using the validated Spanish version [25] of the Schedule

for Affective Disorders and Schizophrenia for School-Age

Children-Present and Lifetime Version (K-SADS-PL) [26],

with both parents and the child as informants. Exclusion

criteria included presence of a psychotic disorder, autism

spectrum disorder, or intelligence quotient (IQ) \70. Although all participants had a primary diagnosis of OCD,

the presence of other non-primary comorbid Axis I disor-

ders was permissible given the high rates of comorbidity

seen in childhood OCD [27]. Forty-five children (47.9 %)

did not present any comorbidity; among the remaining 49

(52.1 %) participants, 35 (37.2 %) presented with just one

comorbid condition, nine (9.6 %) with two, three (3.2 %)

with three, and two (2.1 %) with four associated disorders.

Specifically, we found the following rates of associated

secondary disorders: generalized anxiety disorder 21.3 %

(n = 20), eating disorders 9.6 % (n = 9), Tourette’s dis-

order 8.5 % (n = 8), attention deficit/hyperactivity disor-

der 7.4 % (n = 7), major depression 7.4 % (n = 7), social

phobia 4.2 % (n = 4), specific phobia 3.2 % (n = 3),

oppositional defiant disorder 3.2 % (n = 3), dysthymia

2.1 % (n = 2), and bipolar disorder 2.1 % (n = 2).

The final community sample consisted of 1068 students

(female = 542) from five schools in the Levante region of

eastern Spain. Their mean age was 12.38 years

(SD = 2.69; range = 8–18 years). The participating cen-

ters were located in towns and cities of varying size in both

rural and urban areas; three of them were state centers and

two were semi-private. Consequently, the socio-economic

status of the sample ranged widely and was representative

of the recruitment community (n = 1174). The inclusion

criteria for this sample were the following: (1) registration

on the official school lists; (2) provision of written

informed consent; (3) attending school during the assess-

ment; and (4) the ability to understand and complete the

survey. Finally, participants who did not perform the

measurements at either time point were excluded, as were

those who did not respond to some of the questionnaires. In

all, 106 participants were excluded, representing an attri-

tion rate of 9 %. There was no diagnostic assessment of

psychiatric disorders in the community sample, apart from

the administration of some self-report questionnaires

referring to anxiety and depressive symptoms.

Measures

Children’s Florida Obsessive–Compulsive Inventory (C-

FOCI)

Based on the Florida Obsessive–Compulsive Scale [28],

the C-FOCI [19] was developed to assess the presence and

severity of obsessive–compulsive symptoms. Its nature and

psychometric properties have been reviewed above. The

original scale was translated and adapted into Spanish

following international guidelines and technical standards

[29], as follows: (1) the Spanish translation was authorized

by Eric Storch and Wayne Goodman in 2010; (2) a trans-

lation/back-translation procedure was conducted; (3) expert

judgement to support the linguistic equivalence and

understanding of the items was provided by specialists in

related fields (child and adolescent clinical psychology and

psychiatry; psychological assessment; psychometrics, etc.);

(4) experts evaluated the correspondence of each item with

the belonging dimension in order to support the content

validity of construct; (5) the Spanish version of the C-FOCI

was then administered to a pilot sample of children aged

8–10 years, balanced in terms of gender distribution (50/

50), so as to ensure that the item content could be

168 Child Psychiatry Hum Dev (2017) 48:166–179

123

understood by young children. For this step we used the

cognitive interview technique, a qualitative methodology.

Obsessive Compulsive Inventory-Child Version (OCI-CV)

The Spanish version of the OCI-CV consists of a childhood

self-report of 21 items scored on a 3-point Likert scale

(0 = never, 2 = always). Seven scores are derived:

doubting/checking, obsessing, hoarding, washing, ordering,

neutralizing, and a total score. Both the English [15] and

Spanish versions [30, 31] of the OCI-CV show excellent

psychometric properties. Internal consistency in our sample

ranged from .78 to .91 for clinical sample and from .62 to

.90 for community sample.

Short Obsessive–Compulsive Disorder Screener (SOCS)

The SOCS [17] is a childhood self-report of seven items

that assess the presence of common obsessions and com-

pulsions. This instrument showed good internal consis-

tency, test–retest stability, a unidimensional factor

structure, and excellent sensitivity to detect OCD among

both English [17] and Spanish [32] children and adoles-

cents. Internal consistency values were .79 and .71 for

clinical and community samples respectively.

Revised Child Anxiety and Depression Scale (RCADS-30)

The RCADS-30 [33] is an abbreviated 30-item version of

the RCADS [34], a childhood self-report questionnaire

assessing anxiety and depressive symptoms in children and

adolescents. Symptoms of the following conditions are

evaluated on the RCADS-30: panic disorder, social phobia,

separation anxiety disorder, generalized anxiety disorder,

OCD, and major depressive disorder. Scale items are

scored from 0 to 3, corresponding to ‘‘never’’, ‘‘some-

times’’, ‘‘often’’ and ‘‘always’’. The Spanish version of the

RCADS-30 has shown excellent psychometric properties

that are equivalent to those of the full version [33]. Internal

consistency values ranged from .73 to .93 for the clinical

sample and from .70 to .91 for the community sample.

Children’s Yale-Brown Obsessive Compulsive Scale (CY-

BOCS)

The CY-BOCS is a clinician-administered, semi-structured

interview for assessing the severity of childhood obses-

sive–compulsive symptoms [11]. The scale assesses the

content of the patient’s obsessions and compulsions. These

symptoms are then rated on a 5-point scale covering five

areas each for obsessions and compulsions: time spent

daily on the symptoms, interference caused by the symp-

toms, level of distress, degree of resistance, and control. An

individual severity score is derived for both obsessions and

compulsions, while the Total Severity score, ranging from

0 to 40, is a sum of all items, with a higher score indicating

greater severity.

Schedule for Affective Disorders and Schizophrenia

for School-Age Children-Present and Lifetime Version (K-

SADS-PL)

The K-SADS-PL diagnostic interview is useful for the

cross-sectional and longitudinal evaluation of psy-

chopathology in children and adolescents [25]. It has

shown good to excellent reliability for the majority of

mental disorders assessed (k = .76–1). Specifically, its

reliability for any anxiety disorder was k = .84 [25]. In the

present study, 20 % of the interviews were video-taped for

inter-rater agreement and then observed by two indepen-

dent judges. The inter-rater reliability for the diagnosis of

OCD was excellent (k = .90), whereas the reliability for

the diagnosis of comorbid disorders ranged from .70 to .90.

Procedure

The study was approved by the research and ethics com-

mittees of the University Miguel Hernández of Elche and

the Hospital Clinic of Barcelona. Trained professionals (a

psychologist and psychiatrist, who were native Spanish

speakers) administered the C-FOCI and the other self-re-

port questionnaires in both the clinical and community

samples, as well as the K-SADS-PL and CY-BOCS to the

clinical sample alone, at the time of study entry. Patients

were contacted 4 weeks after the first evaluation, at which

point the children once again completed the same ques-

tionnaires in person.

Written informed consent for participation in the study

was obtained from parents and/or guardians and from

children and adolescents in both clinical and community

settings. Furthermore, all schools and clinical centers par-

ticipated voluntarily in this study, after obtaining permis-

sion from the school principal and the educational

psychology service in the case of the schools, or from the

managing directors in the case of the clinical centers.

Data Analysis

Different sets of analyses were conducted in accordance

with the dichotomous (symptom checklist) or ordinal

(Severity Scale) nature of the variables (not ratio scales).

Thus, we selected the most appropriate statistical tests for

each set. First, descriptive statistics were computed. We

calculated the frequency counts for each of the C-FOCI

symptom checklist items and the differences between

clinical and community groups on Severity Scale items

Child Psychiatry Hum Dev (2017) 48:166–179 169

123

using the Mann–Whitney U test. The Probability of

Superiority (PS) measure [35] was used to estimate the

effect size of any differences; PS is a non-parametric effect

size index, is robust against unequal sample sizes, and

provides an alternative to Cohen’s d when data violate

parametric assumptions. Independent t tests were used to

examine gender, age, and comorbid conditions differences

in the C-FOCI symptom checklist and Severity Scale

scores within each sample. Age was divided into two

groups consisting of children aged 8–12 and adolescents

13–19 years in the clinical sample, and children 8–12 and

adolescents 13–18 years in the community sample.

The next stage involved examining the factor structure

and the metric invariance of the C-FOCI across both

samples. Following Storch et al. [19], the hypothesis that

all items are grouped into two independent factors was

tested by confirmatory factor analysis for both the clinical

and community samples as a whole. We also tested whe-

ther the C-FOCI presents metric invariance. This was

performed once, not systematically (i.e., we did not begin

by checking the configuration invariance; later the invari-

ance of the factor loadings; then the measurement errors,

and finally the intercepts). Across cases, all the restrictions

were introduced simultaneously, checking the metric

invariance between the groups compared with a single

calculation. Polychoric correlation matrices and the diag-

onally weighted least squares method were used in all cases

(LISREL 8.8, DWLS procedure). Lastly, the following

were used as goodness of fit indices [36]: RMSEA equal to

or less than .08; CFI and NNFI (or TLI) superior to .95; and

the Satorra–Bentler Chi square. The CFI was also used to

compare the basic model (total sample) with the metric

invariance model between the clinical and community

samples. According to Cheung and Rensvold [37], the

invariance between samples is admissible when the dif-

ference of CFIs (DCFI) is less than or equal to .01. These authors also assert that DCFI is a better estimator of invariance admissibility than Dv2.

In the third stage of the analysis, we provided reliability

estimates by examining internal consistency and 4-week

temporal stability for both samples. Internal consistency

was estimated by calculating the Kuder–Richardson-20

(KR-20) for the symptom checklist using SPSS v22, while

for the Severity Scale it was assessed with standardized

alpha using FACTOR 10.3 software. KR-20 is a measure of

internal consistency for measures with dichotomous choi-

ces, and it is analogous to Cronbach’s a. We calculated the intraclass correlation coefficient (ICC) to assess the test–

retest association over a 4-week interval, as well as a paired

sample t test between Time 1 and Time 2 for 90 partici-

pants from the clinical sample and 603 from the commu-

nity sample. The average time between the two

administrations was 28 days. We then examined known-

group validity using the Mann–Whitney U test and the

Probability of Superiority (PS) measure [35] to estimate the

effect size of any differences between the group with OCD

and the group without OCD on the symptom checklist and

the Severity Scale. The probabilities of superiority corre-

sponding to Cohen’s (1988) standards for small (r = 0.10,

d = 0.20), medium (r = .30, d = 0.50), and large

(r = .50, d = 0.80) effect sizes are approximately 0.56,

0.64, and 0.71 respectively [38, 39]. Next, the concurrent

and divergent validity of the C-FOCI was examined on the

basis of correlations between the C-FOCI and other

empirically validated measures of OCD, specific dimen-

sions of OCD, and related variables such as anxiety or

depressive symptoms. For these analyses we calculated

Pearson correlation coefficients, using Cohen’s criteria as a

measure of effect size (ES): small (.10), medium (.30), and

large (C.50) [38, 39].

The diagnostic accuracy of the C-FOCI for correct

classification of participants with or without OCD was

determined by studying the ROC curve as well as provid-

ing sensitivity and specificity rates. We followed the tra-

ditional academic point system described by Metz [40] for

classifying the accuracy of a diagnostic measure focused

on ROC curve: .90–1.00 = excellent, .80 to .90 = good,

.70 to .80 = fair, .60 to .70 = poor, \.60 = fail. Finally, the predictive validity of the C-FOCI with

respect to a K-SADS-PL diagnosis of OCD was tested

through binary logistic regression analyses. The outcome

variables were the possible diagnoses according to the

K-SADS-PL (i.e., OCD or non-OCD), while the predictor

variables were scores on the symptom checklist and the

Severity Scale.

Results

Descriptive Statistics

For the clinical sample the number of symptoms endorsed

ranged from 0 to 13 (M = 6.46, SD = 3.50). The mean

score for the Severity Scale was 8.47 (SD = 5.16). Boys

(n = 45; M = 6.04, SD = 3.72) and girls (n = 47;

M = 6.77, SD = 3.34) endorsed a similar number of

symptoms on the symptom checklist (t(90) = -0.98,

p = .33), and girls showed a similar symptom severity to

boys on the Severity Scale (M = 7.82, SD = 4.96 vs.

M = 9.04, SD = 5.41 respectively; t(90) = -1.12,

p = .26). A similar number of symptoms were reported by

children (8–12, n = 23) and adolescents (13–19, n = 67)

on the symptom checklist (M = 5.91, SD = 3.72 vs.

M = 6.55, SD = 3.35 respectively; t(88) = -0.74;

p = .46), and these two groups were also comparable in

terms of symptom severity (M = 7.70, SD = 4.79 vs.

170 Child Psychiatry Hum Dev (2017) 48:166–179

123

M = 8.75, SD = 5.42; t(88) = -0.82, p = .41). The

Symptom and Severity Scales were not differentially

scored by children with no comorbid conditions versus

those who had one or more comorbid conditions (symptom

checklist: M = 6.18, SD = 3.64 vs. M = 6.85,

SD = 3.31; t(92) = -0.90, p = .37; Severity Scale:

M = 7.85, SD = 5.31 vs. M = 9.33, SD = 4.87;

t(92) = -1.38, p = .17 respectively).

For the community sample, the number of symptoms

endorsed ranged from 0 to 17 (M = 5.95, SD = 3.77). The

mean for the Severity Scale was 4.69 (SD = 3.77). Boys

and girls endorsed a similar number of symptoms on the

symptom checklist (5.86 vs. 6.03), and they showed com-

parable symptom severity on the Severity Scale (4.65 vs.

4.75; t(1064) = -0.44, p = .66 and t(1064) = -0.75,

p = .45 respectively). A greater number of symptoms were

reported on the symptom checklist by children (8–12,

n = 554) than by adolescents (13–18, n = 514)

(t(1066) = 10.97, p \ .001; 7.11 ± 3.67 vs. 4.71 ± 3.47). Children reported greater symptom severity than did ado-

lescents on the Severity Scale (t(1066) = 2.23, p \ .05; 4.94 ± 3.69 vs. 4.43 ± 3.83) (Table 1).

Confirmatory Factor Analysis

As shown in Table 2, goodness of fit indices for the total

sample indicated that this model fits the data reasonably

well for two independent factors, the symptom checklist

and the Severity Scale, and we found metric invariance

(configurational, of factor loadings, of measurement errors,

and of intercepts) between the clinical and the community

group for the symptom checklist and the Severity Scale.

The RMSEA was below .08, and the CFI and NNFI were

above .90 in all cases; DCFI was equal to 0. Table 3 shows the degree of relationship (standardized

lambda weights) for each item with respect to the symptom

checklist and the Severity Scale. All item weights were

above .44 for the symptom checklist and above .70 for the

Severity Scale.

Reliability

The internal consistency (KR-20) for the symptom check-

list was .73 and .79 for the clinical and community samples

respectively. For the Severity Scale the internal consistency

(standardized alpha) was .89 and .82 for the clinical and

community groups respectively.

Regarding 4-week test–retest reliability, in the clinical

sample the two mean scores for the symptom checklist

were 6.30 (SD = 3.46) and 5.56 (SD = 3.34), with

ICC = .85; the corresponding values for the Severity Scale

were 8.30 (SD = 5.18) and 8.06 (SD = 4.76), with

ICC = .90. In the community sample the two mean scores

for the symptom checklist were 6.31 (SD = 3.75) and 5.70

(SD = 3.77), with ICC = .83; the corresponding values for

the Severity Scale were 4.84 (SD = 3.73) and 4.22

(SD = 3.78), with ICC = .74. Correlations were statisti-

cally significant (p \ .01) in both groups. In regards to the paired sample t tests between Time 1

and Time 2, in the clinical sample the paired sample t test

showed statistically significant differences for the symptom

checklist (t(89) = 2.88; p \ .01), with a small effect size (d = 0.30). There were no significant differences for the

Severity Scale (t(89) = 0.77; p [ .05). In the community sample, the paired sample t test showed statistically sig-

nificant differences for the symptom checklist (t(602) =

5.22; p \ .001) and Severity Scale (t(602) = 4.43; p \ .001), but in both cases the effect sizes were small (d = 0.21 and 0.18 respectively).

Known-Group Validity

Table 1 shows the means and standard deviations of the

C-FOCI for the clinical and community samples. On the

symptom checklist, and in comparison with the community

sample, participants from the clinical setting endorsed a

significantly higher percentage of items related to obses-

sions involving images of death or horrible things (3),

ritualized handwashing, cleaning, or grooming (9), repeti-

tive routine actions (12 and 14), needing to touch objects or

people (13), and avoiding colors or names that are asso-

ciated with scary events or thoughts (16). By contrast, the

community sample showed a significantly higher percent-

age of endorsements for items related to being worried

about ‘‘Accidentally hitting a pedestrian with your car or

hurting someone’’ (5) and ‘‘Losing something valuable’’

(7) or needing to ‘‘Examine the body for signs of illness’’

(15) (p \ .001). There were no statistically significant differences between the two groups in the total number of

symptom checklist items endorsed. Regarding the Severity

Scale, participants from the clinical setting obtained higher

scores than did those from the community sample

(PS = 0.71; a large effect size according to Grissom [41]),

with this being the case for each item of the severity scale

(PS = 18: 0.66; 19: 0.73; 20: 0.71; 21: 0.60; and 22: 0.64).

Convergent and Divergent Validity

The mean score of severity of the CY-BOCS was 27.34

(SD = 7.12; range = 12–40). In the clinical sample the

C-FOCI symptom checklist correlated significantly with

the CY-BOCS Severity Scale (r = .27), and its correlations

with the OCI-CV subscales and total score, the SOCS, and

the RCADS-30 OCD subscale achieved medium to large

effect sizes (r = .39–.77). The C-FOCI Severity Scale was

significantly related to the CY-BOCS Severity Scale

Child Psychiatry Hum Dev (2017) 48:166–179 171

123

Table 1 Frequencies, means, and standard deviations for C-FOCI items

Item C-FOCI symptom checklist OCD

sample

(%)

Community

sample (%)

v2 p

1. Concerns with dirt, germs, chemicals or getting really sick? [Preocupaciones por la

suciedad, los microbios, sustancias quı́micas o por ponerte muy enfermo]

31.9 40.5 2.68 .10

2. Overconcern with keeping objects (clothes, toys, books) in perfect order or arranged

exactly? [Preocupación por mantener en perfecto orden u organizar de forma exacta

ciertos objetos (ropa, juguetes, libros, etc.)]

43.0 47.0 0.69 .45

3. Frequent images of death or other horrible things? [Ideas o imágenes frecuentes de muerte

u otras cosas desagradables]

52.1 32.3 15.15 \.001

4. Fire, someone robbing you or flooding of the house? [Fuego, alguien que te robe, o

inundaciones en tu casa]

30.9 37.2 1.49 .26

5. Accidentally hitting a pedestrian with your car or hurting someone? [Golpear o herir

accidentalmente a alguien]

22.3 34.0 5.30 \.05

6. Spreading an illness (giving someone AIDS)? [Contagiar una enfermedad (p.ej.: SIDA)] 19.1 26.2 2.26 .14

7. Losing something valuable? [Perder algo valioso] 52.1 68.4 10.29 \.01 8. Harm coming to a loved one because you weren’t careful enough? [Llegar a dañar a un ser

querido por no ser lo suficientemente cuidadoso]

38.3 45.4 1.77 .20

9. Excessive or ritualized washing, cleaning or grooming? [Lavarte, limpiarte o asearte

excesivamente siguiendo una serie de pasos o reglas]

46.2 31.1 8.49 \.01

10. Checking light switches, water faucets, the stove, or door locks? [Comprobar los

interruptores de la luz, los grifos, el horno, las cerraduras de las puertas, etc.]

40.4 31.3 3.32 .08

11. Counting, arranging; evening-up behaviors (making sure socks are at same height)?

[Contar u organizar las cosas de forma simétrica o perfecta para ti (asegurarte de que los

calcetines están a la misma altura)]

29.0 23.7 1.20 .31

12. Repeating routine actions (in/out of chair, going through doorway, opening/closing

things) a certain number of times or until it feels just right? [Repetir una y otra vez la

forma de hacer las cosas un número determinado de veces hasta sentir que ‘‘ya está

bien’’ (p.ej.: levantarte y sentarte en una silla, pasar por un puerta, abrir/cerrar cosas)]

49.5 26.6 21.15 \.001

13. Needing to touch objects or people? [Necesidad de tocar objetos o personas] 46.2 25.1 18.80 \.001 14. Unnecessary rereading or rewriting? [Volver a leer o a escribir innecesariamente algo] 55.3 34.8 15.65 \.001 15. Examining your body for signs of illness? [Revisar tu cuerpo para ver si hay algún signo

de enfermedad]

19.6 29.4 4.45 \.05

16. Avoiding colors (‘‘red’’ means blood), numbers (‘‘13’’ is unlucky) or names (those that

start with ‘‘D’’ signify death) that are associated with scary events or thoughts? [Evitar

colores (el ‘‘rojo’’ representa sangre), números (‘‘13’’ es mala suerte) o nombres

(nombres que empiezan por ‘‘M’’ significan muerte) que están relacionados con ideas o

situaciones que provocan miedo]

25.8 12.5 12.40 \.01

17. Needing to ‘‘confess’’ or repeatedly asking for reassurance that you said or did something

correctly? [Necesidad de ‘‘confesar’’ o preguntar repetidamente algo para asegurarte de

que dijiste o hiciste algo correctamente]

46.8 49.9 0.33 .59

C-FOCI Severity Scale Mean (SD) Mean (SD) Mann–

Whitney

U (Z)

p

1. On average, how much time is occupied by these thoughts or behaviors each day? [Por

término medio, >Cuánto tiempo te ocuparon estas ideas o formas de actuar cada dı́a?] 1.64 (1.18) 0.97 (0.93) -5.62 \.001

2. How much do they bother you? [>Cuánto te molestaron estas cosas (ideas desagradables y formar de actuar)?]

2.14 (1.27) 1.09 (1.11) -7.67 \.001

3. How hard is it for you to control them? [>Cuánto te costó controlar estas ideas o formas de actuar?]

2.13 (1.17) 1.16 (1.27) -7.03 \.001

4. How much do they cause you to avoid doing things, going places or being with people?

[>Cuánto te hicieron evitar (estas ideas o formas de actuar) hacer cosas, ir a lugares o estar con personas?]

1.14 (1.23) 0.69 (0.98) -3.54 \.001

5. How much do they interfere with school, your social or family life, or your job?

[>Cuánto te afectaron negativamente estas ideas o formas de actuar en la escuela, con los amigos y con tu familia?]

1.46 (1.32) 0.79 (1.01) -5.06 \.001

172 Child Psychiatry Hum Dev (2017) 48:166–179

123

(r = .40), and its correlations with the aforementioned

OCD-related measures indicated medium to large effects

(r = .38–.72). The exceptions were the OCI-CV Hoarding,

Ordering and Neutralizing subscales, which were weakly

related to the C-FOCI Severity Scale (r = .20–.29).

In the community sample, the symptom checklist was

correlated with OCI-CV subscales and total score, the

SOCS, and the RCADS-30 OCD subscale, showing med-

ium to large effect sizes (r = .37–.71). For the Severity

Scale, the effect sizes of the correlations with the same

measures were between small and medium (r = .27–.54).

With regard to related construct measures such as anx-

iety and depression symptoms, all correlations for both

C-FOCI subscales were significant with small-to-medium

effect sizes for the clinical (r = .25–.62) and community

samples (r = .27–.52). The only exception in both groups

was the RCADS total score, which showed a large effect

size in its correlation with the C-FOCI symptom checklist

and Severity Scale (see Table 4).

Sensitivity and Specificity of the C-FOCI

The area under the curve (AUC) for the C-FOCI symptom

checklist was .63 (SE = .03, p \ .001), suggesting a 63 % probability that a participant with OCD would score higher

on the C-FOCI symptom checklist than a participant from

the community sample. Table 5 shows the sensitivity and

specificity for the set of items. Cut-off scores were selected

to provide the best balance between sensitivity and

specificity for each measure. Therefore, applying the

Youden Index the symptom checklist cut-off score of 7

showed a sensitivity of 57 % and a specificity of 48 %, a

Youden Index of .06, and accuracy or informedness (sub-

jects correctly classified) of 51 %. Although a score of 6 is

less specific (38 %), it is more sensitive (69 %), so it could

be chosen as a good cut-off score to detect OCD.

The AUC of the C-FOCI Severity Scale was .77

(SE = .02, p \ .001), suggesting a 77 % probability that a youth with OCD would obtain a higher severity score than

a young person from the community sample. Table 6

shows the sensitivity and specificity for the Severity Scale.

Cut-off scores were selected to provide the best balance

between sensitivity and specificity for each measure. Thus,

a Severity Scale cut-off score of 7 showed sensitivity of

63 % and specificity of 63 %, a Youden Index of .26, and

accuracy or informedness (subjects correctly classified) of

37 %. A score of 6 displays slightly better sensitivity

(73 %) but lower specificity (53 %).

Predictive Validity

Regarding the symptom checklist, the predictive model

accounted for 8.4 % (Nagelkerke R 2 ) of the variance in

OCD diagnoses, and resulted in 92 % classification accu-

racy. The symptom checklist was related to diagnostic

status, Wald (1) = 42.36, p \ .001, such that higher symptom checklist scores were better predictors of OCD

diagnoses, OR = 1.55 (95 % CI = 1.36–1.78).

Table 1 continued

C-FOCI Severity Scale Mean (SD) Mean (SD) Mann–

Whitney

U (Z)

p

C-FOCI symptom checklist 6.46 (3.50) 5.95 (3.77) -1.45 .15

C-FOCI Severity Scale 8.50 (5.13) 4.69 (3.77) -6.90 \.001

Table 2 Confirmatory factor analysis (total sample:

n = 1162) and multi-group

confirmatory factor analyses

(diagonally weighted least

squares; polychoric correlation

matrix) for children from a

clinical setting (n = 94) and

children from the community

(n = 1068)

Sample/model v2 df RMSEA (90 % CI) CFI NNFI

Total sample

Symptom checklist 880.96 119 .07 (.07–.08) .95 .95

Severity Scale 15.80 5 .04 (.02–.07) 1.0 .99

Metric invariance

Community–clinical

Symptom checklist 1199.01 304 .07 (.07–.08) .95 .95

Severity Scale 24.22* 29 .00 (.00–.06) 1.0 1.0

v2 Satorra-Bentler’s Chi squared. RMSEA root mean square error of approximation, CFI comparative fix index, NNFI non-normed fit index

* p = .72

Child Psychiatry Hum Dev (2017) 48:166–179 173

123

With respect to the Severity Scale, the predictive model

accounted for 13 % (Nagelkerke R 2 ) of the variance in

OCD diagnoses, and resulted in 92 % classification accu-

racy. The Severity Scale was related to diagnostic status,

Wald (1) = 65.86, p \ .001, such that higher Severity Scale scores were better predictors of OCD diagnoses,

OR = 1.23 (95 % CI = 1.17–1.29).

Discussion

We report additional psychometric properties of the

C-FOCI in a European (Spanish) sample. Although pre-

liminary research had supported the psychometric proper-

ties of the instrument [19], several other issues remained to

be addressed, including its factor structure and metric

Table 3 Item content, item factor loading (lambda)

Item Scale name/item content Lambda

Symptom checklist

1. Concerns with dirt, germs, chemicals or getting really sick? [Preocupaciones por la suciedad, los microbios, sustancias

quı́micas o por ponerte muy enfermo]

.70

2. Overconcern with keeping objects (clothes, toys, books) in perfect order or arranged exactly? [Preocupación por mantener en

perfecto orden u organizar de forma exacta ciertos objetos (ropa, juguetes, libros, etc.)]

.62

3. Frequent images of death or other horrible things? [Ideas o imágenes frecuentes de muerte u otras cosas desagradables] .49

4. Fire, someone robbing you or flooding of the house? [Fuego, alguien que te robe, o inundaciones en tu casa] .65

5. Accidentally hitting a pedestrian with your car or hurting someone? [Golpear o herir accidentalmente a alguien] .59

6. Spreading an illness (giving someone AIDS)? [Contagiar una enfermedad (p.ej.: SIDA)] .63

7. Losing something valuable? [Perder algo valioso] .44

8. Harm coming to a loved one because you weren’t careful enough? [Llegar a dañar a un ser querido por no ser lo

suficientemente cuidadoso]

.51

9. Excessive or ritualized washing, cleaning or grooming? [Lavarte, limpiarte o asearte excesivamente siguiendo una serie de

pasos o reglas]

.59

10. Checking light switches, water faucets, the stove, or door locks? [Comprobar los interruptores de la luz, los grifos, el horno, las

cerraduras de las puertas, etc.]

.49

11. Counting, arranging; evening-up behaviors (making sure socks are at same height)? [Contar u organizar las cosas de forma

simétrica o perfecta para ti (asegurarte de que los calcetines están a la misma altura)]

.55

12. Repeating routine actions (in/out of chair, going through doorway, opening/closing things) a certain number of times or until it

feels just right? [Repetir una y otra vez la forma de hacer las cosas un número determinado de veces hasta sentir que ‘‘ya está

bien’’ (p.ej.: levantarte y sentarte en una silla, pasar por un puerta, abrir/cerrar cosas)]

.57

13. Needing to touch objects or people? [Necesidad de tocar objetos o personas] .45

14. Unnecessary rereading or rewriting? [Volver a leer o a escribir innecesariamente algo] .44

15. Examining your body for signs of illness? [Revisar tu cuerpo para ver si hay algún signo de enfermedad] .59

16. Avoiding colors (‘‘red’’ means blood), numbers (‘‘13’’ is unlucky) or names (those that start with ‘‘D’’ signify death) that are

associated with scary events or thoughts? [Evitar colores (el ‘‘rojo’’ representa sangre), números (‘‘13’’ es mala suerte) o

nombres (nombres que empiezan por ‘‘M’’ significan muerte) que están relacionados con ideas o situaciones que provocan

miedo]

.57

17. Needing to ‘‘confess’’ or repeatedly asking for reassurance that you said or did

something correctly? [Necesidad de ‘‘confesar’’ o preguntar repetidamente algo para asegurarte de que dijiste o hiciste algo

correctamente]

.62

Severity Scale

1. On average, how much time is occupied by these thoughts or behaviors each day? [Por término medio, >Cuánto tiempo te ocuparon estas ideas o formas de actuar cada dı́a?]

.79

2. How much do they bother you? [>Cuánto te molestaron estas cosas (ideas desagradables y formar de actuar)?] .90

3. How hard is it for you to control them? [>Cuánto te costó controlar estas ideas o formas de actuar?] .71

4. How much do they cause you to avoid doing things, going places or being with people? [>Cuánto te hicieron evitar (estas ideas o formas de actuar) hacer cosas, ir a lugares o estar con personas?]

.74

5. How much do they interfere with school, your social or family life, or your job? [>Cuánto te afectaron negativamente estas ideas o formas de actuar en la escuela, con los amigos y con tu familia?]

.83

Total sample (n = 1162), community (n = 1068) and clinical (n = 94)

174 Child Psychiatry Hum Dev (2017) 48:166–179

123

invariance across clinical and community samples, the

limited evidence of convergent-divergent validity, test–

retest reliability, and sensitivity/specificity data.

Findings regarding the incidence of obsessions and

compulsions in the community sample indicated that young

people without OCD experience ‘‘normal’’ obsessions that

are comparable in content to those with OCD, and that

what distinguishes people with ‘‘normal’’ obsessions from

people with OCD is the severity of obsessions and com-

pulsions (frequency of symptoms, distress, intensity, etc.)

[19]. Two findings support this idea. First, there were no

significant differences between the clinical and community

samples in terms of mean scores on the C-FOCI symptom

checklist. This may be because our samples were slightly

different to those used in the study by Storch et al. [19]: (1)

our sample had different mean ages and a different age

range; (2) our clinical sample presented fewer comorbid

disorders, and so their degree of severity was lower than in

Storch’s sample; and (3) our community sample was larger

and more heterogeneous. The second finding derives from

the item analysis, which showed a similar percentage of

positive OCD symptoms among the clinical and commu-

nity samples. Results regarding the prevalence of symp-

toms in the community sample indicated that more than

Table 4 Convergent/divergent validity

Measures Children’s Florida Obsessive–Compulsive Inventory

Symptom checklist Severity Scale

Clinical Community Clinical Community

CY-BOCS total severity score .27** – .40** –

SOCS .69** .57** .58** .45**

OCI-CV checking .59** .62** .43** .42**

OCI-CV obsessing .63** .52** .66** .54**

OCI-CV hoarding .39** .37** .21** .27**

OCI-CV Washing .52** .53** .38** .29**

OCI-CV ordering .47** .42** .20** .32**

OCI-CV neutralizing .45** .47** .29** .31**

OCI-CV total score .77** .71** .55** .53**

RCADS-30 separation anxiety .38** .45** .25** .27**

RCADS-30 social phobia .42** .38** .43** .37**

RCADS-30 generalized anxiety .62** .52** .57** .43**

RCADS-30 panic disorder .46** .49** .44** .43**

RCADS-30 obsessive–compulsive disorder .69** .63** .72** .47**

RCADS-30 major depression .46** .39** .57** .42**

RCADS-30 total score .69** .63** .68** .53**

Total sample (n = 1162), community (n = 1068) and clinical (n = 94)

CY-BOCS Children’s Yale-Brown Obsessive Compulsive Scale, SOCS Short OCD Screener, OCI-CV

Obsessive Compulsive Inventory-Child Version, RCADS-30 Revised Child Anxiety and Depression Scale

** p \ .01

Table 5 Sensitivity, specificity, Youden Index, and accuracy of the symptom checklist

Cut-off Sensitivity Specificity Youden Index Accuracy

1 1.00 -.12 -.12 1.01

2 .98 -.03 -.05 .94

3 .94 .06 .00 .85

4 .90 .16 .07 .76

5 .81 .26 .07 .69

6 .69 .38 .07 .59

7 .57 .48 .06 .51

8 .49 .58 .07 .43

9 .37 .68 .05 .35

10 .30 .77 .07 .28

11 .21 .85 .07 .21

12 .16 .91 .07 .16

13 .14 .95 .09 .13

14 .09 .98 .07 .10

15 .09 1.00 .08 .09

16 .07 1.00 .07 .09

17 .01 1.00 .01 .10

Total sample (n = 1162), community (n = 1068) and clinical

(n = 94)

Accuracy (informedness), percentage of children correctly classified

Child Psychiatry Hum Dev (2017) 48:166–179 175

123

two-thirds of the sample feared losing something valuable,

the same rate as that reported by Storch et al. [19]. Addi-

tionally, there were three symptoms that were endorsed by

nearly 50 % of the community sample: (1) overconcern

with order, (2) fear of harm coming to a loved one because

the respondent was not careful enough, and (3) reassurance

seeking and confessing. Storch et al. [19] also reported

rates over 40 % for concern with order and reassurance

seeking and confessing. There is a considerable body of

data indicating that people without OCD experience

‘‘normal’’ obsessions that are comparable in content to

those with OCD [19]. Consistent with our findings, what

distinguishes a person with ‘‘normal’’ obsessions from a

person with OCD is the degree to which symptoms are

frequent, distressing, intense, and provoke efforts to resist.

Indeed, some authors have reported certain obsessions to

be prevalent in the community, asserting that the number of

obsessions and compulsions are endorsed by similar—and

in some cases higher—percentages of community subjects

relative to pediatric OCD patients (e.g., [42]).

Overall, the psychometric results were encouraging.

First, the validity analysis confirmed the factor structure of

two independent factors previously suggested by Storch

et al. [19]. Confirmatory factor analyses showed that the

data fit adequately to the two-dimensional measurement

model. Item factor loadings (lambda) for the Severity Scale

were, in general, higher than those for the symptom

checklist. Regarding invariance, the C-FOCI subscales

presented the expected metric invariance between the

clinical and community samples, with a RMSEA index

below .08 and CFI and NNFI values above .90, indicating

an acceptable fit [36]. These data indicate that respondents

across clinical and community groups attribute the same

meaning to the latent constructs under study (metric

invariance).

With respect to reliability, internal consistency for the

C-FOCI scores was high (.79–.89), except for the symptom

checklist in the clinical sample, where it was accept-

able (.73). These data are consistent with the findings of

Storch et al. [19] and support the existence of a single

consistent dimension for each subscale. C-FOCI scores

also showed adequate temporal stability over 4 weeks,

suggesting that the instrument could be useful for tracking

symptom presence and stability.

Regarding the known-group validity, most symptoms

were significantly more frequent in the clinical sample (3,

9, 12, 13, 14, and 16). Specifically, there were seven

symptoms that were endorsed by close to or over 50 % of

the clinical sample: (1) obsessions involving images of

death or horrible things, and (2) fear of losing something

valuable, whereas the compulsions concerned (3) ritualized

handwashing, cleaning, or grooming, (4) repetitive routine

actions, (5) need to touch objects or people, (6) unneces-

sary rereading or rewriting, and (7) reassurance seeking

and confessing (Table 1). Of these, only the symptoms of

ritualized handwashing, cleaning, or grooming and reas-

surance seeking and confessing coincided with those

reported by Storch et al. [19] in this respect. Therefore,

these data also provide support for the known-group

validity of the C-FOCI symptom checklist. Furthermore,

mean scores on the C-FOCI Severity scale were higher in

our clinical group than in our community sample, with a

medium effect size, supporting the scale’s known-group

validity [19]. In addition, responses such as ‘‘extreme

severity’’ or ‘‘severity’’ across items on the Severity Scale

were, on average, more common in the clinical sample than

in the community sample, indicating that the OCD sample

reported significantly greater severity on each Severity

Scale item. This finding is consistent with the reports of

Rassin and Muris [43] and Storch et al. [19].

With regard to concurrent validity, the relationships

between the C-FOCI scales and three measures with the

strongest empirical support, namely the CY-BOCS, OCI-

CV and SOCS, support the validity of the C-FOCI. In the

clinical sample a stronger positive relationship was found

between the C-FOCI Severity Scale and the Total Severity

Scale of the CY-BOCS than between the C-FOCI symptom

Table 6 Sensitivity, specificity, Youden Index, and accuracy of the Severity Scale

Cut-off Sensitivity Specificity Youden Index Accuracy

1 1.00 -.01 -.01 .91

2 .98 .10 .08 .82

3 .97 .21 .18 .72

4 .89 .33 .22 .62

5 .82 .43 .25 .53

6 .73 .53 .27 .45

7 .63 .63 .26 .37

8 .57 .73 .30 .29

9 .50 .80 .30 .23

10 .45 .86 .31 .18

11 .43 .91 .34 .13

12 .38 .95 .33 .11

13 .29 .97 .25 .10

14 .24 .98 .23 .09

15 .17 .99 .16 .09

16 .14 .99 .13 .09

17 .09 1.00 .08 .09

18 .01 1.00 .01 .10

19 .01 1.00 .01 .10

20 .01 1.00 .01 .10

Total sample (n = 1162), community (n = 1068) and clinical

(n = 94)

Accuracy (informedness), percentage of children correctly classified

176 Child Psychiatry Hum Dev (2017) 48:166–179

123

checklist and the CY-BOCS. However, there were also

moderate associations between the CY-BOCS and specific

anxiety and depression symptom measures. One explana-

tion for this finding is the symptom overlap between

depression, anxiety, and OCD disorders, which other

studies have also found [5, 42].

Finally, in order to determine the accuracy of the scales

for correct classification of children and adolescents with

and without OCD, the present study examined the sensi-

tivity and specificity of the C-FOCI scales using ROC

analysis. Results indicated a significant area under the

curve for the symptom checklist total score, but AUC

values of .63 and .77 for the Severity scale. Values between

.60 and .70 represent poor discrimination, whereas those

between .70 and .80 indicate fair to good discrimination.

Thus, the symptom checklist did not offer a good cut-off

score for achieving an optimal balance between sensitivity

and specificity: the best score would be 7, but this only

achieves a sensitivity of 57 % and a specificity of 48 %;

however, a score of 6 could, despite its low specificity

(38 %), be used to detect children with OCD, due to its

greater sensitivity (69 %). In any case, a score of 13 would

be more specific for identifying healthy children and ado-

lescents who do not have OCD, offering a prevalence rate

for increased symptoms of 4.6 % (n = 49). As for the

C-FOCI Severity scale, a score above 7 is recommended

because it provides the optimal balance between the per-

centage of true positives and true negatives in real cases.

This cut-off score led to an acceptably moderate percentage

of adolescents being incorrectly identified with OCD

(specificity = 63 %) and a moderate proportion of ado-

lescents being overlooked in terms of heightened OCD

symptomatology (sensitivity = 63 %). However, given

that one of the main purposes of the C-FOCI Severity Scale

is to serve as a screening measure for OCD, the best cut-off

score is 6, with a sensitivity of 73 %, specificity of 53 %,

and a Youden’s Index of .27. This C-FOCI score could be

useful for screening youth in clinical settings in order to

avoid overlooking patients who need further assessment.

However, as noted, potential users of this scale could

choose a higher or lower cut-off score, depending on their

objective. For example, a more conservative cut-off score

of 11–12 might be justified when using these subscales for

research purposes in order to avoid false positives, with

prevalence rates of 7.4 % (n = 79) and 4.6 % (n = 49)

respectively (see Table 6). Our sensitivity/specificity

results suggest that the C-FOCI is superior to the LOI-CV

but similar to other OCD screening instruments

[12, 31, 32, 44]. In summary, our prevalence rates with

scores of 13 on the symptom checklist and 11–12 on the

Severity Scale are consistent with a recent study with a

Spanish sample aged from 8 to 12 years which indicated

prevalences of 1.8 % for OCD, 5.5 % for subclinical OCD,

and 4.7 % for symptomatology (assessed with the Leyton

Obsessional Inventory-Child Version Survey) [5]. More-

over, recent studies with Spanish samples using the per-

centage of participants scoring two standard deviations

above the mean score on the OCD subscale on the Spence

Children Anxiety Scale (SCAS) found high scores in 4.9 %

of the subjects between 8 and 17 years had [45], and in

6.6 % in a sample aged between 10 and 17 [46]. Further-

more, we consider that the possible existence of OCD cases

in the community sample, which was as assumed to be free

of OCD, might explain the modest sensitivity and speci-

ficity in our sample.

Regarding the predictive validity of the C-FOCI, the

results from the binary logistic regression analyses indi-

cated that the C-FOCI subscales were significant predictors

of OCD diagnosis (classification accuracy of 92 %). This

result is consistent with those of the previous study with the

C-FOCI [19], which led to the creation of a screening tool

that could accurately classify an OCD diagnosis.

Some limitations of the present study should be noted

that explain the modest convergence, specificity and sen-

sitivity of the instrument. First, we did not examine the

psychometric properties of C-FOCI with a large clinical

sample. Furthermore, our clinical sample showed a lower

comorbidity rate (52.1 %) than previous epidemiological

studies (approximately 80 %) [5]. We stress that our study

did not apply an epidemiological design, and that the

comorbid disorders found in our OCD sample coincided

mainly with those reported by previous studies (highest

rates for Generalized Anxiety Disorder, Separation Anxiety

Disorder, Depression, Social Phobia, and AHDD and other

behavioral disorders) [5]. Second, we included a wide age

range encompassing a number of developmental periods

including early and late adolescents, but we did not con-

duct separate analyses for the different age ranges; this

must be recognized as a limitation of the study. Third, the

instrument’s sensitivity and specificity in differentiating

children with and without OCD were examined in a sample

of children with the disorder and a non-diagnostically

interviewed community sample. Thus, the sensitivity and

specificity were modest overall, acknowledging that this

restricts the measure’s utility as a screening measure.

However, the tool does a good job differentiating between

patients with OCD and those without a disorder

(AUC = .77), which would indicate the need for further

assessment. Fourth, although we describe the process of

adapting and translating C-FOCI into Spanish, it should be

noted as a major constraint that we did not include the

results concerning the translation/cross-cultural validation

(although they are available on request). Finally, the

external validity of findings is limited, particularly for the

US and other English-speaking countries, given the use of

Spanish version of the scale using a sample from Spain.

Child Psychiatry Hum Dev (2017) 48:166–179 177

123

In summary, the C-FOCI is a brief self-report tool (for

further details, see the review by Iniesta-Sepúlveda et al.

[12]) which offers psychometric properties equivalent to

those of other measures. In terms of the Evidence-Based

Assessment classification [10], which defines three levels

of empirical support, the results of this study and those

reported by Storch et al. [19] suggest that the C-FOCI

should be considered as approaching a well-established,

pediatric OCD-specific assessment instrument, given that

at least two published studies by two different research

teams would have demonstrated its reliability and validity.

Thus, notwithstanding the limitations of this study, the

C-FOCI emerges as a promising, valid and useful instru-

ment for the assessment of pediatric obsessive–compulsive

symptomatology.

Summary

The C-FOCI is a self-report measure designed to screen the

presence and severity of obsessive–compulsive symptoms

in children and adolescents, and it presents good psycho-

metric properties. The results of this study involving

community and clinical samples confirm the factor struc-

ture of two independent factors (symptoms and severity),

as well as metric invariance across groups for the symptom

checklist and the Severity Scale. The instrument also

achieves good reliability in terms of internal consistency

and temporal stability, shows modest correlations with

other OCD measures, and has modest sensitivity and

specificity to detect OCD. Overall, the C-FOCI seems to be

a promising screening instrument for assessing the pres-

ence and severity of obsessions and compulsions in youth,

although further research is needed.

Acknowledgments Special thanks are due to E. A. Storch and Wayne Goodman for their permission to use the C-FOCI, and to

Agustin E. Martı́nez-González and Antonio Godoy for their dedica-

tion during the development of this study.

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