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...more likely that unique domains differentially affect family caregivers. research objectives in this study were to: (1) identify the different domains of cognitive changes in the form of behavioral and psychological symptoms after stroke, and (2) establish the reliability of the Brain Impairment Behavior Scale (BIBS) in measuring cognitive domains. Family caregivers of stroke survivors (N = 300) completed the BIBS as part of cross-sectional and longitudinal studies. A subsample of caregivers completed the BIBS twice, 2 weeks apart, to examine the scale's test-retest reliability. We used exploratory factor analysis to identify four domains of behavioral and psychological symptoms in the BIBS: apathy, depression/emotional distress, comprehension/memory problems, and irritability. Internal consistency for the subscales representing each identified domain ranged from .78 to .91, and the 2-week intra-class correlation coefficients ranged from .75 to .88. Future research and clinical use of this measure will increase our understanding of how specific domains of stroke survivors' behavioral and psychological symptoms affect the well-being of family caregivers.
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Stroke is a leading cause of adult disability (Raina, Dukeshire, Lindsay, & Chambers, 1998). In addition to the physical difficulties that can last well into the first year after a stroke (Mayo, Wood-Dauphinee, Cote, Durcan, & Carlton, 2002), stroke is also commonly associated with cognitive changes (Desmond et al., 2000). Behavioral and psychological symptoms are thought to represent the "outward manifestation of some underlying cognitive, psychological, or physiological deficit regardless of origin" (Gauthier, Baumgarten, & Becker, 1996, p. 325). These symptoms can have a profound effect on the emotional well-being of family caregivers who provide essential support to stroke survivors when they return home (Anderson, Linto, & Stewart-Wynne, 1995; Cameron, Cheung, Streiner, Coyte, & Stewart, 2006; Draper, Poulos, Cole, Poulos, & Ehrlich, 1992; Kinney, 1995; White, Poissant, Cote-LeBlanc, & Wood-Dauphinee, 2006). As a result, stroke survivor rehabilitation and the sustainability of home care can be threatened. Therefore, it is important to identify behavioral and psychological symptoms in stroke survivors.
Measures that examine the relationship between cognitive changes and family caregivers' health were developed for psychiatric (Anderson et al., 1995) and elderly populations (Draper et al., 1992). Because these measures were not developed or tested with a population of caregivers of stroke survivors, the measures may not capture the uniqueness of stroke survivors' symptoms and, therefore, could underestimate the occurrence of those symptoms. In addition, previous research commonly viewed behavioral and psychological symptoms as a global construct (Anderson et al.; Draper et al.; Kinney, 1995; Schulz, Tompkins, & Rau, 1988). Yet it is more likely that distinct aspects or domains of symptoms differentially affect caregiver outcomes.
The Brain Impairment Behavior Scale (BIBS) was developed to identify the presence of behavioral and psychological symptoms in the stroke population as assessed by family caregivers (Williams, 1994; Williams & Dahl, 2002). In this article, we examine the psychometric properties of BIBS. Specifically, we identified the underlying domains of behavioral and psychological symptoms captured by the scale and determined the measure's internal consistency and stability over time.
Methods
Measure
The BIBS was developed through literature review, clinical experience, and consultation with family caregivers of stroke survivors (Williams, 1994; Williams & Dahl, 2002). Preliminary research by Williams, using a sample of 26 family caregivers of stroke survivors, identified some infrequently endorsed items and some complex items (e.g., asking two questions within one item). We revised the measure by removing the infrequently endorsed items, simplifying the complex items, and adding eight new items from the literature and four items from clinical experience to yield a 37-item scale (Fig. 1; Cameron, 2004). Some of the new items were "becomes uncooperative," "becomes suspicious or accusing," "becomes fearful and afraid," and "gets depressed." Family caregivers, who have frequent contact with the stroke survivors and therefore have ample opportunities to observe them, were asked in a structured interview to answer, for each item, "How often during the past 2 weeks did you observe the care receiver behaving this way?" Responses ranged from 1 (never) to 5 (all the time). Higher scores indicated more frequent behavioral and psychological symptoms as perceived by family caregivers. To support data collection with the French-speaking participants in Montreal, the measure was translated into French by using the forward and backward translation approach (Bullinger et al., 1998).
Participants
Family caregivers were defined as the people who, without financial compensation, were primarily responsible for providing or coordinating the stroke survivors' care in the home. Caregivers were included if they spoke English or French well enough to participate in the structured interview. All caregivers provided written informed consent, and participating institutions' research ethics boards approved the study protocol.
Participants for the factor analysis and estimations of internal consistency were selected from three...
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