Behavioral Inattention Test (BIT)

Evidence Reviewed as of before: 12-10-2011
Author(s): Sabrina Figueiredo, BSc
Editor(s): Anita Menon, MSc; Nicol Korner-Bitensky, PhD OT

Purpose

The Behavioral Inattention Test (BIT), initially called as Rivermead Behavioral Inattention Test, is a short screening battery of tests to assess the presence and the extent of visual neglect on a sample of everyday problems faced by patients with visual inattention (Wilson, Cockburn, & Halligan, 1987).

In-Depth Review

Purpose of the measure

The Behavioral Inattention Test (BIT), initially called as Rivermead Behavioral Inattention Test, is a short screening battery of tests to assess the presence and the extent of visual neglect on a sample of everyday problems faced by patients with visual inattention (Wilson, Cockburn, & Halligan, 1987).

Available versions

The BIT was developed in 1987 by Barbara Wilson, Janet Cockburn and Peter Halligan.

Features of the measure

Items:

The BIT is divided into two subtests: Conventional and Behavioral. The BIT Conventional subtest (BITC) consists of 6 items: line crossing, letter cancelation, star cancellation, figure and shape copying, line bisection, and representational drawing. The BIT Behavioral subtest (BITB) consists of 9 items: pre-scanning, phone dialing, menu reading, article reading, telling and setting the time, coin sorting, address and sentence copying, map navigation, and card sorting. To minimize practice and learning effects upon re-testing, parallel versions of the test were created (Wilson et al., 1987).

A client will be diagnosed as being visual neglect if they failure to attend the target stimuli and based on the relative spatial location of targets omitted (Wilson et al., 1987).

The BIT items are as follow (Halligan, Cockburn, & Wilsom, 1991):

  • BITC subtest
Item Test description
Line crossing Patients are required to detect and cross out all target lines on a page. When administering the test, the examiner demonstrates the nature of the task to the patient by crossing out two of four lines located in a central column, and then instructing them to cross out all lines they can see on the page.
Letter Cancellation Paper and pencil test in which patients are required to scan, locate, and cross out designated targets from a background of distractor letters. The test consists of 5 rows of 34 upper case letters presented on a rectangular page. Forty target stimuli are positioned such that each appears in equal number on both sides of the page. Each letter is 6 mm high and positioned 2 mm apart.
Star Cancellation This test consists of a random array of verbal and non-verbal stimuli. The stimuli are 52 large stars (14 mm), 13 randomly positioned letters and 19 short (3-4 letters) words are interspersed with 56 smaller stars (8mm) which comprise the target stimuli. The patient is instructed to cancel all the small stars.
Figure and Shape copying In this test, the patient is required to copy three separate, simple drawings from the left side of the page. The three drawings (a four pointed star, a cube, and a daisy) are arranged vertically and are clearly indicated to the patient. The second part of the test requires the patient to copy a group of three geometric shapes presented on a separate stimulus sheet. Unlike the previous items, the contents of the page are not pointed out to the patient.
Line Bisection Patients are required to estimate and indicate the midpoint of a horizontal line. The expectation is that the patient with left neglect will choose a midpoint to the right of true center. Each patient is presented with three horizontal, 8-inch black lines, 1- mm thick, displayed in a staircase fashion across the page. The extent of each line is clearly pointed out to the patient who is then instructed to mark the center.
Representational Drawing Patient is asked to draw pictures of a clock face, together with the numbers and a setting of the hands; a man or a woman; and a simple outline drawing of a butterfly. The task is designed to assess patient’s visual imagery independent of sensory input. Patients with left sided neglect typically use the right side of the page and their drawings after contain major omissions of features on the left hand side. Drawings of a clock face, the human form and a butterfly have shown themselves to be clinically sensitive.
  • BITB subtest
Item Test description
Picture Scanning Three large photographs (a meal, a wash basin and toiletries, and a large room flanked by various pieces of furniture and hospital aids), each measuring 357 x 278 mm are presented one at a time. Each photograph is placed in front of the seated patient who is not permitted to move it. The patient is instructed to name and or point the main items in each picture.
Telephone Dialing A telephone with a numbered dial or a push-button keyboard is presented. Each number is placed directly in front of the telephone and patient is instructed to dial the number sequence presented.
Menu reading A menu “open-out” page (420 x 297 mm) containing 18 common food items arranged in 4 adjacent columns (2 on the left and 2 on the right) is presented. The food items are presented in 6 mm high letters. Patient is instructed to open the menu and read out all the items. Language-impaired patients are permitted to point to all the words they can see.
Article Reading Three short columns of text are presented, which patients are then instructed to read.
Telling and Setting the time This test has three parts. First, the patient is required to read the time from photographed settings on a digital clock face. Second, the patient is required to read the time from three settings on an analogue clock face. Finally, the patient is instructed to set times on the analogue clock face as they are called out by the examiner.
Coin Sorting An array of familiar coins is presented. The client is the asked to indicate the locations of the coin type called out by the examiner. This task requires selective scanning of the coin array in order to not miss any instance of the named denomination.
Address and Sentence copying Patient is required to copy an address and a sentence on separate pages.
Map Navigation Patient is required to follow and locate spatial points (letters) positioned on a network of pathways located on a sheet of paper. More specifically, after having been shown the junctions of each pathway, patients are instructed to use their fingers to trace out the sequence of the letters said by the examiner
Card Sorting Sixteen playing cards are presented in a 4×4 matrix. Initially, each card is pointed out to the patient, who is then required to point to each of the cards types present as the examiner calls them out.

Scoring:

The BIT total score, as well as the sub-scores for the BITC and BITB are obtained by adding the subtests scores together. Maximum scores fort the BIT, BITC and BITB are respectively 227, 146, and 81. Higher scores are indicative of more severe visual impairment (Menon & Korner-Bitensky, 2004).

  • BITC subtest
Item Scoring
Line crossing The four central lines are not included and neglect is diagnosed in any lines are missed by the patient. A score sheet is provided to notate the nature of the neglect.
Letter Cancellation The maximum score is 40, and a scoring template allows scorer to divide the total array into four columns, two on the left and two on the right. On completion of the task, the total number of omitted target letters is calculated, and the location of the omissions is noted.
Star Cancellation As with the letter cancellation task, the test sheet can be subdivided into columns to calculate the number and location of errors.
Figure and Shape copying Scoring is based on completeness of each drawing. Neglect is defined as an omission or gross distortion of any major contralesional component of the drawing.
Line Bisection The test is scored by measuring deviations from the true mid-point. Deviations to left scored as negative; to the right as positive. Deviation score is calculated using the normative data obtained from the age-matched controls. Each of the three lines is scored out of a maximum of three. Using data from the control sample, score values between o and 3 are assigned to the patient’s performance.
Representational Drawing Scoring is similar to copying tasks, where neglect is defined as the omission or gross distortion of any major contralesional component of the drawing.
  • BITB subtest
Item Scoring
Picture Scanning Only omissions are scored, though errors of identification are also noted. Scoring of this and all other BITB testes is out of a total of nine and is calculated from the total number of omission recorded.
Telephone Dialing Dialing sequence is recorded, together with number and location of omissions or substitutions.
Menu reading Each of 18 items is scored as correct or incorrect, where incorrect response refers to partial entire word substitutions or omission.
Article Reading Scoring is based on the percentage of words omitted across all three columns. Word omissions and partial or entire word substitutions are scored as errors.
Telling and Setting the time All three parts are scored according to the numbers of omissions or substitutions made.
Coin Sorting Scoring is based on the number of omissions
Address and Sentence copying Score is calculated from the number of letters omitted or substituted from each side of the page
Map Navigation Failure to complete any segment of the route sequence incurs a penalty deduction of one point down to a minimum of zero for each trial
Card Sorting To score, the position and total number of omissions are recorded.

Cut-offs scores for the BIT, BITC, and BITB are respectively 196 out of 227, 129 out of 146 and 67 out of 81 (Halligan et al., 1991; Menon & Korner-Bitensky, 2004).

To score the relative spatial location component, the number of screening tests that demonstrated an overall lateralized performance is calculated. If half of the tests show lateralized performance and half do not, the index of lateralized performance is then determined by the total number of omissions/errors made on each side. The severity of visual negligence can be calculated based on the client’s performance on the 6 BITC tests. This score is determined by the number of conventional tests on which a given client demonstrates visual negligence. Severity scores range from 1 to 6, with higher scores indicating more severe visual negligence (Halligan et al., 1991).

Time:

The BIT takes approximately 30 to 40 minutes to administer (Menon & Korner-Bitensky, 2004).

Subscales:

BITC – BIT Conventional subtest

BITB – BIT Behavioral subtest

Equipment:

  • Forms for the BITC and BTIB;
  • Photographs of 1) a meal, 2) wash-basin and toiletries, 3) a large room with pieces of furniture and hospital aids and 4) different settings of a digital clock;
  • Open-out menu;
  • Analogue clock;
  • Six different types of coins;
  • Playing cards;
  • Paper and pencil.

Training:

Not required.

Alternative forms of the BIT

  • BIT – shortened version: Developed by Stone, Wilsom, & Rose in 1987, the test is comprised of three Conventional (BITC) subtests (line crossing, star cancelation tests, figure copying) and five Behavioral (BITB) subtests (scanning a picture, reading a menu, eating a meal, reading an article, sorting coins). This version takes, on average, 10 to 15 minutes to administer (Menon & Korner-Bitensky, 2004).

Client suitability

Can be used with:

  • Clients with stroke

Should not be used with:

  • The BIT should not be used with clients who have difficulty communicating (e.g. apraxia or aphasia).

In what languages is the measure available?

English, Chinese.

Summary

What does the tool measure? The BIT estimates the presence and the extent of visual neglect.
What types of clients can the tool be used for? The BIT can be used with, but is not limited to clients with stroke.
Is this a screening or assessment tool? Assessment.
Time to administer The BIT takes 30 to 40 minutes to administer.
Versions BIT; BIT shortened version
Other Languages English, Chinese
Measurement Properties
Reliability

No studies have examined the internal consistency of the BIT.

  • Two studies have examined the test-retest reliability of the BIT. All reported excellent test-retest reliability using Pearson correlation coefficient.
  • No studies have examined the intra-rater reliability of the BIT.
  • Two studies have examined the inter-rater reliability of the BIT and reported excellent inter-rater reliability using Pearson correlation coefficient.
Validity

Content:

One study examined the content validity of the BIT and reported the item generation process when creating the measure.

Criterion:

Concurrent Validity:
No studies have reported the concurrent validity of the BIT in clients with stroke.

Predictive Validity:

One study examined the predictive validity of the BITB and reported that BITB scores measured at 10 days post-stroke is an excellent predictor of poor functional outcome at 3, 6 and 12 months post-stroke.

Construct:

Convergent/Divergent:

Three studies have examined the convergent validity of the BIT and reported excellent correlations between the BIT, the Occupational Therapy Checklist and the Barthel Index, along with adequate correlations with the Rivermead Activities of Daily Living Assessment.

Known Groups:

One study reported that BITC scores were able to distinguish between those with and without visual neglect.

Floor/Ceiling Effects No studies have reported floor/ceiling effects of the BIT in clients with stroke.
Sensitivity/Specificity One study examined the specificity and sensitivity of the BIT and reported that both subtests are able to accurately identify individuals with visual neglect.
Does the tool detect change in patients? No studies have reported the responsiveness of the BIT in clients with stroke.
Acceptability The tests are easy and simple to administer.
Feasibility The tests are easy to administer, simple and relatively unambiguous to score, and are sufficiently wide ranging to detect different forms of visual neglect.
How to obtain the tool?

The BIT can be obtained from on the website:
http://www.pearsonclinical.com/psychology/products/100000138/behavioral-inattention-test-bit.html?Pid=015-8054-628&Mode=summary

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the Behavioral Inattention Test (BIT) in individuals with stroke. We identified 5 studies.

Floor/Ceiling Effects

No studies have reported floor/ceiling effects of the BIT in clients with stroke.

Reliability

Internal Consistency:

No studies have reported the internal consistency of the BIT in clients with stroke.

Test-retest:

Wilson, Cockburn, and Halligan (1987) examined the test-retest reliability of the BIT in 28 clients with stroke and 14 healthy individuals. Participants were re-assessed within 1 week. The test-retest reliability for the BIT, as calculated using Pearson Correlation Coefficient, was excellent (r = 0.83).

Halligan, Cockburn, and Wilsom (1991) estimated the test-retest reliability of the BIT conventional subtest (BITC) and the BIT behavioral subtest (BITB) in 10 clients with stroke. Participants were re-assessed within 15 days. The test-retest reliability was excellent for both BITC and BITB (r = 0.89; r = 0.97, respectively).

Intra-rater:

No studies have reported the intra-rater reliability of the BIT in clients with stroke.

Inter-rater:

Wilson et al. (1987) assessed the inter-rater reliability of the BIT in 7 clients with stroke. Two raters assessed participants simultaneously. 100% agreement level was found between raters.

Halligan et al. (1991) verified the inter-rater reliability of the BIT conventional subtest (BITC) and the BIT behavioral subtest (BITB) in 13 clients with stroke. Two independent raters scored participants separately but simultaneously. Correlation between raters mean scores, as calculated using Pearson Correlation Coefficient, was excellent (r = 0.99) for both BITC and BITB.

Validity

Content:

Wilson et al. (1987) obtained information about client’s everyday difficulties in order to construct a brief battery of tests that included real world’ experiences of patients recovering from stroke. Information was retrieved from published cases, behavioral observation of patients with neglect, as well as from discussions with occupational therapists, physiotherapists, clinical psychologists, and neurologists, all of whom had worked with patients with visual neglect. The final selection of items was determined based on results of a pilot study.

Criterion:

Concurrent:

The concurrent validity of the BIT has not been examined in clients with stroke.

Predictive:

Jehkonen, Ahonen, Dastidar, Koivisto, Laippala, Vilkki et al. (2000) examined in 50 clients with stroke to determine if visual neglect measured 10 days post stroke was predictive of poor functional outcomes at 3, 6 and 12 months post stroke. Visual neglect was measured with the BIT and functional outcomes with the Frenchay Activities Index (FAI) (Holbrook & Skilbeck, 1983). Linear regression analysis indicated that the BIT is an excellent predictor of poor functional outcomes, accounting for 73%, 64% and 61% of the total variance of the FAI at 3, 6 and 12 months respectively.

Halligan et al. (1991) analyzed the percentage of people that were correctly classified as having visual neglect using the BITC and the BITB. This study included 80 clients with stroke. Results were as follows:

  • BITC
Right brain damaged clients (n = 26) Left brain damaged clients (n = 54)
Sensitivity Specificity Sensitivity Specificity
Line crossing 65% 76% 75% 96%
Letter cancelation 77% 82% 100% 95%
Star cancelation 100% 64% 100% 77%
Figure copying 96% 97% 100% 91%
Line bisection 65% 76% 75% 96%
Representational drawing 42% 64% 0% 85%
  • BITB
Right brain damaged clients (n = 26) Left brain damaged clients (n = 54)
Sensitivity Specificity Sensitivity Specificity
Picture scanning 65% 76% 25% 88%
Telephone dialing 57% 72% 25% 88%
Menu reading 65% 76% 75% 96%
Article reading 38% 64% 50% 92%
Telling time 69% 78% 100% 100%
Coin sorting 100% 100% 100% 95%
Address and sentence copying 65% 76% 50% 92%
Map navigation 46% 67% 100% 95%
Card sorting 54% 70% 25% 88%

Construct:

Convergent/Divergent:

Halligan et al. (1991) examined the convergent validity of the BIT by comparing it to the Occupational Therapist Checklist and the Rivermead Activities of Daily Living Assessment (Whiting & Lincoln, 1980) in 80 clients with stroke. Excellent correlations were found between the BIT and the Occupational Therapist Checklist (r = -0.65); adequate correlations between the BIT and the Rivermead Activities of Daily Living Assessment (r = 0.55).

Hartman-Maier and Katz (1995) verified the convergent validity of the BIT Behavioral subtest by comparing it to a checklist of activities of daily living (ADL). Correlations, as calculated using Pearson Coefficient Correlation, were excellent (r = 0.77).

Cassidy, Bruce, Lewis, and Gray (1999) evaluated the convergent validity of the BIT by comparing it to the Barthel Index (Mahoney & Barthel, 1965) in 44 clients with stroke. Correlations between both measures were excellent (r = 0.64).

Known Groups:

Halligan et al. (1991) studied 80 clients with stroke to determine if the BITC subtest was able to distinguish between persons with visual neglect from those healthy ones. Individuals with visual neglect performed significantly worse on the BITC as compared to healthy ones (p<0.001; calculated using Kruskal-Wallis test). Therefore, the BITC is capable of discriminating between known groups.

Responsiveness

No studies have reported the responsiveness of the BIT in clients with stroke.

References

  • Albert, M. L. (1973). A simple test of visual neglect. Neurology, 23, 658-664.
  • Beschin, N., Robertson, I. H. (1997). Personal versus extrapersonal neglect: a group study of their dissociation using a reliable clinical test. Cortex. 33, 379-384.
  • Brunila, T., Jalas, M., Lindell, J.A., Tenovuo, O., Hamalainen, H. The two part picture in detection of visuospatial neglect. Clin Neuropsychol 2003;17:45-53.
  • Cassidy, T.P., Bruce, D.W., Lewis, S., & Gray, S.G. (1999). The association of visual field deficits and visuospatial neglect in acute right hemisphere stroke patients. Age Ageing, 28, 257-260
  • Diller, L., Ben-Yishay, Y., Gerstman, L. J., Goodin, R., Gordon, W., Weinberg, J. (1974). Studies in scanning behavior in hemiplegia. Rehabilitation Monograph No. 50, Studies in cognition and rehabilitation in hemiplegia. New York: New York University Medical Center, Institute of Rehabilitation Medicine.
  • Goodenough, F. L. (1926). The measurement of intelligence by drawing. New York: World Books.
  • Halligan, P., Cockburn, J., Wilson, B. (1991). The Behavioural Assessment of Visual Neglect. Neuropsychological Rehabilitation 1, 5-32.
  • Hartman-Maeir, A., Katz, N. (1995). Validity of the Behavioral Inattention Test: relationship with functional tasks. Am J Occup Therapy, 49, 507-516.
  • Holbrook, M., Skilbeck, C. E. (1983). An activities index for use with stroke patients. Age and Ageing, 12(2), 166-170.
  • Jehkonen, M., Ahonen, J.P., Dastidar, P., et al. (2000). Visual neglect as a predictor of functional outcome one year after stroke. Acta Neurol Scand, 101, 195-201.
  • Mahoney, F. I., Barthel, D. W. (1965). Functional evaluation: The Barthel Index. Md State Med J, 14, 61-5.
  • Menon, A., Korner-Bitensky, N. (2004). Evaluating unilateral spatial neglect post stroke: working your way through the maze of assessment choices. Top Stroke Rehabil 11, 41-66.
  • Zoccolotti, P., Antonucci, G., Judica, A. (1992). Psychometric characteristics of two semi-structured scales for the functional evaluation of hemi-inattention in extrapersonal and personal space. Neuropsychological Rehabilitation, 2, 179-191.
  • Whiting, S. & Lincoln, N. (1980). An A.D.L. assessment for stroke patients. British Journal of Occupational Therapy, 43, 44-46.
  • Wilson, B., Cockburn, J., Halligan, P. (1987) Development of a behavioral test of visuospatial neglect. Arch Phys Med Rehabil 68, 98-102.

See The Measure

How to obtain the BIT

The BIT can be obtained from on the website:
http://www.pearsonclinical.com/psychology/products/100000138/behavioral-inattention-test-bit.html?Pid=015-8054-628&Mode=summary

The BIT Complete Kit, including manual, 25 record forms, various stimulus, test and playing cards, and clock face costs US$ 339.00. A package including only the record forms (n = 25) costs US$42.00.

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