This article was downloaded by: [University of Arizona] On: 03 June 2013, At: 22:28 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Clinical and Experimental Neuropsychology Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ncen19
Normative data on the boston diagnostic aphasia examination in a spanish-speaking population a
a
b
Monica Rosselli , Alfredo Ardila , Angela Florez & Cielo Castro
b
a
Miami Institute of Psychology of the Caribbean Center for Advanced Studies, b
Fundacion Universitaria Konrad Lorenz, Bogota, Colombia Published online: 04 Jan 2008.
To cite this article: Monica Rosselli , Alfredo Ardila , Angela Florez & Cielo Castro (1990): Normative data on the boston diagnostic aphasia examination in a spanish-speaking population, Journal of Clinical and Experimental Neuropsychology, 12:2, 313-322 To link to this article: http://dx.doi.org/10.1080/01688639008400977
PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: http://www.tandfonline.com/page/terms-andconditions This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sublicensing, systematic supply, or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand, or costs or damages whatsoever or
Downloaded by [University of Arizona] at 22:28 03 June 2013
howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.
Journal of Clinical and Experimental Neuropsychology 1990, Vol. 12, NO. 2,pp. 313-322.
0168-8634/90/1202-0313 $3.00 @ Swets & Zeitlinger
Normative Data on the Boston Diagnostic Aphasia Examination in a Spanish-Speaking Population* Monica Rosselli and Alfredo Ardila Miami Institute of Psychology of the Caribbean Center for Advanced Studies
and Angela Florez and Cielo Castro Downloaded by [University of Arizona] at 22:28 03 June 2013
Fundacion Universitaria Konrad Lorenz (Bogota, Colombia) ABSTRACT Normative data of the Boston Diagnostic Aphasia Examination (Goodglass & Kaplan, 1972) in a Spanish-speaking population is presented. This test was given to 180 neurologically normal adults grouped according to three variables: sex, age, and educational level. The statistically significant differences found are presented. Few differences appeared between sexes, but there were marked differences among the different age groups and in particular among educational levels. A correction to the scoring is proposed for each of the subtests according the patient’s educational level.
One of the most complex problems in neuropsychological diagnosis in general, and in the assessment of aphasia in particular, is that of adequately distinguishing between the effects of brain damage and demographic factors on performance. The principal variables which influence a subject’s style of verbal expression and the way language is used are sociocultural level, sex, age, and regional origin (Labov, 1983). Difficulty in distinguishing between neurological and cultural effects is particularly accentuated in environments in which a large proportion of the population has a low educational level, as is the case of the socalled developing countries. On occasion, although subjects with very low educational levels are observed to function adequately in their environment, their scores on standard neuropsychological tests are similar to those of patients with brain damage. This is particularly evident in verbal tests (e.g., Ardila & Rosselli, 1988; Ardila, Rosselli, & Rosas, 1989; Ostrosky et al., 1985, 1986). The test most widely used in Spanish in diagnosing aphasic language disturbances is the Boston Diagnostic Aphasia Examination (BDAE) (Goodglass & Kaplan, 1972) which was translated to Spanish in 1979 and published in Argentina (Goodglass & Kaplan, 1979). In 1980, a normative study of the test
* Send correspondence to: Dr. Alfredo Ardila, Instituto Colombiano de Neuropsicologia, Apartado Aereo 17021, Bogota, Colombia Accepted for publication: April 4, 1989.
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MONICA ROSSELLI ET AL.
carried out among an English-speaking population appeared in which the effects of age and educational level variables were analyzed (Borod, Goodglass, & Kaplan, 1980). This study did not, however, consider the effect of sex, In 1983 a second English edition appeared (Goodglass & Kaplan, 1983), with only a few and minor changes made in the test procedure. The score system was revised: Z scores were changed t o percentiles. Norms for neurologically normal adults were included. In 1986 this new edition was translated into a new Spanish version. Data obtained from 40 aphasic patients are included (Garcia-Albea, Sanchez- Bernardos, & del Viso-Pabon, 1986); however, the Spanish version lacks norms for neurologically normal subjects. The present study was carried out with the objectives of: (1) providing norms for the BDAE for a Spanish-speaking population; (2) comparing the scores obtained in the two normative groups (English and Spanish speakers), and (3) analyzing the effects of sex, age, and education on test performance. METHOD Subjects A sample of 180 native Spanish speakers was selected and stratified according to three variables: (1) sex, (2) age (16-30,31-50 and 51-65), and (3) level of education (0-5,6-12, and 13years or more). Groups were formed apriori. Educational level was defined by the number of years of formal school attendance. A factorial design was thus obtained, 2 x 3 x 3, with 10 subjects in each cell. This sample was taken in Bogota (Colombia). Different environments were tapped in selecting subjects: factories, relatives of patients in waiting rooms in hospitals, and universities. Subjects were volunteers. All of them performed adequately in their environment. None presented neurological or psychiatric backgrounds; for this purpose, a quick neurologic and psychiatric screening test was used. All the subjects presented motor and sensory integrity.
Instrument
The Spanish version of the BDAE prepared by Silvia Cuschnir de Fairman (Goodglass & Kaplan, 1979) was used. The “paraphasias”, “music”, “articulation agility” and “verbal ability” sections were not included. The correlation of age and education with test performance on all 28 subtests was performed. In addition, an ANOVA 2 x 3 x 3 was carried out in each of the subtests. The effects of the variables and their interactions were then analyzed. RESULTS Table 1 presents the correlations of age and educational level with test performance on all 28 subtets. All correlations between age and test performance, excepting Phrase Length, Commands, Responsive Naming, Body-Part Naming, Word Reading, Repetition of Words, Automatized Sequences, Reciting, Mechanics in Writing, Sentences t o Dictation, and Narrative Writing,
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BOSTON DIAGNOSTIC APHASIA EXAMINATION
Table 1 Correlations between ace and educational level with the different subtests of the BDAE. Subtests FLUENCY Phrase length
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AUDITORY-COMPREHENSION Word discrimination Body-part identification Commands Complex material NAMING Responsive naming Confrontation Animal naming Body-part naming ORAL READING Word reading Oral sentence REPETITION Words High-probability Low-probability AUTOMATIC SPEECH Automatized sequences Reciting READING COMPREHENSION Symbol discrimination Word recognition Oral spelling Word-picture matching Sentences-paragraphs WRITING Mechanics Serial writing Primer-level dictation Written confrontation Spelling to dictation Sentences to dictation Narrative writing
Age
Educational Level
r
P
r
P
.01
NS
.36
,001
-.20 -.I3
.003 .03 NS .o 1
.36 .48
.oo 1
.oo
.001 NS
.47
,001
NS
.007 .oo 1 .001
.001 .001
.oo
-.I7
-.o 1 -.24 -.I8 .05
.oo 1 .007 NS
.18 SO .28 .42
-.I0 -.23
NS .001
.38 .35
.oo 1
NS
.oo1
.oo
-.28
.oo 1
-.40
,001
.26 .24
-.06
NS NS
.39
.001 NS
-.29 -.21 -.44 -. 18 -.26
.oo 1
.41
.003 .oo 1
.32 .57 .39 .59
.oo 1 .0d1 .oo 1 ,001 .oo I
-.11
NS
-.25 -. 17 -.39 -.35 -.12 -.I 1
,001
.36 .42 .35 .29 .24 .44 .64
.oo
.oo
.o 1 .oo 1
.01 .001 .oo 1 NS NS
.oo
NS
.001
,001 .001
.oo I .oo 1 .oo 1 .oo 1 .oo 1
were statistically significant. A significant correlation between educational ievci and test performance was observed in all subtests, but Commands, Repetition of Words and Reciting. In general education correlated more highly than age with the BDAE subtests. Comparison between sexes disclosed that only one of the subtests (Confron-
10.0
29.8
29.7 104.0 15.6 28.5
NAMING Responsive naming Confrontation Animal naming Body-part naming
ORAL READING Word reading Oral sentence
70.9 19.4 15.0 10.5
6.9
M
AUDITORY COMPREHENSION Word discrim. Body-part ident Commands Complex material
FLUENCY Phrase length
Subtests
0.9 0.0
1.4 2.9 4.3 3.1
3.4 1.6 0.0 1.8
0.5
SD
23-30 yo-10
21-30 93- 105 8-20 16-30
54-72 15-20 15-15 4-12
4-7
Range
16-30 yrs
29.5 9.8
29.8 103.0 16.9 29.3
15.0 10.5
70.7 19.7
6.1
M
4.5 1.3
1.7 4.1 2.7 4.6
0.6 0.0 2.0
4.1
0.4
SD
31-50
0-30 0-10
21-30 85-105 9-20 24-30
50-72 17-20 15-15 5-12
4-7
Range
29.0 9.5
26.9 101.0 15.6 28.8
68.2 18.8 15.0 9.9
6.9
3.1 1.4
5.8 6.8 3.4 3.4
8.3 3.0 0.0 1.9
0.2
M SD
0-30 4-10
21-30 75-105 4-20 10-30
15-20 15-15 4-12
51-72
6-7
Range
5 1-65 yrs
Mean, Standard Deviations, Ranges and level of significance between differences,for the three age groups on the BDAE.
Table 2
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NS .05
NS
.001 .05
NS
.05
NS
.02 .01
NS
P
r
z-
-I
m
tl
5
a
FP
5
m
c
W
10.0 8.0 8.0 7.8 2.0 9.9 8.0 7.0 9.7 8.9 2.9 45.9 14.7 9.9 9.8 11.5 3.4
REPETITION Words High-probability Low-probability
AUTOMATIC SPEECH Automatized sequen Reciting
READING COMPREHENSION Symbol discrim Word recognition Oral spelling Word-picture match Sentences-paragr
WRITING Mechanics Serial writing Primer-level dict Written confront Spelling to dict Sentences to dict Narrative writing
0.3 3.7 1.2 0.3 0.6 1.4 0.9
0.4 0.0 1.2 0.6 1.2
0.4 0.0
0.0 0.0 0.0
1-3 29-47 7-15 8-10 5-10 4-12 1-4
7-10 8-8 3-8 7-10 5-10
5-8 2-2
10-10 8-8 8-8
2.9 46.1 14.7 9.9 10.0 11.6 3.3
9.8 7.9 6.8 9.7 8.4
7.9 2.0
10.0 7.9 7.9
0.5 0.0 1.1 0.5
1.1
0.3 3.1
0.6 0.4 1.3 0.6 1.5
0.2 0.0
0.0 0.4 0.2
1-3 30-47 9-15 6- 10 10-10 0-12 0-4
6-10 6-8 1-8 7- 10 5-10
5-8 2-2
10-10 6-8 6-8
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2.8 38.7 13.7 8.5 9.9 10.7 3.2
0.9 14.0 3.4 2.3 1.3 0.2 1.7
8.8 2.5 7.5 1.4 5.5 1.4 9.6 0.9 9.7 1.0
7.7 1.1 2.0 0.0
10.0 0.0 8.0 0.0 7.1 1.3
0-3 0-47 0-15 0-10 0-10 3-12 0-4
4-10 0-8 2-8 0-10 0-10
5-8 2-2
10-10 8-8 4-8
NS .001 .05 .001 .01 NS NS
.05 .01
.001
.001 .01
NS NS
NS .01 .01
3 2
z
c2
X
5>
5i
a 2
z
t:
z
C
2
m
6.6 67.6 18.6 15.0 9.5 29.2 100.0 15.4 27.2 27.0 9.4
AUDITORY COMPREHENSION Word discrim. Body-part ident Commands Complex material
NAMING Responsive naming Confrontation Animal naming Body-part naming
ORAL READING Word reading Oral sentence
M
FLUENCY Phrase length
Subtests
7.1 2.0
3.2 7.1 3.4 4.1
8.9 2.0 0.0 2.0
0.8
0-30 0-10
21-30 75-105 4-20 10-30
50-72 15-20 15-15 4-12
4-7
0-5 JTS SD Range
29.9 9.9
29.9 104.0 16.6 29.6
70.5 19.7 15.0 10.5
7.0
M
0.1 0.2
0.4 2.9 3.0 4.4
3.4 1.1 0.0 1.6
0.0
SD
20-30 8-10
27-30 95-105 9-20 24-30
55-72 15-20 15-15 7-12
7-7
Range
6-12 yrs
0.0
0.0 0.0 2.2 0.0
30.0 0.0 10.0 0.0
30.0 105.0 17.2 30.0
30-30 10-10
30-30 105 12-20 30-30
65-72 19-20 15-15 8-12
7-7
13 or more SD Range
71.6 1.5 19.9 0.1 15.0 0.0 11.1 1.1
7.0
M
P
.001 .001
.05 .001
.05 .001
>
r
2 NS
R
w
8z p
oo
c-
w
.001
.001 .05
.001
Mean, Standard Deviations, Ranges and level of significance between differences, for the three educational levels in the BDAE.
Table 3
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10.0 7.6 7.3 7.6 2.0 9.2 7.4 5.5 9.1 6.9 2.7 40.8 13.8 9.1 9.1 10.9 2.5
REPETITION Words High-probability Low-probability
AUTOMATIC SPEECH Automatized sequen Reciting
READING COMPREHENSION Symbol discrim Word recognition Oral spelling Word-picture match Sentences-paragr
WRITING Mechanics Serial writing Primer-level dict Written confront Spelling to dict Sentences to dict Narrative writing 0.6 10.6 3.2 2.0 2.1 2.5 0.7
1.5 1.6 1.5 1.7 1.7
0.7 0.0
0.0 0.9 1.7
0-3 0-47 0-15 0- 10 0-10 0-12 0-3
4-10 0-8 1-8 0-10 0-10
5-8 2-2
10-10 6-8 4-8
2.9 46.3 14.0 9.7 9.1 11.8 3.7
9.5 7.9 6.8 9.1 8.4
7.8 2.0
10.0 7.9 7.7
0.1 3.6 1.3 0.7 0.6 1.1 0.7
0.8 0.4 1.4 0.6 1.4
0.8 0.0
0.0 0.4 0.8
2-3 2-47 8-15 8-10 5-10 4-12 0-4
8-10 6-8 4-8 8-10 4-10
5-8 2-2
10-10 6-8 4-8
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0.3 0.2 0.9 0.2 1.1 3.0 0.0 46.8 0.5 14.9 0.1 9.1 0.7 9.9 0.2 11.9 0.2 3.9 0.4
9.9 7.9 7.3 9.9 9.1
8.0 0.0 2.0 0.0
10.0 0.0 8.0 0.0 7.9 0.4
3-3 45-41 14-15 8-10 9-10 10-12 2-4
8-10 6-8 6-8 8-10 7-10
8-8 2-2
10-10 8-8 6-8
.oo1
.001
.oo 1 .001 .oo 1 .o 1 .oo1
.o 1 .o 1 .oo 1 .02 .oo1
NS
.oo 1
NS .05 .05
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320
MONICA ROSSELLI ET AL.
tation Naming) showed a statistically significant difference. This main effect certainly could have occurred by chance in 28 comparisons. Furthermore, this difference is very small and clinically meaningless. Two more subtests (Word Reading and Symbol Discrimination) appeared slightly different, but without reaching a significant level. (p < .lo). Seventeen out of the 28 tests used were shown to be sensitive to age, with the younger subjects obtaining better scores (Table 2). However, some of the differences among age groups appeared to be considerably larger than others: Confrontation Naming, Symbol Discrimination, Oral Spelling, Serial Writing, and Written Confrontation. Only three of the subtests (Commands, Repetition of Words, and Reciting) did not show significant differences among the three educational levels considered (Table 3).
DISCUSSION Our results agree with those obtained by Borod et al. (1980) in the sense that BDAE is sensitive to age and educational level variables. These authors also found that the educational level variable is markedly more important than the age variable. It is worth noting that our group with an educationally low level was considerably larger (60 subjects) than that used by Borod et al. (11 subjects), and the age range for the group with least formal education was from 0 to 5 years in our study as compared with 0 to 8 in the study by Borod et al. The average educational level was, therefore, lower in our study. It should be emphasized that in our study the most important differences were found between the low and the middle educational levels while the differences between the middle and high educational level were generally less. Low educational levels tend to be associated with an important cultural deprivation. It was observed that standard deviations for the lowest educational group was substantially higher than for the rest of the groups. Possibly the ceiling of the tests was low for higher educational groups, and hence, dispersions were minimal. As in the study by Borod et al. (1980), age showed significant differences less frequently than educational level. However, we found significant age differences in tests for which these authors found none (e.g., Body Part Identification, Comprehension of Oral Spelling, and Spelling to Dictation). In others, we failed to find the differences mentioned by these authors (e.g., Commands, and Automatized Sequences). We do not understand the reason for these discrepancies in the results. In most tests, however, the results did coincide. It can be supposed that differences in spelling tasks has something to do with the differences in writing systems between English and Spanish: In Spanish, as a consequence of using a much more phonological writing system, spelling is a quite unusual language task; underlying language-cognitive process might be
321
BOSTON DIAGNOSTIC APHASIA EXAMINATION
Table 4 Suggested cut-off scores for normal performance on the BDAE according to the subject's level of education. Subtests
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FLUENCY Phrase length
Years of Education 0-5 years 6-12 years
13 or more
5.0
7.0
7.0
AUDITORY COMPREHENSION Word discrimination Body-part identification Commands Complex ideational material
51.0 14.5 15.0 5.5
63.5 17.5 15.0 7.5
68.5 20.0 15.0 9.0
NAMING Responsive naming Confrontation Animal naming Body-part naming
23.0 86.0 8.5 19.0
29.0 98.0 10.5 21.0
30.0 105.0 13.0 30.0
ORAL READING Word reading Oral sentence
13.0 5.5
29.0 9.5
30.0 10.0
REPETITION Words High-probability Low-probability
10.0 6.0 4.0
10.0 7.0
6.0
10.0 8.0 7.0
AUTOMATIC SPEECH Automatized sequences Reciting
6.0 2.0
6.5 2.0
8.0 2.0
READING COMPREHENSION Symbol discrimination Word recognition Oral spelling Word-picture matching Sentences-paragraphs
6.0 4.0 2.5 5.5 3.5
8.0 7.0 4.0 8.5 5.5
9.5 7.5 5.5 9.5 7.0
1.5 19.5 7.5 5.0 5.0 6.0 1.o
2.5 39.0 11.5 8.5 8.0 9.5 2.0
3.0 46.0 14.5 8.5 9.5 11.5 3.0
WRITING Mechanics Serial writing Primer-level dictation Written confrontation naming Spelling to dictation Sentences to dictation Narrative writing
different, and is probably much more linguistically biased. It should be emphasized that most of the meaningful differences among age groups were between the oldest group and the other two. In several subtests there were not any differences between the two younger groups.
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MONICA ROSSELLl ET AL.
Taking into account importance of the educational level, we propose that the different subtests should have different cut-off points according to the educational level of the subject. This corrected score could be determined by the group’s mean score minus two standard deviations, as presented in Table 4 . Without using this corrected cut-off score, the likelihood of a subject to be wrongly diagnosed as aphasic, might increase significantly, particularly in the lowest educational level group. We expect that the norms obtained in this research could be useful in other Latin-American Spanish-speaking countries. These norms could be considered as well as the most applicable for Spanish speakers in the USA. It is very important to bear in mind that the USA represents the fgth Spanish-speaking country in the world (after Mexico, Spain, Argentina and Colombia) with some 20 millon of Spanish speakers. This population is composed basically of Spanish speakers coming from different Latin-American countries, mainly Mexico, Puerto Rico, Cuba and Colombia. The pressing need of norms for Spanish-speaking populations in the USA is clearly evident. REFERENCES Ardila, A., & Rosselli, M. (1988) Effects of educational level on linguistic abilities. Eighth Annual Meeting NationalAcademy of Neuropsychologists, Orlando, F1. Ardila, A., Rosselli, M., & Rosas, P. (1989). Neuropsychological assessment in illiterates: Visuospatial and memory abilities. Brain and Cognition. I1 147-166. Borod, J.C., Goodglass, H., & Kaplan, E. (1980). Normative data on the Boston Diagnostic Aphasia Examination and the Boston Naming Test. Journal of Clinical Neuropsychology, 2.209-2 15 Garcia-Albea, J.E., Sanchez-Bernardos, M.L., & del Viso-Pabon, S. (1986). Test de Boston para el diagnostic0 de la afasia: Adaptacion EspaAola. In H.Goodglass & E. Kaplan, La evaluacion de la afasia y de transtornos relacionados. 2a ed. (pp. 129-198). Translated by Carlos Wernicke. Madrid: Editorial Medica Panamericana. Goodglass, H., & Kaplan, E. (1972). The assessment of aphasia and related disorders. Philadelphia: Lea & Febiger Goodglass, H., & Kaplan, E. (1979). Evaluacion de la afasia y de transtornos similares. (Translated by Silvia Cuschnir de Fairman). Buenos Aires: Editorial Medica Panamericana. Goodglass, H., & Kaplan, E. (1983). The assessment of aphasia andrelateddisorders. (2nd Ed.). Philadelphia: Lea & Febiger. Labov, W. (1983). Modelos sociolinguisticos. Madrid: Ediciones Catedra. Ostrosky, F., Canseco, E., Quintanar, L., Navarro, E., Meneses, S., & Ardila, A. (1985). Sociocultural effects in neuropsychological assessment. International Journal of Neuroscience, 2 7, 53-66 Ostrosky, F., Quintanar, L., Meneses, S., Canseco, E., Navarro., E., & Ardila, A. (1986). Actividad cognoscitiva y nivel sociocultural. Revista de Znvestigacion Clinica (Mexico), 38, 37-42.
Journal of Clinical and Experimental Neuropsychology Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ncen19
Normative data on the boston diagnostic aphasia examination in a spanish-speaking population a
a
b
Monica Rosselli , Alfredo Ardila , Angela Florez & Cielo Castro
b
a
Miami Institute of Psychology of the Caribbean Center for Advanced Studies, b
Fundacion Universitaria Konrad Lorenz, Bogota, Colombia Published online: 04 Jan 2008.
To cite this article: Monica Rosselli , Alfredo Ardila , Angela Florez & Cielo Castro (1990): Normative data on the boston diagnostic aphasia examination in a spanish-speaking population, Journal of Clinical and Experimental Neuropsychology, 12:2, 313-322 To link to this article: http://dx.doi.org/10.1080/01688639008400977
PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: http://www.tandfonline.com/page/terms-andconditions This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sublicensing, systematic supply, or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand, or costs or damages whatsoever or
Downloaded by [University of Arizona] at 22:28 03 June 2013
howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.
Journal of Clinical and Experimental Neuropsychology 1990, Vol. 12, NO. 2,pp. 313-322.
0168-8634/90/1202-0313 $3.00 @ Swets & Zeitlinger
Normative Data on the Boston Diagnostic Aphasia Examination in a Spanish-Speaking Population* Monica Rosselli and Alfredo Ardila Miami Institute of Psychology of the Caribbean Center for Advanced Studies
and Angela Florez and Cielo Castro Downloaded by [University of Arizona] at 22:28 03 June 2013
Fundacion Universitaria Konrad Lorenz (Bogota, Colombia) ABSTRACT Normative data of the Boston Diagnostic Aphasia Examination (Goodglass & Kaplan, 1972) in a Spanish-speaking population is presented. This test was given to 180 neurologically normal adults grouped according to three variables: sex, age, and educational level. The statistically significant differences found are presented. Few differences appeared between sexes, but there were marked differences among the different age groups and in particular among educational levels. A correction to the scoring is proposed for each of the subtests according the patient’s educational level.
One of the most complex problems in neuropsychological diagnosis in general, and in the assessment of aphasia in particular, is that of adequately distinguishing between the effects of brain damage and demographic factors on performance. The principal variables which influence a subject’s style of verbal expression and the way language is used are sociocultural level, sex, age, and regional origin (Labov, 1983). Difficulty in distinguishing between neurological and cultural effects is particularly accentuated in environments in which a large proportion of the population has a low educational level, as is the case of the socalled developing countries. On occasion, although subjects with very low educational levels are observed to function adequately in their environment, their scores on standard neuropsychological tests are similar to those of patients with brain damage. This is particularly evident in verbal tests (e.g., Ardila & Rosselli, 1988; Ardila, Rosselli, & Rosas, 1989; Ostrosky et al., 1985, 1986). The test most widely used in Spanish in diagnosing aphasic language disturbances is the Boston Diagnostic Aphasia Examination (BDAE) (Goodglass & Kaplan, 1972) which was translated to Spanish in 1979 and published in Argentina (Goodglass & Kaplan, 1979). In 1980, a normative study of the test
* Send correspondence to: Dr. Alfredo Ardila, Instituto Colombiano de Neuropsicologia, Apartado Aereo 17021, Bogota, Colombia Accepted for publication: April 4, 1989.
Downloaded by [University of Arizona] at 22:28 03 June 2013
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MONICA ROSSELLI ET AL.
carried out among an English-speaking population appeared in which the effects of age and educational level variables were analyzed (Borod, Goodglass, & Kaplan, 1980). This study did not, however, consider the effect of sex, In 1983 a second English edition appeared (Goodglass & Kaplan, 1983), with only a few and minor changes made in the test procedure. The score system was revised: Z scores were changed t o percentiles. Norms for neurologically normal adults were included. In 1986 this new edition was translated into a new Spanish version. Data obtained from 40 aphasic patients are included (Garcia-Albea, Sanchez- Bernardos, & del Viso-Pabon, 1986); however, the Spanish version lacks norms for neurologically normal subjects. The present study was carried out with the objectives of: (1) providing norms for the BDAE for a Spanish-speaking population; (2) comparing the scores obtained in the two normative groups (English and Spanish speakers), and (3) analyzing the effects of sex, age, and education on test performance. METHOD Subjects A sample of 180 native Spanish speakers was selected and stratified according to three variables: (1) sex, (2) age (16-30,31-50 and 51-65), and (3) level of education (0-5,6-12, and 13years or more). Groups were formed apriori. Educational level was defined by the number of years of formal school attendance. A factorial design was thus obtained, 2 x 3 x 3, with 10 subjects in each cell. This sample was taken in Bogota (Colombia). Different environments were tapped in selecting subjects: factories, relatives of patients in waiting rooms in hospitals, and universities. Subjects were volunteers. All of them performed adequately in their environment. None presented neurological or psychiatric backgrounds; for this purpose, a quick neurologic and psychiatric screening test was used. All the subjects presented motor and sensory integrity.
Instrument
The Spanish version of the BDAE prepared by Silvia Cuschnir de Fairman (Goodglass & Kaplan, 1979) was used. The “paraphasias”, “music”, “articulation agility” and “verbal ability” sections were not included. The correlation of age and education with test performance on all 28 subtests was performed. In addition, an ANOVA 2 x 3 x 3 was carried out in each of the subtests. The effects of the variables and their interactions were then analyzed. RESULTS Table 1 presents the correlations of age and educational level with test performance on all 28 subtets. All correlations between age and test performance, excepting Phrase Length, Commands, Responsive Naming, Body-Part Naming, Word Reading, Repetition of Words, Automatized Sequences, Reciting, Mechanics in Writing, Sentences t o Dictation, and Narrative Writing,
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BOSTON DIAGNOSTIC APHASIA EXAMINATION
Table 1 Correlations between ace and educational level with the different subtests of the BDAE. Subtests FLUENCY Phrase length
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AUDITORY-COMPREHENSION Word discrimination Body-part identification Commands Complex material NAMING Responsive naming Confrontation Animal naming Body-part naming ORAL READING Word reading Oral sentence REPETITION Words High-probability Low-probability AUTOMATIC SPEECH Automatized sequences Reciting READING COMPREHENSION Symbol discrimination Word recognition Oral spelling Word-picture matching Sentences-paragraphs WRITING Mechanics Serial writing Primer-level dictation Written confrontation Spelling to dictation Sentences to dictation Narrative writing
Age
Educational Level
r
P
r
P
.01
NS
.36
,001
-.20 -.I3
.003 .03 NS .o 1
.36 .48
.oo 1
.oo
.001 NS
.47
,001
NS
.007 .oo 1 .001
.001 .001
.oo
-.I7
-.o 1 -.24 -.I8 .05
.oo 1 .007 NS
.18 SO .28 .42
-.I0 -.23
NS .001
.38 .35
.oo 1
NS
.oo1
.oo
-.28
.oo 1
-.40
,001
.26 .24
-.06
NS NS
.39
.001 NS
-.29 -.21 -.44 -. 18 -.26
.oo 1
.41
.003 .oo 1
.32 .57 .39 .59
.oo 1 .0d1 .oo 1 ,001 .oo I
-.11
NS
-.25 -. 17 -.39 -.35 -.12 -.I 1
,001
.36 .42 .35 .29 .24 .44 .64
.oo
.oo
.o 1 .oo 1
.01 .001 .oo 1 NS NS
.oo
NS
.001
,001 .001
.oo I .oo 1 .oo 1 .oo 1 .oo 1
were statistically significant. A significant correlation between educational ievci and test performance was observed in all subtests, but Commands, Repetition of Words and Reciting. In general education correlated more highly than age with the BDAE subtests. Comparison between sexes disclosed that only one of the subtests (Confron-
10.0
29.8
29.7 104.0 15.6 28.5
NAMING Responsive naming Confrontation Animal naming Body-part naming
ORAL READING Word reading Oral sentence
70.9 19.4 15.0 10.5
6.9
M
AUDITORY COMPREHENSION Word discrim. Body-part ident Commands Complex material
FLUENCY Phrase length
Subtests
0.9 0.0
1.4 2.9 4.3 3.1
3.4 1.6 0.0 1.8
0.5
SD
23-30 yo-10
21-30 93- 105 8-20 16-30
54-72 15-20 15-15 4-12
4-7
Range
16-30 yrs
29.5 9.8
29.8 103.0 16.9 29.3
15.0 10.5
70.7 19.7
6.1
M
4.5 1.3
1.7 4.1 2.7 4.6
0.6 0.0 2.0
4.1
0.4
SD
31-50
0-30 0-10
21-30 85-105 9-20 24-30
50-72 17-20 15-15 5-12
4-7
Range
29.0 9.5
26.9 101.0 15.6 28.8
68.2 18.8 15.0 9.9
6.9
3.1 1.4
5.8 6.8 3.4 3.4
8.3 3.0 0.0 1.9
0.2
M SD
0-30 4-10
21-30 75-105 4-20 10-30
15-20 15-15 4-12
51-72
6-7
Range
5 1-65 yrs
Mean, Standard Deviations, Ranges and level of significance between differences,for the three age groups on the BDAE.
Table 2
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NS .05
NS
.001 .05
NS
.05
NS
.02 .01
NS
P
r
z-
-I
m
tl
5
a
FP
5
m
c
W
10.0 8.0 8.0 7.8 2.0 9.9 8.0 7.0 9.7 8.9 2.9 45.9 14.7 9.9 9.8 11.5 3.4
REPETITION Words High-probability Low-probability
AUTOMATIC SPEECH Automatized sequen Reciting
READING COMPREHENSION Symbol discrim Word recognition Oral spelling Word-picture match Sentences-paragr
WRITING Mechanics Serial writing Primer-level dict Written confront Spelling to dict Sentences to dict Narrative writing
0.3 3.7 1.2 0.3 0.6 1.4 0.9
0.4 0.0 1.2 0.6 1.2
0.4 0.0
0.0 0.0 0.0
1-3 29-47 7-15 8-10 5-10 4-12 1-4
7-10 8-8 3-8 7-10 5-10
5-8 2-2
10-10 8-8 8-8
2.9 46.1 14.7 9.9 10.0 11.6 3.3
9.8 7.9 6.8 9.7 8.4
7.9 2.0
10.0 7.9 7.9
0.5 0.0 1.1 0.5
1.1
0.3 3.1
0.6 0.4 1.3 0.6 1.5
0.2 0.0
0.0 0.4 0.2
1-3 30-47 9-15 6- 10 10-10 0-12 0-4
6-10 6-8 1-8 7- 10 5-10
5-8 2-2
10-10 6-8 6-8
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2.8 38.7 13.7 8.5 9.9 10.7 3.2
0.9 14.0 3.4 2.3 1.3 0.2 1.7
8.8 2.5 7.5 1.4 5.5 1.4 9.6 0.9 9.7 1.0
7.7 1.1 2.0 0.0
10.0 0.0 8.0 0.0 7.1 1.3
0-3 0-47 0-15 0-10 0-10 3-12 0-4
4-10 0-8 2-8 0-10 0-10
5-8 2-2
10-10 8-8 4-8
NS .001 .05 .001 .01 NS NS
.05 .01
.001
.001 .01
NS NS
NS .01 .01
3 2
z
c2
X
5>
5i
a 2
z
t:
z
C
2
m
6.6 67.6 18.6 15.0 9.5 29.2 100.0 15.4 27.2 27.0 9.4
AUDITORY COMPREHENSION Word discrim. Body-part ident Commands Complex material
NAMING Responsive naming Confrontation Animal naming Body-part naming
ORAL READING Word reading Oral sentence
M
FLUENCY Phrase length
Subtests
7.1 2.0
3.2 7.1 3.4 4.1
8.9 2.0 0.0 2.0
0.8
0-30 0-10
21-30 75-105 4-20 10-30
50-72 15-20 15-15 4-12
4-7
0-5 JTS SD Range
29.9 9.9
29.9 104.0 16.6 29.6
70.5 19.7 15.0 10.5
7.0
M
0.1 0.2
0.4 2.9 3.0 4.4
3.4 1.1 0.0 1.6
0.0
SD
20-30 8-10
27-30 95-105 9-20 24-30
55-72 15-20 15-15 7-12
7-7
Range
6-12 yrs
0.0
0.0 0.0 2.2 0.0
30.0 0.0 10.0 0.0
30.0 105.0 17.2 30.0
30-30 10-10
30-30 105 12-20 30-30
65-72 19-20 15-15 8-12
7-7
13 or more SD Range
71.6 1.5 19.9 0.1 15.0 0.0 11.1 1.1
7.0
M
P
.001 .001
.05 .001
.05 .001
>
r
2 NS
R
w
8z p
oo
c-
w
.001
.001 .05
.001
Mean, Standard Deviations, Ranges and level of significance between differences, for the three educational levels in the BDAE.
Table 3
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10.0 7.6 7.3 7.6 2.0 9.2 7.4 5.5 9.1 6.9 2.7 40.8 13.8 9.1 9.1 10.9 2.5
REPETITION Words High-probability Low-probability
AUTOMATIC SPEECH Automatized sequen Reciting
READING COMPREHENSION Symbol discrim Word recognition Oral spelling Word-picture match Sentences-paragr
WRITING Mechanics Serial writing Primer-level dict Written confront Spelling to dict Sentences to dict Narrative writing 0.6 10.6 3.2 2.0 2.1 2.5 0.7
1.5 1.6 1.5 1.7 1.7
0.7 0.0
0.0 0.9 1.7
0-3 0-47 0-15 0- 10 0-10 0-12 0-3
4-10 0-8 1-8 0-10 0-10
5-8 2-2
10-10 6-8 4-8
2.9 46.3 14.0 9.7 9.1 11.8 3.7
9.5 7.9 6.8 9.1 8.4
7.8 2.0
10.0 7.9 7.7
0.1 3.6 1.3 0.7 0.6 1.1 0.7
0.8 0.4 1.4 0.6 1.4
0.8 0.0
0.0 0.4 0.8
2-3 2-47 8-15 8-10 5-10 4-12 0-4
8-10 6-8 4-8 8-10 4-10
5-8 2-2
10-10 6-8 4-8
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0.3 0.2 0.9 0.2 1.1 3.0 0.0 46.8 0.5 14.9 0.1 9.1 0.7 9.9 0.2 11.9 0.2 3.9 0.4
9.9 7.9 7.3 9.9 9.1
8.0 0.0 2.0 0.0
10.0 0.0 8.0 0.0 7.9 0.4
3-3 45-41 14-15 8-10 9-10 10-12 2-4
8-10 6-8 6-8 8-10 7-10
8-8 2-2
10-10 8-8 6-8
.oo1
.001
.oo 1 .001 .oo 1 .o 1 .oo1
.o 1 .o 1 .oo 1 .02 .oo1
NS
.oo 1
NS .05 .05
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MONICA ROSSELLI ET AL.
tation Naming) showed a statistically significant difference. This main effect certainly could have occurred by chance in 28 comparisons. Furthermore, this difference is very small and clinically meaningless. Two more subtests (Word Reading and Symbol Discrimination) appeared slightly different, but without reaching a significant level. (p < .lo). Seventeen out of the 28 tests used were shown to be sensitive to age, with the younger subjects obtaining better scores (Table 2). However, some of the differences among age groups appeared to be considerably larger than others: Confrontation Naming, Symbol Discrimination, Oral Spelling, Serial Writing, and Written Confrontation. Only three of the subtests (Commands, Repetition of Words, and Reciting) did not show significant differences among the three educational levels considered (Table 3).
DISCUSSION Our results agree with those obtained by Borod et al. (1980) in the sense that BDAE is sensitive to age and educational level variables. These authors also found that the educational level variable is markedly more important than the age variable. It is worth noting that our group with an educationally low level was considerably larger (60 subjects) than that used by Borod et al. (11 subjects), and the age range for the group with least formal education was from 0 to 5 years in our study as compared with 0 to 8 in the study by Borod et al. The average educational level was, therefore, lower in our study. It should be emphasized that in our study the most important differences were found between the low and the middle educational levels while the differences between the middle and high educational level were generally less. Low educational levels tend to be associated with an important cultural deprivation. It was observed that standard deviations for the lowest educational group was substantially higher than for the rest of the groups. Possibly the ceiling of the tests was low for higher educational groups, and hence, dispersions were minimal. As in the study by Borod et al. (1980), age showed significant differences less frequently than educational level. However, we found significant age differences in tests for which these authors found none (e.g., Body Part Identification, Comprehension of Oral Spelling, and Spelling to Dictation). In others, we failed to find the differences mentioned by these authors (e.g., Commands, and Automatized Sequences). We do not understand the reason for these discrepancies in the results. In most tests, however, the results did coincide. It can be supposed that differences in spelling tasks has something to do with the differences in writing systems between English and Spanish: In Spanish, as a consequence of using a much more phonological writing system, spelling is a quite unusual language task; underlying language-cognitive process might be
321
BOSTON DIAGNOSTIC APHASIA EXAMINATION
Table 4 Suggested cut-off scores for normal performance on the BDAE according to the subject's level of education. Subtests
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FLUENCY Phrase length
Years of Education 0-5 years 6-12 years
13 or more
5.0
7.0
7.0
AUDITORY COMPREHENSION Word discrimination Body-part identification Commands Complex ideational material
51.0 14.5 15.0 5.5
63.5 17.5 15.0 7.5
68.5 20.0 15.0 9.0
NAMING Responsive naming Confrontation Animal naming Body-part naming
23.0 86.0 8.5 19.0
29.0 98.0 10.5 21.0
30.0 105.0 13.0 30.0
ORAL READING Word reading Oral sentence
13.0 5.5
29.0 9.5
30.0 10.0
REPETITION Words High-probability Low-probability
10.0 6.0 4.0
10.0 7.0
6.0
10.0 8.0 7.0
AUTOMATIC SPEECH Automatized sequences Reciting
6.0 2.0
6.5 2.0
8.0 2.0
READING COMPREHENSION Symbol discrimination Word recognition Oral spelling Word-picture matching Sentences-paragraphs
6.0 4.0 2.5 5.5 3.5
8.0 7.0 4.0 8.5 5.5
9.5 7.5 5.5 9.5 7.0
1.5 19.5 7.5 5.0 5.0 6.0 1.o
2.5 39.0 11.5 8.5 8.0 9.5 2.0
3.0 46.0 14.5 8.5 9.5 11.5 3.0
WRITING Mechanics Serial writing Primer-level dictation Written confrontation naming Spelling to dictation Sentences to dictation Narrative writing
different, and is probably much more linguistically biased. It should be emphasized that most of the meaningful differences among age groups were between the oldest group and the other two. In several subtests there were not any differences between the two younger groups.
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MONICA ROSSELLl ET AL.
Taking into account importance of the educational level, we propose that the different subtests should have different cut-off points according to the educational level of the subject. This corrected score could be determined by the group’s mean score minus two standard deviations, as presented in Table 4 . Without using this corrected cut-off score, the likelihood of a subject to be wrongly diagnosed as aphasic, might increase significantly, particularly in the lowest educational level group. We expect that the norms obtained in this research could be useful in other Latin-American Spanish-speaking countries. These norms could be considered as well as the most applicable for Spanish speakers in the USA. It is very important to bear in mind that the USA represents the fgth Spanish-speaking country in the world (after Mexico, Spain, Argentina and Colombia) with some 20 millon of Spanish speakers. This population is composed basically of Spanish speakers coming from different Latin-American countries, mainly Mexico, Puerto Rico, Cuba and Colombia. The pressing need of norms for Spanish-speaking populations in the USA is clearly evident. REFERENCES Ardila, A., & Rosselli, M. (1988) Effects of educational level on linguistic abilities. Eighth Annual Meeting NationalAcademy of Neuropsychologists, Orlando, F1. Ardila, A., Rosselli, M., & Rosas, P. (1989). Neuropsychological assessment in illiterates: Visuospatial and memory abilities. Brain and Cognition. I1 147-166. Borod, J.C., Goodglass, H., & Kaplan, E. (1980). Normative data on the Boston Diagnostic Aphasia Examination and the Boston Naming Test. Journal of Clinical Neuropsychology, 2.209-2 15 Garcia-Albea, J.E., Sanchez-Bernardos, M.L., & del Viso-Pabon, S. (1986). Test de Boston para el diagnostic0 de la afasia: Adaptacion EspaAola. In H.Goodglass & E. Kaplan, La evaluacion de la afasia y de transtornos relacionados. 2a ed. (pp. 129-198). Translated by Carlos Wernicke. Madrid: Editorial Medica Panamericana. Goodglass, H., & Kaplan, E. (1972). The assessment of aphasia and related disorders. Philadelphia: Lea & Febiger Goodglass, H., & Kaplan, E. (1979). Evaluacion de la afasia y de transtornos similares. (Translated by Silvia Cuschnir de Fairman). Buenos Aires: Editorial Medica Panamericana. Goodglass, H., & Kaplan, E. (1983). The assessment of aphasia andrelateddisorders. (2nd Ed.). Philadelphia: Lea & Febiger. Labov, W. (1983). Modelos sociolinguisticos. Madrid: Ediciones Catedra. Ostrosky, F., Canseco, E., Quintanar, L., Navarro, E., Meneses, S., & Ardila, A. (1985). Sociocultural effects in neuropsychological assessment. International Journal of Neuroscience, 2 7, 53-66 Ostrosky, F., Quintanar, L., Meneses, S., Canseco, E., Navarro., E., & Ardila, A. (1986). Actividad cognoscitiva y nivel sociocultural. Revista de Znvestigacion Clinica (Mexico), 38, 37-42.
