Brain Injury, June 2012; 26(6): 844–852

Preliminary validation of the Spanish version of the Frontal

Systems Behavior Scale (FrSBe) using Rasch analysis

ALFONSO CARACUEL1,2, ANTONIO VERDEJO-GARCÍA1,2, MARÍA JOSÉ

FERNÁNDEZ-SERRANO1, LAURA MORENO-LÓPEZ1, SANDRA SANTAGO-
RAMAJO1, IGNACIO SALINAS-SÁNCHEZ3, & MIGUEL PÉREZ-GARCÍA1,2
1
Departamento de Personalidad, Evaluación y Tratamiento Psicológico, University of Granada, Granada, Spain,
2
Institute of Neurosciences F. Olóriz, University of Granada, Granada, Spain, and 3Virgen de las Nieves Hospital,
Brain Inj Downloaded from informahealthcare.com by EBSCO on 05/16/12

Granada, Spain

(Received 11 January 2011; revised 16 June 2011; accepted 22 June 2011)

Abstract
For personal use only.

Primary objective: To explore the construct validity of the Spanish version of the Frontal Systems Behavioral Scale (FrSBe)
using Rasch modelling.
Methods: Item responses of 245 Spanish subjects were analysed using Rasch analysis: self-rating of 65 participants with
TBI or stroke (sample A), family-rating of the same 65 participants (sample B) and self-rating of 115 healthy individuals
(sample C).
Results: After removing or grouping several problematic items, the Apathy and the Executive Dysfunction sub-scales
were found to be valid measures for samples A and B and the Disinhibition sub-scale was valid for samples B and C. Person
Separation Index of reliability of sub-scales was greater than 0.83 for sample B and 0.72 for A and C. All items showed
disordered threshold categories in samples A and B and five items were ordered in sample C.
Conclusions: With a few modifications, the sub-scales of the FrSBe-Spanish version are adequate measures for the
assessment of the behavioural syndromes derived from frontal systems dysfunction in persons with brain injury. The family-
rating form is preferable to the self-rating form. Only the Disinhibition scale is a valid measure for the behavioural
assessment of the normal population. A reduction of response categories is suggested.

Keywords: FrSBe, Rasch analysis, prefrontal cortex systems, apathy, disinhibition, executive dysfunction, frontal behaviours,
traumatic brain injury, stroke

Introduction executive dysfunction is a major issue for neuropsy-

The prevalence rate of traumatic brain injury (TBI)
in the US is estimated to be 1893 out of 100 000 [1].
Executive functions, which are importantly endorsed
by structure and function of the frontal lobes,
are highly sensitive to the brain damage resulting
from traumatic injury [2]. Furthermore, 39%
of people after stroke have disorders of executive
functioning [3]. Therefore, the assessment of
chological practice in the area of acquired brain
injury (ABI). The Frontal Systems Behavior Scale
(FrSBe) [4], formerly known as the Frontal Lobe
Personality Scale (FloPS) [5], is a rating scale that
was designed to provide an estimation of overall
behavioural disturbances related to prefrontal sys-
tems damage (total score) and three independent
measures of specific behavioural syndromes

Correspondence: Alfonso Caracuel, PhD, Facultad de Psicologı́a, Campus de Cartuja, 18071, Granada, Spain. E-mail: acaracuel@ugr.es
ISSN 0269–9052 print/ISSN 1362–301X online ß 2012 Informa UK Ltd.
DOI: 10.3109/02699052.2012.655365

associated with damage to particular prefrontal-
subcortical (PFC) systems [6–8]. The scale is
composed of 46 items, which are grouped into
the following three sub-scales: Apathy (14 items,
FrSBe-Ap), Disinhibition (15 items, FrSBe-Dis) and
Executive dysfunction (17 items, FrSBe-Exe). There
is one self-rating form that is completed by the
patient and one family form that is completed by
an informant. Both forms assess behaviour before
(i.e. premorbid or baseline) and after frontal systems
damage occurred (i.e. morbid or current state). The
manual provides normative data (T scores) from a
sample of 436 healthy adults and their relatives [4].
The FrSBe has been used for the behavioural
assessment of a number of disorders involving
damage to PFC systems [9, 10], including frontal
and non-frontal ABI [5, 11, 12], Alzheimer’s
Disease [13], Parkinson’s Disease [14, 15], multiple
Brain Inj Downloaded from informahealthcare.com by EBSCO on 05/16/12
sclerosis [16–18], amyotrophic lateral sclerosis [19]
and substance use disorders [20–23]. Although it
was designed to be administered to neurological
samples, the scale has also been applied to obsessive
compulsive disorder [24], schizophrenia [25, 26]
and secondary psychopathy [27]. Its use has also
spread among healthy populations for the assess-
For personal use only.
ment of the risk of developing alcohol use disorders,
maladaptative eating behaviours, financial decisions,
empathy and metacognitive awareness [28–35].
Concerning the reliability of the sub-scales,
the manual reports that the Cronbach’s alpha
coefficients in the normal population range between
0.78–0.87 for the family form and between 0.72–
0.79 for the self-rating form. Slightly greater  values
were found for samples of neurological patients, with
the FrSBe-Exe sub-scale showing the greatest
reliability indexes [4, 9]. With regard to validity,
a factor analysis in a normative sample yielded
support to the validity of the three scales. However,
items 33 and 43 loaded onto FrSBe-Ap, which is not
the originally assigned sub-scale for these items [5].
In addition, a factor analysis of the family-rating
form in a large neurological patient sample found
that six items (items 6, 23, 33, 36, 40 and 43) loaded
onto a factor other than the corresponding sub-scale
[10]. Both series of items were maintained in their
original scales, but the authors suggested that some
revision or elimination of specific items may be
warranted to refine the scales and enhance their
validity [9].
A Spanish version of the FrSBe, which was
approved by the authors and the editors of the
scale, has been used for the assessment of persons
with ABI and substance abusers in Spanish samples
[22, 36]. The self-rating form of this Spanish version
had similar reliability  values as those found in
US populations. Regarding validity, this version
discriminated between persons with frontal ABI,
Validation of the FrSBe-Spanish version 845
substance abusers and healthy control participants.
However, the scores of individuals with ABI and
healthy controls were moderately lower than those
collected for their corresponding groups in the
original norms. This was attributed to cultural
differences between Spanish and US samples [36].
In spite of these positive findings regarding the
scale’s reliability, further analysis that employs novel
psychometric tools may improve the construct
validity of the FrSBe-Spanish version. Since Rasch
analysis tests several measurement requirements
(construct validity, unidimensionality, appropriate-
ness of response categories) [37], it is a highly
recommended method of refining measurement
tools [38]. Although the FrSBe is widely used
in both clinical and research settings, to date, no
studies have attempted to apply Rasch analysis to
this scale. There is considerable scarcity of specific
measures to assess executive dysfunction in Spanish
speakers. Some of the measures used in English-
speaking countries have been translated, but they
mostly lack studies on psychometric properties and
validation. The aim of the current study was to
explore the construct validity of the Spanish version
of the FrSBe using Rasch analysis in samples of
participants with brain injury and the normal
population.
Methods
Participants and settings
Data from the following three samples were ana-
lysed: (A) Sixty-five participants (14 women) with
ABI (45 TBI, 20 Stroke) aged 15–65 years old
(M ¼ 30.11; SD ¼ 12.12) with 8–16 years of educa-
tion (M ¼ 10.23; SD ¼ 2.75). The average time
incurred since their injury was 22.4 months
(SD ¼ 20.55 months). (B) Sixty-five relatives of the
sample A participants (10 men) aged 25–67 years
old (M ¼ 50.55; SD ¼ 22.34) with 4–16 years of
education (M ¼ 8.23; SD ¼ 3.55). (C) One hundred
and fifteen healthy participants (17 women) aged
18–50 years (M ¼ 30.11; SD ¼ 8.48) with 8–17 years
of education (M ¼ 12.25; SD ¼ 2.65).
The selection criteria for sample A were:
(i) documented moderate–severe TBI or stroke
(i.e. initial Glasgow Coma Scale 13; post-traumatic
amnesia greater than 24 hours or a period of
unconsciousness longer than 6 hours); (ii) time
incurred since injury over 30 days; (iii) minimum age
of 15 years; (iv) the absence of severe language
comprehension problems; (v) resides at home and
substantially self-reliant in daily life activities; and
(vi) availability of a relative who was willing and
capable of completing the scale. A consecutive series
of 65 patients who met the selection criteria were
 846 A. Caracuel et al.
recruited from the outpatient rehabilitation depart-
ment of the Virgen de las Nieves Hospital (Granada,
Spain). They completed the scale during the first
appointment as part of the typical assessment
protocol. Healthy individuals were selected by
means of local advertisements and using snowball
or chain sampling among adults from the commu-
nity. The selection criteria for the health sample
included the absence of a history of mental retarda-
tion, learning disability, psychiatric disorders, sub-
stance abuse, neurological disorders or systemic
diseases that might affect the central nervous
system. Individuals from samples A and C com-
pleted the scale by rating their own current
behaviour, whereas sample B participants rated the
current behaviour of their relatives. All participants
read, understood and signed an informed consent
prior to completing the scale in the presence of, and
Brain Inj Downloaded from informahealthcare.com by EBSCO on 05/16/12
if necessary with the assistance of, a clinician.
Materials
A Spanish version of the Frontal Systems Behavior
Scale (FrSBe) [4] that was adapted and reproduced
by special permission of the publisher (Psychological
For personal use only.
Assessment Resources, Inc.) was used. A useful
abbreviation of the original items can be found
elsewhere [10]. Participants respond using a Likert
scale that ranges from 1–5 (1 ¼ almost never,
2 ¼ seldom, 3 ¼ some times, 4 ¼ frequently and
5 ¼ almost always). Items are visually divided into
two sets. The first set (items 1–32) asks about
negative or maladaptative behaviours and the second
set (items 33–46) is about positive or adaptative
behaviours. Ratings from the second set are reverse-
scored; therefore, higher ratings indicate a greater
frequency of abnormal frontal systems behaviour.
Analysis
The Rasch model [39] is a probabilistic model of
measurement within the Item Response or Latent
Trait Theory. Based on this model, only (i) the
amount of symptom expressed by the item and
(ii) the subject’s disorder determine the probabilities
of category choice. For this model, the probability
that a person endorses an item is a logistic
function of the difference between these two para-
meters estimated from the matrix of responses [40].
People with low syndrome severity should endorse
item categories connected to low symptom severity.
Rasch analysis tests the extent to which the observed
pattern of responses fits the pattern expected by the
probabilistic model. Items and persons are calibrated
and placed on a common scale, with the logit as the
unit [41]. One logit can be defined as the increase
in the subject’s disorder that increases the prob-
ability of responding in a given category rather than
in the category below by a factor of e1 ¼ 2.71 [42].
Construct validity under the Rasch analysis is
determined by examining the hierarchy of the
items in the latent construct as well as by evaluating
its fit to the model [43]. Steps in conducting a Rasch
analysis and its interpretations have been explained
in detail by others [37, 44–46]. A brief explanation
of the key features of the Rasch analysis that
grounded the present study can be found in
Kersten et al. [47]. Rasch analysis was performed
using RUMM2020 software [48] and descriptive
statistics were calculated using SPSS V17.0 for
Windows.
Results
Rasch analysis of the whole scale
Inspection of the data revealed that only a few
missing data points were spread throughout the
scale, with frequencies lower than 2% for all items.
Separate analysis for each sample were conducted
for the 46 items of the whole scale. The Rating
Scale version of the Rasch model was adopted
because there were less than 10 observations in
some response categories [49]. Considering the non-
significant summary chi-square item-trait interac-
tion, a good overall fit to the model was found for the
three samples. However° the whole scale showed
multidimensionality in all samples, then, this analy-
sis was not reported and subsequent analyses were
conducted examining the three sub-scales separately.
Rasch analyses of the sub-scales for each sample
Sample A: Participants with ABI. The five analyses
conducted are listed in Table I. The FrSBe-Ap sub-
scale fits to the model after deleting item 11 and
grouping items 41 and 42 into one item. This
grouping was done because these two items showed
high residual correlations, indicating local response
dependency. This grouping strategy failed for items
11 and 39 and, thus, the former was removed,
improving the fit of the FrSBe-Ap. The FrSBe-Dis
sub-scale showed fit but its unidimensionality was
questionable because 6.15% of t-test was significant
at 95% confidence (italics in Table I), while the
criterion is typically set at a maximum of 5%.
Regarding the FrSBe-Exe, after deleting item 36, the
sub-scale achieved an overall fit (non-significant p
after Bonferroni adjustment). In relation to the
reliability of the scales using Rasch analysis, the
Person Separation Index (PSI) is an estimate
that may be interpreted in a manner similar to
Cronbach’s alpha reliability coefficient. A low PSI,
ranging from 0.73–0.74, was found for the three sub-
scales.
 Validation of the FrSBe-Spanish version 847

Table I. Summary of results of the Rasch analyses of the FrSBe for participants with ABI (sample A).

Correlated
Item-trait Deleted or item Item Fit Person Fit
interaction grouped residuals Residual Residual Reliability Unidimensionality
Sub-scale #Analysis 2 (Df) p items >0.30 Mean (SD) Mean (SD) PSI Sig t-test CI

Apathy
(n ¼ 65) 1st 21.01 (14) 0.09 11 (deleted) 11–39 0.176 (1.2) 0.170 (1.3) 0.70 2.31% (6.1–22.7)
(n ¼ 65) 2nd 13.33 (12) 0.34 41 þ 42 41–42 0.470 (0.88) 0.079 (1.1) 0.74 4.62% (1.5–12.7)
(grouped)
Disinhibition
(n ¼ 65) 1st 21.79 (15) 0.11 0.041 (1.2) 0.185 (1.3) 0.73 6.15% (1.9–15.2)
Executive dysfunction
(n ¼ 65) 1st 31.9 (17) 0.01 36 (deleted) 0.230 (1.6) 0.149 (1.5) 0.71 12.31% (6.1–22.7)
(n ¼ 65) 2nd 29.03 (16) 0.02* 0.224 (1.4) 0.178 (1.5) 0.74 4.62% (1.5–12.7)

# Analysis: number of each analysis. Item-trait interaction, 2, (Df), p: summary chi-square for all items in the sub-scale, indicating the
overall fit to the model; Df: Degree of freedom. Deleted or grouped items: deleted items for item misfit or grouped into a super-item.
Correlated item residuals >0.30: items showing residual correlations above 0.3. Item Fit Residual, Mean and SD: summary of item fit
statistics; Person Fit Residual, Mean and SD: summary of person fit statistics. Reliability PSI: Person Separation Index of reliability.
Brain Inj Downloaded from informahealthcare.com by EBSCO on 05/16/12

Unidimensionality, Sig t-test CI: % of significant t-test at 95% of confidence and Confidence Interval. * non-significant p after Bonferroni
adjustment.

Table II. Summary of results of the Rasch analyses of the FrSBe for relatives (sample B).

Correlated
For personal use only.

Item-trait item Item Fit Person Fit

interaction Deleted residuals Residual Residual Reliability Unidimensionality
Sub-scale #Analysis 2 (Df) p items >0.30 Mean (SD) Mean (SD) PSI Sig t-test CI

Apathy
(n ¼ 64) 1st 18.48 (14) 0.18 0.009 (1.4) 0.088 (1.1) 0.87 3.13% (0.8–10.7)
Disinhinbition
(n ¼ 65) 1st 30.89 (15) 0.009 43 0.213 (1.4) 0.147 (1.1) 0.79 6.15% (1.9–15.2)
(n ¼ 64) 2nd 25.94 (14) 0.2 0.170 (1.3) 0.151 (1.1) 0.83 3.13% (0.8–10.7)
Executive dysfunction
(n ¼ 65) 1st 22.71 (17) 0.15 0.51 (1.0) 0.136 (1.3) 0.86 4.62% (1.5–12.7)
2
# Analysis: number of each analysis. Item-trait interaction,  , (Df), p: summary chi-square for all items in the sub-scale, indicating the
overall fit to the model; Df: Degree of freedom. Deleted items: deleted for item misfit. Correlated item residuals >0.30: items showing
residual correlations above 0.3. Item Fit Residual, Mean and SD: summary of item fit statistics; Person Fit Residual, Mean and SD:
summary of person fit statistics. Reliability PSI: Person Separation Index of Reliability. Unidimensionality, Sig t-test CI: % of significant
t-test at 95% of confidence and Confidence Interval.

obtained adequate unidimensionality. Only the

Sample B: Relatives of participants with ABI. The
four analyses conducted are listed in Table II. The
three sub-scales achieved all of the Rasch model
requirements after deleting item 43 due to misfit.
The PSI ranged between 0.83–0.87. This indicates
that persons with ABI can be sorted into three
separate groups of dysfunction severity (mild,
moderate and severe) using the FrSBe [43].
Sample C: Healthy participants. The seven analyses
conducted are listed in Table III. Despite the
changes that were made in the FrSBe-Ap (item 1
deleted; items 41 and 42 grouped) and the FrSBe-
Exe (items 17 and 33 deleted), neither sub-scale
FrSBe-Dis showed fit and unidimensionality after
deleting item 43.
Hierarchy of the items on the sub-scales. Rasch
analysis calibrates items based on endorsement
probability and person disorder. Thus, the items
that are easier to endorse are the most representative
of the latent construct and are located on the side
of the higher negative location of the logit scale
(see Figures 1–3). The opposite location indicates
that the item had a lower probability of endorse-
ment, representing higher disorder severity. Along
with the fit to the model, this hierarchy of items
was used to examine the construct validity of the
 848 A. Caracuel et al.

Table III. Summary of results of the Rasch analyses of the FrSBe for control participants (sample C).

Correlated
Item-trait Deleted or item Item Fit Person Fit
interaction grouped residuals Residual Residual Reliability Unidimensionality
Sub-scale #Analysis 2 (Df) p items >0.30 Mean (SD) Mean (SD) PSI Sig t-test CI

Apathy
(n ¼ 114) 1st 37.2 (15) 0.0006 1 (deleted) 41–42 0.107 (0.97) 0.237 (0.97) 0.72 7.89% (4–14.5)
(n ¼ 114) 2nd 16 (12) 0.16 41 þ 42 0.170 (0.69) 0.210 (0.74) 0.71 6.14% (2.7–12.3)
(grouped)
Disinhinbition
(n ¼ 114) 1st 36.12 (15) 0.001 43 (deleted) 0.125 (0.94) 0.194 (0.87) 0.73 6.14% (2.7–12.3)
(n ¼ 114) 2nd 20.69 (14) 0.1 0.148 (0.92) 0.205 (0.85) 0.72 1.7% (1.6–4.8)

Executive dysfunction
(n ¼ 115) 1st 14.15 (17) 0.6 33 (deleted) 0.006 (1.7) 0.207 (1.1) 0.71 7.83% (4–14.3)
(n ¼ 115) 2nd 16.93 (16) 0.3 17 (deleted) 0.043 (1.3) 0.207 (1.1) 0.72 6.96% (3.3–13.3)
(n ¼ 114) 3rd 12.20 (15) 0.6 0.122 (1.1) 0.253 (1.1) 0.75 7.02% (3.4–13.4)

#Analysis: number of each analysis. Item-trait interaction, 2, (Df), p: summary chi-square for all items in the sub-scale, indicating the
overall fit to the model; Df: Degree of freedom. Deleted or grouped items: deleted items for item misfit or grouped into a super-item.
Brain Inj Downloaded from informahealthcare.com by EBSCO on 05/16/12

Correlated item residuals >0.30: items showing residual correlations above 0.3. Item Fit Residual, Mean and SD: summary of item fit
statistics; Person Fit Residual, Mean and SD: summary of person fit statistics. Reliability PSI: Person Separation Index of reliability.
Unidimensionality, Sig t-test CI: % of significant t-test at 95% of confidence and Confidence Interval. *non-significant p after Bonferroni
adjustment.

sub-scale. There was great concordance on item Differential Item Functioning (DIF). DIF indicates
location between the three samples; therefore, that different sub-groups within the sample respond
combined results from all samples are reported. in a different manner to an individual item, despite
For personal use only.

On the FrSBe-Ap, items 41, 42, 8, 14, 29, 1 and
21 achieved the highest negative locations, whereas
item 16 had the highest positive location. On the
FrSBe-Dis, the highest negative locations were for
items 2, 4, 6, 45, 18, 12, 32 and 10, whereas the
opposite was found for item 31. On the FrSBe-Exe,
items 3, 25, 36, 7, 13, 37 and 35 were on the
negative side of the latent construct and item 20 had
the highest positive location.
equal severity of the disorder being measured. Sub-
groups of participants were coded according to the
original normative data of the FrSBe [4]: gender,
education (12 and >12 years), age (39 and >39
years) and diagnosis (only for the ABI sample: TBI
or Stroke). An ANOVA of person-item deviation
residuals with the above-mentioned characteristics
and class intervals as factors was conducted [37]. No
item showed DIF by the factors used.

Targeting. Targeting of the sub-scales to the sam-

Response categories. In order to determine whether
the categorization worked as intended, threshold
ordering was inspected. A threshold is the transition
between two consecutive response categories. For
each item, the expectation is that as the patient’s
disorder severity increases, the probability of select-
ing each category increases in an ordered fashion
[50] from ‘almost never’ to ‘almost always’.
However, all items showed disordered threshold
categories in samples A and B, and only five items
were ordered for sample C. This can typically be
managed by collapsing adjacent categories. Different
re-scoring patterns were attempted by reducing the
number of response categories from five to four.
However, most items continued to show disordered
thresholds. Finally, a 3-point response scale showed
adequate ordering in most of the items. These
changes did not improve the overall fit of the sub-
scales; therefore, these analyses are not detailed in
the manuscript.
ples was examined on the logit scale using compar-
isons of the items and person locations. The best
targeting was found for the FrSBe-Exe sub-scale and
the worst for the FrSBe-Ap sub-scale. Figures 1–3
show the targeting of the FrSBe-Exe data for the
three samples. Targeting was most successful for the
relatives and least successful for the healthy
participants.
Discussion
The first aim of the study was to explore the
construct validity of the Spanish version of the
FrSBe and its sub-scales using Rasch analysis. These
analyses were used to describe item response
characteristics of the self-ratings of persons with
brain injury, relatives’ ratings of these participants
and the self-ratings of healthy individuals.
Theoretically, more than one latent construct is
expected in the FrSBe [6]. This has been confirmed

Brain Inj Downloaded from informahealthcare.com by EBSCO on 05/16/12
Figure 1. Person-threshold map: Distribution of participants with ABI using self-rating form (upper part of the graph) and item thresholds
for the FrSBe-Exe subscale (lower part of the graph).
For personal use only.
Figure 2. Person-threshold map: Distribution of participants with ABI rated by their relatives (upper part of the graph) and item thresholds
for the FrSBe-Exe subscale (lower part of the graph).
using the Rasch model and, thus, the whole scale
cannot be considered a unidimensional instrument.
The main implication of this is that a sum-score of
the 46 items included in the FrSBe does not
constitute a valid and meaningful measure. Rather
than an overall score, Rasch analysis supports the
use of a behavioural profile [51] of frontal systems
dysfunction formed by the scores of the three sub-
scales.
The construct validity of the sub-scales for persons
with brain injury is supported by the results from
Rasch analysis, with the exception of the self-rating
form of the Disinhibition sub-scale. However, some
Validation of the FrSBe-Spanish version 849
changes were needed within each sub-scale in order
to achieve both a perfect fit and unidimensionality.
Some of these proposed changes were previously
suggested in the literature. First, during the process
of development of the original scale, an independent
expert rater sorted most of the items into the same
sub-scales proposed by the authors, with the excep-
tion of items 11, 20, 31, 33, 34, 35 and 43. Then, a
subsequent factor analysis in a normative sample
showed that five of these items were correctly
assigned by the authors, but items 33 and 43 loaded
onto a sub-scale other than the originally assigned
sub-scale [5]. The current Rasch analysis also found
 850 A. Caracuel et al.
Brain Inj Downloaded from informahealthcare.com by EBSCO on 05/16/12
Figure 3. Person-threshold map: Distribution of healthy participants (upper part of the graph) and item thresholds for the FrSBe-Exe
subscale (lower part of the graph).
that several items (items 1, 11, 17, 33, 36 or 43) fail to
For personal use only.
fit to the model. These results raise concern about
potential problems with the coherence between
the content of the item and the latent trait [52].
The deletion of these items improved unidimension-
ality and reliability of the three sub-scales, supporting
their poor contribution to the latent traits. However,
several hypotheses might explain the misfits found
across samples. For example, problems derived from
unclear and subjective content, negative wording or
the use of more than one statement might impact on
the items’ behaviour. Furthermore, since grouping
items with lack of local independency improved the fit
of the Apathy sub-scale, it was suggested to reword
items 41 (get involved with activities spontaneously)
and 42 (do things without being requested to do so) into
a single item.
The construct validity of the sub-scales for normal
populations was supported only for the Disinhibition
sub-scale. Unidimensionality for the Apathy and
Executive dysfunction sub-scales was not achieved.
In these healthy participants, some behaviours
contained in these sub-scales may be connected
to dimensions other than the functioning of the
prefrontal cortex systems.
The construct validity of the three sub-scales was
also supported by the hierarchy of items within each
sub-scale. All items on the negative side of the logit
scales were the most representative and common in
clinical practice of each latent construct. As further
support, several infrequent items fell on the positive
extreme of the logit scale and these are the typical
symptoms of the greatest dysfunctions. Some of
these items reflect pathognomonic signs of frontal
systems disorder, including items 31 (find that food
has no taste or smell), 20 (make up fantastic stories when
unable to remember something) and 16 (lose control of
my urine or bowels and it doesn’t seem to bother me).
This excessive specificity might be problematic
for targeting the sub-scales to healthy or non-
neurological populations (see Figure 3).
Regarding the index of reliability, only the
relatives’ ratings had a PSI greater than 0.80 to
adequately classify syndrome severity into the three
meaningful groups of mild, moderate and severe.
Taking into account construct validity, reliability
and targeting of the authorised FrSBe-Spanish
version, the family-rating form achieved all require-
ments of the Rasch model of measurement
after deleting item 43 (s/he is sensitive to the needs
of other people). There was no DIF by gender,
age, education or diagnostic, further supporting the
psychometric properties of the scale.
However, with respect to response categories,
41 items from the healthy participants’ sample
showed disordered thresholds. This lack of order
indicates that participants failed to use the 5-point
scale in a manner that is consistent with the metric
estimate of the underlying construct [37]. The
fact that, similar to persons with brain injury,
healthy individuals’ responses showed disordered
responses indicates that this limitation of the scale
is not linked to the degree of brain damage-
related disturbance. Threshold disorder may indi-
cate that more categories exist in the scale than
are needed to describe the construct [53]. As

recommended by some authors [52], simplifying the
response format can be a useful strategy for
improving the precise assessment of behaviour.
These preliminary findings may yield relevant
clinical and psychometric implications. The FrSBe-
SA is the only tool for the assessment of executive
functioning in Spanish individuals with ABI that
has demonstrated fulfilment of the stringent valida-
tion criteria used by the Rasch analysis. Because
executive dysfunction is one of the most common
problems experienced by ABI sufferers, this scale
guarantees an appropriate clinical assessment for
a substantial amount of potential Spanish-speaking
clients. The FrSBe-SA is also a valid measure for the
assessment of rehabilitation outcomes, such that
it may allow carrying out comparative studies of
results of rehabilitation programmes implemented in
Brain Inj Downloaded from informahealthcare.com by EBSCO on 05/16/12
different countries where the instrument is
available [54].
A number of limitations of this study must be
addressed in future research endeavours. Certain
aspects of the results should be replicated using
a larger sample size. For instance, the absence of
DIF by gender or diagnosis should be replicated
For personal use only.
in samples that include a greater number of females
and participants with stroke. Future studies should
also test a shortened Likert scale of three or four
response categories, assess the construct validity of
the premorbid rating form in neurological popula-
tions or check DIF by treatment time. In addition,
it is important to note that the results were obtained
in a sample of Spanish speakers in Spain and,
therefore, replications with Latin-American popula-
tions are warranted to further explore the cross-
cultural validity of the scale. Future research should
also test the design of different versions of the
scale for individuals with ABI and their relatives or
informants.
Conclusions
The Rasch analysis of the Spanish version of the
FrSBe raised mild construct validity concerns that
were previously discussed within the framework of
the development of the original scale. The deletion
of a minimal amount of items and the grouping
of two items improved the overall fit to the Rasch
model of the three sub-scales. The construct validity
of the three sub-scales was supported for the family-
rating form, but only for the Apathy and the
Executive dysfunction sub-scales for the self-rating
form. Only the Disinhibition scale was a valid
measure for the behavioural assessment of the
normal population. A reduction of response cate-
gories is suggested.
Validation of the FrSBe-Spanish version 851
Declaration of Interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
References
1. Tagliaferri F, Compagnone C, Korsic M, Servadei F,
Kraus J. A systematic review of brain injury epidemiology
in Europe. Acta Neurochirurgica 2006;148:255–268.
2. Stuss DT, Levine B. Adult clinical neuropsychology: Lessons
from studies of the frontal lobes. Annual Review of
Psychology 2002;53:401–433.
3. Nys GMS, van Zandvoort MJE, de Kort PLM, Jansen BPW,
de Haan EHF, Kappelle LJ. Cognitive disorders in acute
stroke: Prevalence and clinical determinants. Cerebrovascular
Disease 2007;23:408–416.
4. Grace J, Malloy PF. Frontal Systems Behavior Scale (FrSBe).
Professional manual. Lutz, FL: Psychological Assessment
Resources, Inc; 2001.
5. Grace J, Stout JC, Malloy PF. Assessing frontal lobe
behavioral syndromes with the Frontal Lobe Personality
Scale. Assessment 1999;6:269–284.
6. Cummings JL. Frontal-subcortical circuits and human
behavior. Archives of Neurology 1993;50:873–880.
7. Masterman DL, Cummings JL. Frontal-subcortical circuits:
The anatomic basis of executive, social and motivated
behaviors. Journal of Psychopharmacology 1997;11:
107–114.
8. Tekin S, Cummings JL. Frontal-subcortical neuronal
circuits and clinical neuropsychiatry: An update. Journal of
Psychosomatic Research 2002;53:647–654.
9. Malloy P, Grace J. A review of rating scales for measuring
behavior change due to frontal systems damage. Cognitive
and Behavioral Neurology 2005;18:18–27.
10. Stout JC, Ready RE, Grace J, Malloy PF, Paulsen JS. Factor
analysis of the Frontal Systems Behavior Scale (FrSBe).
Assessment 2003;10:79–85.
11. Lane-Brown AT, Tate RL. Measuring apathy after traumatic
brain injury: Psychometric properties of the Apathy
Evaluation Scale and the Frontal Systems Behavior Scale.
Brain Injury 2009;23:999–1007.
12. Reid-Arndt SA, Nehl C, Hinkebein J. The Frontal Systems
Behaviour Scale (FrSBe) as a predictor of community
integration following a traumatic brain injury. Brain Injury
2007;21:1361–1369.
13. Malloy P, Tremont G, Grace J, Frakey L. The Frontal
Systems Behavior Scale discriminates frontotemporal demen-
tia from Alzheimer’s disease. Alzheimer’s and Dementia
2007;3:200–203.
14. Denheyer M, Kiss ZH, Haffenden AM. Behavioral effects of
subthalamic deep brain stimulation in Parkinson’s disease.
Neuropsychologia 2009;47:3203–3209.
15. Marsh L, Biglan K, Gerstenhaber M, Williams JR.
Atomoxetine for the treatment of executive dysfunction in
Parkinson’s disease: A pilot open-label study. Movement
Disorders 2009;24:277–282.
16. Basso MR, Shields IS, Lowery N, Ghormley C, Combs D,
Arnett PA, et al. Self-reported executive dysfunction,
neuropsychological impairment, and functional outcomes in
multiple sclerosis. Journal of Clinical and Experimental
Neuropsychology 2008;30:920–930.
17. Chiaravalloti ND, DeLuca J. Assessing the behavioral
consequences of multiple sclerosis: An application of the
frontal systems behavior scale (FrSBe). Cognitive and
Behavioral Neurology 2003;16:54–67.
 852 A. Caracuel et al.
18. Goverover Y, Chiaravalloti N, DeLuca J. The relationship
between self-awareness of neurobehavioral symptoms, cog-
nitive functioning, and emotional symptoms in multiple
sclerosis. Multiple Sclerosis 2005;11:203–212.
19. Grossman A, Woolley-Levine S, Bradley W, Miller R.
Detecting neurobehavioral changes in amyotrophic lateral
sclerosis. Amyotrophic Lateral Sclerosis 2007;8:56–61.
20. Spinella M. Relationship between drug use and prefrontal-
associated traits. Addiction Biology 2003;8:67–74.
21. Verdejo-Garcı́a A, Bechara A, Recknor EC, Pérez-Garcı́a M.
Executive dysfunction in substance dependent individuals
during drug use and abstinence: An examination of the
behavioral, cognitive and emotional correlates of addiction.
Journal of the International Neuropsychological Society
2006;12:405–415.
22. Verdejo-Garcı́a A, Pérez-Garcı́a M. Substance abusers’ self-
awareness of the neurobehavioral consequences of addiction.
Psychiatry Research 2008;158:172–180.
23. Verdejo-Garcı́a A, Rivas-Pérez C, López-Torrecillas F,
Pérez-Garcı́a M. Differential impact of severity of drug use
on frontal behavioral symptoms. Addictive Behaviors
Brain Inj Downloaded from informahealthcare.com by EBSCO on 05/16/12
2006;31:1373–1382.
24. Batistuzzo MC, Taub A, Nakano E, D’Alcante CC,
de Mathis ME, Hoexter MQ, et al. Performance of patients
with refractory obsessive-compulsive disorder in the Frontal
Systems Behavior Scale. Neurocase 2009;15:157–162.
25. Kawada R, Yoshizumi M, Hirao K, Fujiwara H, Miyata J,
Shimizu M, et al. Brain volume and dysexecutive behavior
in schizophrenia. Progress in Neuro-Psychopharmacology
For personal use only.
and Biological Psychiatry 2009;33:1255–1260.
26. Yoshizumi M, Hirao K, Ueda K, Murai T. Insight in social
behavioral dysfunction in schizophrenia: Preliminary study.
Psychiatry and Clinical Neurosciences 2008;62:669–676.
27. Ross SR, Benning SD, Adams Z. Symptoms of executive
dysfunction are endemic to secondary psychopathy: An
examination in criminal offenders and noninstitutionalized
young adults. Journal of Personality Disorders 2007;21:
384–399.
28. Hoerold D, Dockree PM, O’Keeffe FM, Bates H, Pertl M,
Robertson IH. Neuropsychology of self-awareness in young
adults. Experimental Brain Research 2008;186:509–515.
29. Lyvers M, Czerczyk C, Follent A, Lodge P. Disinhibition
and reward sensitivity in relation to alcohol consumption by
university undergraduates. Addiction Research and Theory
2009;17:668–677.
30. Lyvers M, Thorberg FA, Ellul A, Turner J, Bahr M. Negative
mood regulation expectancies, frontal lobe related behaviors
and alcohol use. Personality and Individual Differences
2010;48:332–337.
31. Spinella M. Prefrontal substrates of empathy: Psychometric
evidence in a community sample. Biological Psychology
2005;70:175–181.
32. Spinella M. Measuring the executive regulation of emotion
with self-rating scales in a nonclinical population. Journal of
General Psychology 2007;134:101–111.
33. Spinella M, Lyke J. Executive personality traits and eating
behavior. International Journal of Neuroscience 2004;114:
83–93.
34. Spinella M, Yang B, Lester D. Prefrontal system dysfunction
and credit card debt. International Journal of Neuroscience
2004;114:1323–1332.
35. Spinella M, Yang B, Lester D. Prefrontal cortex dysfunction
and attitudes toward money: A study in neuroeconomics.
Journal of Socio-Economics 2008;37:1785–1788.
36. Caracuel A, Verdejo-Garcı́a A, Vilar-Lopez R, Perez-
Garcia M, Salinas I, Cuberos G, et al. Frontal behavioral
and emotional symptoms in Spanish individuals with
acquired brain injury and substance use disorders. Archives
of Clinical Neuropsychology 2008;23:447–454.
37. Tennant A, Conaghan PG. The Rasch measurement model
in rheumatology: What is it and why use it? When should it be
applied, and what should one look for in a Rasch paper?
Arthritis Care and Research 2007;57:1358–1362.
38. Bond TG, Fox CM. Applying the Rasch Model:
Fundamental measurement in the human sciences. 2nd ed.
Mahwah, NJ: Lawrence Erlbaum; 2007.
39. Rasch G. Probabilistic models for some intelligence and
attainment tests. Chicago, IL: University of Chicago Pr (Tx);
1980.
40. Lawton G, Lundgren-Nilsson A, Biering-Sorensen F,
Tesio L, Slade A, Penta M, et al. Cross-cultural validity of
FIM in spinal cord injury. Spinal Cord 2006;44:746–752.
41. Tesio L. Measuring behaviours and perceptions: Rasch
analysis as a tool for rehabilitation research. Journal of
Rehabilitation Medicine 2003;35:105–115.
42. Decruynaere C, Thonnard J, Plaghki L. Measure of experi-
mental pain using Rasch analysis. European Journal of Pain
2007;11:469–474.
43. Linacre JM. Understanding Rasch measurement: Optimizing
rating scale category effectiveness. Journal of Applied
Measurement 2002;3:85–106.
44. Fox CM, Jones JA. Uses of Rasch modeling in counseling
psychology research. Journal of Counseling Psychology
1998;45:30–45.
45. Hagquist C, Bruce M, Gustavsson JP. Using the Rasch
model in nursing research: An introduction and illustrative
example. International Journal of Nursing Studies 2009;46:
380–393.
46. Pallant JF, Tennant A. An introduction to the Rasch
measurement model: An example using the Hospital
Anxiety and Depression Scale (HADS). British Journal of
Clinical Psychology 2007;46:1–18.
47. Kersten P, Ashburn A, George S, Low J. The Subjective
Index for Physical and Social Outcome (SIPSO) in stroke:
Investigation of its subscale structure. BMC Neurology
2010;10:26.
48. Andrich D, Lyne A, Sheridan B, Luo G. RUMM2020. Perth:
RUMM Laboratory; 2003.
49. Linacre JM. Comparing ‘Partial Credit’ and ‘Rating Scale’
models. Rasch Measurement Transactions 2000;14:768.
50. Wilson M. Constructing measures: An item response
modelling approach. London: Lawrence Erlbaum
Associates; 2005.
51. Tesio L. Functional assessment in rehabilitative medicine:
Principles and methods. Europa Medicophysica 2007;43:
515–523.
52. Nilsson AL, Sunnerhagen KS, Grimby G. Scoring alter-
natives for FIM in neurological disorders applying
Rasch analysis. Acta Neurologica Scandinavica 2005;111:
264–273.
53. Bode RK, Heinemann AW, Semik P. Measurement proper-
ties of the Galveston Orientation and Amnesia Test (GOAT)
and improvement patterns during inpatient rehabilitation.
The Journal of Head Trauma Rehabilitation 2000;15:
637–655.
54. Caracuel A, Bateman A, Teasdale TW, Verdejo-Garcı́a A,
Pérez-Garcı́a M. Spanish, French, and British Cross-cultural
Validation of the European Brain Injury Questionnaire.
The Journal of Head Trauma Rehabilitation. Ahead of print.