Applied Neuropsychology: Adult
ISSN: 2327-9095 (Print) 2327-9109 (Online) Journal homepage: http://www.tandfonline.com/loi/hapn21
Utility of the Cognistat Judgment Subtest in Motorically Impaired Populations Rachel A. Mills, H. Edward Fouty & Brianna M. Brandon To cite this article: Rachel A. Mills, H. Edward Fouty & Brianna M. Brandon (2015) Utility of the Cognistat Judgment Subtest in Motorically Impaired Populations, Applied Neuropsychology: Adult, 22:6, 407-408, DOI: 10.1080/23279095.2014.949720 To link to this article: http://dx.doi.org/10.1080/23279095.2014.949720
Published online: 17 Mar 2015.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=hapn21 Download by: [University of Lethbridge]
Date: 28 October 2015, At: 05:10
APPLIED NEUROPSYCHOLOGY: ADULT, 22: 407–408, 2015 Copyright # Taylor & Francis Group, LLC ISSN: 2327-9095 print/2327-9109 online DOI: 10.1080/23279095.2014.949720
Utility of the Cognistat Judgment Subtest in Motorically Impaired Populations Rachel A. Mills, H. Edward Fouty, and Brianna M. Brandon
Downloaded by [University of Lethbridge] at 05:10 28 October 2015
Psychology, University of Central Florida, Daytona Beach, Florida
The Cognistat is one the most frequently employed measures to briefly evaluate cognitive functioning. However, clinical experience indicates that the questions within the Judgment subtest may be biased and insensitive toward persons with motor impairments. These issues may impact the examinee’s performance and decrease the validity of the test—not to mention possibly create undue emotional distress. Suggestions for rectifying these issues are presented.
Key words:
Cognistat, Judgment subtest, motor bias, motor impairment
The Cognistat (Kiernan, Mueller, & Langston, 2014) is a widely utilized screening measure designed to assess higher cerebral functioning across multiple cognitive domains: Orientation, Attention, Language (Comprehension, Repetition, and Naming), Construction, Memory, Calculation, and Reasoning (Similarities and Judgment). The Cognistat’s ability to briefly assess cognitive functioning makes it versatile in a variety of situations including time-sensitive medical and rehabilitation settings. Each of the Cognistat’s subtests, excluding Memory, employs a screen and metric approach. The screen approach involves administration of an item that requires ability in a specific functional domain. If the examinee correctly answers the screen, the examiner proceeds to the next subtest. If the screen is failed, the metric items are administered; these items are arranged in order of increasing difficulty and are utilized to demarcate degree of impairment. The authors reported that screen failures occur in approximately 20% of normal individuals. To decrease the occurrence of false positives and improve test reliability, it has been recommended that all metric items be administered to all examinees (e.g., Drane et al., 2003; Oehlert et al., 1997). However, Fouty and Brzezinski (2009) noted that there is one exception to this recommendation: Both the screen and the metric for
Address correspondence to H. Edward Fouty, Ph.D., Psychology, University of Central Florida, 1200 W. International Speedway Blvd., Daytona Beach, FL 32120-2811. E-mail: [email protected]
the Construction subtest should be administered because they measure unique, separate cognitive functions. The Judgment subtest presents examinees with problematic situations and asks what they would do if placed in the situations. This subtest evaluates an individual’s ability to identify a problematic situation and develop an appropriate hypothetical strategy to address that situation. The strength of this approach is its reliance on executive functions with minimal focus on other cognitive abilities (Woods, Patterson, & Whitehouse, 2000). These authors asserted that because the examinee need not actually perform the activities, the test only requires minimal attentional, perceptual, motor, and memory skills. Thus, the test can be easily administered to individuals with motor impairments. However, our clinical experience with persons with motor impairments (e.g., quadriplegia, hemiplegia, hemiparesis) on an inpatient medical rehabilitation unit indicates this contention may not be entirely without problems. We find two major concerns with the Judgment subtest when examining individuals with motor impairments. The first issue concerns individuals with co-occurring motor impairment and cognitive deficits. Cognitively, many persons with executive dysfunction lack the ability to think abstractly when presented with hypothetical situations. Thus, they find it difficult to think outside of their disability. For instance, Question 2 of the Judgment subtest—“What would you do if while walking beside a lake you saw that a 2year-old child was playing alone at the end of a pier?” (p. 4
Downloaded by [University of Lethbridge] at 05:10 28 October 2015
408
MILLS, FOUTY, & BRANDON
of the test booklet)—typically results in a concrete response with little likelihood of achieving a 2-point score. We have often encountered responses such as, “I’m in a wheelchair, how would I be walking beside a lake?”; “I wouldn’t do anything, I can’t walk”; or “I would call someone for help” (which is a 0-point manualized response). The frequency of observed incorrect answers by examinees with motor impairment suggests that a motor ability bias exists for this subtest. The second major issue dovetails with the aforementioned motor ability bias and extends to an insensitivity inherent to posing these questions to those with motor impairments. In a current zeitgeist focusing on cultural sensitivity, we must take care to ensure that our awareness and sensitivity extends to being ability-sensitive. Although an examiner could alter the question slightly to throw in a caveat such as, “If you were physically able … ,” this deviation would have profound effects upon the assessment. Primarily, this deviation from the manualized administration procedures decreases the validity of the instrument and confounds interpretation of the results. In addition, this approach is also concerning as it highlights the individual’s impairment/disability. This may affect the individual emotionally and negatively affect the examiner–examinee relationship; both factors have been reported to influence neuropsychological performance (Rosti-Otajärvi, Mäntynen, Koivisto, Huhtala, & Hämäläinen, 2014). To address these issues, two possibilities exist. First, the current questions could be rephrased from a personalized tense to a global tense, similar to the questioning paradigm used in the Wechsler Comprehension subtest (Wechsler, 2008). For example, each question might begin, “What is the thing to do if … ” instead of “What would you do if ….” This would not only make the question more ability-sensitive, but it would also remove the need for increased abstract thinking by individuals with co-occurring motor and cognitive disabilities. Second, new questions that do not necessitate the need for a hypothetical motor response could be written. Either option would require restandardization and renorming of the
Cognistat. We leave these possible solutions to be debated among the scientific community. In conclusion, there are certainly psychometric issues with the Cognistat Judgment subtest (e.g., internal consistency reliability, sources of measurement error), but this test surely will remain in use despite such limitations. Our purpose here is one aspect of psychometrics (i.e., insensitivity due to question wording). Above all, we must remember that in a society striving toward cultural sensitivity, it is important that our psychometric instruments reflect our sensitivity across all domains.
REFERENCES Drane, D. L., Yuspeh, R. L., Huthwaite, J. S., Klinger, L. K., Foster, L. M., Mrazik, M., & Axelrod, B. N. (2003). Healthy older adult performance on a modified version of the Cognistat (NCSE): Demographic issues and preliminary normative data. Journal of Clinical and Experimental Neuropsychology, 25, 133–144. Fouty, H. E., & Brzezinski, S. B. (2009). Rectifying the inconsistent administration procedures of the Cognistat Constructional Ability subtest. Applied Neuropsychology, 16, 169–170. Kiernan, R. J., Mueller, J., & Langston, J. W. (2014). Cognistat manual. San Francisco, CA: Cognistat. Oehlert, M. E., Hass, S. D., Freeman, M. R., Williams, M. D., Ryan, J. J., & Sumerall, S. W. (1997). The Neurobehavioral Cognitive Status Examination: Accuracy of the ‘screen-metric’ approach in a clinical sample. Journal of Clinical Psychology, 53, 733–737. Rosti-Otajärvi, E., Mäntynen, A., Koivisto, K., Huhtala, H., & Hämäläinen, P. (2014). Predictors and impact of the working alliance in the neuropsychological rehabilitation of patients with multiple sclerosis. Journal of the Neurological Sciences, 338, 156–161. doi:10.1016/j.jns.2013.12.039 Wechsler, D. (2008). Wechsler Adult Intelligence Scale-Fourth Edition. San Antonio, TX: Pearson. Woods, D. C., Patterson, M. B., & Whitehouse, P. J. (2000). Utility of the Judgment Questionnaire subtest of the Neurobehavioral Cognitive Status Examination in the evaluation of individuals with Alzheimer’s disease. Clinical Gerontologist, 21(4), 49–66.
ISSN: 2327-9095 (Print) 2327-9109 (Online) Journal homepage: http://www.tandfonline.com/loi/hapn21
Utility of the Cognistat Judgment Subtest in Motorically Impaired Populations Rachel A. Mills, H. Edward Fouty & Brianna M. Brandon To cite this article: Rachel A. Mills, H. Edward Fouty & Brianna M. Brandon (2015) Utility of the Cognistat Judgment Subtest in Motorically Impaired Populations, Applied Neuropsychology: Adult, 22:6, 407-408, DOI: 10.1080/23279095.2014.949720 To link to this article: http://dx.doi.org/10.1080/23279095.2014.949720
Published online: 17 Mar 2015.
Submit your article to this journal
Article views: 20
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=hapn21 Download by: [University of Lethbridge]
Date: 28 October 2015, At: 05:10
APPLIED NEUROPSYCHOLOGY: ADULT, 22: 407–408, 2015 Copyright # Taylor & Francis Group, LLC ISSN: 2327-9095 print/2327-9109 online DOI: 10.1080/23279095.2014.949720
Utility of the Cognistat Judgment Subtest in Motorically Impaired Populations Rachel A. Mills, H. Edward Fouty, and Brianna M. Brandon
Downloaded by [University of Lethbridge] at 05:10 28 October 2015
Psychology, University of Central Florida, Daytona Beach, Florida
The Cognistat is one the most frequently employed measures to briefly evaluate cognitive functioning. However, clinical experience indicates that the questions within the Judgment subtest may be biased and insensitive toward persons with motor impairments. These issues may impact the examinee’s performance and decrease the validity of the test—not to mention possibly create undue emotional distress. Suggestions for rectifying these issues are presented.
Key words:
Cognistat, Judgment subtest, motor bias, motor impairment
The Cognistat (Kiernan, Mueller, & Langston, 2014) is a widely utilized screening measure designed to assess higher cerebral functioning across multiple cognitive domains: Orientation, Attention, Language (Comprehension, Repetition, and Naming), Construction, Memory, Calculation, and Reasoning (Similarities and Judgment). The Cognistat’s ability to briefly assess cognitive functioning makes it versatile in a variety of situations including time-sensitive medical and rehabilitation settings. Each of the Cognistat’s subtests, excluding Memory, employs a screen and metric approach. The screen approach involves administration of an item that requires ability in a specific functional domain. If the examinee correctly answers the screen, the examiner proceeds to the next subtest. If the screen is failed, the metric items are administered; these items are arranged in order of increasing difficulty and are utilized to demarcate degree of impairment. The authors reported that screen failures occur in approximately 20% of normal individuals. To decrease the occurrence of false positives and improve test reliability, it has been recommended that all metric items be administered to all examinees (e.g., Drane et al., 2003; Oehlert et al., 1997). However, Fouty and Brzezinski (2009) noted that there is one exception to this recommendation: Both the screen and the metric for
Address correspondence to H. Edward Fouty, Ph.D., Psychology, University of Central Florida, 1200 W. International Speedway Blvd., Daytona Beach, FL 32120-2811. E-mail: [email protected]
the Construction subtest should be administered because they measure unique, separate cognitive functions. The Judgment subtest presents examinees with problematic situations and asks what they would do if placed in the situations. This subtest evaluates an individual’s ability to identify a problematic situation and develop an appropriate hypothetical strategy to address that situation. The strength of this approach is its reliance on executive functions with minimal focus on other cognitive abilities (Woods, Patterson, & Whitehouse, 2000). These authors asserted that because the examinee need not actually perform the activities, the test only requires minimal attentional, perceptual, motor, and memory skills. Thus, the test can be easily administered to individuals with motor impairments. However, our clinical experience with persons with motor impairments (e.g., quadriplegia, hemiplegia, hemiparesis) on an inpatient medical rehabilitation unit indicates this contention may not be entirely without problems. We find two major concerns with the Judgment subtest when examining individuals with motor impairments. The first issue concerns individuals with co-occurring motor impairment and cognitive deficits. Cognitively, many persons with executive dysfunction lack the ability to think abstractly when presented with hypothetical situations. Thus, they find it difficult to think outside of their disability. For instance, Question 2 of the Judgment subtest—“What would you do if while walking beside a lake you saw that a 2year-old child was playing alone at the end of a pier?” (p. 4
Downloaded by [University of Lethbridge] at 05:10 28 October 2015
408
MILLS, FOUTY, & BRANDON
of the test booklet)—typically results in a concrete response with little likelihood of achieving a 2-point score. We have often encountered responses such as, “I’m in a wheelchair, how would I be walking beside a lake?”; “I wouldn’t do anything, I can’t walk”; or “I would call someone for help” (which is a 0-point manualized response). The frequency of observed incorrect answers by examinees with motor impairment suggests that a motor ability bias exists for this subtest. The second major issue dovetails with the aforementioned motor ability bias and extends to an insensitivity inherent to posing these questions to those with motor impairments. In a current zeitgeist focusing on cultural sensitivity, we must take care to ensure that our awareness and sensitivity extends to being ability-sensitive. Although an examiner could alter the question slightly to throw in a caveat such as, “If you were physically able … ,” this deviation would have profound effects upon the assessment. Primarily, this deviation from the manualized administration procedures decreases the validity of the instrument and confounds interpretation of the results. In addition, this approach is also concerning as it highlights the individual’s impairment/disability. This may affect the individual emotionally and negatively affect the examiner–examinee relationship; both factors have been reported to influence neuropsychological performance (Rosti-Otajärvi, Mäntynen, Koivisto, Huhtala, & Hämäläinen, 2014). To address these issues, two possibilities exist. First, the current questions could be rephrased from a personalized tense to a global tense, similar to the questioning paradigm used in the Wechsler Comprehension subtest (Wechsler, 2008). For example, each question might begin, “What is the thing to do if … ” instead of “What would you do if ….” This would not only make the question more ability-sensitive, but it would also remove the need for increased abstract thinking by individuals with co-occurring motor and cognitive disabilities. Second, new questions that do not necessitate the need for a hypothetical motor response could be written. Either option would require restandardization and renorming of the
Cognistat. We leave these possible solutions to be debated among the scientific community. In conclusion, there are certainly psychometric issues with the Cognistat Judgment subtest (e.g., internal consistency reliability, sources of measurement error), but this test surely will remain in use despite such limitations. Our purpose here is one aspect of psychometrics (i.e., insensitivity due to question wording). Above all, we must remember that in a society striving toward cultural sensitivity, it is important that our psychometric instruments reflect our sensitivity across all domains.
REFERENCES Drane, D. L., Yuspeh, R. L., Huthwaite, J. S., Klinger, L. K., Foster, L. M., Mrazik, M., & Axelrod, B. N. (2003). Healthy older adult performance on a modified version of the Cognistat (NCSE): Demographic issues and preliminary normative data. Journal of Clinical and Experimental Neuropsychology, 25, 133–144. Fouty, H. E., & Brzezinski, S. B. (2009). Rectifying the inconsistent administration procedures of the Cognistat Constructional Ability subtest. Applied Neuropsychology, 16, 169–170. Kiernan, R. J., Mueller, J., & Langston, J. W. (2014). Cognistat manual. San Francisco, CA: Cognistat. Oehlert, M. E., Hass, S. D., Freeman, M. R., Williams, M. D., Ryan, J. J., & Sumerall, S. W. (1997). The Neurobehavioral Cognitive Status Examination: Accuracy of the ‘screen-metric’ approach in a clinical sample. Journal of Clinical Psychology, 53, 733–737. Rosti-Otajärvi, E., Mäntynen, A., Koivisto, K., Huhtala, H., & Hämäläinen, P. (2014). Predictors and impact of the working alliance in the neuropsychological rehabilitation of patients with multiple sclerosis. Journal of the Neurological Sciences, 338, 156–161. doi:10.1016/j.jns.2013.12.039 Wechsler, D. (2008). Wechsler Adult Intelligence Scale-Fourth Edition. San Antonio, TX: Pearson. Woods, D. C., Patterson, M. B., & Whitehouse, P. J. (2000). Utility of the Judgment Questionnaire subtest of the Neurobehavioral Cognitive Status Examination in the evaluation of individuals with Alzheimer’s disease. Clinical Gerontologist, 21(4), 49–66.
