Child Neuropsychology A Journal on Normal and Abnormal Development in Childhood and Adolescence
ISSN: 0929-7049 (Print) 1744-4136 (Online) Journal homepage: http://www.tandfonline.com/loi/ncny20
When a funnel becomes a martini glass: Adolescent performance on the Boston Naming Test Tammy Mandernach Martielli & Lynn Bennett Blackburn To cite this article: Tammy Mandernach Martielli & Lynn Bennett Blackburn (2015): When a funnel becomes a martini glass: Adolescent performance on the Boston Naming Test, Child Neuropsychology, DOI: 10.1080/09297049.2015.1014899 To link to this article: http://dx.doi.org/10.1080/09297049.2015.1014899
Published online: 08 May 2015.
Submit your article to this journal
Article views: 216
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ncny20 Download by: [York University Libraries]
Date: 07 November 2015, At: 17:24
Child Neuropsychology, 2015 http://dx.doi.org/10.1080/09297049.2015.1014899
When a funnel becomes a martini glass: Adolescent performance on the Boston Naming Test
Downloaded by [York University Libraries] at 17:24 07 November 2015
Tammy Mandernach Martielli1,2 and Lynn Bennett Blackburn3 1
Department of Psychology, Saint Louis University, St. Louis, MO, USA Independent Practice, St. Louis, MO, USA 3 Department of Psychology, St. Louis Children’s Hospital, St. Louis, MO, USA 2
The Boston Naming Test (BNT), a component of the Boston Diagnostic Aphasia Examination, is often used by neuropsychologists to assess confrontation naming. Research indicates that performance on the BNT is impacted by a variety of factors including age, gender, measured intelligence, educational attainment, vocabulary knowledge, level of acculturation, and ethnicity. Extant normative data are available for adults and for younger children; however, descriptive data are lacking for neurologically intact adolescents. The current study obtained normative data for the BNT, second edition in 15- to 18-year-old adolescents. The sample included 200 participants (100 male, 100 female) who were screened to exclude individuals with neurologic, psychiatric, or academic difficulties. There were no statistically significant differences in BNT scores based on gender, age, or grade. Normative means and standard deviations, collapsed across age and gender, are provided. The relationship of the current data to existing child and adult norms, as well as the clinical utility of examining individual item responses for the BNT in this sample are addressed. Keywords: Boston Naming Test; Normative data; Adolescents.
Originally developed as a component of the Boston Diagnostic Aphasia Examination, the Boston Naming Test (BNT; Kaplan, Goodglass, & Weintraub, 1978, 1983, 2001) is one of the most widely used assessment instruments in the field of neuropsychology (Camara, Nathan, & Puente, 2000; Rabin, Barr, & Burton, 2005). Numerous studies have identified variables that impact performance on the BNT including age, gender, ethnicity, level of acculturation, language, geographic region, education level, and vocabulary knowledge (see Baron, 2004; Mitrushina, Boone, Razani, & D’Elia, 2005, for a detailed review). However, concerns have been raised regarding both use and interpretation of the BNT due to incomplete normative data, inconsistencies in administration and scoring procedures and construct validity (Bortnik et al., 2013; Mitrushina et al., 2005). In particular, there is a gap in the normative data for 15- to 18-year-old adolescents. Therefore, although confrontation naming skills are frequently assessed as a component of a The authors would like to thank Jeffrey D. Gfeller and Honore M. Hughes for their support of the current project. The authors of the article have no relevant disclosures to report. Address correspondence to Tammy Mandernach Martielli, Independent Practice, 4542 West Pine Blvd., St. Louis, MO 63108, USA. E-mail: [email protected]
© 2015 Taylor & Francis
Downloaded by [York University Libraries] at 17:24 07 November 2015
2
T. M. MARTIELLI & L. B. BLACKBURN
neuropsychological evaluation, interpretation of performance in the 15- to 18-year-old age range is problematic. Based on previous studies, there is a general increase in BNT score from age 4 to 13 (Yeates, 1994), continued increase in BNT score after age 18 into early adulthood with a gradual decline over middle adulthood, and a significant decline after approximately age 70 (Au et al., 1995; Nicholas, Obler, Albert, & Goodglass, 1985). Normative data for the 60-item BNT have been documented in a limited number of studies for children ages 5 to 13 years (Cohen, Town, & Buff, 1988; Guilford & Nawojczyk, 1988; Halperin, Healey, Zeitchik, Ludman, & Weinstein, 1989; Kaplan et al., 1983; Kirk, 1992). Yeates conducted a metaanalysis of the existing children’s norms and presented data for children ages 5 to 13. See Baron (2004) for a detailed review of existing normative data for children on the BNT. Adult normative data are available for individuals over age 18. A comprehensive review of adult normative data, variables impacting BNT performance, and limitations of the BNT has been compiled by Mitrushina et al. (2005) and Strauss, Sherman, and Spreen (2006). Mitrushina et al. also provide a thorough review of the difficulties in interpreting BNT performance across all age groups. Subsequently, Zec, Burkett, Markwell, and Larsen (2007a, 2007b) provided additional adult normative data stratified by age, education, and gender. The gap in normative data for the BNT reflects a more global problem in neuropsychology. Overall, research directed at identifying age-related cognitive changes in typically developing individuals has primarily focused on the extreme ends of the lifespan—infancy and aging (Korkman, 2001)- resulting in a paucity of normative data for adolescents (Baron, 2004). Regarding the BNT, the majority of normative studies have been conducted with adult and older adult samples compared to child samples, leaving clinicians to extrapolate information from those older and younger samples when interpreting performance of adolescents. Downward extensions of adult normative data for clinical interpretation represent significant fundamental errors in assumptions of the underlying constructs being measured. Regarding the BNT, criticisms of the dated stimuli suggest that some of the stimuli are not familiar to younger individuals. Specifically regarding children, word retrieval difficulties versus a lack of word knowledge was examined by Kirk (1992). The author examined BNT errors in children ages 5 to 13. Based on the findings, a reordered list of BNT items was provided according to percentage correct in the normative sample. Additional evidence for the possibility of a cohort effect on the BNT is provided by Schmitter-Edgecombe, Vesneski, and Jones (2000) who identified four items in which phonemic cues did not improve the performance of younger adult participants (18 to 22 years) relative to older adult participants (ages 58 to 74 and ages 75 to 93), suggesting that these words or objects were not familiar to the younger participants (items included yoke, trellis, abacus, and palette). These findings in both young adult (Schmitter-Edgecombe et al., 2000) and child (Kirk, 1992) populations highlight the importance of describing normative performance in an adolescent sample on the BNT in order to identify specific items that may not be familiar to adolescents and thereby facilitate more meaningful interpretations of test performance. The current study sought to provide normative data for an age range that has not previously been described in terms of confrontation naming ability as measured by the BNT by collecting data from adolescents ages 15 through 18. Based on previous research with older and younger samples, the role of age, gender, education level, and estimated verbal intelligence were examined. It was hypothesized that an age- and grade-level related, linear
ADOLESCENT BNT NORMS
3
trend of increasing BNT raw scores would be observed. It was also hypothesized that the resulting frequency distribution would be non-normally distributed (negatively skewed). To further aid in test interpretation, the error frequency of each BNT item as well as exemplars of commonly missed items also are provided. METHOD
Downloaded by [York University Libraries] at 17:24 07 November 2015
Participants Participants included volunteers from the Saint Louis University Psychology Department Participant Pool and students from local high schools in the St. Louis metropolitan area. Participants who were 18 years of age and recruited from the Saint Louis University Psychology Department Participant Pool were provided with informed consent by the examiner before testing began. Each participant completed a demographic questionnaire and a medical/psychological history form that included neurological, psychiatric, and educational history. High school students were recruited through a study packet containing an informational letter, demographic questionnaire, medical/psychological history form, and consent form to take home to their parents/guardians. Interested students returned the history forms and parent/guardian signed consent prior to participating in the study. Participant assent was obtained at the time of testing. Study approval was obtained through the Saint Louis University Institutional Review Board (IRB). All students who returned the consent form and questionnaires participated in the study. Data from participants were excluded from the normative sample based on either self or parental endorsement of a history of neurological disease, motor disorder, head injury with loss of consciousness, learning disability, attention deficit/hyperactivity disorder (ADHD), developmental disability, psychiatric illness, or current medications with possible motor or cognitive side effects. The data from 89 of the 289 participants (30.8%) were excluded based on either self or parental endorsement of one or more of these conditions. No participant endorsed a history of special education services, grade retention or grade acceleration. The final sample consisted of 200 healthy individuals (100 male and 100 female) ages 15 to 18 years old (birth years ranged from 1986 to 1989). Each of the four age groups (15, 16, 17, and 18) consisted of 25 males and 25 females. All 15-, 16-, and 17-yearold participants were recruited from local high schools. Among the 18-year-old participants, 12 male (48%) and 5 female (20%) were collected from local high schools, while the remaining 18-year-old participants were collected from the Saint Louis University Psychology Department Participant Pool. Exclusions were not based on ethnicity; however, all participants in the final analyses were Caucasian. The mean level of combined parental education for the sample was 15.8 years (15.4 maternal and 16.2 paternal). Procedure The Wechsler Test of Adult Reading (WTAR) and BNT were administered as part of a larger test battery designed to collect normative data for measures of motor and language functioning. Each student participated in one test session that was approximately 45 minutes in length. Test administration was completed in the following order: Annett Handedness Questionnaire, Grooved Pegboard, Finger Tapping Test, Grip Strength Test, Wechsler Test of Adult Reading, and BNT. The examiners consisted of graduate students in a clinical psychology doctoral program with specialization in neuropsychology.
Downloaded by [York University Libraries] at 17:24 07 November 2015
4
T. M. MARTIELLI & L. B. BLACKBURN
Examiners were thoroughly trained by the primary author including several practice administrations and observations to ensure consistent administration and recording procedures between examiners. The WTAR (Wechsler, 2001) was used to determine reading recognition skills as an estimate of verbal intelligence. This measure consists of 50 words that are read aloud from a stimulus card. For the purposes of the current study, all participants were scored using normative values for 16- to 18-year-olds, as the WTAR was not standardized on 15-yearolds. Internal consistency for the 16- to 18-year-old age group is .90 (WTAR manual; Wechsler, 2001). Furthermore, the WTAR has been used to predict verbal intelligence and has a correlation of .66 in 16- to 17-year-olds and .74 in 18- to 19-year-olds with the Wechsler Adult Intelligence Scale – Third Edition (WAIS-III), Verbal IQ (WTAR manual; Wechsler, 2001). In contrast, however, performance of the WTAR normative sample only correlated .29 with BNT performance (WTAR manual; Wechsler, 2001). The BNT (Kaplan et al., 2001) consists of 60 black and white line drawings of objects presented individually. Participants were allowed 20 seconds to provide a verbal response to each of the drawings. If the participant did not provide a response in 20 seconds, the stimulus cue was provided. If the participant provided a response that reflected a perceptual misunderstanding of the drawing, indicated he or she was unfamiliar with the item or provided a “don’t know” response, the stimulus cue was provided. If the participant was unable to provide a correct response following the semantic cue, a phonemic cue was provided. According to instructions provided in the BNT stimulus manual (Kaplan et al., 2001), following administration of the last item (Card 60), the examiner returned to items missed by the participant following the phonemic cue and presented the item again with four written multiple-choice options that were read aloud to the participant. The total score was based on the sum of spontaneously given correct responses and correct responses when provided the stimulus cue. Correct responses following a phonemic cue were not included in the participant’s total accuracy score but instead, per the test authors, were obtained for qualitative purposes. The authors of the test indicate that for older children and adults, the examiner may elect to begin testing at Item 30; however, there is a basal rule of eight consecutive correct responses that must be established if this starting point is used. In the current study, all participants started with Item 1. For all participants, the authors of the BNT identify a ceiling of eight consecutive errors, which was utilized in the current study. RESULTS An initial examination (analysis of variance, ANOVA) of the relationship between gender and BNT performance revealed that male and female participants performed similarly in regard to BNT raw score, which represents the sum of spontaneously generated correct responses and correct responses following a stimulus cue, F(1, 198) = 1.009, p = .316. Table 1 provides normative data for the BNT, based on gender. Therefore, performance of male and female participants was combined for the remaining analyses. The next phase of data analysis examined the relationship between performance on the BNT and individual age level. An ANOVA revealed no significant age differences in BNT performance, F(3, 196) = 1.576, p = .196. Table 2 provides normative data for the BNT for each age level. Given the previously reported relationship between BNT performance and years of education in adult literature, performance on the BNT across grade level was examined.
ADOLESCENT BNT NORMS
5
Table 1 BNT Norms by Gender Collapsed Across Age (N = 200). Gender
n
M
SD
Male Female
100 100
51.00 51.61
4.52 4.05
Downloaded by [York University Libraries] at 17:24 07 November 2015
Table 2 BNT Norms by Age Collapsed Across Gender (N = 200). Age
n
M
SD
15 16 17 18
50 50 50 50
50.98 51.46 50.50 52.28
4.16 3.78 4.80 4.30
An ANOVA revealed consistent performance across grade level, F(4, 195) = 0.888, p = .472. There were no significant differences between high school and college 18-year-old participants, F(1, 48) = 1.814, p = .184. Table 3 provides normative data for the BNT for each grade level. These findings suggest stable BNT performance from 15 through 18 years of age and from 9 to 13 years of education, respectively. Given the consistent performance across age and grade level, the sample was collapsed across these variables for the remaining analyses. Table 4 provides normative data for the BNT, collapsed across gender, age, and grade. Normative data regarding the benefit from semantic and phonemic cueing, as well as from the multiple-choice condition, collapsed across age and gender, are presented in Table 5. Finally, individual items were evaluated in terms of error frequency. The most commonly provided inaccurate responses for items with an error rate of 10% or greater are provided in Appendix A. Table 3 BNT Norms by Grade Collapsed Across Age (N = 200). Grade
n
M
SD
9 10 11 12 13
14 57 65 31 33
51.29 51.11 50.75 52.42 51.70
4.70 4.00 4.40 3.79 4.84
Table 4 Norms Collapsed Across Gender, Age, and Grade (N = 200).
Test BNT
WTAR
Score Number of spontaneous correct responses Spontaneous + Number correct following stimulus cue Estimated IQ
M
SD
Median
Mode
Range
15th percentile
85th percentile
50.92
4.26
51
54
38–59
46
55
51.30
4.29
52
54
38–59
47
55
102.52
8.23
103
104
78–119
95
112
6
T. M. MARTIELLI & L. B. BLACKBURN Table 5 Normative Data Regarding the Benefit from Semantic and Phonemic Cueing and the Multiple-Choice Condition, Collapsed Across Age and Gender (N = 200). SD
50.92 2.56 0.42 8.45 4.43 4.18 3.27
4.26 3.79 0.79 4.32 2.30 2.85 2.50
Regarding the relationship between confrontation naming and estimated verbal intelligence, there was a significant positive correlation between BNT and WTAR scores, (Pearson r = .429, p < .001). Males and females achieved comparable estimates of intellectual functioning, based on single word reading (WTAR), F (1, 198) = 0.870, p = .679. It should be noted, however, that the distribution of BNT scores, as predicted, was not normal (Kolmogorov-Smirnov, p = .026) and therefore violates the underlying assumption of normality of the previously reported parametric statistics. Figure 1 illustrates the distribution of BNT scores. Given the negatively skewed distribution of
Frequency
Downloaded by [York University Libraries] at 17:24 07 November 2015
Spontaneously Correct Stimulus Cue Given Correct After Stimulus Cue Phonemic Cue Given Correct After Phonemic Cue Multiple Choice Given Correct After Multiple Choice
M
22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 Score Figure 1 Frequency of raw BNT scores.
ADOLESCENT BNT NORMS
7
Table 6 Cumulative Percent of BNT Scores (N = 200).
Downloaded by [York University Libraries] at 17:24 07 November 2015
Score 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59
Cumulative Percent 0.5 1.0 3.0 3.5 4.0 5.0 6.0 10.5 14.0 19.0 22.5 31.5 37.5 46.0 55.5 63.5 74.5 84.5 92.5 96.5 98.5 100
BNT scores, Table 6 provides the cumulative percentage of BNT scores obtained by participants in the sample. Estimated intelligence (WTAR) was normally distributed (Kolmogorov-Smirnov, p = .461).
DISCUSSION The current study was conducted to provide normative data for 15- to 18-year-old adolescents on the Boston Naming Test. The study investigated the effect of gender, age, grade level and estimated verbal intelligence (as measured by single word reading) on confrontation naming performance. Given that the BNT items were selected several decades ago, individual item responses were obtained to assist in qualitative clinical interpretation of incorrect responses in contemporary adolescents. The primary findings of the study suggest that (a) in this age and education range, there is overall consistency in BNT performance with no significant gender differences, (b) the mean BNT performance obtained in this sample corresponds with the developmental trend demonstrated over existing child and adult normative data (i.e., acquisition continuing into adulthood, with leveling off and gradual loss) and (c) the results can be applied clinically (taking into account factors listed in more detail below). Based on the present data, gender differences in confrontation naming ability as measured by the BNT are minimal by late adolescence with males obtaining approximately one-half point lower score than females. Interpreted from a developmental framework, the absence of a statistically significant gender effect is generally consistent with previous studies of confrontation naming in younger children and adults. Halperin et al. (1989) did not find a statistically significant gender effect in children, although there was
Downloaded by [York University Libraries] at 17:24 07 November 2015
8
T. M. MARTIELLI & L. B. BLACKBURN
a trend for higher scores among males. With respect to adults, findings from previous research are inconsistent. Some studies suggest that males obtain higher scores than females on measures of confrontation naming (Lansing, Ivnik, Cullum, & Randolph, 1999; Randolph, Lansing, Ivnik, Cullum, & Hermann, 1999; Tombaugh & Hubley, 1997; Welch, Doineau, Johnson, & King, 1996), whereas several studies did not identify a statistically significant gender effect (Cruice, Worrall, & Hickson, 2000; Fastenau, Denberg, & Mauer, 1998; Henderson, Frank, Pigatt, Abramson, & Houston, 1998; Ivnik, Malec, Smith, Tangalos, & Petersen, 1996; LaBarge, Edwards, & Knesevich, 1986; Saxton et al., 2000; Zec et al., 2007a). As noted earlier, age and formal education have both been associated with BNT performance in previous studies of adults (Giovannetti, Goldstein, Schullery, Barr, & Bilder, 2003; Ivnik et al., 1996; Lansing et al., 1999; Saxton et al., 2000; Thompson & Heaton, 1989; Welch et al., 1996; Zec et al., 2007a, 2007b). The current findings did not suggest statistically significant change in confrontation naming on the BNT within this age and education range. This finding is not surprising given the confound of age and educational attainment (current grade level) in children. Whereas educational attainment reported for adults reflects the end points of formal education, in children it marks agerelated progress through school. Lastly, a statistically significant relationship was identified between estimated verbal intelligence (single word reading) and confrontation naming (.43), which is consistent with previous literature addressing the adult population (Thompson & Heaton, 1989; Tombaugh & Hubley, 1997). These authors reported correlations ranging from .53 to .79 for the BNT and WAIS-R vocabulary subtest. Compared to those studies, the current correlation is somewhat weaker. Several considerations may explain this discrepancy. The adult studies used the WAIS-R Vocabulary subtest as an estimate of verbal intelligence, which is more strongly correlated with the BNT than the WTAR. Specifically, the participant’s knowledge of phonics may have allowed for decoding of the words without knowledge of word meaning. Further, the item content of the BNT may not be familiar to contemporary adolescents, thus reducing the relationship between word reading (decoding) and object naming. The current study fills a gap in published age-based normative data by demonstrating that adolescents ages 15 to 18 show continued development of confrontation naming skills on the BNT relative to 13-year-olds, with 15- to 18-year-olds obtaining scores approximately two points higher than 13-year-olds (compared to Yeates, 1994). Moreover, the current data indicate that individuals in the 15- to 18-year-old cohort have not yet achieved adult levels in confrontation naming ability, as measured by the BNT, with adolescents in this sample performing two points lower than the 18- to 22-year-old adults in the Schmitter-Edgecombe et al. (2000) normative sample. Therefore, when compared to previous norms for older and younger age groups, there appears to be continued increase in BNT raw score into early adulthood. A summary of mean BNT scores across the lifespan is displayed in Figure 2. The current data further elucidate the development of BNT performance in males and females ages 15 to 18 and suggest that during adolescence, individuals maintain a consistent level of performance, although alternate explanations should be considered. The current findings could represent a cohort effect, which may be eliminated with more current stimuli. The current BNT stimuli were compiled in 1978 and based on frequency estimates produced in 1944 (Thorndike & Lorge, 1944) and 1967 (Kucera & Francis, 1967). As previous literature has consistently reported a relationship between BNT
ADOLESCENT BNT NORMS
9
60 Mean BNT Score
55 50 45 40 35 30
Downloaded by [York University Libraries] at 17:24 07 November 2015
70–79
60–69
50–59
40–49
18–22
15–18
13
12
11
10
9
8
7
6
5
25
Age Figure 2 Mean BNT scores across the lifespan.
Note. Mean scores for ages 5–13 were obtained from Yeates (1994); mean score for ages 15–18 was obtained from the current study; mean score for ages 18–22 was obtained from Schmitter-Edgecombe et al. (2000); mean score for ages 40–79 was obtained from Kaplan et al. (1983).
performance and word frequency, as well as between BNT performance and age of word acquisition, the dated nature of these measures and the BNT stimuli and scoring criteria may obscure any possible gender, age or education differences. In fact, many of the participants spontaneously reported never having come in contact with several of the stimuli and many participants produced synonyms of the stimuli that are not considered correct based on traditional scoring procedures. In terms of clinical applicability, the current normative data can be used to aid clinicians in assessment of confrontation naming skills in 15- to 18-year-old individuals. However, it should be noted that the distribution of the current data was not found to be normal, thereby violating basic assumptions of parametric statistical procedures. Although not extreme, given the negatively skewed distribution of BNT performance, it may be more appropriate to report whether the score is within expected limits, based on cumulative percentage rather than reporting a transformed standard score or percentile (see Table 6). Additionally, given the current qualitative findings regarding common errors in adolescents, it may aid in clinical interpretation to compare a patient’s errors to those produced by other adolescents. In the current sample, many easier items were missed compared to supposedly more difficult items. For example, 28.5% of the current sample missed Number 44, “muzzle” while only 2.5% of the sample misidentified Number 45 “unicorn.” Furthermore, there were several items on the BNT that, although the current sample did not receive credit for the item, their inaccurate responses seemed to be consistent within the group, possibly suggesting a cohort effect. For example, 65.5% misidentified Item Number 51 (latch) with the most common response being “lock,” which current scoring criteria would consider inaccurate. The most commonly provided inaccurate responses for items with an error rate of 10% or greater are included in Appendix A for further qualitative analysis. While the current findings can be used as a general guide for interpreting BNT test performance in the 15- to 18-year-old age range, the current sample was limited regarding demographic factors suspected to impact BNT performance, based on existing adult
Downloaded by [York University Libraries] at 17:24 07 November 2015
10
T. M. MARTIELLI & L. B. BLACKBURN
literature, and may not be generalizable to adolescents in different regions of the country, different ethnicities, and different quality of educational background. Specifically, the sample was Caucasian with average estimated intelligence, from a medium-sized Midwestern city, who attended private Jesuit high schools and university, with slightly higher educated parents than reported by the U.S. census. This study highlights several areas that merit future investigation related to BNT assessment and interpretation in adolescents. Further examination of the factors known to impact confrontation naming from adult and child literature should be more thoroughly explored, as this study represents only an initial attempt to characterize confrontation naming in late adolescents. Additionally, future research exploring changes in scoring criteria and stimuli to reflect objects to which contemporary adolescents are generally exposed will help determine if any developmental trends exist in terms of age, gender, or education for confrontation naming within this age group. Finally, all participants in this study were Caucasian. Adult normative data for the BNT indicate differential performance between various ethnicities (Boone, Victor, Wen, Razani, & Pontón, 2007; Heaton, Miller, Taylor, & Grant, 2004). Therefore, additional research should be conducted in this age range to include non-Caucasian individuals. Original manuscript received 4 December 2014 Revised manuscript accepted 29 January 2015 First published online 6 May 2015
REFERENCES Au, R., Joung, P., Nicholas, M., Obler, L. K., Kass, R., & Albert, M. L. (1995). Naming ability across the adult life span. Aging, Neuropsychology, and Cognition, 2(4), 300–311. doi:10.1080/ 13825589508256605 Baron, I. S. (2004). Neuropsychological evaluation of the child. New York, NY: Oxford University Press. Boone, K. B., Victor, T. L., Wen, J., Razani, J., & Pontón, M. (2007). The association between neuropsychological scores and ethnicity, language, and acculturation variables in a large patient population. Archives of Clinical Neuropsychology, 22(3), 355–365. doi:10.1016/j. acn.2007.01.010 Bortnik, K. E., Boone, K. B., Wen, J., Lu, P., Mitrushina, M., Razani, J., & Maury, T. (2013). Survey results regarding use of the Boston Naming Test: Houston, we have a problem. Journal of Clinical and Experimental Neuropsychology, 35(8), 857–866. doi:10.1080/ 13803395.2013.826182 Camara, W. J., Nathan, J. S., & Puente, A. E. (2000). Psychological test usage: Implications in professional psychology. Professional Psychology: Research and Practice, 31, 141–154. doi:10.1037/0735-7028.31.2.141 Cohen, M. J., Town, P., & Buff, A. (1988). Neurodevelopmental differences in confrontational naming in children. Developmental Neuropsychology, 4, 75–81. doi:10.1080/ 87565648809540392 Cruice, M. N., Worrall, L. E., & Hickson, L. M. H. (2000). Boston Naming Test results for healthy older Australians: A longitudinal and cross-sectional study. Aphasiology, 14(2), 143–155. doi:10.1080/026870300401522 Fastenau, P. S., Denburg, N. L., & Mauer, B. A. (1998). Parallel short forms for the Boston Naming Test: Psychometric properties and norms for older adults. Journal of Clinical and Experimental Neuropsychology, 20(6), 828–834. doi:10.1076/jcen.20.6.828.1105
Downloaded by [York University Libraries] at 17:24 07 November 2015
ADOLESCENT BNT NORMS
11
Giovannetti, T., Goldstein, R. Z., Schullery, M., Barr, W. B., & Bilder, R. M. (2003). Category fluency in first-episode schizophrenia. Journal of the International Neuropsychological Society, 9(3), 384–393. doi:10.1017/S1355617703930049 Guilford, A. M., & Nawojczyk, D. C. (1988). Standardization of the Boston Naming Test at the kindergarten and elementary school levels. Language Speech and Hearing Services in Schools, 19, 395–400. doi:10.1044/0161-1461.1904.395 Halperin, J. M., Healey, J. M., Zeitchik, E., Ludman, W. L., & Weinstein, L. (1989). Developmental aspects of linguistic and mnestic abilities in normal children. Journal of Clinical and Experimental Neuropsychology, 11, 518–528. doi:10.1080/01688638908400910 Heaton, R. K., Miller, S. W., Taylor, M. J., & Grant, I. (2004). Revised comprehensive norms for an expanded Halstead-Reitan Battery: Demographically adjusted neuropsychological norms for African American and Caucasian adults. Lutz, FL: Psychological Assessment Resources. Henderson, L. W., Frank, E. M., Pigatt, T., Abramson, R. K., & Houston, M. (1998). Race, gender, and educational level effects on Boston Naming Test scores. Aphasiology, 12(10), 901–911. doi:10.1080/02687039808249458 Ivnik, R. J., Malec, J. F., Smith, G. E., Tangalos, E. G., & Petersen, R. C. (1996). Neuropsychological tests’ norms above age 55: COWAT, BNT, MAE Token, WRAT-R Reading, AMNART, STROOP, TMT, and JLO. The Clinical Neuropsychologist, 10(3), 262–278. doi:10.1080/13854049608406689 Kaplan, E., Goodglass, H., & Weintraub, S. (1978). The Boston Naming Test: Experimental edition. Boston, MA: Kaplan and Goodglass. Kaplan, E., Goodglass, H., & Weintraub, S. (1983). Boston Naming Test (Revised 60-item version). Philadelphia, PA: Lea & Febiger. Kaplan, E., Goodglass, H., & Weintraub, S. (2001). Boston Naming Test (2nd ed). Philadelphia, PA: Lippincott Williams & Wilkins. Kirk, U. (1992). Confrontation naming in normally developing children: Word-retrieval or word knowledge? The Clinical Neuropsychologist, 6, 156–170. doi:10.1080/13854049208401852 Korkman, M. (2001). Introduction to the special issue on normal neuropsychological development in the school-age years. Developmental Neuropsychology, 20(1), 325–330. doi:10.1207/ S15326942DN2001_1 Kucera, H., & Francis, W. (1967). Computational analysis of present-day American English. Providence, RI: Brown University Press. LaBarge, E., Edwards, D., & Knesevich, J. W. (1986). Performance of normal elderly on the Boston Naming Test. Brain and Language, 27, 380–384. doi:10.1016/0093-934X(86)90026-X Lansing, A. E., Ivnik, R. J., Cullum, C. M., & Randolph, C. (1999). An empirically derived short form of the Boston Naming Test. Archives of Clinical Neuropsychology, 14(6), 481–487. doi:10.1093/arclin/14.6.481 Mitrushina, M., Boone, K. B., Razani, J., & D’Elia, L. F. (2005). Handbook of normative data for neuropsychological assessment. New York, NY: Oxford University Press. Nicholas, M., Obler, L., Albert, M., & Goodglass, H. (1985). Lexical retrieval in healthy aging. Cortex, 21, 595–606. doi:10.1016/S0010-9452(58)80007-6 Rabin, L. A., Barr, W. B., & Burton, L. A. (2005). Assessment practices of clinical neuropsychologists in the United States and Canada: A survey of INS, NAN, and APA Division 40 members. Archives of Clinical Neuropsychology, 20(1), 33–65. doi:10.1016/j.acn.2004.02.005 Randolph, C., Lansing, A. E., Ivnik, R. J., Cullum, C. M., & Hermann, B. P. (1999). Determinants of confrontation naming performance. Archives of Clinical Neuropsychology, 14(6), 489–496. doi:10.1093/arclin/14.6.489 Saxton, J., Ratcliff, G., Munro, C. A., Coffey, E. C., Becker, J. T., Fried, L., & Kuller, L. (2000). Normative data on the Boston Naming Test and two equivalent 30-item short forms. The Clinical Neuropsychologist (Neuropsychology, Development and Cognition: Section D), 14(4), 526–534. doi:10.1076/clin.14.4.526.7204
Downloaded by [York University Libraries] at 17:24 07 November 2015
12
T. M. MARTIELLI & L. B. BLACKBURN
Schmitter-Edgecombe, M., Vesneski, M., & Jones, D. W. R. (2000). Aging and word-finding: A comparison of spontaneous and constrained naming tests. Archives of Clinical Neuropsychology, 15(6), 479–493. Strauss, E., Sherman, E. M. S., & Spreen, O. (2006). A Compendium of neuropsychological tests: Administration, norms, and commentary (3rd ed). New York, NY: Oxford University Press. Thompson, L. L., & Heaton, R. K. (1989). Comparison of different versions of the Boston Naming Test. Clinical Neuropsychologist, 3(2), 184–192. doi:10.1080/13854048908403291 Thorndike, E. L., & Lorge, I. (1944). The Teacher’s word book of 30,000 words. New York, NY: Teacher’s College Press, Columbia University. Tombaugh, T. N., & Hubley, A. M. (1997). The 60-item Boston Naming Test: Norms for cognitively intact adults aged 25 to 88 years. Journal of Clinical and Experimental Neuropsychology, 19(6), 922–932. doi:10.1080/01688639708403773 Wechsler, D. (2001). Wechsler Test of Adult Reading (WTAR). San Antonio, TX: The Psychological Corporation. Welch, L. W., Doineau, D., Johnson, S., & King, D. (1996). Educational and gender normative data for the Boston Naming Test in a group of older adults. Brain and Language, 53, 260–266. doi:10.1006/brln.1996.0047 Yeates, K. O. (1994). Comparison of developmental norms for the Boston Naming Test. The Clinical Neuropsychologist, 8, 91–98. doi:10.1080/13854049408401546 Zec, R. F., Burkett, N. R., Markwell, S. J., & Larsen, D. L. (2007a). A Cross-sectional study of the effects of age, education, and gender on the Boston Naming Test. The Clinical Neuropsychologist, 21(4), 587–616. doi:10.1080/13854040701220028 Zec, R. F., Burkett, N. R., Markwell, S. J., & Larsen, D. L. (2007b). Normative data stratified for age, education, and gender on the Boston Naming Test. The Clinical Neuropsychologist, 21(4), 617–637. doi:10.1080/13854040701339356
APPENDIX A Percent incorrect responses to individual items on the BNT
Item # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Object
% Incorrect
Bed Tree Pencil House Whistle Scissors Comb Flower Saw Toothbrush Helicopter Broom Octopus Mushroom Hanger Wheelchair Camel Mask
0 0 0 0 0 0 0 1.0 0.5 0 0 0.5 2.0 0 0 0 0.5 0
Common responses for items missed by at least 10% of sample
(Continued )
ADOLESCENT BNT NORMS
13
(Continued).
Downloaded by [York University Libraries] at 17:24 07 November 2015
Item # 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Object
% Incorrect
Pretzel Bench Racquet Snail Volcano Seahorse Dart Canoe Globe Wreath Beaver Harmonica Rhinoceros Acorn Igloo Stilts Dominoes Cactus Escalator Harp Hammock Knocker Pelican Stethoscope Pyramid Muzzle Unicorn Funnel Accordion Noose Asparagus Compass Latch Tripod Scroll Tongs Sphinx Yoke Trellis Palette Protractor Abacus
0 0.5 0 2.0 0 7.0 3.5 2.5 0 0.5 14.0 4.0 4.5 5.0 0.5 5.5 4.0 0.5 2.5 10.0 10.0 15.0 21.0 25.5 1.0 28.5 2.5 14.0 34.0 36.0 15.0 30.0 65.5 43.5 20.0 42.5 38.5 79.0 91.0 57.0 42.0 87.0
Common responses for items missed by at least 10% of sample
Squirrel, chipmunk, otter, don’t know
Violin, don’t know Don’t know Door, doorbell, don’t know Seagull, bird Don’t know Nuzzle, mask, harness, don’t know Cylinder, martini glass Harmonica, xylophone, don’t know Rope, don’t know Don’t know Protractor, don’t know Lock Easel, stand, don’t know Document, script, don’t know Prongs, pinchers, tweezers Pyramid, pharaoh, don’t know Harness, bridle, don’t know Fence, lattice, don’t know Paint, easel, don’t know Compass, ruler, don’t know Counter, counting, don’t know
ISSN: 0929-7049 (Print) 1744-4136 (Online) Journal homepage: http://www.tandfonline.com/loi/ncny20
When a funnel becomes a martini glass: Adolescent performance on the Boston Naming Test Tammy Mandernach Martielli & Lynn Bennett Blackburn To cite this article: Tammy Mandernach Martielli & Lynn Bennett Blackburn (2015): When a funnel becomes a martini glass: Adolescent performance on the Boston Naming Test, Child Neuropsychology, DOI: 10.1080/09297049.2015.1014899 To link to this article: http://dx.doi.org/10.1080/09297049.2015.1014899
Published online: 08 May 2015.
Submit your article to this journal
Article views: 216
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ncny20 Download by: [York University Libraries]
Date: 07 November 2015, At: 17:24
Child Neuropsychology, 2015 http://dx.doi.org/10.1080/09297049.2015.1014899
When a funnel becomes a martini glass: Adolescent performance on the Boston Naming Test
Downloaded by [York University Libraries] at 17:24 07 November 2015
Tammy Mandernach Martielli1,2 and Lynn Bennett Blackburn3 1
Department of Psychology, Saint Louis University, St. Louis, MO, USA Independent Practice, St. Louis, MO, USA 3 Department of Psychology, St. Louis Children’s Hospital, St. Louis, MO, USA 2
The Boston Naming Test (BNT), a component of the Boston Diagnostic Aphasia Examination, is often used by neuropsychologists to assess confrontation naming. Research indicates that performance on the BNT is impacted by a variety of factors including age, gender, measured intelligence, educational attainment, vocabulary knowledge, level of acculturation, and ethnicity. Extant normative data are available for adults and for younger children; however, descriptive data are lacking for neurologically intact adolescents. The current study obtained normative data for the BNT, second edition in 15- to 18-year-old adolescents. The sample included 200 participants (100 male, 100 female) who were screened to exclude individuals with neurologic, psychiatric, or academic difficulties. There were no statistically significant differences in BNT scores based on gender, age, or grade. Normative means and standard deviations, collapsed across age and gender, are provided. The relationship of the current data to existing child and adult norms, as well as the clinical utility of examining individual item responses for the BNT in this sample are addressed. Keywords: Boston Naming Test; Normative data; Adolescents.
Originally developed as a component of the Boston Diagnostic Aphasia Examination, the Boston Naming Test (BNT; Kaplan, Goodglass, & Weintraub, 1978, 1983, 2001) is one of the most widely used assessment instruments in the field of neuropsychology (Camara, Nathan, & Puente, 2000; Rabin, Barr, & Burton, 2005). Numerous studies have identified variables that impact performance on the BNT including age, gender, ethnicity, level of acculturation, language, geographic region, education level, and vocabulary knowledge (see Baron, 2004; Mitrushina, Boone, Razani, & D’Elia, 2005, for a detailed review). However, concerns have been raised regarding both use and interpretation of the BNT due to incomplete normative data, inconsistencies in administration and scoring procedures and construct validity (Bortnik et al., 2013; Mitrushina et al., 2005). In particular, there is a gap in the normative data for 15- to 18-year-old adolescents. Therefore, although confrontation naming skills are frequently assessed as a component of a The authors would like to thank Jeffrey D. Gfeller and Honore M. Hughes for their support of the current project. The authors of the article have no relevant disclosures to report. Address correspondence to Tammy Mandernach Martielli, Independent Practice, 4542 West Pine Blvd., St. Louis, MO 63108, USA. E-mail: [email protected]
© 2015 Taylor & Francis
Downloaded by [York University Libraries] at 17:24 07 November 2015
2
T. M. MARTIELLI & L. B. BLACKBURN
neuropsychological evaluation, interpretation of performance in the 15- to 18-year-old age range is problematic. Based on previous studies, there is a general increase in BNT score from age 4 to 13 (Yeates, 1994), continued increase in BNT score after age 18 into early adulthood with a gradual decline over middle adulthood, and a significant decline after approximately age 70 (Au et al., 1995; Nicholas, Obler, Albert, & Goodglass, 1985). Normative data for the 60-item BNT have been documented in a limited number of studies for children ages 5 to 13 years (Cohen, Town, & Buff, 1988; Guilford & Nawojczyk, 1988; Halperin, Healey, Zeitchik, Ludman, & Weinstein, 1989; Kaplan et al., 1983; Kirk, 1992). Yeates conducted a metaanalysis of the existing children’s norms and presented data for children ages 5 to 13. See Baron (2004) for a detailed review of existing normative data for children on the BNT. Adult normative data are available for individuals over age 18. A comprehensive review of adult normative data, variables impacting BNT performance, and limitations of the BNT has been compiled by Mitrushina et al. (2005) and Strauss, Sherman, and Spreen (2006). Mitrushina et al. also provide a thorough review of the difficulties in interpreting BNT performance across all age groups. Subsequently, Zec, Burkett, Markwell, and Larsen (2007a, 2007b) provided additional adult normative data stratified by age, education, and gender. The gap in normative data for the BNT reflects a more global problem in neuropsychology. Overall, research directed at identifying age-related cognitive changes in typically developing individuals has primarily focused on the extreme ends of the lifespan—infancy and aging (Korkman, 2001)- resulting in a paucity of normative data for adolescents (Baron, 2004). Regarding the BNT, the majority of normative studies have been conducted with adult and older adult samples compared to child samples, leaving clinicians to extrapolate information from those older and younger samples when interpreting performance of adolescents. Downward extensions of adult normative data for clinical interpretation represent significant fundamental errors in assumptions of the underlying constructs being measured. Regarding the BNT, criticisms of the dated stimuli suggest that some of the stimuli are not familiar to younger individuals. Specifically regarding children, word retrieval difficulties versus a lack of word knowledge was examined by Kirk (1992). The author examined BNT errors in children ages 5 to 13. Based on the findings, a reordered list of BNT items was provided according to percentage correct in the normative sample. Additional evidence for the possibility of a cohort effect on the BNT is provided by Schmitter-Edgecombe, Vesneski, and Jones (2000) who identified four items in which phonemic cues did not improve the performance of younger adult participants (18 to 22 years) relative to older adult participants (ages 58 to 74 and ages 75 to 93), suggesting that these words or objects were not familiar to the younger participants (items included yoke, trellis, abacus, and palette). These findings in both young adult (Schmitter-Edgecombe et al., 2000) and child (Kirk, 1992) populations highlight the importance of describing normative performance in an adolescent sample on the BNT in order to identify specific items that may not be familiar to adolescents and thereby facilitate more meaningful interpretations of test performance. The current study sought to provide normative data for an age range that has not previously been described in terms of confrontation naming ability as measured by the BNT by collecting data from adolescents ages 15 through 18. Based on previous research with older and younger samples, the role of age, gender, education level, and estimated verbal intelligence were examined. It was hypothesized that an age- and grade-level related, linear
ADOLESCENT BNT NORMS
3
trend of increasing BNT raw scores would be observed. It was also hypothesized that the resulting frequency distribution would be non-normally distributed (negatively skewed). To further aid in test interpretation, the error frequency of each BNT item as well as exemplars of commonly missed items also are provided. METHOD
Downloaded by [York University Libraries] at 17:24 07 November 2015
Participants Participants included volunteers from the Saint Louis University Psychology Department Participant Pool and students from local high schools in the St. Louis metropolitan area. Participants who were 18 years of age and recruited from the Saint Louis University Psychology Department Participant Pool were provided with informed consent by the examiner before testing began. Each participant completed a demographic questionnaire and a medical/psychological history form that included neurological, psychiatric, and educational history. High school students were recruited through a study packet containing an informational letter, demographic questionnaire, medical/psychological history form, and consent form to take home to their parents/guardians. Interested students returned the history forms and parent/guardian signed consent prior to participating in the study. Participant assent was obtained at the time of testing. Study approval was obtained through the Saint Louis University Institutional Review Board (IRB). All students who returned the consent form and questionnaires participated in the study. Data from participants were excluded from the normative sample based on either self or parental endorsement of a history of neurological disease, motor disorder, head injury with loss of consciousness, learning disability, attention deficit/hyperactivity disorder (ADHD), developmental disability, psychiatric illness, or current medications with possible motor or cognitive side effects. The data from 89 of the 289 participants (30.8%) were excluded based on either self or parental endorsement of one or more of these conditions. No participant endorsed a history of special education services, grade retention or grade acceleration. The final sample consisted of 200 healthy individuals (100 male and 100 female) ages 15 to 18 years old (birth years ranged from 1986 to 1989). Each of the four age groups (15, 16, 17, and 18) consisted of 25 males and 25 females. All 15-, 16-, and 17-yearold participants were recruited from local high schools. Among the 18-year-old participants, 12 male (48%) and 5 female (20%) were collected from local high schools, while the remaining 18-year-old participants were collected from the Saint Louis University Psychology Department Participant Pool. Exclusions were not based on ethnicity; however, all participants in the final analyses were Caucasian. The mean level of combined parental education for the sample was 15.8 years (15.4 maternal and 16.2 paternal). Procedure The Wechsler Test of Adult Reading (WTAR) and BNT were administered as part of a larger test battery designed to collect normative data for measures of motor and language functioning. Each student participated in one test session that was approximately 45 minutes in length. Test administration was completed in the following order: Annett Handedness Questionnaire, Grooved Pegboard, Finger Tapping Test, Grip Strength Test, Wechsler Test of Adult Reading, and BNT. The examiners consisted of graduate students in a clinical psychology doctoral program with specialization in neuropsychology.
Downloaded by [York University Libraries] at 17:24 07 November 2015
4
T. M. MARTIELLI & L. B. BLACKBURN
Examiners were thoroughly trained by the primary author including several practice administrations and observations to ensure consistent administration and recording procedures between examiners. The WTAR (Wechsler, 2001) was used to determine reading recognition skills as an estimate of verbal intelligence. This measure consists of 50 words that are read aloud from a stimulus card. For the purposes of the current study, all participants were scored using normative values for 16- to 18-year-olds, as the WTAR was not standardized on 15-yearolds. Internal consistency for the 16- to 18-year-old age group is .90 (WTAR manual; Wechsler, 2001). Furthermore, the WTAR has been used to predict verbal intelligence and has a correlation of .66 in 16- to 17-year-olds and .74 in 18- to 19-year-olds with the Wechsler Adult Intelligence Scale – Third Edition (WAIS-III), Verbal IQ (WTAR manual; Wechsler, 2001). In contrast, however, performance of the WTAR normative sample only correlated .29 with BNT performance (WTAR manual; Wechsler, 2001). The BNT (Kaplan et al., 2001) consists of 60 black and white line drawings of objects presented individually. Participants were allowed 20 seconds to provide a verbal response to each of the drawings. If the participant did not provide a response in 20 seconds, the stimulus cue was provided. If the participant provided a response that reflected a perceptual misunderstanding of the drawing, indicated he or she was unfamiliar with the item or provided a “don’t know” response, the stimulus cue was provided. If the participant was unable to provide a correct response following the semantic cue, a phonemic cue was provided. According to instructions provided in the BNT stimulus manual (Kaplan et al., 2001), following administration of the last item (Card 60), the examiner returned to items missed by the participant following the phonemic cue and presented the item again with four written multiple-choice options that were read aloud to the participant. The total score was based on the sum of spontaneously given correct responses and correct responses when provided the stimulus cue. Correct responses following a phonemic cue were not included in the participant’s total accuracy score but instead, per the test authors, were obtained for qualitative purposes. The authors of the test indicate that for older children and adults, the examiner may elect to begin testing at Item 30; however, there is a basal rule of eight consecutive correct responses that must be established if this starting point is used. In the current study, all participants started with Item 1. For all participants, the authors of the BNT identify a ceiling of eight consecutive errors, which was utilized in the current study. RESULTS An initial examination (analysis of variance, ANOVA) of the relationship between gender and BNT performance revealed that male and female participants performed similarly in regard to BNT raw score, which represents the sum of spontaneously generated correct responses and correct responses following a stimulus cue, F(1, 198) = 1.009, p = .316. Table 1 provides normative data for the BNT, based on gender. Therefore, performance of male and female participants was combined for the remaining analyses. The next phase of data analysis examined the relationship between performance on the BNT and individual age level. An ANOVA revealed no significant age differences in BNT performance, F(3, 196) = 1.576, p = .196. Table 2 provides normative data for the BNT for each age level. Given the previously reported relationship between BNT performance and years of education in adult literature, performance on the BNT across grade level was examined.
ADOLESCENT BNT NORMS
5
Table 1 BNT Norms by Gender Collapsed Across Age (N = 200). Gender
n
M
SD
Male Female
100 100
51.00 51.61
4.52 4.05
Downloaded by [York University Libraries] at 17:24 07 November 2015
Table 2 BNT Norms by Age Collapsed Across Gender (N = 200). Age
n
M
SD
15 16 17 18
50 50 50 50
50.98 51.46 50.50 52.28
4.16 3.78 4.80 4.30
An ANOVA revealed consistent performance across grade level, F(4, 195) = 0.888, p = .472. There were no significant differences between high school and college 18-year-old participants, F(1, 48) = 1.814, p = .184. Table 3 provides normative data for the BNT for each grade level. These findings suggest stable BNT performance from 15 through 18 years of age and from 9 to 13 years of education, respectively. Given the consistent performance across age and grade level, the sample was collapsed across these variables for the remaining analyses. Table 4 provides normative data for the BNT, collapsed across gender, age, and grade. Normative data regarding the benefit from semantic and phonemic cueing, as well as from the multiple-choice condition, collapsed across age and gender, are presented in Table 5. Finally, individual items were evaluated in terms of error frequency. The most commonly provided inaccurate responses for items with an error rate of 10% or greater are provided in Appendix A. Table 3 BNT Norms by Grade Collapsed Across Age (N = 200). Grade
n
M
SD
9 10 11 12 13
14 57 65 31 33
51.29 51.11 50.75 52.42 51.70
4.70 4.00 4.40 3.79 4.84
Table 4 Norms Collapsed Across Gender, Age, and Grade (N = 200).
Test BNT
WTAR
Score Number of spontaneous correct responses Spontaneous + Number correct following stimulus cue Estimated IQ
M
SD
Median
Mode
Range
15th percentile
85th percentile
50.92
4.26
51
54
38–59
46
55
51.30
4.29
52
54
38–59
47
55
102.52
8.23
103
104
78–119
95
112
6
T. M. MARTIELLI & L. B. BLACKBURN Table 5 Normative Data Regarding the Benefit from Semantic and Phonemic Cueing and the Multiple-Choice Condition, Collapsed Across Age and Gender (N = 200). SD
50.92 2.56 0.42 8.45 4.43 4.18 3.27
4.26 3.79 0.79 4.32 2.30 2.85 2.50
Regarding the relationship between confrontation naming and estimated verbal intelligence, there was a significant positive correlation between BNT and WTAR scores, (Pearson r = .429, p < .001). Males and females achieved comparable estimates of intellectual functioning, based on single word reading (WTAR), F (1, 198) = 0.870, p = .679. It should be noted, however, that the distribution of BNT scores, as predicted, was not normal (Kolmogorov-Smirnov, p = .026) and therefore violates the underlying assumption of normality of the previously reported parametric statistics. Figure 1 illustrates the distribution of BNT scores. Given the negatively skewed distribution of
Frequency
Downloaded by [York University Libraries] at 17:24 07 November 2015
Spontaneously Correct Stimulus Cue Given Correct After Stimulus Cue Phonemic Cue Given Correct After Phonemic Cue Multiple Choice Given Correct After Multiple Choice
M
22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 Score Figure 1 Frequency of raw BNT scores.
ADOLESCENT BNT NORMS
7
Table 6 Cumulative Percent of BNT Scores (N = 200).
Downloaded by [York University Libraries] at 17:24 07 November 2015
Score 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59
Cumulative Percent 0.5 1.0 3.0 3.5 4.0 5.0 6.0 10.5 14.0 19.0 22.5 31.5 37.5 46.0 55.5 63.5 74.5 84.5 92.5 96.5 98.5 100
BNT scores, Table 6 provides the cumulative percentage of BNT scores obtained by participants in the sample. Estimated intelligence (WTAR) was normally distributed (Kolmogorov-Smirnov, p = .461).
DISCUSSION The current study was conducted to provide normative data for 15- to 18-year-old adolescents on the Boston Naming Test. The study investigated the effect of gender, age, grade level and estimated verbal intelligence (as measured by single word reading) on confrontation naming performance. Given that the BNT items were selected several decades ago, individual item responses were obtained to assist in qualitative clinical interpretation of incorrect responses in contemporary adolescents. The primary findings of the study suggest that (a) in this age and education range, there is overall consistency in BNT performance with no significant gender differences, (b) the mean BNT performance obtained in this sample corresponds with the developmental trend demonstrated over existing child and adult normative data (i.e., acquisition continuing into adulthood, with leveling off and gradual loss) and (c) the results can be applied clinically (taking into account factors listed in more detail below). Based on the present data, gender differences in confrontation naming ability as measured by the BNT are minimal by late adolescence with males obtaining approximately one-half point lower score than females. Interpreted from a developmental framework, the absence of a statistically significant gender effect is generally consistent with previous studies of confrontation naming in younger children and adults. Halperin et al. (1989) did not find a statistically significant gender effect in children, although there was
Downloaded by [York University Libraries] at 17:24 07 November 2015
8
T. M. MARTIELLI & L. B. BLACKBURN
a trend for higher scores among males. With respect to adults, findings from previous research are inconsistent. Some studies suggest that males obtain higher scores than females on measures of confrontation naming (Lansing, Ivnik, Cullum, & Randolph, 1999; Randolph, Lansing, Ivnik, Cullum, & Hermann, 1999; Tombaugh & Hubley, 1997; Welch, Doineau, Johnson, & King, 1996), whereas several studies did not identify a statistically significant gender effect (Cruice, Worrall, & Hickson, 2000; Fastenau, Denberg, & Mauer, 1998; Henderson, Frank, Pigatt, Abramson, & Houston, 1998; Ivnik, Malec, Smith, Tangalos, & Petersen, 1996; LaBarge, Edwards, & Knesevich, 1986; Saxton et al., 2000; Zec et al., 2007a). As noted earlier, age and formal education have both been associated with BNT performance in previous studies of adults (Giovannetti, Goldstein, Schullery, Barr, & Bilder, 2003; Ivnik et al., 1996; Lansing et al., 1999; Saxton et al., 2000; Thompson & Heaton, 1989; Welch et al., 1996; Zec et al., 2007a, 2007b). The current findings did not suggest statistically significant change in confrontation naming on the BNT within this age and education range. This finding is not surprising given the confound of age and educational attainment (current grade level) in children. Whereas educational attainment reported for adults reflects the end points of formal education, in children it marks agerelated progress through school. Lastly, a statistically significant relationship was identified between estimated verbal intelligence (single word reading) and confrontation naming (.43), which is consistent with previous literature addressing the adult population (Thompson & Heaton, 1989; Tombaugh & Hubley, 1997). These authors reported correlations ranging from .53 to .79 for the BNT and WAIS-R vocabulary subtest. Compared to those studies, the current correlation is somewhat weaker. Several considerations may explain this discrepancy. The adult studies used the WAIS-R Vocabulary subtest as an estimate of verbal intelligence, which is more strongly correlated with the BNT than the WTAR. Specifically, the participant’s knowledge of phonics may have allowed for decoding of the words without knowledge of word meaning. Further, the item content of the BNT may not be familiar to contemporary adolescents, thus reducing the relationship between word reading (decoding) and object naming. The current study fills a gap in published age-based normative data by demonstrating that adolescents ages 15 to 18 show continued development of confrontation naming skills on the BNT relative to 13-year-olds, with 15- to 18-year-olds obtaining scores approximately two points higher than 13-year-olds (compared to Yeates, 1994). Moreover, the current data indicate that individuals in the 15- to 18-year-old cohort have not yet achieved adult levels in confrontation naming ability, as measured by the BNT, with adolescents in this sample performing two points lower than the 18- to 22-year-old adults in the Schmitter-Edgecombe et al. (2000) normative sample. Therefore, when compared to previous norms for older and younger age groups, there appears to be continued increase in BNT raw score into early adulthood. A summary of mean BNT scores across the lifespan is displayed in Figure 2. The current data further elucidate the development of BNT performance in males and females ages 15 to 18 and suggest that during adolescence, individuals maintain a consistent level of performance, although alternate explanations should be considered. The current findings could represent a cohort effect, which may be eliminated with more current stimuli. The current BNT stimuli were compiled in 1978 and based on frequency estimates produced in 1944 (Thorndike & Lorge, 1944) and 1967 (Kucera & Francis, 1967). As previous literature has consistently reported a relationship between BNT
ADOLESCENT BNT NORMS
9
60 Mean BNT Score
55 50 45 40 35 30
Downloaded by [York University Libraries] at 17:24 07 November 2015
70–79
60–69
50–59
40–49
18–22
15–18
13
12
11
10
9
8
7
6
5
25
Age Figure 2 Mean BNT scores across the lifespan.
Note. Mean scores for ages 5–13 were obtained from Yeates (1994); mean score for ages 15–18 was obtained from the current study; mean score for ages 18–22 was obtained from Schmitter-Edgecombe et al. (2000); mean score for ages 40–79 was obtained from Kaplan et al. (1983).
performance and word frequency, as well as between BNT performance and age of word acquisition, the dated nature of these measures and the BNT stimuli and scoring criteria may obscure any possible gender, age or education differences. In fact, many of the participants spontaneously reported never having come in contact with several of the stimuli and many participants produced synonyms of the stimuli that are not considered correct based on traditional scoring procedures. In terms of clinical applicability, the current normative data can be used to aid clinicians in assessment of confrontation naming skills in 15- to 18-year-old individuals. However, it should be noted that the distribution of the current data was not found to be normal, thereby violating basic assumptions of parametric statistical procedures. Although not extreme, given the negatively skewed distribution of BNT performance, it may be more appropriate to report whether the score is within expected limits, based on cumulative percentage rather than reporting a transformed standard score or percentile (see Table 6). Additionally, given the current qualitative findings regarding common errors in adolescents, it may aid in clinical interpretation to compare a patient’s errors to those produced by other adolescents. In the current sample, many easier items were missed compared to supposedly more difficult items. For example, 28.5% of the current sample missed Number 44, “muzzle” while only 2.5% of the sample misidentified Number 45 “unicorn.” Furthermore, there were several items on the BNT that, although the current sample did not receive credit for the item, their inaccurate responses seemed to be consistent within the group, possibly suggesting a cohort effect. For example, 65.5% misidentified Item Number 51 (latch) with the most common response being “lock,” which current scoring criteria would consider inaccurate. The most commonly provided inaccurate responses for items with an error rate of 10% or greater are included in Appendix A for further qualitative analysis. While the current findings can be used as a general guide for interpreting BNT test performance in the 15- to 18-year-old age range, the current sample was limited regarding demographic factors suspected to impact BNT performance, based on existing adult
Downloaded by [York University Libraries] at 17:24 07 November 2015
10
T. M. MARTIELLI & L. B. BLACKBURN
literature, and may not be generalizable to adolescents in different regions of the country, different ethnicities, and different quality of educational background. Specifically, the sample was Caucasian with average estimated intelligence, from a medium-sized Midwestern city, who attended private Jesuit high schools and university, with slightly higher educated parents than reported by the U.S. census. This study highlights several areas that merit future investigation related to BNT assessment and interpretation in adolescents. Further examination of the factors known to impact confrontation naming from adult and child literature should be more thoroughly explored, as this study represents only an initial attempt to characterize confrontation naming in late adolescents. Additionally, future research exploring changes in scoring criteria and stimuli to reflect objects to which contemporary adolescents are generally exposed will help determine if any developmental trends exist in terms of age, gender, or education for confrontation naming within this age group. Finally, all participants in this study were Caucasian. Adult normative data for the BNT indicate differential performance between various ethnicities (Boone, Victor, Wen, Razani, & Pontón, 2007; Heaton, Miller, Taylor, & Grant, 2004). Therefore, additional research should be conducted in this age range to include non-Caucasian individuals. Original manuscript received 4 December 2014 Revised manuscript accepted 29 January 2015 First published online 6 May 2015
REFERENCES Au, R., Joung, P., Nicholas, M., Obler, L. K., Kass, R., & Albert, M. L. (1995). Naming ability across the adult life span. Aging, Neuropsychology, and Cognition, 2(4), 300–311. doi:10.1080/ 13825589508256605 Baron, I. S. (2004). Neuropsychological evaluation of the child. New York, NY: Oxford University Press. Boone, K. B., Victor, T. L., Wen, J., Razani, J., & Pontón, M. (2007). The association between neuropsychological scores and ethnicity, language, and acculturation variables in a large patient population. Archives of Clinical Neuropsychology, 22(3), 355–365. doi:10.1016/j. acn.2007.01.010 Bortnik, K. E., Boone, K. B., Wen, J., Lu, P., Mitrushina, M., Razani, J., & Maury, T. (2013). Survey results regarding use of the Boston Naming Test: Houston, we have a problem. Journal of Clinical and Experimental Neuropsychology, 35(8), 857–866. doi:10.1080/ 13803395.2013.826182 Camara, W. J., Nathan, J. S., & Puente, A. E. (2000). Psychological test usage: Implications in professional psychology. Professional Psychology: Research and Practice, 31, 141–154. doi:10.1037/0735-7028.31.2.141 Cohen, M. J., Town, P., & Buff, A. (1988). Neurodevelopmental differences in confrontational naming in children. Developmental Neuropsychology, 4, 75–81. doi:10.1080/ 87565648809540392 Cruice, M. N., Worrall, L. E., & Hickson, L. M. H. (2000). Boston Naming Test results for healthy older Australians: A longitudinal and cross-sectional study. Aphasiology, 14(2), 143–155. doi:10.1080/026870300401522 Fastenau, P. S., Denburg, N. L., & Mauer, B. A. (1998). Parallel short forms for the Boston Naming Test: Psychometric properties and norms for older adults. Journal of Clinical and Experimental Neuropsychology, 20(6), 828–834. doi:10.1076/jcen.20.6.828.1105
Downloaded by [York University Libraries] at 17:24 07 November 2015
ADOLESCENT BNT NORMS
11
Giovannetti, T., Goldstein, R. Z., Schullery, M., Barr, W. B., & Bilder, R. M. (2003). Category fluency in first-episode schizophrenia. Journal of the International Neuropsychological Society, 9(3), 384–393. doi:10.1017/S1355617703930049 Guilford, A. M., & Nawojczyk, D. C. (1988). Standardization of the Boston Naming Test at the kindergarten and elementary school levels. Language Speech and Hearing Services in Schools, 19, 395–400. doi:10.1044/0161-1461.1904.395 Halperin, J. M., Healey, J. M., Zeitchik, E., Ludman, W. L., & Weinstein, L. (1989). Developmental aspects of linguistic and mnestic abilities in normal children. Journal of Clinical and Experimental Neuropsychology, 11, 518–528. doi:10.1080/01688638908400910 Heaton, R. K., Miller, S. W., Taylor, M. J., & Grant, I. (2004). Revised comprehensive norms for an expanded Halstead-Reitan Battery: Demographically adjusted neuropsychological norms for African American and Caucasian adults. Lutz, FL: Psychological Assessment Resources. Henderson, L. W., Frank, E. M., Pigatt, T., Abramson, R. K., & Houston, M. (1998). Race, gender, and educational level effects on Boston Naming Test scores. Aphasiology, 12(10), 901–911. doi:10.1080/02687039808249458 Ivnik, R. J., Malec, J. F., Smith, G. E., Tangalos, E. G., & Petersen, R. C. (1996). Neuropsychological tests’ norms above age 55: COWAT, BNT, MAE Token, WRAT-R Reading, AMNART, STROOP, TMT, and JLO. The Clinical Neuropsychologist, 10(3), 262–278. doi:10.1080/13854049608406689 Kaplan, E., Goodglass, H., & Weintraub, S. (1978). The Boston Naming Test: Experimental edition. Boston, MA: Kaplan and Goodglass. Kaplan, E., Goodglass, H., & Weintraub, S. (1983). Boston Naming Test (Revised 60-item version). Philadelphia, PA: Lea & Febiger. Kaplan, E., Goodglass, H., & Weintraub, S. (2001). Boston Naming Test (2nd ed). Philadelphia, PA: Lippincott Williams & Wilkins. Kirk, U. (1992). Confrontation naming in normally developing children: Word-retrieval or word knowledge? The Clinical Neuropsychologist, 6, 156–170. doi:10.1080/13854049208401852 Korkman, M. (2001). Introduction to the special issue on normal neuropsychological development in the school-age years. Developmental Neuropsychology, 20(1), 325–330. doi:10.1207/ S15326942DN2001_1 Kucera, H., & Francis, W. (1967). Computational analysis of present-day American English. Providence, RI: Brown University Press. LaBarge, E., Edwards, D., & Knesevich, J. W. (1986). Performance of normal elderly on the Boston Naming Test. Brain and Language, 27, 380–384. doi:10.1016/0093-934X(86)90026-X Lansing, A. E., Ivnik, R. J., Cullum, C. M., & Randolph, C. (1999). An empirically derived short form of the Boston Naming Test. Archives of Clinical Neuropsychology, 14(6), 481–487. doi:10.1093/arclin/14.6.481 Mitrushina, M., Boone, K. B., Razani, J., & D’Elia, L. F. (2005). Handbook of normative data for neuropsychological assessment. New York, NY: Oxford University Press. Nicholas, M., Obler, L., Albert, M., & Goodglass, H. (1985). Lexical retrieval in healthy aging. Cortex, 21, 595–606. doi:10.1016/S0010-9452(58)80007-6 Rabin, L. A., Barr, W. B., & Burton, L. A. (2005). Assessment practices of clinical neuropsychologists in the United States and Canada: A survey of INS, NAN, and APA Division 40 members. Archives of Clinical Neuropsychology, 20(1), 33–65. doi:10.1016/j.acn.2004.02.005 Randolph, C., Lansing, A. E., Ivnik, R. J., Cullum, C. M., & Hermann, B. P. (1999). Determinants of confrontation naming performance. Archives of Clinical Neuropsychology, 14(6), 489–496. doi:10.1093/arclin/14.6.489 Saxton, J., Ratcliff, G., Munro, C. A., Coffey, E. C., Becker, J. T., Fried, L., & Kuller, L. (2000). Normative data on the Boston Naming Test and two equivalent 30-item short forms. The Clinical Neuropsychologist (Neuropsychology, Development and Cognition: Section D), 14(4), 526–534. doi:10.1076/clin.14.4.526.7204
Downloaded by [York University Libraries] at 17:24 07 November 2015
12
T. M. MARTIELLI & L. B. BLACKBURN
Schmitter-Edgecombe, M., Vesneski, M., & Jones, D. W. R. (2000). Aging and word-finding: A comparison of spontaneous and constrained naming tests. Archives of Clinical Neuropsychology, 15(6), 479–493. Strauss, E., Sherman, E. M. S., & Spreen, O. (2006). A Compendium of neuropsychological tests: Administration, norms, and commentary (3rd ed). New York, NY: Oxford University Press. Thompson, L. L., & Heaton, R. K. (1989). Comparison of different versions of the Boston Naming Test. Clinical Neuropsychologist, 3(2), 184–192. doi:10.1080/13854048908403291 Thorndike, E. L., & Lorge, I. (1944). The Teacher’s word book of 30,000 words. New York, NY: Teacher’s College Press, Columbia University. Tombaugh, T. N., & Hubley, A. M. (1997). The 60-item Boston Naming Test: Norms for cognitively intact adults aged 25 to 88 years. Journal of Clinical and Experimental Neuropsychology, 19(6), 922–932. doi:10.1080/01688639708403773 Wechsler, D. (2001). Wechsler Test of Adult Reading (WTAR). San Antonio, TX: The Psychological Corporation. Welch, L. W., Doineau, D., Johnson, S., & King, D. (1996). Educational and gender normative data for the Boston Naming Test in a group of older adults. Brain and Language, 53, 260–266. doi:10.1006/brln.1996.0047 Yeates, K. O. (1994). Comparison of developmental norms for the Boston Naming Test. The Clinical Neuropsychologist, 8, 91–98. doi:10.1080/13854049408401546 Zec, R. F., Burkett, N. R., Markwell, S. J., & Larsen, D. L. (2007a). A Cross-sectional study of the effects of age, education, and gender on the Boston Naming Test. The Clinical Neuropsychologist, 21(4), 587–616. doi:10.1080/13854040701220028 Zec, R. F., Burkett, N. R., Markwell, S. J., & Larsen, D. L. (2007b). Normative data stratified for age, education, and gender on the Boston Naming Test. The Clinical Neuropsychologist, 21(4), 617–637. doi:10.1080/13854040701339356
APPENDIX A Percent incorrect responses to individual items on the BNT
Item # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Object
% Incorrect
Bed Tree Pencil House Whistle Scissors Comb Flower Saw Toothbrush Helicopter Broom Octopus Mushroom Hanger Wheelchair Camel Mask
0 0 0 0 0 0 0 1.0 0.5 0 0 0.5 2.0 0 0 0 0.5 0
Common responses for items missed by at least 10% of sample
(Continued )
ADOLESCENT BNT NORMS
13
(Continued).
Downloaded by [York University Libraries] at 17:24 07 November 2015
Item # 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
Object
% Incorrect
Pretzel Bench Racquet Snail Volcano Seahorse Dart Canoe Globe Wreath Beaver Harmonica Rhinoceros Acorn Igloo Stilts Dominoes Cactus Escalator Harp Hammock Knocker Pelican Stethoscope Pyramid Muzzle Unicorn Funnel Accordion Noose Asparagus Compass Latch Tripod Scroll Tongs Sphinx Yoke Trellis Palette Protractor Abacus
0 0.5 0 2.0 0 7.0 3.5 2.5 0 0.5 14.0 4.0 4.5 5.0 0.5 5.5 4.0 0.5 2.5 10.0 10.0 15.0 21.0 25.5 1.0 28.5 2.5 14.0 34.0 36.0 15.0 30.0 65.5 43.5 20.0 42.5 38.5 79.0 91.0 57.0 42.0 87.0
Common responses for items missed by at least 10% of sample
Squirrel, chipmunk, otter, don’t know
Violin, don’t know Don’t know Door, doorbell, don’t know Seagull, bird Don’t know Nuzzle, mask, harness, don’t know Cylinder, martini glass Harmonica, xylophone, don’t know Rope, don’t know Don’t know Protractor, don’t know Lock Easel, stand, don’t know Document, script, don’t know Prongs, pinchers, tweezers Pyramid, pharaoh, don’t know Harness, bridle, don’t know Fence, lattice, don’t know Paint, easel, don’t know Compass, ruler, don’t know Counter, counting, don’t know
