Is the Boston Naming Test still fit for purpose?

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Is the Boston Naming Test Still Fit For Purpose? a

Alexandra Harry & Simon F. Crowe

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School of Psychological Science, Faculty of Science, Technology and Engineering, La Trobe University, Bundoora, Australia Published online: 07 Mar 2014.

Click for updates To cite this article: Alexandra Harry & Simon F. Crowe (2014) Is the Boston Naming Test Still Fit For Purpose?, The Clinical Neuropsychologist, 28:3, 486-504, DOI: 10.1080/13854046.2014.892155 To link to this article: http://dx.doi.org/10.1080/13854046.2014.892155

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The Clinical Neuropsychologist, 2014 Vol. 28, No. 3, 486–504, http://dx.doi.org/10.1080/13854046.2014.892155

Is the Boston Naming Test Still Fit For Purpose? Alexandra Harry, and Simon F. Crowe


School of Psychological Science, Faculty of Science, Technology and Engineering, La Trobe University, Bundoora, Australia The Boston Naming Test (BNT) (Kaplan, Goodglass, & Weintraub, 1983) is the most commonly used test of confrontation naming in neuropsychology (Rabin, Barr, & Burton, 2005). However, there are significant criticisms of the BNT which suggest that it might not be the assessment measure of choice. These criticisms are that the BNT has poor psychometric properties, is not adequately standardized, and has inadequate norms. It is further suggested that when considered in the context of contemporary conceptualizations of the neuropsychology of naming, the BNT does not adequately capture the processes known to be required for successful naming, and does not sample widely enough from the content domain of “naming”. These criticisms suggest that the BNT is flawed as a measure of naming, and are discussed in detail in this review. Other stand-alone visual confrontation naming tasks are reviewed to evaluate whether any might be viable substitutes for the BNT in clinical neuropsychology. The Naming Test from the Neuropsychological Assessment Battery (Stern & White, 2009) was identified as a possible alternative to the BNT, however, neither of these tests was designed with reference to models of the neuropsychology of naming, and development of a new test of naming is indicated. Keywords: Confrontation naming; Boston Naming Test; Aphasia; Word finding difficulty; Language assessment.

INTRODUCTION Naming difficulty is the most common symptom of language dysfunction seen in clinical assessment following stroke (Laine & Martin, 2006) and naming deficits may be the first, or only, indicator of language dysfunction shown in a neuropsychological assessment (McKenna & Warrington, 1980). Progressive naming difficulty is also a feature of neurodegenerative diseases such as Alzheimer’s disease and the semantic variant of fronto-temporal dementia (Mesulam et al., 2009). Monitoring naming deficits across time is useful in assessing the degree of deterioration in neurodegenerative disorders and the degree of recovery following brain injury (Franzen, 2000). A sensitive and valid test of naming ability is therefore of critical importance in neuropsychological assessment. Neuropsychological assessment of naming is usually performed using a visual confrontation naming test in which the patient is required to identify and correctly name a series of pictured objects (Ellis, Kay, & Franklin, 1992). Although naming may be performed in other modalities, tests using visual stimuli and requiring verbal responses

Address correspondence to: Simon F. Crowe Ph.D., School of Psychological Science, Faculty of Science, Technology and Engineering, La Trobe University, Bundoora, Victoria 3086, Australia. E-mail: [email protected] (Received 31 July 2013; accepted 4 February 2014)

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IS THE BNT FIT FOR PURPOSE?

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are useful in identifying naming impairment in a wide variety of pathophysiological presentations including stroke (Lezak, Howieson, & Loring, 2004), Alzheimer’s disease (AD) and vascular dementia (Graves, Bezeau, Fogarty, & Blair, 2004), semantic dementia (SD) (Mesulam et al., 2009), herpes simplex virus encephalitis (Barbarotto, Capitani, & Laiacona, 1996), and temporal lobe epilepsy (Busch, Frazier, Haggerty, & Kabu, 2005). Despite significant and well-documented criticisms (e.g., Bortnik et al., 2013), the BNT (Kaplan et al., 1983) continues to be the test most commonly used in clinical neuropsychology practice to assess naming (Bortnik et al., 2013; Rabin et al., 2005), and the BNT is often translated into other languages for use (e.g., Swedish, Portuguese, and French) (Brusewitz & Tallberg, 2010; Miotto, Sato, Lucia, Camargo, & Scaff, 2010; Roberts & Doucet, 2011). Criticisms of the BNT include that it has poor psychometric properties (Hamby, Bardi, & Wilkins, 1997), is not adequately standardized (Ferman, Ivnik, & Lucas, 1998), and has inadequate norms (Ross & Lichtenberg, 1998). In addition to these criticisms, it is argued here that the BNT fails to capture advances that have occurred in the neuropsychology of naming since 1983, and further, it does not adequately capture the processes known to be required in naming, nor sample widely enough from the content domain of “naming”. As there are other stand-alone visual confrontation naming tasks available, it is possible that one of these may address the issues known to exist for the BNT. This paper provides an overview of the BNT, details criticisms of the BNT and practice considerations, describes a current conceptualization of the neuropsychology of naming, and considers the implications of this for naming assessment. Finally, it provides a review of the few published stand-alone visual naming tasks to determine whether they might be considered to be viable substitutes for the BNT in clinical neuropsychology.

THE BOSTON NAMING TEST The BNT consists of 60 line-drawn pictures which are reported by the authors to be presented in order of difficulty from “easiest” (e.g., “tree”) to “most difficult” (e.g., “abacus”) items (Kaplan et al., 1983). Participants have 20 seconds in which to name the presented item correctly. If the participant initially names the item presented incorrectly due to misperception or a failure to recognize the object, then a stimulus cue is offered and the participant is allowed a further 20 seconds to name the picture. Phonemic cues are given after a failure to respond or an incorrect response (and may follow a stimulus cue). Items correct following a stimulus cue are counted towards total correct when scoring, whereas items correct following phonemic cueing are not. Most published information regarding the BNT uses the 1983 edition (Lezak et al., 2004; Mitrushina, Boone, Razani, & D’Elia, 2005; Strauss, Sherman, & Spreen, 2006) which is also the edition most commonly used by neuropsychologists (Bortnik et al., 2013). This review refers to the 1983 edition throughout.

PSYCHOMETRIC PROPERTIES OF THE BNT Validity and reliability of the BNT are considered to be “well established” (Pedraza, Sachs, Ferman, Rush, & Lucas, 2011, p. 434). There are detailed reviews


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of this issue available from a number of sources (e.g., Mitrushina et al., 2005; Strauss et al., 2006) but only the key findings are summarized here. Studies of the reliability of the BNT have generally focused on test–retest reliability, which is good for the 60-item version from 2 weeks (r = .91; Flanagan & Jackson, 1997) to up to 11 months (r = .92; Dikmen, Heaton, Grant, & Temkin, 1999). Validity studies for the BNT include studies of its diagnostic and predictive properties, and generally such studies support the use of the BNT, for example in distinguishing between AD, dementia with Lewy Bodies, and normal ageing (Ferman et al., 2006). Other validity research examining the association between BNT scores and other measures shows high positive correlations with verbal fluency (Locascio, Growden, & Corkin, 1995), and verbal IQ, and moderate positive correlations with performance IQ (Axelrod, Ricker, & Cherry, 1994). The BNT score has a non-normal score distribution due to a ceiling effect and negative skew. Despite this, the BNT is considered adequate for the purpose of detecting impairment; that is, assessing the degree of “naming deficit” rather than the level of naming skill (Mitrushina et al., 2005, p. 179). However, a non-normal distribution introduces error into z-score interpretation of test results, and the ceiling effect reduces the utility of the BNT in detecting impairment (Brooks, Strauss, Sherman, Iverson, & Slick, 2009). For many patient groups it is suggested that finer discrimination is needed to identify subtle deficits or gradual declines in performance than can be provided by the BNT (e.g., patients with HIV infection, multiple sclerosis, mild cognitive impairment; Hamby et al., 1997). Hamby et al., (1997) argue that clinically significant differences in functioning may occur “within normal limits” (p. 546) and detection of these cognitive differences contributes information to important patient decisions, especially those concerning work and treatment. In their study Hamby et al. (1997) assessed 117 cognitively intact HIV positive patients using a variety of tests including the BNT. They examined the sampling distributions of responses for each test and used measures of skew and kurtosis to assess how well the test discriminated among participants. The sampling distribution of scores for the BNT was “poor”; that is, most scores were near the maximum score, and the distribution was significantly negatively skewed and kurtotic. The authors concluded that, given these properties, it is inappropriate to transform patient BNT scores into z-scores and associated percentiles, even in clinical settings. Indeed in clinical settings there is a high risk of overpathologizing scores marginally below the normative average if this practice is adopted (Bortnik et al., 2013). For skewed distributions it is recommended that percentile ranks obtained directly from raw scores are used rather than z-scores (Brooks et al., 2009; Crawford, Garthwaite, & Slick, 2009); however, published reference material tends to translate BNT scores into standard scores and percentiles (e.g., Strauss et al., 2006) and clinicians need to access original sources for this information (e.g., Tombaugh & Hubley, 1997). Some of the items of the BNT also have flaws which introduce further error into assessment of naming with this instrument. In a sample of 300 consecutive neuropsychological outpatient referrals, Pedraza et al. (2011) used item response theory to examine item difficulty and discrimination for the BNT. They found that the numbering of item presentation did not reflect item difficulty, several items provided redundant information, and several items had very poor discriminative properties. In


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their study the test as a whole was most reliable for individuals in the low-average range of naming ability (i.e., at approximately –1.0 standardized units), with considerable measurement error evident in scores for individuals in the high-average range of naming ability (Pedraza et al., 2011).


STANDARDIZATION OF THE BNT Inter-rater reliability data have not been reported for the BNT, which means that one of the major criticisms of the BNT (i.e., that it has poor standardization), has not been adequately addressed. Scoring differences may have an impact on clinical decisions, as demonstrated by an examination of two possible interpretations of the BNT’s discontinuation rule (Ferman et al., 1998). Ferman et al.’s (1998) research was initiated after an informal survey of neuropsychologists working across 10 medical centers found that half were using a “lenient” and half were using a “rigorous” interpretation of the discontinuation rule (Ferman et al., 1998, p. 14). This division in practice with the BNT is probably widespread. In 2004 a survey of 445 National Academy of Neuropsychology (NAN) members was similarly divided, with 54% of survey respondents using a “rigorous” and 46% using a “lenient” interpretation of the BNT discontinuation rule (Bortnik et al., 2013). In the lenient interpretation, items answered correctly following phonemic cuing are not counted as one of the six consecutive failures for discontinuation; in the rigorous interpretation, items answered correctly following phonemic cuing are counted as a failure for discontinuation. In a sample of 331 healthy participants and 132 AD patients, Ferman et al. (1998) found that applying different discontinuation protocols changed scores, and that this occurred more often for the AD group (33% of scores changed) than the healthy group (6% of scores changed). Although the average score change was approximately 3 points in both groups, the score difference was more likely to be “clinically meaningful” (i.e., 4 points or more; Ferman et al., 1998, p. 15) for the AD group, in which 10% of participants had meaningful score changes, compared with only 3% of those in the healthy group. Ferman et al.’s (1998) study indicates that differing interpretations of the discontinuation criterion for the BNT may disproportionately affect assessment of naming in those with impairment, a concern which is magnified by acknowledging that this is not the only likely source of inter-rater error for the BNT. Additional examiner differences occur in decisions about which responses are regarded as acceptable synonyms, whether or not 20 seconds are allowed for a participant response, and in the treatment of visually ambiguous items (Bortnik et al., 2013; Lopez, Arias, Hunter, Charter, & Scott, 2003; Nicholas, Brookshire, MacLennan, Schumacher, & Porrazzo, 1989). Several authors have commented on the sparse nature of the BNT instructions for administration and scoring, and raised concerns regarding the normative data that follow from this (Bortnik et al., 2013; Ferman et al., 1998; Lopez et al., 2003). As norms for the BNT (e.g., Mitrushina et al., 2005; Strauss et al., 2006) often do not provide information about the administration and scoring protocols used, it is difficult to have confidence that the comparison of test scores across studies, or in norm-referenced clinical assessment, is valid (Lopez et al., 2003).

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NORMATIVE DATA FOR THE BNT Given the criticisms of the BNT already outlined, it is important to consider whether the published norms for the test adequately represent the populations with which it is used. Confrontation naming is known to be influenced by a number of variables including age, education, intelligence, gender, and ethnicity (Randolph, Lansing, Ivnik, Munroe Cullum, & Hermann, 1999). Studies of the BNT have shown mixed results with regard to these factors, but this is at least partly due to the restricted range of the variables of interest in the samples collected. For example, although Mitrushina and colleagues’ (2005) meta-analysis of 14 published studies of BNT normative data contained 1684 participants, the range of data for participants was markedly restricted for IQ scores (113–119) and years of education (11–16). Despite this issue there are a number of identifiable trends (if not always significant findings): BNT scores tend to be negatively correlated with age (Zec, Burkett, Markwell, & Larsen, 2007; Zec, Markwell, Burkett, & Larsen, 2005); and positively correlated with education, vocabulary (Hawkins & Bender, 2002), and intelligence (Mitrushina et al., 2005); men tend to have higher BNT scores than do women (Hall, Vo, Johnson, Wiechmann, & Bryant, 2012); and Caucasian examinees tend to have higher BNT scores than do other ethnic groups (Pedraza et al., 2009). Clinical norms need to account and control for these relationships with demographic characteristics, and clinicians should access norms appropriate to their patients’ reference groups. Although participants on whom most normative data for the BNT are based tend to be better educated, less ethnically diverse, and have a higher IQ than those patients likely to be seen in some practice settings (Ross & Lichtenberg, 1998), 53% of NAN survey respondents reported that they did not consider ethnicity, and 41% did not consider English as a second language when interpreting a client’s BNT test scores (Bortnik et al., 2013). Uncritical use of norms may lead to classification errors, as demonstrated by results from a sample taken in a medical rehabilitation setting (Ross & Lichtenberg, 1998). The 233 neurologically intact older (65–95 years) participants in this sample were more ethnically diverse (56% African American), participants were less educated (M = 11.1 years, SD = 3.2), and there were a greater proportion of females (73%) than for most BNT study samples. The normative data showed substantially lower mean BNT scores and greater standard deviations across age groups than other samples. For example, a 72-year-old person with 10 years of education and a BNT score of 38 would be classed as average (i.e., at the 50th percentile) using this study’s norms, but would be classed as below average (i.e., at the 5th percentile) using Mayo’s Older Americans Normative study norms (Ivnik, Malec, Smith, Tangalos, & Peterson, 1996). These findings emphasize the importance of having and using BNT norms which adequately represent the relevant clinical population.

RELATIONSHIP OF THE BNT TO VOCABULARY MEASURES In addition to norms accounting for age, sex, education, and ethnicity, some authors have suggested that BNT norms should be reported with vocabulary measures to control for the large amount of variance naming shares with vocabulary (e.g., Wilkins, Hamby, & Thompson, 1996). BNT scores are reported to be significantly



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correlated with Wechsler Adult Intelligence Scale – Revised (WAIS-R; Wechsler, 1981) Vocabulary sub-test scores, with moderate correlations in healthy samples (r = .65, Killgore & Adams, 1999; r = .53, Tombaugh & Hubley, 1997) and higher correlations in clinical samples (r = .75, Hamberger, 1999; r = .79, Thompson & Heaton, 1989). Similar findings have been reported with a reading vocabulary test (Hawkins & Bender, 2002). There are currently no published studies of the association between the BNT and more recent editions of the Wechsler Vocabulary scales. However, the available evidence suggests that because the BNT does not differentiate between failure of word retrieval and failure of knowledge, assessment of vocabulary is necessary so that a patient with a limited vocabulary and without a naming deficit is not misclassified as having a naming deficit (Hamberger, 1999). Support for this position is provided by a study of sensitivity and specificity of the BNT, in which WAIS-R Vocabulary score was used to predict BNT scores in a sample of 85 patients consecutively referred for neuropsychological assessment (Killgore & Adams, 1999). The results showed that although adjustment for Vocabulary did not improve BNT sensitivity (i.e., rate of naming impairment detected accurately); specificity (i.e., rate of false positives) was significantly improved by adjusting for Vocabulary when compared with unadjusted norms. Further, using a vocabulary measure to control for shared variance was more important for assessment of naming in individuals with a limited vocabulary because a low average Vocabulary score predicted a below average BNT score, when referenced to most published norms. Similar results were demonstrated using reading vocabulary (i.e., the Gates-MacGinitie Reading Test) to predict BNT scores in groups including an HIV positive sample (Wilkins et al., 1996), a psychiatric sample, and a healthy control sample (Hawkins et al., 1993). Such results suggest that BNT cut-offs should not be used with individuals who have a limited vocabulary, and that a vocabulary measure should be used alongside the BNT to minimize false-positive misclassification errors (Hawkins & Bender, 2002). Critical use of vocabulary scores is recommended as it is possible that vocabulary scores may be affected by word-finding difficulties that are not detected by the BNT.

SUMMARY OF BNT PRACTICE RECOMMENDATIONS Psychometrically, as the BNT does not have a normal distribution, use of z-scores or standard scores to obtain percentiles may overpathologize a mildly reduced performance (Bortnik et al., 2013) and it is recommended that percentiles are obtained directly from raw scores (Brooks et al., 2009; Crawford et al., 2009). The BNT is most reliable for individuals in the low-average range of naming ability (Pedraza et al., 2011). There are two possible interpretations of the discontinuation rule, and norms used should reflect the method used by the practitioner when interpreting scores (Ferman et al., 1998). Clinicians should access norms appropriate to their patients’ background with reference to age, sex, education, and ethnicity, and consider these factors in interpretation of scores. Clinicians may also consider vocabulary development and reading skill level when interpreting scores.

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COGNITIVE PROCESSES UNDERLYING VISUAL NAMING


In general, naming tests such as the BNT distinguish between normal (average) naming and impaired (below average) naming on a quantitative basis, making the assumption that naming is a unitary construct (Benson, 1988). However, there is widespread agreement that intact performance on visual confrontation naming tasks relies on a number of cognitive processes (see Figure 1), disruption of any of which may result

Figure 1. Simple standard model of the cognitive processes underlying naming (black text) and examples of naming impairments following failure of processes (red text). Adapted from “A standard model of spoken and written word processing” by M. Laine and N. Martin, 2006, Anomia: Theoretical and clinical aspects, p. 38. Copyright 2006 by Psychology Press.



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in impaired performance. Therefore, although a lower than expected score on a test may indicate that a naming deficit exists, more detailed neuropsychological assessment is required to provide information about the nature of that deficit. There is consensus within neuropsychology that picture naming requires the cognitive processes shown in Figure 1 (Ellis et al., 1992; Hillis, 2007; Laine & Martin, 2006). These processes include: visual analysis of the picture; recognition of the visual stimulus as familiar; activation of the semantic representation of the object (i.e., the meaning of an object) via the semantic system; a lexical-semantic process which directs selection and retrieval of semantic information in a task appropriate way; modality-independent lexical access to the phonological word form of the object (i.e., the speech sounds used in the word); and the motor programming and articulation required for saying the word. Patterns of impairment after brain damage or degenerative disease (see examples in red, Figure 1) provide evidence that these are distinct cognitive processes required for intact naming performance (DeLeon et al., 2007; Hillis, 2007; Laine & Martin, 2006). The model shown omits a hypothesized “lemma” level of processing, in which the phonological word form is accessed from semantic representation, and where the grammatical (i.e., syntactic) role of the word is specified. However, whether this level of processing is essential is vigorously debated (DeLeon et al., 2007; Lambon Ralph, Moriarty, & Sage, 2002). The inclusion of both a semantic system and a lexical-semantic system in Figure 1 is relevant to neuropsychology practice because distinguishing whether impairment has occurred to one or other of these processes may assist differential diagnosis (DeLeon et al., 2007; Jeffries & Lambon-Ralph, 2006). The semantic system in Figure 1 is important as it includes both a distributed modality-specific neural network and an amodal hub (Patterson, Nestor, & Rogers, 2007), which also has implications for assessment of naming. There is agreement among most investigators that semantic memory is based on a widely distributed modality-specific neural network, and that this network is at least partly organized by the sensory features (e.g., shape, name, motion, and color) of an object, as well as by the motor functions associated with an object’s use (Martin, 2007; Patterson et al., 2007). An amodal hub for the distributed network is proposed to explain how semantic memory can generalize across concepts that may have similar semantic significance (e.g., prawns and scallops are both seafood), but do not necessarily have similar attributes (e.g., scallops and prawns have different shapes, colors, and shell structures; Patterson et al., 2007). In this model, damage to the hub will produce a semantic impairment that is independent of the modality of input and output. There are limitations to the schematic shown in Figure 1. First, it reduces cognitive processes to discrete serial stages rather than showing likely activation networks, or feedback and feed-forward processes (DeLeon et al., 2007). Second, the deficits shown rarely occur in their “pure” form in patients, who are usually compromised across a range of processes (Rohrer et al., 2008). Despite these limitations, the schematic remains useful. It provides a summary of what is known about the processes underlying naming and it provides information about what might be usefully included in measures of naming, as discussed next.

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IMPLICATIONS FOR ASSESSMENT OF NAMING WITH THE BNT


Category-specific semantic deficits The first implication for naming in the schematic shown in Figure 1 is that the distributed modality-specific semantic network allows the possibility that semantic deficits may be category specific. Category-specific semantic deficits have been documented for at least 100 published cases (Capitani, Laiacona, Mahon, & Caramazza, 2003). In a review of the literature from 1984 to 2001 Capitani et al. (2003) identified 79 case studies in which there was a category-specific deficit, including 61 cases of disproportionate impairment for biological categories (animals, and fruit/vegetables) and 18 cases with a disproportionate impairment for artefacts (i.e., man-made objects). While broad category dissociations have been described, such as living things being more impaired than nonliving things (Laws & Gale, 2002), these broad categories fractionate into reported dissociations for proper names, animals, and tools (Damasio, Tranel, Grabowski, Adolphs, & Damasio, 2004); musical instruments and body parts (Laws, Gale, Frank, & Davey, 2002); and nonliving foods (e.g., cake, bread, and cheese) and creatures (i.e., animals, mammals, birds, reptiles; Cree & McRae, 2003). Category-specific deficits have been reported in patients with a wide variety of neurological pathologies including stroke (Damasio et al., 2004), herpes simplex virus encephalitis (Noppeney et al., 2007), traumatic brain injury (Laiacona, Barbarotto, & Capitani, 1993), temporal lobe epilepsy (Lu et al., 2002), and other conditions (Coppens & Frisinger, 2005). It is therefore important that naming tasks adequately sample performance across an appropriate number of semantic domains. In order to detect selective semantic impairment, tests of confrontation naming should use a number of each of the items from the subcategories that have produced documented dissociations. The BNT omits insects, body parts, and fruit; it only has one exemplar in the categories of bird (“pelican”), flower (“flower”), and vegetable (“asparagus”) and does not adequately sample from the range of possible semantic categories required to identify selective semantic impairment.

Category-level impairments The second implication of this model is that the category level at which a stimulus item is presented (e.g., rose versus flower) will affect the performance of patients with semantic deficits (Lambon Ralph & Patterson, 2008). The role of the amodal hub is to enable generalizations across concepts, and it is thought that the impairment in semantic dementia and other progressive dementias is a failure of this process. Lambon Ralph and Patterson (2008) provide case study evidence to demonstrate both under- and over-generalization errors in patients with semantic dementia. An undergeneralization error occurs when a patient uses a word appropriately with evidence of understanding in one context (e.g., patient states he used to work as a petroleum engineer), but then fails to recognize or comprehend the same word in a different context (e.g., what is petroleum?). Over-generalization errors occur when a basic-level label is produced (e.g., flower) where a subordinate is required (e.g., rose). In patients with semantic dementia, over-generalization errors are produced more frequently than under-generalization errors (Lambon Ralph & Patterson, 2008; Mesulam et al., 2009).


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The BNT contains two stimulus items (“tree” and “flower”) which require a basic-level response. While the inclusion of these items is not problematic, it can be argued on the basis of Lambon Ralph and Patterson’s (2008) work that it would be helpful the BNT also required subordinate responses within these and other categories. More research is required to investigate Lambon Ralph and Patterson’s (2008) hypothesis further, but their findings suggest that the category level of stimulus items may affect the capacity of a confrontation naming test to detect early or subtle semantic impairment.


Lexical and semantic aspects to the task of naming The final implication of the schematic shown in Figure 1 is that there are both semantic (i.e., memory) and lexical (i.e., language) aspects to the task of confrontation naming. Identifying whether a naming failure is due to an error in one or the other aspect of the task is difficult. Traditionally, patterns of errors across tasks, as well as error types, were presumed to provide an indication of the component of naming that is impaired in a particular case (Rohrer et al., 2008). Unfortunately labelling errors as lexical/phonemic (failure to retrieve the appropriate name for the stimulus), or semantic (failure to access the underlying conceptual representation) can be misleading as semantic errors can also be produced by patients with impairment to the lexical-semantic executive process (Rohrer et al., 2008). Further, scoring errors is complex due to the wide variety of error types seen in clinical assessment (e.g., classified by 17 categories in LaBarge, Balota, Storandt & Smith, 1992). However, there is evidence that an approach which incorporates analysis of naming responses by basic error type, combined with analysis of the effectiveness on response of phonemic cueing, may assist with differential diagnosis in a clinical setting (Jefferies & Lambon Ralph, 2006; Jefferies, Patterson, & Lambon Ralph, 2008). In a case-series design Jefferies and Lambon Ralph (2006) compared the performance of 10 patients with semantic dementia (SD; associated with semantic deficits) and 10 patients with stroke (in this study, associated with lexical-semantic deficits) on a battery of semantic tests. They administered the BNT using phonemic cueing only. Although both groups achieved similar scores on the tests, showing semantic errors in naming and comprehension, within each group there was also a distinctive pattern of test performance. That is, the SD group showed high correlations in performance across three different semantic tasks (r = .77 to r = .96), but the stroke group did not (r = 0 to r = .68); the SD group was sensitive to the effects of stimulus familiarity, but the stroke group was not; the stroke group made more phonological errors than the SD group; and the stroke group benefitted from phonemic cueing, but the SD group did not (Jefferies & Lambon Ralph, 2006). Jefferies et al. (2008) conducted more detailed assessment of cueing effects for six of these stroke patients compared with eight newly recruited cases of SD, and found that stroke patients showed a significantly larger cueing effect than the SD group. The results of the studies by Jefferies and Lambon Ralph (2006) and Jefferies et al. (2008) suggest that understanding errors and cueing effects may emerge as a useful paradigm for assessing confrontation naming performance in the future. In a clinical setting, cueing and error patterns may assist in hypothesis testing if patients with


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lexical/phonological impairment tend to make few semantic errors and show benefit from cueing, patients with semantic-lexical executive deficits tend to make more semantic errors and show benefit from cueing, and patients with semantic deficits tend to show deficits across modalities and to show less benefit from cueing. These results indicate that errors should be recorded at the basic level, that is, perceptual, semantic, or phonological. Although some attempts have been made to record and code errors in BNT responses, there is currently no standardized method for doing so (Mitrushina et al., 2005). The results also suggest that norms for the BNT should include a score which takes into account total number of items named correctly, and number of items named correctly with a phonemic cue. Currently sets of norms for the BNT which take into account cueing effects provide data for items named correctly, items named correctly with a stimulus cue, and items named correctly with a both a stimulus and a phonemic cue (e.g., Tombaugh & Hubley, 1997), which is probably not helpful.

SUMMARY OF IMPLICATIONS FOR NAMING The distributed modality specific semantic network accounts for category-specific naming deficits (Patterson et al., 2007). If naming deficits can be category-specific, an ideal test of naming would sample from a variety of subcategories that have documented dissociations (e.g., fruit, tools, furniture), which the BNT does not do. The amodal hub of the semantic system (Patterson et al., 2007) and recent research in semantic dementia (Jeffries & Lambon Ralph, 2006) suggest that an ideal test of naming would also require subordinate labels (e.g., apple) within those subcategories (e.g., fruit), which the BNT was not designed to do. Finally, research is required to explore further whether a naming test could help distinguish between lexical-semantic and semantic deficits using basic error types and phonemic cueing (Jeffries & Lambon Ralph, 2006). In standardized administration of the BNT, phonemic cueing may follow semantic cueing which is unhelpful, and the data regarding error categorization using the BNT is complex and inconsistent.

REVIEW OF OTHER MEASURES OF VISUAL CONFRONTATION NAMING Review of other measures of naming shows that more recent tests and tasks generally consist of color photographs, whereas older instruments are black and white line drawings. Although it is generally accepted that color photographs are more ecologically valid (e.g., Moreno-Martínez, Montoro, & Laws, 2011), a position supported by a recent meta-analysis of 35 studies with 1535 participants which showed that color information has a moderate effect size on object recognition in naming tasks (d = .36; Bramão, Reis, Petersson, & Faísca, 2011); few researchers have systematically compared performance on color photographic stimuli with black and white line-drawn stimuli (Bramão et al., 2011). In one such study Adlington, Laws, and Gale (2009a) compared the performance of 41 AD patients with 40 elderly controls on color, grey scale, and line-drawn items. The control group significantly benefited from the addition of color, and the control group showed a significant interaction effect for color by category, whereas the AD group showed neither effect. While exploring this issue further is



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beyond the scope of this review, the effects of color on naming for clinical groups requires further research attention. There are a number of other measures of confrontation naming that could be considered possible substitutes for the BNT, if substitution would address the issues associated with the BNT. Review of stand-alone visual naming tasks showed that there were three clinical and three cognitive tasks that might be considered. Clinical tasks are those (like the BNT) which are designed to measure impairment in a clinical setting. Cognitive tasks have a format similar to clinical tasks (i.e., requiring naming of pictures), but are designed to measure or study cognitive processes in naming. The differences between the two are substantial, and although both make reference to “normative data”, clinical tasks are generally analyzed in terms of sample characteristics (i.e., demographic variables) and psychometric properties (e.g., internal consistency), and cognitive tasks are generally examined in terms of sample ratings of stimulus characteristics (e.g., object familiarity, visual complexity). Clinical tests The three measures identified as possible alternatives to the BNT by literature review are presented in Table 1. Unfortunately none of the available measures addresses all the deficiencies of the BNT. The Graded Naming Test (GNT; McKenna & Warrington, 1980) allows for dissociation between names of objects and proper names, but it does not allow for dissociation between other categories. The GNT has 30 line-drawn items in object naming, and some of these appear to be dated and/or UK culture-specific (e.g., “monocle”, “mitre”), Table 1. Properties of various clinical tests for assessment of visual confrontation naming Name of test (year)

Stimulus items

Number of items

Graded Naming Test (1980)a Philadelphia Naming Test (1997)c

Line drawn

30 Objects, 30 Proper names

Line drawn

The NABe Naming Test (2009)f

Colour photos

175 animate and inanimate objects 31

a

Standardization sample b

305 healthy participants matched for normal IQ distribution 240d stroke patients

950 healthy participants matched to demographics of US population

McKenna & Warrington 1980. Warrington 1997. c Roach et al., 1997. d Walker & Schwartz 2012. e Neuropsychological Assessment Battery. f Stern & White 2009. g Yochim et al., 2009. b

Distribution

Reliability

Validity

Possibly normal

Unknown

Unknown

Unknown

Correlated with reading scores, vocabulary scores Correlated with the Western Aphasia Batteryd

Ceiling effect

Alternate form

Correlated with the Boston Naming Test


498


or otherwise problematic (e.g., “retort”). When the test was re-standardized by Warrington in 1997, the test scores appeared to have a normal distribution (this was pictured) and it had no obvious ceiling, but no data were provided. The GNT does not use a cueing paradigm. The main strength of the GNT is that it was standardized against reading and vocabulary scores (McKenna & Warrington, 1980) and then re-standardized against an estimate of premorbid functioning (i.e., the National Adult Reading Test; Warrington, 1997). The purpose of the Philadelphia Naming Test (PNT; Roach et al., 1996) is to inform the clinician about aphasic deficits with respect to other individuals with aphasia, as compared with the purpose of the BNT, which is to inform the clinician about the presence or absence of a naming deficit (Walker & Schwartz, 2012). The PNT takes into account most types of participant error, and the complexity of its scoring system reflects this. The PNT scoring system requires tape recording of participant responses for labeling and coding and scoring by speech pathologists (Roach et al., 1996), which rules it out from use in most clinical neuropsychology settings. The Neuropsychological Assessment Battery (NAB) Naming Test (NABNT) was originally published as a module of the NAB (White & Stern, 2003), and is now published as a stand-alone measure of naming (Stern & White, 2009). There is little empirical research so far with the NABNT, and evidence for the construct validity of the BNT far outweighs what is known about the NABNT. However, the NABNT has advantages over the BNT in that it has two parallel forms designed for re-testing, and excellent norms (i.e., a demographically corrected normative sample of 1448 individuals). Standardization may potentially be better as it is supplied with a training DVD. The NABNT may have more ecological validity than the BNT as it uses color photographs, and the NABNT is also likely to be quicker to administer than the BNT as less time is allowed for responding (i.e., 5 seconds), there are fewer items, and there is no basal assessment. Unfortunately the format of administration is similar to the BNT regarding cueing, and the NABNT score distribution also shows a ceiling effect (Brooks et al., 2009). It is likely that the NABNT has shortcomings similar to the BNT due to these issues. The design of NABNT was not informed by the cognitive processes underlying naming, and the number and type of categories addressed in this test is not outlined in the literature. Although one of the reported strengths of the NABNT is that it is less affected by age and education than the BNT (Stern & White, 2009) this finding was not supported in a study of the NABNT and BNT in 70 healthy participants (Yochim, Kane, & Mueller, 2009) which showed significant correlations with age (r = –.28 to –.32) and education (r = .28 to .32). Recent studies have shown the NABNT correlates with the BNT at .56 in a non-impaired sample (Yochim et al., 2009), and .74 to .80 in a sample with brain injury (Zgaljardic et al., 2013). Cognitive tasks There are three cognitive tasks that might be considered possible substitutions for the BNT with further development, as presented in Table 2. Although sometimes termed “tests”, they are better understood as banks of items as they do not have the properties of psychometric tests. That is, there is little or no examination of the psychometric properties of the items in terms of the instrument as a whole, there are a large


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Table 2. Properties of various cognitive tasks requiring visual confrontation naming

Name/authors of task (year) Snodgrass and Vanderwart (1980) Hatfield Image Test (2009)a Bank of Standardized Stimuli (2010)b

Type of stimulus items

Number of items

Standardization sample

Number of categories

Line drawn

260

219

15

Colour photos Colour photos

147 480

152 72

15 –

a


b

Adlington et al., 2009b. Brodeur et al., 2010.

number of items, and reference samples are small relative to the number of items (see Table 2). Items are usually examined in terms of an objective measure such as lexical frequency, and participant ratings of a number of psycholinguistic variables, such as age of acquisition, familiarity, manipulability, name agreement, typicality, and visual complexity (Moreno-Martínez & Montoro, 2012). The value of psycholinguistic variables in clinical research is debated, and some researchers regard them as of limited worth (Damasio, Grabowski, Tranel, Hichwa, & Damasio, 1996). However, as Jeffries and Lambon Ralph (2006) demonstrated differential effects for stimulus familiarity in stroke versus SD patients, these variables should not be disregarded too quickly. Of the three published banks of items for English speakers identified by literature review, two were discounted. The Snodgrass and Vanderwart (1980) corpus is widely used but is over 50 years old and known to have a low ceiling (Brodeur, Dionne-Dostie, Monteiul, & Lepage, 2010). The Bank of Standardized Stimuli (BOSS; Brodeur et al., 2010) contains 480 items which is far too large to realistically trial as a clinical alternative. The most viable candidate is the 147-item Hatfield Image Test (HIT; Adlington, Laws, & Gale, 2009b). The strength of the HIT is that its design is theoretically driven. Items were chosen to sample widely from categories known to be dissociated in category-specific impairment (e.g., body parts, musical instruments, tools), and to represent a wide range of difficulty in order to avoid negative skew and a ceiling effect in score distribution (Adlington et al., 2009b). The HIT is available free in the public domain (http://testbed.herts.ac.uk/HIT/hit_apply.asp) and was identified as a credible and viable task to trial as an alternative to the BNT.

SUMMARY OF OTHER MEASURES OF VISUAL CONFRONTATION NAMING This literature review suggests that although the BNT has significant flaws as a measure of naming in a neuropsychological setting, there are few tasks that could be readily substituted for the BNT to address these issues. A cognitive task, the HIT (Adlington et al., 2009b), may address some of the key limitations of the BNT (i.e., sampling from a range of categories and having a normal score distribution) and is worth trialing as an alternative to the BNT. However, further development of this instrument is required. There are no neuropsychological norms for the HIT, it is too long to administer in a clinical setting, and its relationship with other psychometric measures is unknown. The HIT also has a number of items that appear to be culture-specific to the

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UK (e.g., “sporran”, “Stilton cheese”). The recently published NABNT (Stern & White, 2009) has alternate forms for retesting, excellent norms, and may present an improvement over the BNT on these issues. However, the NABNT has shortcomings similar to the BNT in that it has a ceiling effect, and the design of NABNT was not driven by consideration of the cognitive processes underlying naming. At the time of this review, neuropsychologists have limited options for practice other than to consider either the NABNT or the better known BNT.


FUTURE DIRECTIONS This review shows that there is wide disparity between cognitive and clinical neuropsychological approaches in published stand-alone visual naming tasks. Reconciliation of these approaches would be mutually beneficial to both fields. That is, cognitive tasks showing more consideration of psychometrics, and clinical tasks being informed by cognitive models of naming and consideration of stimulus characteristics such as familiarity, effect of color, and other modalities (e.g., naming to description). The current review clearly indicates that development of a new test of naming is needed for twenty-first-century clinical neuropsychology practice. An ideal test of naming would not only show adequate consideration of psychometric issues (e.g., a normal distribution) and have relevant norms, it would also be driven by a contemporary model of naming, and consider category impairments, category level required in responses, and basic error analysis, and develop a new cueing paradigm. As the BNT is the most commonly used visual confrontation naming test, it is strongly recommended that future studies provide information on administration and scoring protocols and collect data for measures of reading and vocabulary, and that clinicians carefully consider the issues raised in this paper and in other recent reviews (e.g., Bortnik et al., 2013) when using the BNT.

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