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Neurological SciencesOfficial Journal of the ItalianNeurological Society ISSN 1590-1874 Neurol SciDOI 10.1007/s10072-015-2251-9

The Italian version of the Brain InjuryRehabilitation Trust (BIRT) personalityquestionnaires: five new measures ofpersonality change after acquired braininjuryBenedetta Basagni, Eduardo Navarrete,Debora Bertoni, Charlotte Cattran,Daniela Mapelli, Michael Oddy &Antonio De Tanti

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ORIGINAL ARTICLE

The Italian version of the Brain Injury Rehabilitation Trust(BIRT) personality questionnaires: five new measuresof personality change after acquired brain injury

Benedetta Basagni1 • Eduardo Navarrete2 • Debora Bertoni1 • Charlotte Cattran3,4 •

Daniela Mapelli5 • Michael Oddy3 • Antonio De Tanti1

Received: 25 March 2015 / Accepted: 13 May 2015

� Springer-Verlag Italia 2015

Abstract The aim of this study was to describe the

translation and adaptation of the BIRT personality ques-

tionnaires for the Italian population. This included the

replication of validity testing and the collection of norma-

tive data. Following translation and adaptation according to

cross-cultural guidelines, the questionnaires were adminis-

tered as a pre-test to a sample of 20 healthy subjects and

then to 10 patients. The questionnaires were then adminis-

tered to 120 healthy subjects equally distributed by sex,

education, and age, to collect normative data from an Italian

population. The questionnaires were easily administered to

both healthy subjects and patients. Statistical analysis on

normative data was conducted to find the mean value for

each questionnaire. This study lays the foundations for us-

ing a new instrument to assess behavioral changes after

acquired brain injury on the Italian population.

Keywords Acquired brain injury � Personality change �Behavioral disorders � Assessment � Questionnaire

Introduction

The concept of ‘‘personality change’’ following acquired

brain injury (ABI) refers to an alteration in the defining

features of someone’s personality post-injury. Research

within a biopsychosocial framework suggests that these

anomalies are the result of a collection of neurological and

neuropsychological deficits, psychological mechanisms,

and psychosocial processes [1]. Frontal lobe damage, as

well as temporal lobe injury, has long been linked to

emotional/personality changes and social behavior. The

most commonly reported changes are impulsivity and

disinhibition, explosive anger and irritability, labile mood,

aggression, poor motivation, and difficulties maintaining

social relationships [e.g., 2–4]. Some authors have referred

to these common changes as non-cognitive neurobehav-

ioral sequelae [5] or a neurobehavioral disability [3].

Families of ABI patients tend to report that personality

changes are the most difficult to deal with and are a sig-

nificant source of long-term stress [e.g., 6–8]. They have

been shown to have long-term implications on outcome

and as such have predictor value in terms of participation

and social adaptation [5, 9–12]. Combined with cognitive

problems, these difficulties can seriously undermine the

capacity for independent social behavior.

Despite their recognition as a frequent and disabling

consequence of brain injury, the assessment of non-cog-

nitive neurobehavioral sequelae has received little attention

from researchers in recent years, and, as a result, there are

few reliable measures for such changes. Some useful

questionnaires and scales do exist in English: the Current

Behavior Scale [13], the Iowa Scales of Personality Change

[14], the Dysexecutive questionnaire [15], the Frontal

Systems Behavior Scale [16], the Key Behaviors Change

Inventory [17]; and in French: the Inventaire du Syndrome

Electronic supplementary material The online version of thisarticle (doi:10.1007/s10072-015-2251-9) contains supplementarymaterial, which is available to authorized users.

& Benedetta Basagni

bbasagni@gmail.com;

benedetta.basagni@centrocardinalferrari.it

1 Centro Cardinal Ferrari (Servizio di Neuropsicologia), via IV

Novembre, 21, 43012 Fontanellato, Parma, Italy

2 Dipartimento di Psicologia dello Sviluppo e della

Socializzazione, Universita di Padova, Padua, Italy

3 Brain Injury Rehabilitation Trust, Horsham, UK

4 Active Assistance Brain Injury Service, Horsham, UK

5 Dipartimento di Psicologia Generale, Universita di Padova,

Padua, Italy

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DOI 10.1007/s10072-015-2251-9

Author's personal copy

Dysexecutif Comportemental [18]. In the Italian language,

there are some questionnaires for specific measures. For

instance, Isella and colleagues [19] translated the 18-item

Apathy Evaluation Scale of Marin et al. [20] into Italian,

and Margari and colleagues [21] translated the Modified

Overt Aggression Scale [22]. In addition, Gainotti and

Marra [23] propose using standard neuropsychological

testing to assess behavioral anomalies, such as the Stroop

test [24] to assess disinhibition or the Iowa Gambling Task

[25, 26] to assess impulsivity. However, personality and

behavioral disorders are not strongly related to neuropsy-

chological assessment scores [27], suggesting that both

types of impairment are different. The Neuropsychiatric

Inventory [28], validated for Italian population from Binetti

and coworkers [29], is a questionnaire created for neu-

rodegenerative pathologies and dementia-related behav-

ioral symptoms that examined 12 sub-domains of

behavioral functioning: delusions, hallucinations, agitation/

aggression, dysphoria, anxiety, euphoria, apathy, disinhi-

bition, irritability/lability, aberrant motor activity, night-

time behavioral disturbances, and appetite and eating ab-

normalities. The Frontal Behavior Inventory [30], adapted

for Italian by Alberici et al. [31], is also designed for

neurodegenerative pathologies. Cattellani [32] lists a broad

number of scales and questionnaires translated or created in

Italian (e.g., Neurobehavioral Rating Scale [33], Checklist

della condotta sociale, Questionario di efficienza compor-

tamentale, and Iowa Collateral Head Injury Interview

[34]); however, these have not been specifically adapted to

the Italian language using Italian normative data or ade-

quate validation processes. In sum, there are no question-

naires, specifically created to assess the most frequently

cited personality changes following ABI, and with nor-

mative data for Italian population. It is therefore important

to develop specific tools to measure these changes in the

Italian language. This was the main aim of the current

study.

In a recent series of studies, Cattran and colleagues [5,

27, 35, 36] introduced a useful tool to assess behavioral

disturbances for English patients with ABI, the five BIRT

personality questionnaires (henceforth BIRT-PQ). The

BIRT-PQ battery consists of five questionnaires, which can

be administered singly or in combination, to assess the

personality dimensions that are more frequently altered

after acquired brain injury: motivation, impulsivity, disin-

hibition, social cognition, and emotional regulation. There

are two different versions of each questionnaire. One ver-

sion is for the patient who has to provide a description of

his/her own behavior, and the other version is for a family

member or a significant other. In both cases, participants

evaluate on a four-point rating scale the frequency with

which a behavior occurs during everyday life.

In this paper, we concisely first describe the BIRT-PQ

developed by Cattran and colleagues, then we report the

forward–backward translation process for the Italian ver-

sion that was conducted following the self-report guide-

lines for cross-cultural adaptation questionnaires proposed

by Beaton and colleagues [37]. Then we present the par-

tial repeatability of the validation process and the col-

lection of normative data over a sample of normal

subjects.

BIRT personality questionnaires

There are five independent questionnaires measuring mo-

tivation (BMQ), impulsivity (BIQ), disinhibition (BDQ),

social cognition (BSCQ), and emotional regulation

(BREQ). Each questionnaire has two identical versions:

one self- and one informant-rated. The availability of two

different points of view (self and relative) of the same

problem offers an indirect measure of the awareness level

of patients. For details of the development and description

of each of the questionnaires, see Hyde [27], Oddy et al.

[36], and Cattran et al. [5, 35].

The questionnaire contains a total of 150 items: the

BMQ is composed of 34 items, the BIQ of 32, the BDQ of

24, the BSCQ of 28, and the BREQ of 32. For each item,

the patient (or the relative in the informant-rated version)

has to express a frequency judgment along a continuum

from ‘‘always’’ to ‘‘never.’’ The response options are

scored as follows: always (4), often (3), sometimes (2), and

never (1) (e.g., ‘‘I have sudden mood swings’’). In order to

reduce acquiescence, some of the items in each question-

naire are reversed in meaning and scoring (e.g., ‘‘I am in

control’’). Given that the questionnaires are designed

specifically for individuals with a brain injury, the sen-

tences are expressed concisely and simply.

Following the principles proposed by Rust and Golom-

bok [38], in developing the questionnaire and generating

the items, care was taken to identify content areas and

specific manifestations for patients with ABI. Hence, the

main strength of the questionnaire relies on the fact that it

was specifically created to assess the behavioral sequelae

of ABI, which are peculiar and different, for instance, from

dementia-related behavioral symptoms. Importantly, a

further study demonstrated that the questionnaire not only

provides a method of quantifying the extent of non-cog-

nitive neurobehavioral sequelae following brain injury, but

also has a predictive value identifying early patients whose

symptoms are likely to persist and who may require on-

going intervention [5]. The original version presented good

psychometric properties in terms of split-half reliability,

internal consistency, test–retest reliability, and concurrent

validity with existing measures.

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Italian version of the BIRT-PQ

Participants

A total of one hundred and forty healthy adult Italian

participants, with no history of neurological or psychiatric

disease, took part in the study. Twenty participants took

part in the translation and adaptation process (mean age 40;

range 21–57; standard deviation = 10.2), and the others

(i.e., 120 participants) were recruited for collecting nor-

mative data. A sub-group of them (i.e., 18 participants) also

participated in the replication of the validation process (see

below). Ten patients took part as part of the clinical sample

(i.e., pre-test).

Method

Translation and adaptation process In order to create the

Italian version of the BIRT-PQ, we followed the six steps

recommended in the guidelines for the process of cross-

cultural adaptation of self-report measures developed by

Beaton and colleagues [37]. That is, Forward translation,

Synthesis of the translations, Back translation, Expert

committee, Test of the penultimate version, and Submis-

sion of documentation to the developers or coordinating

committee for appraisal of the adaptation process. The

English version was first translated into Italian by two in-

dependent Italian–English high-proficiency bilingual

speakers. A blind ‘‘back-translation’’ was then made into

English by a professional mother-tongue translator. This

version was submitted to the English authors who checked

for any inconsistencies with the original text. Following the

authors’ suggestions, 7 of the 150 items were adjusted in

order to better reflect the meaning of the original sentences.

After the modification of these seven items, the draft re-

ceived the approval of the authors of the original version.

Once this was done, the final stage of the adaptation

process started: the pre-test. In order to explore whether the

items and the response options were correctly understood,

we administered the questionnaire to twenty healthy par-

ticipants not included in the subsequent collection of the

data for the normal population (see below). As shown in

Table 1, six questions were identified as ambiguous in this

pre-test phase. We therefore proposed an adjustment for

these six items. Two independent Italian mother-tongue

psychologists confirmed the meaning equivalence of the

two versions.

In order to investigate whether the questionnaires could

be easily administrable also to brain injury patients, (who

may have cognitive deficits and their understanding of

language may be affected), the questionnaires were also

given to a small sample of patients with ABI. Ten patients

(3 women, mean age 35; range 20–46; standard de-

viation = 8.4) were recruited from the rehabilitation Day

Hospital Service of the Cardinal Ferrari Center. Patients

were selected based on the following criteria: (1) presence

of ABI that began with coma of a duration equal to or

greater than 24 h and a Glasgow Coma Scale (GCS) [39] at

onset\9; (2) Levels of Cognitive Functioning [40] equal to

or[7; (3) absence of visual impairment; and (4) absence of

aphasia. The admission to the Day Hospital Service means

that patients are no longer hospitalized and have spent at

least some time at home (see Table 2 for results). The

patients completed the rating scales without particular

problems.

Replication of the validation process In order to measure

test–retest reliability of the final version, 18 subjects were

asked to complete the five questionnaires on two occasions

2–5 months apart. The test–retest reliability was found to

be very high with correlation coefficients ranging from

0.71 to 0.86 (BMQ = 0.76; BREQ = 0.71; BSCQ = 0.83;

BDQ = 0.77; BIQ = 0.72; all p\ 0.001). In addition,

split-half reliability was performed on 70 subjects and it

Table 1 Final adjustment after the test for pre-final version

Item First version Explication of the change process Final version

BMQ-12 Evito di fare le cose che non

sono obbligatorie

The addition of ‘‘unless’’ clarifies the sentence Evito di fare le cose a meno che

non siano obbligatorie

BMQ-16 Ci metto piu tempo a finire

le cose

In the last version, it was added the basis of the comparison Ci metto piu tempo degli altri a

finire le cose

BREQ-1 Ho repentini sbalzi d’umore The word ‘‘repentini’’ is a low-frequency word in Italian. It was

replaced with a more frequent word

Ho improvvisi sbalzi d’umore

BREQ-20 Sono una persona calma In Italian, the expression ‘‘quite person’’ suggests a personality

trait, while to be calm is an alterable state

Sono calmo

BSCQ-5 Fraintendo le istruzioni The term ‘‘instructions’’ needs a further specification Fraintendo le istruzioni che ricevo

da familiari o colleghi

BSCQ-25 Dico la cosa sbagliata The addition of ‘‘it happens that’’ (‘‘Capita che’’) clarifies the

sentence

Capita che io dica la cosa

sbagliata

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was very high (Guttman split-half coefficient,

BMQ = 0.89; BREQ = 0.88; BSCQ = 0.89; BDQ =

0.78; BIQ = 0.91). The internal consistencies of the

questionnaires were investigated on the same 70 par-

ticipants and were also high and well above the generally

accepted level of 0.7 (Cronbach’s alpha, BMQ = 0.89;

BREQ = 0.92; BSCQ = 0.9; BDQ = 0.83; BIQ = 0.91).

The concurrent validity was impossible to gauge due to the

absence of available Italian measures for all the five

questionnaires. Therefore, we decided to address concur-

rent validity in a future study in which we will administer

the questionnaire to ABI patients and compare the results

with outcome measures (e.g., MPAI-IV [33]).

Collection of normative data for an Italian population

Data were collected from 120 participants stratified by

gender, education, and age. We selected four age groups

(21–30, 31–40, 41–50, and 51–60, with 30 participants per

class) and three levels of education (5–12 years of educa-

tion, 13–16 years of education, and equal or more than

17 years of education, with 40 participants per class).

There were 60 male and 60 female participants. There were

therefore five participants for each typology of group (e.g.,

5 males between 21 and 30 years old with 5–12 years of

education, 5 males between 21 and 30 years old with

13–16 years of education, and so on).

The five questionnaires were analyzed separately. The

effect of the variable Gender was evaluated by independent

t tests and the effects of the variables Education and Age by

one-way between-groups analysis of the variance

(ANOVA).

Results

Gender The only significant difference between males and

females emerged in the questionnaire concerning emo-

tional regulation (BREQ; t (1, 118) = 2.16; p = 0.03). In

the rest of the questionnaires, no differences were observed

between males and females (all t\ 1). See Table 3.

Age No significant differences between the four age

groups were observed in any of the questionnaires (BMQ:

F (3, 116) = 2.07, p = 0.11; BREQ: F (3, 116) = 1.91,

p = 0.13; BDQ: F\ 1; BIQ: F\ 1; BSCQ: F\ 1). See

Table 4.

Education No significant differences between the three

levels of education were observed in any of the question-

naires (BMQ: F\ 1; BREQ: F (2, 117) = 1.84, p = 0.16;

BDQ: F (2, 117) = 1.89, p = 0.15; BIQ: F (2,

117) = 2.11, p = 0.12; BSCQ: F\ 1). See Table 5.

Based on these results, the mean value for the BMQ,

BDQ, BIQ, and BSCQ questionnaires can be considered as

the unique reference value independent of age, sex, and

education; while for the BREQ questionnaire there are two

different reference values depending of gender. See

Table 6.

Discussion

The results revealed that in four scales (i.e., BMQ, BDQ,

BIQ, and BSCQ) there was no effect of sex, age, or years of

education. Thus, the average of the sample for each

Table 2 Pre-test results on a population of 10 sABI patients

Patient Sex Age Etiology Months from the event LCF BMQ BREQ BIQ BDQ BSCQ

P1 F 30 TBI 31 7 54 57 59 38 34

P2 F 46 Meningitis 17 7 74 41 56 39 59

P3 M 39 TBI 57 7 60 48 57 39 36

P4 M 39 TBI 72 7 69 44 49 35 52

P5 M 44 Encephalitis 15 7 100 68 57 33 64

P6 M 42 Anoxia 11 7 77 53 63 46 57

P7 M 31 TBI 173 7 64 52 72 57 51

P8 F 20 TBI 5 7 68 83 74 52 74

P9 M 27 TBI 57 7 59 50 49 45 39

P10 M 30 TBI 8 7 51 39 50 33 41

LCF Levels of Cognitive Functioning

Table 3 Mean value and

standard deviation (SD) for

males and females in each of the

five questionnaires

Sex BMQ BREQ BDQ BIQ BSCQ

Mean SD Mean SD Mean SD Mean SD Mean SD

Male 64 10 53 11 42 7 57 10 49 9

Female 63 11 49 10 42 8 56 10 48 9

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questionnaire can be considered as the reference value. By

contrast, in the emotional regulation scale (i.e., BREQ), the

results showed that males had a significantly higher score

indicating lower emotional control (e.g., lack of inhibitory

control, emotionally labile and impulsive behavior, irri-

tability, and poor temper control). This gender effect in the

BREQ may reflect the fact that it is more acceptable for

men to express their anger directly and in a more an-

tagonistic way than for women [41]. We suggest using z-

scores to calculate the distance, expressed in standard de-

viations, from the mean. Critical z score values when using

a 95 % confidence level are ?1.96 standard deviations

from the mean. The full version of the Italian question-

naires can be downloaded in the Supplemental material.

Conclusion

The development of tools to measure patients’ behavioral

symptoms after ABI has been mainly carried out by the

English mother-tongue scientific community. Therefore,

most of the questionnaires are in English and tailored for

the Anglo-Saxon culture. The aim of the current research

was to lay the foundations for a new instrument to assess

behavioral changes in Italian patients with ABI. We did

this by adapting the English BIRT-PQ into Italian and

collecting the first normative data. The BIRT-PQ has

several advantages, as for instance: (a) it is designed for the

ABI population; (b) each questionnaire can be used inde-

pendently or in combination with the others; (c) it has two

versions (one for the patient and the other for a caregiver);

and (d) it is easy to administer and collect the data. Here,

we have provided an Italian version of the BIRT-PQ. In a

further study, we plan to adopt the BIRT-PQ for patients

and evaluate it against a concurrent outcome measure, as

for example the Italian version of the MPAI-IV [42].

Conflict of interest The authors declare that they have no conflict

of interest.

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