Test Reviews

Undergraduate Neuropsychology

Spring 1997

Outline of Topics

Trail Making Test
PASAT
Reaction Time
Wechsler Adult Intelligence Test - Revised
Word Fluency Tests

THE TRAIL MAKING TEST

Melanie Alsworth

I. Development of the Trail Making Test (TMT)

1. A. The Taylor Number Series was the original form of the test which consisted of connecting a series of numbers from 1 to 50.

   B. Partington revised the test and renamed it A Test of Distributed Attention, but not long after, the name of the test was once again changed, this time to the Partington Pathway Test.

   C. Around 1944, the test became part of the Army Individual Test of General Ability and was given the name Trail Making Test, and is now part of the Halstead-Reitan Test Battery.

II. Standardization and Administration of the TMT

1. A. The test was standardized by Partington and Leiter who found the test to be a good predictor of general mental ability (Kay, 2).

   B. The test consists of two parts, A and B, and since it is a test of speed, the examiner should stress the importance of time and efficiency.

   1. 1. Part A consists of encircled numbers from 1 to 25 randomly spread across a sheet of paper.
      
      1. a. The object of the test is for the subject to connect the numbers in order, beginning with 1 and ending with 25, in as little time as possible.

      
      2. Part B is more complex than A because it requires the subject to connect numbers and letters in an alternating pattern (1-A-2-B-3-C, etc.) in as little time as possible.
      

      1. a. Because Part B requires more thought processing and attention on behalf of the subject, it takes longer to complete the test; however, if one works on Part B for more than two or three minutes, one will become frustrated, and the frustration may influence performance on other tests (Bradford, 46).

      
      3. Normally, the entire test can be completed in 5 to 10 minutes.

      4. Scores are calculated by adding the time it takes for the subject to complete Part A with the time it takes to complete Part B, so it is extremely important for one to understand the directions fully before the pencil touches the paper and time begins.
      

      1. a. If an error is made, the examiner will point it out to the patient for correction and have them return to and continue from the correct location while the clock remains running.
         b. Errors are recorded and the patient continues with the test.

      
      5. Cutoff scores for impairment are based on normative data instead of earlier recorded scores suggested by Matarazzo because there are other factors which may play a role in an individual's score (ex: age, educational level).

III. Reliability of the TMT

1. A. Reitan's method of scoring involves correcting errors the patient makes when they are made so that the test can be completed without error. Therefore, the patient's score, or time, includes the amount of time it takes to correct the errors. Lezak hypothesized that Reitan's method would decrease the reliability of the test; however, a study by William Fals-Stewart concluded that "under circumstances in which the variability of patient's test performance is reduced, the test has high interrater reliability" (Fals-Stewart, 41).

   B. It is extremely difficult to establish estimates of reliability on a test like the Trail Making Test because it is often given to the same patient several times, and the subject's performance may improve from practice effects (Fals-Stewart, 40).
   

   1. 1. "Dye (1979) reported significant improvements when normal subjects were administered the test twice in the same day (Franzen, 125).

   C. Many have designed alternate forms of Trails A and Trails B in an attempt to eliminate the problem of practice effects.
   

   1. 1. Through testing these alternate forms, it has been shown that the total time it takes to finish the tests is very much comparable to the original form of the tests, so reliability of the alternate forms has been proven (Franzen, 128).

   D. The Trail Making Test, especially Trails B, is a good predictor of brain impairment; however, one must be careful when interpreting scores because the occurrence of administrative errors may have an impact on reliability.
   

   1. 1. One error that frequently occurs is the failure of the examiner to correctly return the subject's pencil to the place from which he/she began drawing an incorrect trail.
      2. It is also a common error for the subject to not fully understand the directions of the examiner.
      
      1. a. Those that understand the instructions and observe the test before beginning have a time advantage over those who simply jump right in.

   E. Compared to earlier tables, the normative data used today is very reliable because it takes into account factors such as age and level of education so that when interpreting the scores of someone who is age 50, for example, he/she will not be classified as impaired.
   

   1. 1. "The test is sensitive to age effects; most normals at least 50 years of age would be misclassified using the traditional cutoff scores (Davies, 1968)" (Bradford, 45).

IV. Validity of the TMT

1. A. In terms of construct validity, there are several factors which make Part B harder (Gaudino, 533).
   
   1. 1. Part B is 56.9 cm longer than Part A which makes it longer to complete.
      2. Part B has at least one or more items in the path of the trail which creates visual interference.
      3. The difference in time it takes to complete Part B may also be attributed to the complex cognitive processes involved in alternating between number and letter.

   B. A study focusing on the construct validity of certain verbal and visual memory tests found that the TMT Part B was more closely associated with visual/nonverbal intelligence than with attention/information processing.

V. Relevant Research

1. A. How the TMT Tests Brain Dysfunction
   
   1. 1. Part A of the test requires visual scanning, numeric sequencing and visuomotor speed (Carlton, 435).
      
      1. a. This portion of the test is not a good indicator of brain impairment since there is not a significant amount of time difference between normal subjects and brain-damaged patients (Bradford, 45).

      
      2. Part B of the Trail Making Test is a good general indicator because its cognitive demands include visual scanning, visual-motor coordina- tion and visual-spatial ability adequate enough to understand on an on-going basis the alternating pattern of numbers and letters (Bradford,45-46).
      

      1. a. An impaired patient will take a much greater amount of time to complete Trails B than will a normal subject.
         b. It is also easy for an impaired subject to become extremely confused.
         
         1. 1. One type of confusion involves the patient reaching a stalemate, and even though he is motivated, he loses track of the alphabet and cannot proceed.
            2. Another type of frustration occurs when, after the fifth or sixth sequence, the patient stops, repeats the sequence aloud and tries to proceed but becomes angry and confused and draws lines between incorrect pairs which undoubtedly displays a deficit to the examiner.

VI. Sensitivity to Brain Impairment

1. A. Trails B is a useful tool in identifying general frontal lobe dysfunctions.
   
   1. 1. The test is a major player in indicating an inability to execute and modify a plan of action (Gaudino, 530).

   B. Part B is also a helpful indicator of focal frontal lesions; however, the test itself is not ordinarily an indicator of frontal dysfunction.
   

   1. 1. In order to identify a frontal lesion using Part B, one must show normal performance on most other intelligence and neuropsychological tests (Reitan and Wolfson, 215).

   C. "...Young adult learning-disabled subjects differed from controls only on Part B but not on Part A (O'Donnell, 1983)" (Spreen and Strauss, 326).

VII. Relationship of Performance to Location and Type of Impairment

1. A. The language and spatial demands of the Trail Making Test interact with the side of damage in patients with unilateral impairment (Bradford, 45).
   
   1. 1. Part A would be done poorly by patients with a right-sided lesion, and patients with left-sided lesions would do poorly on B.

   B. "Larger than normal differences between Parts A and B have been interpretive as indicative of left lateralized lesions (Lewinsohn, 1973; Wheeler and Reitan, 1963) but more recent studies have not confirmed this (Schreiber et al, 1976; Wedding, 1979)" (Spreen and Strauss, 327).

   C. The difference in times between Parts A and B was the fourth best discriminator of left, right, diffuse, or no lesion (Corrigan, 403).

VIII. Specific Cognitive Processes Evaluated

1. A. Partington initially thought the test measured motor speed, and he later stated that in addition to motor speed, shifts in organization, recall and recognition were necessary for successful performance (Kay, 5).

   B. Reitan felt that one's ability to search, distinguish between number and letter, and integrate two independent series were specifically related to TMT performance (Kay, 5).

   C. Golden, Osmon, Moses and Berg described Part A as requiring visuospatial scanning and motor sequencing skills, and Part B was believed to involve the retention of a series and integration and direction of behavior following the demands of a complex plan (Kay, 6).

   D. A number of processes are evaluated by the TMT, some of which are common to both Parts (Kay, 13).
   

   1. 1. Common processes include spatial organization, graphomotor speed, recognition of numbers, visual pursuit, vigilance and number sequences.
      2. Part A evaluates the process of rote memory.
      3. Part B is associated with the processes of distinguishing between numbers and letters, integration of two independent series, ability to learn an organizing principle and apply it systematically, serial retention and integration, verbal problem solving, and planning.

IX. Relationship to Other Tests

1. A. The TMT shows a high correlation with the Arithmetic, Digit Span and Digit Symbol subtests of the Wechsler-Bellevue Scale.

   B. Trails B and the Category Test were compared to determine if frontal lobe deficits were more easily detected through these tests, and the results showed that there was no significant differences in performance.
   

   1. 1. However, when comparing total left subjects with total right subjects, the difference on the Category Test barely exceeded the .05 level of significance with the right group performing worse (Reitan and Wolfson, 1995).

   C. Trails A and B, Digit Span Forward and Backward, and TPT Memory and Location scores were compared to find out if any of the tests were differentially sensitive to left or right hemisphere damage, and the findings were that none of the tests discriminated between right or left sided damage (Heilbronner, 257).

REFERENCES

Arnett, James A. and Seth Labovitz (1995). Effects of Physical Layout in Performance on the Trail Making Test. Psychological Assessment, 7, 220-221.

Bradford, David T., Ph. D. (1992). Interpretive Reasoning and the Halstead-Reitan Tests. Vermont: Clinical Psychology Publishing Company, Inc.

Corrigan, John D. and Nancy S. Hinkeldey (1987). Relationships Between Parts A and B of the Trail Making Test. Journal of Clinical Psychology, 43, 402-409.

Fals-Stewart, William (1992). An Interrater Reliability Study of the Trail Making Test (Parts A and B). Perceptual and Motor Skills, 74, 39-42.

Franzen, Michael D., et al (1996). Reliability of Alternate Forms of the Trail Making Test. The Clinical Neuropsychologist, 10, 125-129.

Gass, Carlton S. and Susan K. Daniel (1990). Emotional Impact on Trail Making Test Performance. Psychological Reports, 67, 435-438.

Gaudino, Elizabeth A., Mark W. Geisler and Nancy K. Squires (1995). Construct Validityin the Trail Making Test: What Makes Part B Harder? Journal of Clinical and Experimental Neuropsychology, 17, 529-535.

Heilbronner, Robert L. et al (1991). Lateralized Brain Damage and Performance on Trail Making A and B, Digit Span Forward and Backward, and TPT Memory and Location. Archives of Clinical Neuropsychology, 6, 251-258.

Kay, Gary G. (1984). Neuropsychological Investigation of the Processes Underlying Performance on the Extended Trail Making Test. Dissertation Presented to the Faculty of Memphis State University.

Larrabee, Glenn J. and Glenn Curtiss (1995). Construct Validity of Various Verbal and Visual Memory Tests. Journal of Clinical and Experimental Neuropsychology, 17, 536-547.

Matarazzo, J. D., et al (1974). Psychometric and Clinical Test-Retest Reliability of the Halstead Impairment Index in a Sample of Healthy, Young, Normal Men. Journal of Nervous and Mental Disease, 158, 37-49.

Reitan, R. M. (1971). Trail Making Test Results for Normal and Brain-Damaged Children. Perceptual and Motor Skills, 33, 575-581.

Reitan, Ralph M. and Deborah Wolfson (1995). Category Test and Trail Making Test as Measures of Frontal Lobe Functions. The Clinical Neuropsychologist, 9, 50-56.

Reitan, R. M. and D. Wolfson (1985). The Halstead-Reitan Neuropsychological Test Battery. Tucson: Neuropsychology Press.

Rossini, Edward D. and Michael A. Karl (1994). The Trail Making Test A and B: A Technical Note on Structural Nonequivalence. Perceptual and Motor Skills, 78, 625-626.

Spreen, Otfried and Esther Strauss (1991). A Compendium of Neuropsychological Tests. New York: Oxford University Press.

Spreen, O. and W. H. Gaddes (1969). Developmental Norms for 15 Neuropsychological Tests Age 6 to 15. Cortex, 171-191.

PASAT

Camulous hornsby

I. Development of the PASAT

1. 1. The original 'PASAT' was devised by H. Sampson.
   2. Around 1974 Gronwall and Sampson and Gronwall and Wrightson worked in separate pairs to realize the potential of the test.
   3. The PASAT used at present is attributed to Gronwall and was finalized by 1977 (7).
   4. This PASAT consists of a recording of a male voice speaking 60 digits paced at four different, progressively faster, speeds. The volume is well above the threshold and is adjusted to the patients liking.
   5. The task is to add the number just presented to the one immediately preceeding it and say that sum aloud. Numbers are presented first 2.4 sec. apart, then 2 sec. apart, then 1.6 sec. apart, and finally 1.2 sec. apart (11).
   6. The PASAT is believed to evaluate the 'integrity of the attentional processes (11).
   7. The PASAT can be readily given to a mildly concussed patient in a hospital ward and gives significant and reproducable results (5).
   8. Post-traumatic amnesia timing was often used as a measure of severity of concussion damage, but its predictive value is small, especially when the amnesia was of short duration. Gronwall found that a group of mildly concussed patients whose symptoms persisted did significantly worse on the PASAT than controls (3).
   9. In general, patients with impairment in the reticular activating system, the limbic, or frontal lobe may fail tests of attention and vigilence. This indicates a part of the scope of the PASAT's possible experimental applications (10).

II. Standardization of the Test

1. 1. The normative data for the PASAT are as follows: Mean # of correct responses for each age range...

   [2.4 sec. rate; M=47.4 and S.D.=10.1 for age 16-29 ; M=43.4 and S.D.=10.2 age 30-49; M=43.5 & S.D.=13.6 age 50-69]
   [@ 2.0 sec. rate M=42,SD=12.5 for 16-29 yrs; M=41.9, SD=10.2 for 30-49 yrs; M=35.6,SD=14.6 for 50-69 yrs]
   [@ 1.6 sec. rate M=36,SD=13 age 16-29; M=33.1,SD=12.2 age 30-49; M=30.8,SD=15.9 age 50-69]
   [@ 1.2 sec. rate M=27.4,SD=9.9 age 16-29; M=24.6,SD=10.6 age 30-49; M=21.2,SD=14.4 age 50-69] (12)

   2. PASAT has been used as a successful guide for return to work after concussion, but it is unable to predict when the return will likely be.
   3. The test only becomes truly useful when it is used throughout the course of a recovery. The return of the patient to work, once 'normal' functioning is regained must also be gradual (3).
   4. The clinical and psychometric evidence that validate the PASAT allow for its full use as a tests that is understood to focus on attentional mechanisms (1).
   5. The test offers a homogeneous task for its full duration, making it optimal for such tests as PET study of uptake of tracers in the brain(1).
   6. Only a small negative correlation exists between age and test results among concussed patients studied with PASAT.
   7. There are significant practice effects between 1st and 2cd administrations, but little effect on subsequent tests (3).
   8. One method of detecting malingering= both concussion and control patients will typically make fewer error/omissions during the 1st 1/3 of a trial. There is also very little variance in time scores for each trial at a session. If these patterns are not present, the test is suspect (3).
   9. Borderline malingerers: if there is exactly 0.6 seconds difference between all time score at a test, the patient is given the benifit of the doubt, but should be informed that the scores are nearly unrealistic (3).
   10. Recovery from concussion is defined by the PASAT as making a score within one standard deviation of the mean (6).

III. Sensitivity of the PASAT to Brain Impairment

1. 1. An effect of mild closed-head injury is deficit in information processing ability. The PASAT predicts the degree of this impairment.
   2. Information processing ability relates to performance on memory tasks only when the tasks require complex processing of where time constraints are imposed (4).
   3. Ample evidence exists that patients with normal PASAT scores can function adequately in their normal occupations (3).
   4. As PASAT scores of concussed patients return to normal there is a consistent reduction of reports of post concussion symptoms (4).
   5. PASAT has been used to test whether the Central Executive System of working memory is impaired in multiple sclerosis patients. The assumption is that C.E.S. function and PASAT performance both rely heavily on speed of processing (2).
   6. Being impaired in cognitive processing speed (having poor PASAT score) may lead to poor performance on dual-tasks (2).
   7. Dual-task performances in M.S. patients correlated with performance on the PASAT, but did not with other cognitive/clinical measures (2).

IV. The PASAT's relation to Location/Type of Impairment

1. 1. Biochemical evidence has linked damage deep in the cortex with abnormal secretions of exitotoxins produced by axons of damaged cortical neurons. This leads to deprivation of stimulation and thus affects attention, which the PASAT measures (7).
   2. PET scans taken while patients were taking the PASAThave implicated the already suspected anterior cingulate area in the brain in attention (1).
   3. In the PASAT, the requirement to attend to environmental information could be the link to the anterior cingulate area (1).
   4. Information processing ability correlates significantly with performance in a practical rehabilitation program. The PASAT was hoped to have been a step towards making a measure to predict the time that will be needed for recovery from concussion (3).
   5. Laidlaw found a correlation between hypnotizability and PASAT scores (7).

V. Cognitive Processes Evaluated by the PASAT

1. 1. The most basic process involved in the test is information processing. It is a measure of that rate.
   2. The PASAT task requires active suppression of internal information, specifically the common error of adding the new # to the sum the patient has just spoken must be avoided (1).
   3. Mental speed, or rate of processing has been found important in studies relating neuropsych test results to work functioning (11).
   4. There is no evidence to indicate that patients with normal range scoring on the PASAT have fully recovered their pre-morbid or potential processing capacity. Normal scores are possible with less than normal capacity (3).
   5. Those whose PASAT time score is 5 sec. or less are asked to be retested in 7 days before return to work. Those with scores slower than 5 sec. begin occupational therapy. Then PASAT is given weekly until the scores approach cutoff (3)
   6. Lower processing capacity gives a poor PASAT score and yields better hypnotizability.
   7. From studies of PASAT relation to ease of hypnosis it was hypothesized that hypnosis might be a valid treatment of post concussion syndrome, of which the PASAT is an indicator (7).

VI. Relation of PASAT to Other Tests

1. 1. Brooks et.al. looked at how the Progressive Matrices, Mill Hill Vocab. Scale, Logical Memory, Buschke Procedure, Rey Complex Figure, and PASAT predicted return to work within 7 yrs of severe head injury. They found that PASAT and Logical Memory were the main sources of valid data (11).
   2. Dreary, Langan, Hepburn, and Frier performed factor analysis on PASAT and foud that it has a 'freedom from distraction' factor also found in analysis of the WAIS-R (7).
   3. Factor analysis reveals that PASAT has a greater association with attention and immediate memory and info-processing than with general memory. This contrasted with Trails-B which relies more on spatial ability than attention and immediate memory (8).
   4. The PASAT is closely linked to Digit Span and Mental Control in the same manner that previous factor analyses linked attention, speed of processing, and immediate memory (8).

REFERENCES

1. 1) Deary, I.J. et al.(1994). PASAT performance and the pattern of uptake of (99m)Tc-exametazime in brain estimated with single photon emission tomography. Biological Psychology, 38, 1-18.

   2) D'Esposito, M. et al. (1996). Working memory impairments in multiple sclerosis: evidence from a dual-task paradigm. Neuropsychology, 10:1, 51-56.

   3) Gronwall, D.M.A. (1977). Paced auditory serial-addition task: a measure of recovery from concussion. Perceptual and Motor Skills, 44, 367-373.

   4) Gronwall, D.M.A., & Wrightson, P. (1981). Memory and information processing capacity after closed head injury. Journal of Neurology, Neurosurgery, and Psychiatry, 44, 889-895.

   5) Gronwall, D.M.A., & Wrightson, P. (1974). Delayed recovery of intellectual function after minor head injury. Lancet, 2, 605-609.

   6) Gronwall, D.M.A., & Wrightson, P. (1975). The cumulative effect of concussion. Lancet, 2, 995-997.

   7) Laidlaw, T.M. (1993). Hypnosis and attention deficits after closed head injury. International Journal of Clinical and Experimental Hypnosis, 41:2, 97-111.

   8) Larrabee, G.J. et al. (1995). Construct validity of various verbal and visual memory tests. Journal of Clinical and Experimental Neuropsychology, 17:4, 536-547.

   9) Ogden, J.A. (1996). Fractured Minds. New York: Oxford.

   10) Othmer,E., & Othmer,S.C. (1994). The Clinical Interview Using DSM-IV. Washington: American Psychiatric Press. 11) Sbordone, R.J., & Long, C.J. (1996). Ecological Validity of Neuropsychological Testing. Delray Beach, Florida: GR Press/St.Lucie Press.

   12) Spreen, O., & Strauss, E. (1991). A Compendium of Neuropsychological Tests. New York: Oxford.

Reaction Time Tests

Katina Gillespie

I.

1. Psychologists first became interested in reaction time in the late nineteenth century because of an earlier problem with astronomy (Lachman, Lachman, & Butterfield ,1979).

   A. Each astronomer had a personal equation that gave his amount of measurement "error" as compared to someone else's, this human element in scientific measurement prompted much study of reaction time during the 1800s.(Lachman et al)

   B. The most important contribution was made by Donders (1868-1969), a Dutch physiologist who in 1868 devised methods for studying what he called the :"Speed of Mental Processes" (Lachman et al).
   

   1. 1. He theorized that the total time required to perform a complex task was equal to the sum of times required for completing the individual stages needed for the task, on this assumption, his "subtraction model" consisted of determining the difference between scores for simple and complex reaction time scores (Collins, 1994)
      . 2. This method of measuring mental processes was widely used for about 25 years to break down the components of many cognitive processes (Collins, 1994).

   C. Reaction-time nearly died with the advent of behaviorism,but engineering psychology and information theory revived it with being concerned about performance of well-learned skills and in promoting maximum performance from workers, pilots, and soldiers.(Lachman et al)

   D. The study of choice reaction time under varying information-transmission conditions became a popular kind of research in the 1950s: the telecommunications problem became a psychological problem(Lachman et al).

   E. Information theorists and engineering psychologists shared the contemporary information-processing interest in human performance, but their research had a definite functionalist flavor (Lachman et al).

   F. Human-performance researchers eventually dropped functionalism and discovered structure, they were among the first psychologists to see the value of the computer analogy (Lachman et al).

   G. It now has been propositioned that RT tasks be used to diagnose and to determine the severity of brain damage, RTs may provide additional measures of cognitive functions and increase the accuracy of decisions concerning the extent and presence of brain dysfunction (Western and Long, 1996).

II.

1. With the growth of cognitive psychology, reaction time has become conceptualized as a measure of speed of information processing; and, as such, has been used extensively to study a wide variety of mental activities in both normal and neurologically impaired populations (Collins, 1994).

   A. Shum, McFarland, and Bain (1994) showed that the RT task produced measures that are related to commonly used psychological test of attention that have proven diagnostic and predictive validity, it can be argued that the RT task developed based on the information processing approach is not limited in its generality and clinical applicability.

   B. RT measures are common in research for two primary reasons: 1) measures are components of real life tasks-sports and traffic 2) they measure the time taken for mental events, such as stimulus processing, decision making, and response programming (Taimela, 1991).

   C. Hodgkins (1963) tested 930 men, women, and children to determine the differences between males and females of various ages in their speed of reaction and movement and determined by use of the split-half method the reliability of the test; a random sample of the 15 subjects from each group was used in the computation and the correlations obtained between odd and even scores ranged from .998 and .967.

   D. Rueckert and Grafman (1996) performed a study on sustained attention in patients with right frontal lesions and they showed longer RTs and missed more targets than control subjects and they got worse over time.

   E. Rueckert and Grafman also break down the effects of RT on specific areas of the brain- the anterior cingulate was overall slower and a significant difference on the RT story task, the basal ganglia showed significantly worse (longer RT and more missed targets), they also showed weak data that patients with corpus callosal lesions show greater deficits in sustaining attention that those without callosal lesions.

   F. Right hemisphere damage slowed RTs to a greater extent that left hemisphere damage, although they did not differentiate between patients with anterior and posterior lesions (Rueckert and Grafman, 1996).

   G. There were no main effects of lesion size for RT, proportion missed, or proportion false positive errors for any of the tasks in Rueckert and Grafman's experiment. (1996).

III.

1. Reaction time tests have been recognized since the mid-nineteenth centuries a potentially powerful means of relating mental events to physical measures (Welford, 1980).

   A. Stuss, Stethem, Hugenholtz, Picton, Pivik, and Richard, (1989) findings indicate that traumatic brain injury causes slower information processing, deficits in divided attention, an impairment of focused attention, and inconsistency of performance.

   B. Long term recovery of visual reaction time after a closed head injury was investigated by Van Zomeren and Deelman (1978) and showed that choice reaction in particular seems to have some value for monitoring recovery and predicting final outcome and severity of injury.

   C. It has also been shown that patients with left hemisphere disease show a more marked retardation in speed of response as the tasks grow more complex than do patients with right hemisphere disease (Dee & VanAllen, 1973).

   D. Tartaglione, Bino, Manzino, Spadavecchia, & Favale, (1986) established that in right hemisphere lesions the volume had clear influence on the performance and the degree of RT slowing was proportional to the volume of the lesion, but in the left-hemisphere lesions, the lesion size did not effect velocity, often small lesions were related with more severe RT slowing than larger ones.

IV.

1. In past and recent studies Reaction Time Tests have evaluated specific cognitive processes.

   A. Craik, Govoni, Naveh-Benjamin, and Anderson (1996) did and extensive study on the effects of divided attention on encoding and retrieval processes in human memory and revealed that RT costs may be associated with the attempt to retrieve, regardless of the success of the retrieval attempt and the possibility that performance on a concurrent task is allowed because of response conflicts between concurrent task and recall.

   B. The relationship between psychometric intelligence and speed of information-processing in a newly developed computerized RT task called the Concept-Verification-Test (CVT) was investigated in a sample of 104 undergraduates and found that both the Comprehension RT and the Verification RT correlated negatively with intelligence and found no evidence for the validity of the complexity hypothesis, which is that the more complex the task the slower the RT (Knorr and Neubauer, 1996).

   C. It has been suggested that a relationship between IQ and reaction time (RT), arguing that individuals wiith quicker RTs are able to acquire information about the world more quickly and thus more information in general, which may lead to the development of higher IQ (Saklofske and Zeidner,1995).

   D. In approximately 50 studies, schizophrenics have been found to be slower and more variable than normal controls, RT appears to have trait-like properties as it is stable over time, slowed in remitted patients, predictive of outcome, and mostly independent of the patient's clinical state (Schwartz, Carr, Munich, Glauber, Lesser, and Murray, 1989).

   E. A slowing of RT is also found in affective disorders such as depression and it may be true for mania (Schwartz et al, 1989).

   F. Conflicting results have been obtained in patients with focal brain damage, few studies have shown extension of time of CRT and SRT, but others have found no difference in the extent of response slowing between CRT and SRT , the interpretation of these results remains difficult because most of studies don't take into account for errors and prevent any conclusions being drawn on the efficacy of decision process (Godfrey and Rousseaux, 1996).

   G. The majority of studies have restricted the assessment of decision processes to the evaluation of one performance level measurement, namely RT scores; a limitation to this method is that is does not take into account the fact that humans are able to trade speed for accruacy. (Godfrey and Rousseaux, 1996).

V.

1. The relationship between RT measures and a neuropsychological impairment score have been examined in a couple of studies.

   A. Collins and Long (1996) found statistically significant correlations demonstrating a positive relationship between RT and level of impairment demonstrated on neurological tests (Impairment Index of Halstead-Reitan Battery).

   B. Collins and Long (1996) also showed that by adding the two short RT tests (simple and choice) to the neuropsychological test battery, more accurate predictions can be made about a patient's level of cognitive functioning.

   C. Western and Long (1996) performed a number of experiments to compare the classification ability of RT to the abilities of other tests, a number of tests were compared and the results of two different experiments indicated that RT did show a significant level of agreement with the impairment score, but did not significantly exceed the rates gathered using other tests.

   D. The third experiment of Western and Long (1996) showed that the impairment score in not superior to RT in classifying individuals with recent history of traumatic brain damage versus controls.

   E. The results of Western and Long's (1996) study does not show full agreement between results of neuropsychological testing and RT testing or demonstrate that RT is superior to other tests in predicting neuropsychological impairment, but it does show that RT measures could be used to identify individuals requiring further testing.

   F. There is still much need of further investigation of the use of RT in clinical settings.

References

1. Collins, L. F. (1994). Visual reaction time and its relationship to neuropsychological test performance. Unpublished master's thesis, The University of Memphis. Memphis, Tennessee, North America.

   Collins, L. F. & Long, C. J. (1996). Visual reaction time and its relationship to neuropsychological test performance. Archives of Clinical Neuropsychology, 11, 613-623.

   Craik, F. I. M., Govoni, R., Naveh-Behjamin, M., & Anderson, N. D. (1996). The effects of divided attention on encoding and retrieval processes in human memory. Journal of Experimental Psychology: General, 125(2), 159-180.

   Dee, H. L.& VanAllen M. W. (1973). Speed of decision-making processes in patients with unilateral cerebral disease. Archive of Neurology, 28, 163-166.

   Godfrey, O. & Rousseaux, M. (1996). Binary choice in patients with prefrontal or posterior brain damage. A relative judgement theory analysis. Neuropsychologia,34(10), 1029-1038.

   Hodgkins, J. (1963). Reaction time and speed of movement in males and females of various ages. The Research Quarterly, 34(3), 335-343.

   Knorr, E. & Neubauer, A. C. (1996). Speed of information processing in an inductive reasoning task and its relationship to psychometric intelligence. Personality and Individual Differences, 20(6), 653-660.

   Lachman, R., Lachman, J. L., & Butterfield, E. C. (1979). Cognitive psychology and information processing: An introduction. New Jersey: Lawrence Erlbaum Associates, Publishers.

   Rueckert, L & Grafman, J. (1996). Sustained attention deficits in patients with right frontal lesions. Neuropsychologia, 34(10), 953-963.

   Saklofske, D. H., & Zeidner, M.(eds) (1995). International Handbook of Personality and Intelligence. New York: Plenum Press.

   Shum, D. K., McFarland, K., & Bain, J. D. (1994). Assessment of attention: Relationship between psychological testing and information processing approaches. Journal of Clinical and Experimental Neuropsychology, 16(4), 531-538.

   Stuss, D. T., Stethem L. L., Hugenholtz, H., Picton, T., Pivik, J., & Richard M. T. (1989). Reaction time after head injury: Fatigue, divided and focused attention, and consistency of performance. Journal of Neurology, Neurosurgery, and Psychiatry, 52, 742-748.

   Taimela, S. (1991). Factors affecting reaction -time testing and the interpretation of results. Perceptual and Motor Skills, 73, 1195-1202.

   Tartaglione, A, Bino, G., Manzino, M., Spadavecchia, L., & Favale, C. (1986). Simple reaction-time changes in patients with unilateral brain damage. Neuropsychologia, 24(5), 649-658.

   VanZomeren, A. H. & Deelman B. G. (1978). Long-term recovery of visual reaction time after closed head injury. Journal of Neurology, Neurosurgery, and Psychiatry, 41, 452-457.

   Welford, A. T. (ed) (1980). Reaction Times. New York: Academic Press.

   Western, S. L. & Long, C.J. (1996). Relationship between reaction time and neuropsychological test performance. Archives of Clinical Neuropsychology, 11, 557-571.

WAIS-R

Ellyn Daniel

Development

1. The WAIS-R is a widely used test of intelligence. It was developed in 1981 as a revision of the WAIS. The WAIS was developed in 1955 from the Wechsler Bellvue (1939) which was an alternate form of the Stanford-Binet forms L and M. The WAIS-R still contains some items and characteristics of the earlier Wechsler scales. 80% of WAIS-R items (excluding Digit Symbol) are either directly from the WAIS or slightly modified. (1.)

Standardization

1. The WAIS-R is structured into eleven subtests where items are organized into ascending order of difficulty. These subtests measure verbal and performance abilities (VIQ and PIQ) and Full Scale IQ (FSIQ). A table is used to assess scores of all age groups. The standardization sample is comprised of population trends from the 1970 U.S. census. The sample has been more recently stratified on the characteristics of age, sex, race, geographic region, occupation, education, and rural urban . The mean for the subtest scores is 10 with a standard deviation of 3 (500 subjects). The scores are divided into nine age groups with each group having an average IQ of 100 with a SD of 15. (1.)

Reliability

1. Split-half reliabilities were calculated with the Spearman Brown formula by age group for VIQ, PIQ, and FSIQ on all subtests except for Digit Symbol and Digit Span. Reliability ranges were: VIQ, .95 to .97, PIQ, .88 to .94, and FSIQ, .96 to .98. In all three cases lowest reliabilities were reported for the 16-17 age group. For individual subtests, reliabilities averaged from .68 for Object Assembly to .96 for Vocabulary. (1.)

Validity

1. In a study to understand the effect of malingering and other "compromises" to validity, Trueblood evaluated the WAIS-R and clinical memory data produced by two groups from a mildly head injured sample: MPs (malingered) and QVs ( provided implausible neuropsychological performances but were not clearly malingering). Performance was significantly lower and inconsistent for these two groups than for matched controls.

1. Trueblood believes that the hierarcical structure of the WAIS-R might help malingerers discriminate item difficulty, therefore performing plausibly and avoiding detection. Since all malingerers in this study were identified, the validity of the WAIS-R was not effected. However, the validity can be effected if malingerers are not identified. Trueblood also states that the presence of qualitative characteristics of organically based disorders should not be a basis for strong confidence in data validity because diagnostic errors would be likely to occur. (6.)

   Subtests, Cognitive Processes Evaluated, and Relationship of Performance to Type of Impairment

Language Ability:

1. Information Subtest- This test consists of 29 items that assess general information, current information, cross-cultural information, scientific information, and role related information. The items are in order of difficulty and test time usually takes five minutes. This is a good scale of verbal knowledge information, verbal communication skills, and education and motivation. It provides an estimate of premorbid intellectual functioning because it is the least effected by brain injury. Low scores are indicative of dominant hemisphere dysfunction. Reliabilities range from .87 to .91 with a mean of .89.

   Comprehension Subtest- This test consists of 14 open-ended questions that assess common sense judgement and practical reasoning (11 items) and understanding of proverbs (3 items). Test time is usually ten minutes or less. It measures verbal intellectual ability since it relates to social knowledge and judgement. It is especially sensitive to dominant hemisphere dysfunction. Reliabilities range from .77 to .90 with a mean of .84.

   Similarities Subtest- This test consists of 13 paired items and the patient must explain the similarities of each pair. Abstract responses are given more credit than concrete responses. This is a test of verbal concept formation. Low scores might indicate dysfunction in either the left hemisphere (impaired verbal functions) or frontal lobes (impaired concept formation). Reliabilities range from .78 to .87 with a mean of .84.

   Vocabulary Subtest- This test consist of 35 words to be defined and scored according to quality. It can take from fifteen to twenty-five minutes. Vocabulary reflects social, economic, and cultural knowledge. This test can provide valuable information about premorbid level of functioning. Reliabilities range from .94 to .96 with a mean of .96.

Nonverbal Ability:

1. Block Design Subtest- This test requires block assembly in two-dimensional pattern as shown from a test booklet. There are 10 designs in order of difficulty. Total time is usually ten to fifteen minutes. This test is a measure of visuo-spatial construction. It is sensitive to brain damage but most strongly effected by nondominant right hemisphere lesions, especially with parietal lobe involvement. Reliabilities range from .83 to .89 with a mean of .87.

   Object Assembly Subtest- This test is a puzzle assembly task in which familiar objects are used. It measures speed and accuracy. Bonus points can be given for quick assembly and partial credit can be given for unfinished assembly. Test time is about ten minutes. This measures visual organization and constuction. It is most sensitive to posterior nondominant hemisphere dysfuntion. Lesions in other areas of the cortex can result in impairment of this test as well. Reliabilities range from .52 to .73 with a mean of .68.

   Picture Arrangement Subtest- This test consists of sets of scrambled cartoon pictures. The patient must be able to arrange the pictures in a sensible order. Test time is approximately fifteen minutes. This test evaluates the ability of nonverbal social cues and logical and sequential thinking. Variations and performance errors may reflect certain brain dysfunctions. Reliabilities range from .66 to .82 with a mean of .74.

   Picture Completion Subtest- This test consistsd of 20 pictures, each missing an important detail, and the patient is given twenty seconds to figure out the missing detail. Total test time is five minutes. This tests visual perception and recognition that requires practical and conceptual judgement. This is a very good test of premorbid ability. Impaired ability can be the result of left hemisphere damage. Reliabilities range from .71 to .83 with a mean of .81.

Memory and Learning Ability

1. Digit Span Subtest- This test consists of two parts involving presentation of random number sequences read aloud at the rate of one number per second. The examiner reads digits forward and backward with the span of digits becoming larger. The patient must repeat the sequence of digits. Total task time is less than five minutes. Digits Forward measures auditory memory span and attention. Digits Backward measures active and working memory. Variations can suggest attention, concentration, and sequencing problems that may reflect organic and emotional problems. Reliabilities range from .70 to .89 with a mean of .83.

Attention, Concentration, and Conceptual Tracking

1. Arithmetic Subtest- This test consists of 14 arithmetic problems that require oral solution. Responses are timed. Total task time is between ten and twelve minutes. This test measures concentration, immediate memory, and conceptual manipulation . Reliabilities range from .94 to .96 with a mean of .96.

   Digit Symbol Subtest- This test requires patients to copy symbols as part of a set code. Numbers and symbols must be paired. Tatol test time is less than five minutes. This is a psychomotor performance test that requires motor coordination and sustained attention. It is sensitive to brain dysfunction and emotional problems. Reliabilities range from .73 to .82 with a mean of .82.

(All information under the subheading "Subtests, Cognitive Processes, and Relationship of Performance to Type of Impairment" have been cited from references 1 and 2).

Relevant Research and Relationship to Other Tests

1. Verbal/Performance Dichotomy- Analysis of the factor structure of WAIS-R has frequently been conducted on standardization data and specific patient samples to assess the adequacy of Wechsler's Verbal / Performance dichotomy. The WAIS-R was administered to 102 traumatically brain injured (TBI) patients an average of 9.74 months post injury. Wechsler's Verbal/Performance dichotomy did not hold in this sample. There appears to be differences in the factor strcture of the WAIS-R when used to assess brain damage. Similarities appears to be a scale which loads highly on both the Verbal Comprehension and Perceptual Organization factors, which contradicts the Verbal/Performance dichotomy. Therefore, clinicians should use caution in using standard interpretive methods of the WAIS-R to assess TBI. (5.)

Mayo IQ's-

1. Normative basis for the WAIS-R have been extended through age 97 with the publication of norms that permit compuation of Mayo IQ's for the WAIS-R and Mayo Memory Indices for the WMS-R. Mayo summary scores are correlated highly with traditional Wechsler values, however, they are not interchangeable. Mayo score samples are independent of Wechsler standardization samples, and they have different design features. Mayo norms are based on a sample of older people (age 75 and above).

Satz-Mogel Type Short Form WAIS-R-

1. The Satz-Mogel short form of the WAIS-R is frequently used to shorten a test Battery. Studies have shown a high correlation between the scores for this short form and the full WAIS-R. Satz-Mogel report correlations of .99 for the Verbal Scale IQ, .97 for the Performance Scale IQ, and .99 for the Full Scale IQ. However, correlations are not as high for the individual subtests, which might complicate the use of the short form. High correlation does not mean the short form produces the same or similar scores on the full WAIS-R. It can only tell the clinician the patients relative position within the distribution on the short form is likely to be similar on the full WAIS-R. Caution should be used when interpreting scores from the short form.

References

1. Dean, R.S. (Ed.). (1987).Introduction to Assessing Human Intelligence. Springfield, Il: Charles C. Thomas Publishers.

2. Hartlage, L.C., Asken,M/J., Hornsby, J.L. (1987). Essentials of Neuropsychological Assessment. New York, NY: Springer Publishing Company.

3. Ivnik, R.J., Smith, G.E., Malec, J.F., Tanglos, E.G., & Parisi, J.E. (1993). Comparison of Wechsler vs. Mayo Summary Scores In A Clinical Sample. Journal of Clinical Psychology, 49, 534-542.

4. Mattis, P.J., Hannay, J., Plenger, P.M., Pollock, L. (1994). Head Injury and the Satz-Mogel Type Short Form WAIS-R. Journal of Clinical Psychology,50, 605-613.

5. Moore, A.D., Stambrook, M., Gill, D.D., Hawryluk, G.A., Paters, L.C., Harrison, M.M. (1993). Factor Structure of the Wechsler Adult Intelligence Scale-Revised in a Traumatic Brain Injury Sample. Canadian Journal of Behavioural-Science, 25, 605-614.

6. Trueblood, W. (1994). Qualitative and Quantitative Characteristics of Malingered And Other Invalid WAIS-R and Clinical Memory Data. Journal of Clinical and Experimental Psychology, 16, 597-607.

The Thurstone Word Fluency Test

Kristin Thomas

What Is IT?

1. Task 1 -subjects must write as many words as possible beginning with the letter "S" in five minutes.(1 rule)

   Task 2- subjects must write as many words as possible beginning with the letter "C" in four minutes BUT the words must be four letters only. (2 rules)

   A form of this test was first introduced by Thurstone in Primary Mental Abilities in 1938.

What do the scores mean?

1. An average 18 year old can produce 65 words within the nine minute period (Lezak, 1995).
   Ages 15-25 mean= 52.81
   Ages 26-35 mean= 52.44
   Ages 36-45 mean= 50.59
   Ages 46-55 mean= 50.96
   Ages 56-65 mean=48.26
   Ages 37.10 mean=37.10

It Sounds Like

1. There is also a word fluency test named after Benton that is designed in the same way, for the same purpose but instead of writing the words, the patient names them and the tester records them. This test is an option for people who cannot read or write.

Why Give a Word Fluency Test?

1. Following brain injury, many patients experience changes in the speed and ease of verbal production. (Lezak, 1995).

   Controlled oral association tasks, as represented by measures of verbal fluency, are occasionally included as a component of psychodiagnostic batteries for assessing higher cortical functions. (Bolter, Long, & Wagner, 1983) Measures of verbal fluency and productivity have formed a part of many aphasia batteries and have also been used to assess intellectual loss in patients with cerebral disease, particularly for the purpose of defining the distinctive patterns of performance associated with lesions in different loci. (Borkowski, Benton, & Spreen, 1967)

Why Pick Those Letters?

1. Borkowski, Benton, and Spreen (1967) -purpose of study- to determine the relationship between fluency of controlled associations t single letters and the frequency of words beginning with those letters in the English language. (High frequency =easy letters, ex. F, S, P, T; low frequency in English language=difficult letters ex. (J,U,) They also researched the extent to which verbal production instigated by specific letters differentiated between brain damaged and control patients. Also, they formed several hypotheses:

   1."It could be argued that over a 1 minute period, both difficult and easy letters make significant demands on cognitive linguistic abilities. Hence, it would be predicted that all letters will show equal discrimination between the diagnostic groups."

   2."Letters with few associates may make greater demands on verbal fluency; in contrast, high frequency or easy letters may produce a large number of automized responses that make minimal demands on associative processes. If this is so, it would be predicted that the difficult letters will be more discriminative than the easier letters."

   3."A final possibility is that the differentiation between brain damaged and control patients may be related to an interaction between letter difficulty and level of intelligence. Specifically, for groups of brain damaged and control patients of relatively low intelligence, easy letters may be more discriminative than difficult letters because even normal subjects of modest intelligence can make only a few associations to the difficult letters. In contrast, difficult letters may be more discriminative for groups of patients of relatively high intelligence because these letters make significant demands on associative fluency and the possibility of automatized responses is minimized."

   In summary, they found that for patients with low verbal intelligence, letters with high and low frequency equally discriminated between brain damaged and control subjects. for subjects with high verbal intelligence, only letters of low frequency differentiated between brain damaged and normal controls. So, basically, the people with high verbal intelligence will do better on the first task even if brain damaged, and the second task is what is most reflective of brain damage with subjects of high intelligence.

CONCLUSION

1. Performance on verbal fluency task is related to both associative values of letters employed and patients level of intelligence.

So, What Does It Measure Cognitively?

1. "Estes (1974) pointed out that successful performance on these tests depends on the subject's ability to 'organize output in terms of clusters of meaningfully related words.' He also noted that word-naming tests indirectly involve short term memory in keeping track of what words have already been said'....As Estes (1974) suggested, word fluency tests provide an excellent means of finding out whether and how well subjects organize their thinking." (Lezak, 1995)

   "Fluency tests requiring word generation according to an initial letter give the greatest scope to subjects seeking a strategy for guiding the search for words and are most difficult for subjects who cannot develop strategies of their own. (Lezak, 1995)

Is This Test Sensitive to Brain Damage?

Yes

OK- It's Sensitive to Brain Damage Where?

"Accumulated evidence from several studies suggests that verbal fluency deficits are primarily associated with lesions in the dominant frontal lobe. (Benton, 1968; Milner, 1964; Perret, 1974; Ramier & Hecaen, 1970)

Verbal fluency is associated with frontal lobe damage, particularly the left frontal lobe anterior to Broca's area (Milner, 1975; Ramier and Hacaen, 1970). (Lezak, 1995)

However, I must note two points

1. "Newcombe (1969) found a significant difference between right and left brain damaged subjects on a verbal fluency task, with the left hemisphere damage associated with a poorer performance; however, deficits in verbal fluency were not s[specific for frontal lobe involvement. (Bolter et al, 1983")

2. "However, when fluency is tested during PET scanning, the metabolic pattern suggests that rather than predominantly frontal involvement in this task, both temporal and frontal regions participate bilaterally in a 'system...Of especial interest was the finding that normal subjects with the lowest fluency scores had the highest metabolic rates, suggesting that poorer performers have to invest more effort in the task." (Lezak, 1995)

Milner, 1964

1. showed that verbal associative fluency, seen in performance on the Thurstone Word Fluency Test is greatly reduced in patients with left prefrontal excisions when compared to those with right prefrontal or left temporal excisions.

Benton, 1968

1. stated that Milner's findings that "patients with left prefrontal excisions suffer a specific impairment in verbal associative fluency which is not shown by those with right prefrontal lesions, coupled with Zangwill's (1966) perceptive view that injury of the left prefrontal area may be expressed in higher level verbal deficits, have had the effect of reopening the question of the extent to which interhemispheric differences are demonstrable in patients with unilateral prefrontal lesions and also whether they are comparable to those found for patients with unilateral posterior lesions." (Benton, 1967)

   -With his study, he confirmed that word fluency deficiency is related to left frontal lob damage when he found that "bilateral frontal lesions do not entail a greater impairment of performance than unilateral, left frontal lesions, despite the larger mass of cerebral tissue destroyed ." (Perret, 1973)

Perret, 1974

1. confirmed deficits in frontal lesions after left frontal lesions -He found "The left frontal deficit observed in word fluency confirms the findings of Milner (1964) and Benton(1968) with similar tests of word fluency. The results of the present study are also in complete agreement with those of Ramier and Hecaen (1970): left hemisphere lesions produce lower performances than right hemisphere lesions (table 4) and frontal lesions yield stronger deficits than non frontal lesions (means 25.2 and 32.7) respectively. Accordingly, the deficits are summed in the left frontal group , which in fact yields the lowest performance of all patient groups."

   Average number of words produced

   Group	# words
   Left Hemisphere	25.4
   Right Hemisphere Con	33.3
   Control	43.2

   -In summary, "Perret found that patients with left hemisphere lesions did significantly more poorly than did patients with right hemisphere lesions, and that both of these groups earned lower total fluency scores than did normal controls..." (Pendleton, et al., 1982)

So Is It Useful?

1. 1. Diagnostic Utility of the Thurstone Word FLuency Test In Neuropsychological Evaluations (Pendleton et al., 1982) -investigated diagnostic utility of the Thurstone in detecting and localizing cerebral lesions.

   They hypothesized that:
   

   1. 1."Patients with cerebral damage, regardless of lesion location, would show impairment on this test"
      2."Frontal lesion groups, regardless of side of lesion, would be more impaired than nonfrontal groups"
      3."Left hemisphere lesion groups would be more impaired than right hemisphere groups"
      4."Patients with left frontal lesions would show more impairment than would right frontal lesion patients"

   They fond that

   1."Results of the comparisons between individual brain damaged groups and normal control group indicate that the word fluency score is sensitive to cerebral dysfunction, regardless of whether the lesion is diffuse or focal and regardless of lesion localization...This diagnostic accuracy suggests that the TWFT can be used as a relatively sensitive "screening' test for the presence of cerebral dysfunction"

   2."Patients with focal lesions involving the frontal lobes were significantly more impaired than were patients with nonfrontal lesions"

   3."Patients with left hemisphere lesions were significantly more impaired than were patients who had right hemisphere lesions"

CONCLUSION

1. "It appears that the TWFT can be a valuable addition to standardized neuropsychological test batteries such as the Halstead-Reitan Battery. It is most sensitive to frontal lobe lesions, especially when left hemisphere is involved, and thus should help in the localizing these lesions. Our results suggest that the TWFT performance is best interpreted relative to other test performances rather than on a level of performance basis alone." (Pendleton et al., 1982)

   2. The Utility of the Thurstone Word Fluency Test in Identifying Cortical Damage (Bolter, Long, and Wagner, 1983)

   study designed to "determine if the verbal intelligence and letter association value directly effect the discriminating power of the Thurstone Word Fluency Test for identifying cortical lesion."(1983)

   They noted Borkowski, Benton, and Spreen's (1967) finding that "performance on a verbal fluency task is related both to the association value of the letters and the patient's level of intelligence." (Bolter, Long, and Wagner, 1983) and that, for people with low verbal intelligence, both letters with high and low association value discriminated between brain damaged and normal controls while only the letters with low association value discriminated for people with high verbal intelligence.

   "As suggested by Borkowski's et al. findings, the interaction between the verbal intelligence of the subjects being tested and the association value of the letters employed may also affect the localizing ability of a word fluency test." (Bolter et al., 1983)

   Hypothesis- the S and C conditions would be different in their sensitivity to left lateralized cortical lesions and left frontal lesions when controlling for verbal intelligence.

   They found:
   1.

   Thurstone's Word Fluency Test

   Group	VIQ mean	VIQ sd	Words mean	Words sd	S - mean	S - sd	C - mean	C - sd
   Controls
   Low VIQ	92.4	6.6	59.0	10.0	47.0	7.8	12.0	3.7
   High VIQ	115.5	12.1	60.5	14.7	46.8	11.0	14.4	4.8
   Brain Damaged
   Low VIQ	87.3	10.3	28.0	13.2	21.7	10.1	6.3	3.9
   High VIQ	114.7	11.3	51.0	20.0	37.5	15.7	13.5	5.9

   Performance on the word fluency test does depend on verbal intelligence and the association value of the letter (consistent with Borkowski's article)

   More words were produced with the S letter (high association value than the C letter (having low association value because of the four letter condition)

   2. "Although not statistically different from each other, patients with left hemisphere involvement tended to do more poorly than those with right hemisphere dysfunction."

   3. "Similarly, patients with left frontal damage tended to do more poorly than patients with lesions elsewhere in the brain."

CONCLUSIONS

1. 1. Thurstone Word Fluency Test is highly sensitive to brain damage.
   2. "Regardless of the patient's verbal intelligence, the high association stimulus potion of this test ('S' letter) appears to be more sensitive to the effects of cortical damage than the low association stimulus portion ('C' letter)."

REFERENCES

1. Benton, A.L. Differntial behavioral effects in frontla lobe disease. Neuropsychologia 6,53-60, 1968.

   Borkowski, J.G., Benton, A.L., & Spreen, O. Word fluency and brain damage. Neuropsychologia, 1967, 6, 135-140.

   Bolter, J. B, Long, C.J., & Wagner, M. The utility of the thurstone word fluency test in identifying cortical damage. Clinical Neuropsychology, 1983, 5:2, 78-82.

   Lezak, M.D. Neuropsychological Assessment. New York: Oxford University Press, 1995.

   Milner, B. Some effects of frontal lobectomy in man. In J.Warren and U. Akent, (Eds.), The Frontal Granular Cortex and Behavior. New York: McGraw-Hill, 1964.

   Newcombe, F. Missile Wounds of the Brain. London: Oxford University Press, 1969.

   Pendleton, M.G., Heaton, R.K., Lehman, R.A.W., & Hulihan, D. Diagnostic utility of the thurstone fluency test in neuropsychological evaluations. Journal of Clinical Neuropsychology, 1982, 4:4, 307-317.

   Perrett, E. The left frontal lobe in man and the suppresion of habitual responses in verbal categorical behaviors. Neuropsychologia, 1974, 12, 323-330.

   Ramier, A. & Hecaen, H. Role respectif des attenintes frontales et de la lateralization lesionele dons les deficits de la "fluence verbale." Revue Neuropsychologiques, 1970, 123, 17-22.

   Thurstone, L. Primary Mental Abilities. Chicago: University of Chicago Press, 1938.

   Zangwill, O.L. Psychological deficits associated with frontal lobe lesions. International Journal of Neurology, 1966, 5, 395.

The Mini-Mental State Exam(MMSE)

Erin Middleton

I. Development

A. A short (5-10 minute) screening test developed by Folstein, Folstein, and McHugh in 1975 to assess cognitive impairment or characterize functioning (2,3,6,7)

1. First validated with hospital patients and later adapted to be used in National Institute of Mental Health's Epidemiological Catchment Area Program (6)

2. One of the tests used most frequently to assess cognitive functioning in older people (1)

B. The MMSE consists of five areas

1. Orientation = includes questions about time, day, date and location (3)

2. Registration = a short-term memory task (3)

3. Attention and Calculation = subject counts backwards by seven from 100 (3)

4, Recall = subject is asked to recall three objects named in Registration section (3)

5. Language := subject names simple objects, repeats a sentence, and follows a command (3)

a. This section also includes a visuospatial task where the subject is asked to copy overlapping pentagons (3,7)

C. Scores on the MMSE range from 0 (severely impaired) to 30 (perfect score) (3)

1. Mean scores on MMSE

a, Mean score for normal elderly people is 27.6 (10)

b. Mean score for mood disorder and depressed patients is 25.1 (10)

c. Mean score for depressed patients who also have related disturbances in orientation and memory is 19.0 (10)

d. Mean score for demented patients is 9,7 (10)

2. Meaning of scores

a. Severely impaired = score less than 18 (6)

b. Mildly impaired = scores between 18 and 23 (6)

c. Unimpaired = scores of 24 and above (6)

II. Standardization

A, Reliability

1. MMSE has demonstrated good reliability

a. For same examiner, retest reliability in a 24-hour period is r = .89 (10)
b. For different examiners, reliability is r= .83 in same time period (1 0)
c. Within 28 days the correlation coefficient is .98 (10)
d. Another study found within 28 days that r = .99 for demented, depressed and schizophrenic patients (3)

2. MMSE has also been shown to discriminate demented patients from less severe cases

a. Sometimes used to discriminate between different types of dementia, such as that related to Alzheimer's as opposed to that related to Huntington's disease (2)

3. Nevertheless, some organizations, such as NIA Alzheimer's Disease Centers and Alzheimer's Disease Diagnostic and Treatment Centers of California, use MMSE in conjunction with other measures, like the Blessed Information, Orientation, and Concentration Test (IOCT) (1 2)

a. The combination of the two (even though they are similar) provides more accurate assessment (12)
b. Most assessments of cognitive functioning, on an individual basis, seem to exclude important information (I 2)

4. Another problem with reliability of MMSE (and most cognitive functioning measures) may be in scoring (12)

a. A summary score may not be as reliable as grouping items so that they address separate areas of deficit (12)

B. Validity

1. Shows concurrent validity

a. Seems to be strongly correlated with Wechsler Adult Intelligence Scale (1,3)
b. In a study of 26 psychiatric patients, MMSE showed correlation of r = .78 with Verbal IQ and r = .66 with Performance IQ of the WAIS (1,3)

2. One study evaluated the validity of MMSE for recognizing dementia and delirium in 97 patients on a general medical ward (3)

a. When a score of 23 and below was considered impaired and 24 and above was considered unimpaired, the MMSE correctly detected 87% of impaired patients and 82% of unimpaired patients (3)
b. Has also been validated against anatomical support of dementia due to Alzheimer's (10)

C. Relevant Research

1. Previous research has shown MMSE performance to be related strongly to age and level of education (7,8)

a. Age is negatively associated with score (7)
b. Education is positively associated with score (1,7)
c. Uneducated people, therefore, have increased risk of being falsely diagnosed as impaired cognitively (1)
d. Some researchers think an education level adaptation would make assessments more accurate (1)

2. Studies have shown a negative correlation between the MMSE and rural residency, lower level of occupation, being a minority, and being a female (8)

a. The cause of these relationships may also be related to less education (8)

3. Researchers are not sure if level of education is directly involved in cognitive changes or if there is another related variable that should be implicated (1)

a. One study found "health behaviors and general health status" to be possibly related (1)
b. Another study found genetic effects as a cause for the education-cognition correlation (l)
c. A genetic relationship has also been found in some animal studies (1)

4. A study by Kelman, et al. found individuals that were severely impaired on the MMSE were older, poorer, had less education, had worse health, and were more likely to be women than those who were unimpaired (6)

a. However, those who were mildly impaired only differed from unimpaired in age and income, not education or health (6)
b. This may be suggestive for different origins for mild and severe impairment (6)
c. This study also found overall prevalence of Impairment was not significantly different between (39,2%) and women (42.1%) (6)

III. Sensitivity to Brain Impairment

A. MMSE identifies the signs of Impairment but does not provide a diagnosis (6)

1. Impairment may be the result of many things, including dementia, depression, brain injury, and retardation (6)

a. A negative correlation has also been noted between MMSE score and Parkinson's disease, diabetes and stroke in older individuals (7)

B. Tasks that address verbal and visuospatial skills, such as the MMSE's Language section, are effective in determining the stage of dementia (5)

C. Episodic memory tasks, such as the Recall section of the MMSE, are more useful in detecting the presence of dementia (5)

IV. Relationship of Performance to Type of Impairment

A. Patients who show deficits in Attention and Calculation area are sometimes schizophrenic or depressed; also seen in epilepsy, dementia, and head injury patients (9)

B, When patient cannot answer questions about orientation, suggests "severe organic pathology" (9)

1. Confabulation on the Orientation section may suggest severely impaired memory, such as the type related to chronic alcoholism (9)

V. Specific Cognitive Processes Evaluated

A. MMSE is used for the assessment of dementia as a result of disease and multi-infarct dementia (4,12)

B. May be used without adaptation in the assessment of the severity of dementia in schizophrenic patients (4)

1. The clinical qualities of schizophrenia and thus psychiatric illnesses in general do not seem to reduce the reliability of the test (4)

C. In cases of head injury with cognitive deficits, MMSE can be used repeatedly over time to follow patient's recovery (3)

VI. Relationship to Other Tests

A. When dementia is being assessed, poor MMSE score may be easier to understand than poor scores on other tests, such as the WAIS-R (3)

1,WAIS-R is more ambiguous (3)

2. Implications for "day-today competency" of patient are apparent from bad MMSE score (3)

a. These straight-forward implications can be understood by non-psychologists, such as lawyers, judges, and social workers, who need information about patient's functioning (3)

B. The Iowa Screening Battery For Mental Decline designed to assess same problems as MMSE (1)

1. This test also positively correlates with educational level (1)

C. Mattis Dementia Rating Scale (MDRS) covers more aspects of cognitive functioning than MMSE, (11)

1. However, MMSE takes less time to administer, so may be preferred, especially in cases where attention span is a consideration (11)

The Mini-Mental State Exam

Maximum Score	Item	Achieved Score	Scoring Criteria
(5)	What is the year, season, date, day, and month?		1 point for each correct answer
(5)	Where are we now? (County, state, city, _____ hospital, and floor or address)		1 point for each correct answer
(3)	Name three objects: table, comb, tree. Ask the _____ patient to repeat them after you have told them.		1 point for each correct answer on 1st trial
(5)	Spell the word 'world' backwards.		1 point for each letter correct
(3)	What are those three words I said to you?		1 point for each correct word
(2)	Show the patient a pencil and watch and ask patient _____ to name them.		1 point for each correct answer
(1)	Please say what I say: "No if's, and's, or but's."		1 point if no error
(3)	A 3-stage command: "Please listen. Take this paper in your right hand; fold it in half and put it on the floor."		1 point for each correct act
(1)	Show the patient a card with the sentence: Close your eyes. Ask the patient to read it and do what it says.		1 point if patient closes eyes
(1)	Please write a sentence here (give patient a pencil and paper.). Any sentence will do.		1 point if complete, meaningful sentence is written
(1)	Show the patient a card with a figure. Ask him to copy it.		1 point if drawing resembles figure

References

1. Carmelli, D. et al. (1995) Genetic Mediation in the Relationship of Education to Cognitive Function in Older People. Psycholoqy-and Aging (1), 48-53.
2. Fillenbaum, G.G., Molls, R.C., Welsh, K.A,, & Wilkinson, W.E. (1994)
Discrimination Between Stages of Alzheimer's Disease With Subsets of Mini-Mental State ExarNnaton Items. Archives of Neurology, 51, 916-920,
3. Gregory, R.J. (1987) Adult Intellectual Assessment. Boston: Allyn and Bacon, Inc.
4. Harvey, P.D. et al. (1 992) Assessment of Dementia in Elderly Schizophrenics With Structured Rating Scales, Schizophrenia Research, 7, 85-90.
5. Herlitz, A. et al. (I 995) Episodic Memory and Visuospatial Ability in Detecting and Staging Dementia in a Community-Based Sample of Very Old Adults. Journal of Gerontology, 50A, (2), M 107- M 113.
6. Kelman, H,R. et al. (I 994) Cognitive Impairment and Mortality in Older Community Residents. American Journal of Public Health, 84 (8), 1255-1259.
7. Launer, L.J. et al. (1993) Are Age and Education Independent Correlates of the Mini-Mental State Exam Performance of Community-Dwelling Elderly? Journal of Gerontology-, 48 (6), P271-P277.
8. Liu, H. et al. (I 994) Performance on a Dementia Screening Test in Relation to Demographic Variables, Archives of Neurology, 51, 910-915.
9. Morrison, J. (1 993) The First Interview. New York: The Guilford Press.
10. Othmer, E. & Othmer, S. (1 994) The Clinical Interview Using DSM-IV, Volume 1: Fundamentals, Washington, D.C.: American Psychiatric Press.
11. Spreen, 0, & Strauss, E. (1991) A Compendium of Neuropsychological Tests. New York: Oxford University Press.
12. Weiler, P.G. et al. (I 994) Comparison of Mental Status Tests: Implications for Alzheimer's Patients and Their Caregivers- Journal of Gerontology, 49, (1), 544-551.

 

Exams for Testing Aphasia with Specific Regard to the Reitan-Indiana Aphasia Screening Test

Robyn Brien

I. History of Aphasia Testing

DEVELOPMENT:

A. In 1861 Broca described a rather detailed testing procedure that employed clinicians in examining aphasics. He began by asking a patient conversational questions, commented on the patient's speech output and comprehension, and went on to describe his gestures, tested his tongue movements, his writing, and arithmetic.

B. Hughlings Jackson added sign making, writing, comprehension, repetition, reading, and tongue movements, as well as a description of spontaneous speech, as regular features of the aphasia examination. In 1906 Pierre Marie emphasized the importance of deficits in comprehension and worked with Moutier, an aphasic patient, who described a complete set of systematic tests for aphasics in a large monograph entitled "L'aphasie de Broca."

C. The first systematic aphasia examination in English was detailed in two large volumes by Henry Head in 1926. He examined head-injured soldiers by tailoring tests to their deficits and covering the possible modalities affected. Few anecdotal controls were used, the administration was not standardized, and he emphasized flexibility. However, many of his ideas in testing have been adopted.

1. Naming and recognition of common objects used the same six objects in assessing word recognition, nonverbal matching, naming, reading, and writing, much like the PICA. He studied sentence formation by using picture description, writing, copying, and reading of sentences, as well as comprehension tests which are considered a precursor to the Token Test. He also studied sequential tasks which identified left and right orientation and praxis.

2. Head complemented these tests with understanding a paragraph from a newspaper, arithmetic tests, setting a clock, drawing objects from a model and memory, sketching a ground plan of a familiar room, finding the way along some familiar route, completing puzzles, and playing games such as dominoes and cards.

D. A standardized test battery was constructed by Weisenberg and McBride in 1935 from various existing intelligence tests, but was reconstructed several times to reduce the amount of time of the test and to make it more sensitive for mild and severe disorders. Definitions of severity were not given and standardization was incomplete, however, they did obtain nonnative data.

E. The battery from 1935 and later editions of it was considered a precursor of many of the current tests of word recognition and sentence comprehension, as well as for apraxia. (Incagnoli, Goldstein, Golden, 1986)

STANDARDIZATION:

F. In the 1960's aphasia testing became well established because of a need for diagnostic; assessment and planning for therapy, and to compare patients for research. Eisenson's Examination for Aphasia (I 954), The Language DAodah6es Test for Aphasia (LMTA- 1 96 1), and The Minnesota Test for Differential Diagnosis of Aphasia were some of the batteries that became prominent during this time. Since then, others have been developed, adopted, and standardized.

G. Aphasia testing can be difficult to standardize because of differences between goals of clinicians and researchers. Specifically for the Reitan-Indiana Aphasia Screening Test, standardization can be difficult in relation to the examiner/interpreter of the test. The person must be able to identify a defective performance and judge whether or not it is the type of deficit that is characteristic of persons with cerebral damage. Adequate experience and education of the examiner is paramount in detecting abnormal brain functions. These questions all contribute to the reliability and validity of the test, and in order to make results more clear and reliable, Reitan published a 1984 volume that provided detailed illustrations of brain related deficits on the Aphasia Test. (Reitan, 1985) In 1970, Russell, Neuringer, and Goldstein published a quantitative scoring system that included a 5-point scaling of the figure drawings, a modification of the one or zero (presence or absence of impaired response) system. Relatively higher interrater reliabilities have been reported using this method. (Williams, Shane-1986)

RELEVANT RESEARCH:

H. One portion of the Aphasia Screening Test requires the copying of the general shape of a skeleton key. A study published in 1985 studied 138 normal and 1,235 neuropsychological/neurological patients and key orientation (reversed, vertical, diagonal, indeterminant) to determine clinical significance of this portion of the test. Even though each of the patient groups produced nonstandard orientations more frequently than the normal control group (79% more frequently), the difference did not approach statistical significance.

The report concluded that nonstandard orientations in drawings are infrequent, somewhat unreliable in appearance, and without definite relationship to other variables. They occur slightly more commonly in patients than in normal controls, but the difference is not reliable. (Dodril, 198'))

1. A comparison of clinical and automated interpretation of the Halstead-Reitan Battery was done in 1981 and found that the clinicians' independent ratings of the battery were more reliable and more accurate. The test for the aphasia exam used the zero to five ratings system since it does not use a conven6onal scoring procedure. This report contributes to the assumption that the reliability and validity of the test are in the hands of the examiner and his/her interpretations. (Heaton, 1981)

J. A study done in 1990 compared teaming disabled individuals, head injured individuals and nondisabled young adults using the Aphasia Screening Test for naming, pronunciation, and sentence interpretation. All people were given the WAIS and the HRNTB. Results concluded that the teaming disabled and head injured did not differ in responses and made significantly more errors on the aphasia exam than did the nondisabled individuals. It also reported that one-third of the learning disabled and head injured peopled exhibited language deficits, and severity ratings for the aphasia exam did not improve group discrimination. (O'Donnell, et.al., 1990)

K. A study done in Toronto, Ontario compared patients with lateralized stroke or tumor in the frequency of errors on specific test items of the Aphasia Screening Test. Right and left hemisphere damaged patients showed a statistically significant difference on only one of the 33 items-- drawing the skeleton key by the right hemisphere group. Another significant statistic involved the categorization according to task type, such as spelling, reading, calculation, etc. The right hemisphere patients made significantly more errors in drawing the figures of the AST. (Snow, 1987)

II. The Reitan-Indiana Aphasia Screening Test

A. Description. The Reitan-Indiana Aphasia Screening Test is a modification of the Halstead-Reitan Aphasia Screening Test of 1949 that included 51 items which covered the major areas of language disability. The Reitan-Indiana dropped some of the nondiscriminant questions and consists of 32 items. The test is devised to identify failures of performance and specific deficits, therefore not employing any definite scoring system. Observations of indications of brain-related deficiencies and abnormalities give results. The test asks the patient to perform a series of tasks such as naming common objects, spelling simple words, identifying individual numbers and letters, reading/writing/enunciating/understanding spoken language, identifying body parts, calculating simple arithmetic problems, differentiating between right and left, and copying simple shapes. (Reitan, 1985)

B. The administrator follows instructions on the back of each card that corresponds to the s6nmulus seen by the subject. The most likely type of deficit associated with a negative performance is noted on the back of the card for the administrator's observational use. The administrator should encourage the patient to attempt every task and encourage him/her to perform correctly on the first attempt each time. The administrator should listen and observe closely and write down each response as it occurs.

C. As stated earlier, there is no scoring table for the aphasia exam, but rather is observed for deficits in brain function. (Reitan, 1985)

III. Sensitivity to Brain Impairment

A. According to Wheeler & Reitan (1962, 1963), the Reitan-Indiana Aphasia Screening Test research results have shown that performances on the test are strongly correlated to the status of each cerebral hemisphere and actually appear to contain almost as much diagnostic information as the test in the entire Halstead-Reitan Battery. The statement is based on discriminant function analyses of the Aphasia and Sensory-perceptual Examination which permitted classification of normal subjects and persons with right, left, and generalized cerebral lesions into their appropriate groups with essentially the same degree of accuracy as achieved using the rest of the HRB. (Wheeler, Burke, & Reitan, 1963) Additional information regarding brain sensitivity is addressed in the next section.

IV. Relationship of Performance to Location and Type of Impairment

A. For complete understanding of an Aphasia Exam, it is necessary to be familiar with terminology associated with disorders.

1. Dysarthria--disorder of articulation in which basic language (grammar and word choice) is intact. Patients with this problem produce distorted speech sounds that are unintelligible and may not resemble normal words.

2. Dysprosody--interruption of speech melody, focusing on inflection and rhythm. Speech may be sound monotonal or have characteristics of a foreign accent.

3. Apraxia--the inability to carry out skilled movements of the face and speech apparatus in the presence of normal comprehension, muscle strength, and coordination.

4. Aphasia--patient produces errors of grammar and word choice.

5. Alexia--loss of reading ability in a literate person with functional vision.

6. Agraphia--an acquired disturbance in writing, referring specifically to errors of language and not to problems with formation of letters. (Strub, Black 1990)

B. Cerebral Dominance. 90% of the population is thought to be right handed, and of this percentage, 99% are strongly left hemisphere dominant for language. Therefore, damage to the left hemisphere will cause aphasia whereas damage to the opposite hemisphere will spare language functions in these people. Of left handed people, 40% are right hemisphere dominant for speech while 60% are left hemisphere dominant. Also the degree of dominance is not as strong as right handers, with 80% of all left handers having some mixed dominance for language. (Benson, Geschwind, 1968)

C. Areas of the Brain.

1. Wernicke's Area (posterior language area) is the cortical area primarily concerned with the comprehension of spoken language. Patients with damage to this are often referred to as 'receptive aphasics.'

2. Language production occurs in the anterior language area, within Broca's area. Patients with damage to this are often referred to as 'expressive aphasics'.

**One problem with the terminology of 'expressive' and 'receptive' is that all aphasics have some degree of abnormal language expression. The classifications described in the following text follow anatomic patterns of the brain and are useful in localizing lesions. However, this system will be more difficult in the classification of left handed patient.

a. Global Aphasia.
Performance: It is the most common, most severe, and characterized by speech that is nonexistent of reduced to a few words or sounds, such as ba, ba, ba. Comprehension will be absent, with the patient only identifying a few selected words such as his/her name. Reading and writing will also be nonexistent.
Location: Lesion in language areas I and 2, which are completely or almost completely damaged. A very common lesion is an occlusion of the internal carotid artery or the middle cerebral artery at its origin.
b. Broca's Aphasia.
Performance: Nonfluent, dysarthric, effortful speech of mostly nouns and verbs characterizes this disorder. Repetition and reading aloud are as severely impaired as spontaneous speech, but auditory and reading comprehension are intact. Naming will show paraphasias at times.
Location: This syndrome results in a lesion in Broca's area, covering more than area 44. (Lesions only in area 44 produce transient dysarthria or dysprosody.) Auditory and visual comprehension are intact because parietal and temporal lobes have not been damaged.
c. Wernicke's Aphasia.
Performance: The patient will exhibit fluent, effortless, well articulated speech, but the output will contain many paraphasias and be lacking substantive words. Often the patient with this form of aphasia will experience a great desire to overpower the listener with his/her speech. Spontaneous speech will range from comprehensive sentences with occasional errors to completely incomprehensible jargon spoken as if complete, meaningful sentences had been spoken. The prominent feature of Wernicke's Aphasia is a severe disturbance of auditory comprehension. The patient will answer questions inappropriately and be unaware that their answers are nonsense. Repetition is impaired, Naming is paraphasic, and reading and writing are impaired.
Location: The lesion causing this form of aphasia is in Wernicke's area. The more severe the auditory comprehension the more likely it is that the lesion involves the posterior portion of the superior temporal gyrus. If single word comprehension is good, and comprehension of complex material is impaired, the lesion is more likely to involve the parietal lobe rather than the superior-temporal.
d. Conduction Aphasia.
Performance: It is characterized by fluent, yet halting speech with word finding pauses and literal paraphasias. Comprehension is good, naming is mildly disturbed, but repetition is severely defective. Reading is good, but Nvm6ng shows errors in spelling, word choice, and syntax.
Location: The lesion is usually involves the arcuate fasciculus, which is a long fiber tract between the anterior and posterior areas.
e. Anomic Aphasia
Performance: It is characterized by word finding difficulty and an inability to name objects on confrontation.
Location: Localization of this type of lesion is difficult because lesions in many parts of the dominant hemisphere can cause Anomic aphasia. The most severe anomics are thought to have lesions in the temporal lobe involving the second and third temporal gyri, or in the parieto-temporal area.
f. Transcortical Aphasia.
Performance: It is characterized by intact repetition of spoken language, but disruption of other language functions. Patients will have difficulty producing language, yet comprehend what is being asked, while others will produce fluent speech, yet have poor comprehension.
Location: Lesions are thought to be within the borderzones between major cerebral vessels--anterior and middle cerebral arteries.
g. Pure Word Deafness
Performance: Patients will have a complete lack of comprehension of verbal language with no aphasic speech, agraphia, or alexia.
Location: The lesion is thought to be in the posterior language area but has not been specified.
h. Articulation Disturbances
Performance: The patient will not speak at all but will completely communicate normally when reading or writing.
Location: Lesions are in the inputs to the muscles of articulation. (Strub, Black-1990)
3. The potential is good for lateralizing lesions, categorizing them as expressive, receptive, or both, and for contributing to an overall neuropsychological evaluation, according to answers on the Reitan-Indiana AST. (Weisenburg, 1964)

IV. Specific Cognitive Processes

A. From clinical experience with aphasics, standards derived from intelligence testing and construction of other psychological tests, the following are statements of what an aphasia test measures:

1. Explore all potentially disturbed language modalities.
2. Discriminate between clinically relevant aphasia types.
3. A range of difficulty in order to examine a representative range of severity of deficits (construct validity).
4. Discriminate between normals, aphasics and non-aphasic brain-damaged individuals (criterion validity).
5. Rate speech output or expressive function.
6. Measure comprehension, naming, repetition, reading, and writing.
7. Measure simple arithmetic ability.
8. Measure simple copying, drawing capability.
10. Distinguish lateralization, receptive, expressive, or receptive/expressive language (Incagnoli, Goldstein, Golden, 1986).

V. Relationship to other tests

A. The Language Modalities Test for Aphasia uses a film strip to present visual stimuli, as well as auditory stimuli presented by the examiner. Responses are oral and graphic for both kinds of stimuli. A matching response is also used. There is a screening section of 11 items. If necessary, this is followed by another 46 items. The stimuli include objects, words, numbers, and sentences f increasing length. The scale is scored by syntactic errors, semantic errors, jargon or unintelligible response, or no response.

B. Boston Diagnostic Aphasia Examination is a comprehensive test designed for the diagnosis of presence and type of aphasic syndromes leading to differences concerning cerebral localization, measurements of levels of performance over a wide range for both initial evaluation and detection of change over time, and comprehensive assessment of the assets and liabilities of the patients in all areas as a guide to therapy. Expository speech, auditory comprehension, oral expression, reading comprehension, writing tasks, supplementary language teas, and supplementary nonlanguage tests are components of the exam. (Logue, Schear, 1984)

VI. Strengths and Weaknesses of the Reitan-Indiana Aphasia Screening Test

A. Strengths of the RIAVSI' are that specific deficits of known cerebral significance can be discerned and lateralized.

B. A weakness is that experience and knowledge on behalf of the examiner is absolutely paramount in detection.

References

1. Benson, Geschwind, (1968) Cerebral dominance and its disturbances, Clinical Pediatrics, 15, 759.
2. Dodrill, C. (1985) Incidence and doubtful significance of nonstandard orientations in reproduction of the key from the Aphasia Screening Test, Perceptual and Motor Skills, 60 (2), 411-415.
3. Heaton, R. (1981) A comparison of clinical and automated interpretation of the Halstead-Reitan Battery, Journal of Clinical Neuropsychology, 3, 121-141.
4. Incagnoli, Goldstein, Golden, (1986), Clinical Application of Neuropsychological Test Battery, Plenum Press.
5. Logue, Schear, (I 984), Clinical Neuropsychology, A Multidisciplinary Approach, Charles C. Thomas-Publisher.
6. O'Donnell, Romero, Leicht, (1990), A comparison of language deficits in learning-disabled, head injured, and nondisabled young adults: Results from an abbreviated Aphasia Screening Test, Journal of Clinical Psychology, 46, 310-315.
7. Reitan, Wolfson, (1990), The Halstead-Reitan Neuropsychological Test Battery, Theory and Clinical Interpretation, Neuropsychology Press.
8. Snow, (1987), Aphasia Screening Test performance in patients with lateralized brain damage, Journal of Clinical Psychology, 43, 266-27 1.
9. Strub, Black, (1990), The Mental Status Examination in Neurology, F.A. Davis Company.
10. Wheeler, Burke, and Reitan (1963), An application of discriminant functions to the problem of predicting brain damage using behavioral variables, Perceptual and Motor Skills, 16, 417-440.
11. Williams, Shane, (1986), The Reitan-Indiana Aphasia Screening Test: Scoring and Factor Analysis, Journal of Clinical Psychology, 42, 156-160.
12. Weisenburg, (1964), Aphasia: A Clinical and Psychological Study, Hafner Publishing Company.