Abstract

The current study assessed the internal consistency, alternate forms reliability, and convergent/divergent validity of the Naming Test of the Neuropsychological Assessment Battery (NAB) in patients with acquired brain injury. Fifty-nine patients were administered the NAB Naming Test (forms 1 and 2) and the Boston Naming Test (BNT), as well as other tests of neuropsychological functioning. Forms 1 and 2 of the NAB Naming Test demonstrated adequate internal consistency and alternate forms reliability. The NAB Naming Test was significantly associated with scores from the BNT, as well as scores from tests that assess visuospatial skills, semantic fluency, and verbal memory. The divergent validity of the NAB Naming Test was demonstrated by non-significant associations with tests of attention and processing speed. BNT scores correlated significantly with the educational level and estimated premorbid intelligence but not age, whereas the NAB Naming Test scores only correlated significantly with estimated premorbid intelligence. The current study provides independent validation supporting the utility of the NAB Naming Test for patients with acquired brain injury.

Introduction

Anomia is common in patients with acquired brain injury and is typically attributed to damage of the dominant hemisphere (Blumenfeld, 2002; Kerr, 1995; Lezak, Howieson, Bigler, & Tranel, 2012). Neuropsychological tests that assess confrontation naming, particularly the Boston Naming Test (BNT; Kaplan, Goodglass, & Weintraub, 1978, 2001), are frequently used by neuropsychologists (Rabin, Barr, & Burton, 2005), yet few measures of confrontation naming exist and those most commonly used are susceptible to education and culture effects (Hawkins & Bender, 2002; Ross & Lichtenberg, 1998).

The Neuropsychological Assessment Battery (NAB; Stern & White, 2003) is a comprehensive battery of tests developed to assess cognitive skills in adults (aged 18–97) with a variety of neurological disorders. The six modules that comprise the NAB include Attention, Language, Memory, Spatial, and Executive Functions, as well as a Screening module. The NAB incorporates a test of visual confrontation naming ability (Naming Test) within its Language module. The NAB Naming Test (Stern & White, 2003, 2009) has 31-items (for each alternate form [forms 1 and 2]) and is similar to the BNT as it provides the examinee with semantic and phonemic cues if necessary. However, unlike the line drawings from the BNT, the visual stimuli from the NAB Naming Test consist of color digital photographs that were reported to appear more realistic, thus enhancing the ecological validity of the instrument (Stern & White, 2009).

The NAB Naming Test professional manual (Stern & White, 2009) provides standardization data from a sample of neurologically intact individuals (n = 1,448). The internal consistency for each form of the NAB Naming Test (averaged across age group) was found to be adequate (form 1: α = 0.79; form 2: α = 0.73) with an alternate forms reliability coefficient of 0.72. Stern and White (2009) reported that scores on the NAB Naming Test were moderately correlated with those from the BNT (r = .56). In addition, they reported that the NAB Naming Test and BNT scores were strongly correlated (r = .76) using a clinical sample of patients with aphasia (n = 27). In their independent validation study of the NAB Naming Test using a sample (n = 240) of neurologically impaired individuals (predominantly including mild cognitive impairment, senile dementia of the Alzheimer's type, Parkinson's disease, and/or dementia with Lewy Bodies), Sachs, Rush, and Pedraza (2011) reported adequate internal consistency (forms 1 and 2; α = 0.78), good alternate forms reliability (r = .80), and strong correlations with scores from the BNT (form 1, r = .76; form 2, r = .79). In another independent analysis assessing the association of the subtests of the Screening module of the NAB (Stern & White, 2003) with various standardized neuropsychological tests (across cognitive domains) in a sample of patients with acquired brain injury, Zgaljardic and Temple (2010) reported that BNT scores significantly correlated with scores from the 10-item NAB Screening Naming Test (r = .80).

Yochim, Kane, and Mueller (2009) conducted the first independent analyses assessing the internal consistency, alternate forms reliability, and convergent/divergent validity of the NAB Naming Test in a sample of neurologically intact community-dwelling older adults (n = 70). Yochim and colleagues (2009) reported that the magnitude of the correlation coefficients between scores from the NAB Naming Test and the BNT was significantly greater than that of the correlation coefficients between scores from the NAB Naming Test and neuropsychological tests assessing memory and visuospatial skills, supporting the convergent validity of the NAB Naming Test. As for divergent validity, they reported that neither form of the NAB Naming Test correlated significantly with less related measures such as those that assess processing speed or verbal abstraction. Overall, their findings were relatively consistent with the reliability and validity coefficients provided from the NAB standardization data using a non-clinical sample.

The aim of the current study was to provide an independent analysis of the reliability and validity of the NAB Naming Test in a sample of patients with acquired brain injury. To date, there is a limited validation of the NAB Naming Test using a neurologically impaired sample of patients, particularly those with brain injury. It is hypothesized that (a) the internal consistency and alternate forms reliability of the NAB Naming Test in our sample will be consistent with the NAB standardization data and prior independent analyses; (b) the convergent validity of the NAB Naming Test will be established by its associations with the BNT and other tests of neuropsychological functioning that appear to be related to visual confrontation naming (e.g., memory, language, and visuospatial skills); and (c) divergent validity of the NAB Naming Test will be established by weak associations with tests that are less related with visual confrontation naming ability (e.g., attention and processing speed). Lastly, the current study explored the relationship between demographic variables (e.g., age, education level, and estimate premorbid intelligence) and the NAB Naming Test.

Method

Participants

Fifty-nine patients (41 men and 18 women) admitted to a residential post-acute brain injury rehabilitation program with either a history of moderate to severe traumatic brain injury, as defined by a Glasgow Coma Scale score between 3 and 12, loss of consciousness greater than 30 min, and/or positive neuroimaging findings, or a history of cerebrovascular accident participated in the current study. Participants were included only if they had adequate visual and auditory acuity, preserved auditory comprehension skills, and English as their primary language. Exclusion criteria included history of a prior neurological disorder, psychiatric disorder, learning disability, or longstanding alcohol or illicit substance abuse. None of the study patients were in litigation for the purposes of remuneration for their injuries. All procedures were approved by an institutional review board.

The mean age of the sample was 44.1 years (SD = 14.4; range = 19–68) and the mean educational attainment was 13.4 years (SD = 2.8; range = 7–20). The mean estimated premorbid full-scale IQ, assessed using the North American Adult Reading Test (NAART; Blair & Spreen, 1989), was 101.5 (SD = 9.3). The ethnic breakdown of the sample was 44 Caucasian, 10 Hispanic, and 5 African American. Thirty-six participants sustained a traumatic brain injury secondary to motor vehicle accident, gunshot wound, or fall and 23 participants experienced a non-traumatic brain injury secondary to cerebrovascular accident. The mean interval between injury onset and study test administration was 0.8 years (SD = 1.8; range = 0.06–9.5). All but three patients (7.4, 8.1, and 9.5 years) were tested less than 1.5 years post-injury.

Procedures

Both forms of the NAB Naming Test (counterbalanced) and the BNT (Kaplan et al., 2001) were administered along with neuropsychological tests that assess visual perception and abstraction, speeded word generation (semantic and phonemic fluency), auditory concentration, verbal working memory, word-list learning, and processing speed. In order to minimize the influence of motor speed and dexterity on test performance, as some patients in our sample presented with motor weakness and/or paresis of their dominant upper extremity, only tests that did not include a motor component were selected. As a means to ensure that each patient was oriented and maintained preserved auditory comprehension skills, the Orientation Log (O-Log; Novack, 2000) and the Token Test of the Multilingual Aphasia Examination (MAE; Benton, Hamsher, & Sivan, 1994) were also administered but not included in the statistical analyses. None of the study patients performed below impairment cutoff (O-Log ≤ 25; MAE Token Test ≤ 38) on these measures.

The current test battery included the following: Digits Span (forward and backward) from the Neuropsychological Assessment Battery (NAB; Stern & White, 2003), Matrix Reasoning of the Wechsler Abbreviated Scale of Intelligence (Wechsler, 1999), the Controlled Oral Word Association Test (Benton et al., 1994), Animal Naming (Morris et al., 1989), the oral version of the Symbol-Digit Modalities Test (Smith, 1982), the Judgment of Line Orientation Test (Benton, Sivan, Hamsher, Varney, & Spreen, 1994; Benton, Varney, & Hamsher, 1978), and the Hopkins Verbal Learning Test-Revised (Brandt & Benedict, 2001). The test battery was administered during a single testing session and each participant completed all tests. Administration of all tests adhered to the standardized procedures. The means and the standard deviations (SD) for all test variables used in the statistical analyses are presented in Table 1.

Table 1.

Descriptive data for neuropsychological test raw scores by cognitive domain

 Mean SD Range 
Attention and processing speed 
 NAB Digits Span Forward 7.9 2.3 4–13 
 NAB Digits Span Backward 3.5 2.1 0–9 
 SDMT (oral version) 41.1 15.4 0–77 
Language 
 NAB Naming Test (form 1) 29.2 2.7 18–31 
 NAB Naming Test (form 2) 29.1 2.1 22–31 
 Boston Naming Test 51.3 6.4 29–60 
 COWA 25.9 10.1 6–50 
 Animal Naming 16.1 4.1 9–30 
Memory 
 HVLT-R Total (Trials 1–5) 20.6 5.0 10–33 
 HVLT-R Delayed Recall 6.0 3.3 0–12 
Spatial 
 JLO 23.4 5.6 9–31 
 Matrix Reasoning 21.0 7.8 2–32 
 Mean SD Range 
Attention and processing speed 
 NAB Digits Span Forward 7.9 2.3 4–13 
 NAB Digits Span Backward 3.5 2.1 0–9 
 SDMT (oral version) 41.1 15.4 0–77 
Language 
 NAB Naming Test (form 1) 29.2 2.7 18–31 
 NAB Naming Test (form 2) 29.1 2.1 22–31 
 Boston Naming Test 51.3 6.4 29–60 
 COWA 25.9 10.1 6–50 
 Animal Naming 16.1 4.1 9–30 
Memory 
 HVLT-R Total (Trials 1–5) 20.6 5.0 10–33 
 HVLT-R Delayed Recall 6.0 3.3 0–12 
Spatial 
 JLO 23.4 5.6 9–31 
 Matrix Reasoning 21.0 7.8 2–32 

Notes: NAB = Neuropsychological Assessment Battery; SDMT = Symbol Digit Modalities Test; HVLT-R = Hopkins Verbal Learning Test-Revised; JLO = Judgment of Line Orientation Test; COWA = Controlled Oral Word Association Test.

Statistical Analyses

The internal consistency of each form of the NAB Naming Test was calculated using Cronbach's alpha (Schmitt, 1996). Alternate forms reliability and convergent and divergent validity of the NAB Naming Test (forms 1 and 2), as well as the relationships between tests of confrontation naming (NAB and BNT) and select demographic variables (i.e., age, education, and estimated premorbid IQ), were assessed using Pearson product–moment correlation coefficients. Data analyses were conducted with raw scores. The magnitude of the differences between correlations was analyzed using Steiger's Z (two-tailed; Steiger, 1980).

Results

The internal consistency (Schmitt, 1996) of each form of the NAB Naming Test was calculated and found to be adequate (form 1, α = 0.82; form 2, α = 0.70). Forms 1 and 2 of the NAB Naming Test were found to be equivalent (r = .73, p < .001; paired t-test [t = 0.70, df = 58, p > .05]). In order to explore the convergent validity of the NAB Naming Test, correlation coefficients were separately calculated between scores on the NAB Naming Test (forms 1 and 2) and the BNT and other non-motor tests of neuropsychological functioning including tests of verbal memory, visuospatial skills, and language (Table 2). Divergent validity was assessed by correlating each visual confrontation naming test with scores from two separate tests of attention/auditory concentration (NAB Digits Span Forward) and processing speed (oral version of the Symbol Digit Modalities Test; Table 2). The magnitude of the differences in correlation coefficients between each test of confrontation naming ability and other tests of neuropsychological functioning were not significant (Steiger's Z-test [two-tailed]; p > .05).

Table 2.

Correlation coefficients among neuropsychological tests and demographic variables

 NAB1 NAB2 BNT 
NAB1 — .73*** .80*** 
NAB2 .73*** — .74*** 
BNT .80*** .74*** — 
Age .13 .06 .19 
Education .20 .03 .38** 
NAART .44*** .36** .65*** 
WASI-MR .37** .39** .42*** 
JLO .25 .37** .44*** 
COWA .04 −.12 .14 
ANIMAL .29* .20 .30* 
DIGITS F .19 −.03 .17 
DIGITS B .25 .29* .28* 
HVLT-R Total .18 .05 .23 
HVLT-R Delay .37** .27* .36** 
SDMT .25 .21 .24 
 NAB1 NAB2 BNT 
NAB1 — .73*** .80*** 
NAB2 .73*** — .74*** 
BNT .80*** .74*** — 
Age .13 .06 .19 
Education .20 .03 .38** 
NAART .44*** .36** .65*** 
WASI-MR .37** .39** .42*** 
JLO .25 .37** .44*** 
COWA .04 −.12 .14 
ANIMAL .29* .20 .30* 
DIGITS F .19 −.03 .17 
DIGITS B .25 .29* .28* 
HVLT-R Total .18 .05 .23 
HVLT-R Delay .37** .27* .36** 
SDMT .25 .21 .24 

Notes: NAART = North American Adult Reading Test; NAB1 = Neuropsychological Assessment Battery Naming Test (form 1); NAB2 = Neuropsychological Assessment Battery Naming Test (form 2); BNT = Boston Naming Test; WASI-MR = Wechsler Abbreviated Scale of Intelligence-Matrix Reasoning; JLO = Judgment of Line Orientation; COWA = Controlled Oral Word Association Test; ANIMAL = Animal Naming; DIGITS F = Neuropsychological Assessment Battery Digits Span Forward; DIGITS B = Neuropsychological Assessment Battery Digits Span Backward; HVLT-R Total = Hopkins Verbal Learning Test-Revised Total Recall; HVLT-R Delay = Hopkins Verbal Learning Test-Revised Delayed Recall; SDMT = Symbol Digit Modalities Test (oral version).

*p < .05.

**p < .01.

***p < .001.

Patient age did not significantly correlate with scores from either the NAB Naming Test (form 1: r = .13; form 2: r = .06) or the BNT (r = .19). Education (in years) correlated significantly with BNT scores (r = .38, p < .01), but not with scores from either form of the NAB Naming Test (form 1: r = .20; form 2: r = .03). Estimated premorbid IQ (NAART) correlated significantly with scores from each form of the NAB Naming Test (form 1: r = .44, p < .001; form 2: r = .36, p < .01) and the BNT (r = .65, p < .001; Table 2). The magnitude of the correlation coefficient found between the NAART and the BNT scores was significantly greater than those found between the NAART and scores from form 1 (Z = −3.1, p = .002) and form 2 (Z = −3.7, p < .0001) of the NAB Naming Test.

Discussion

To date, there is a small body of literature supporting the reliability and validity of the NAB in neurological patient samples. The current study was the first to our knowledge to conduct an independent analysis of the convergent and divergent validity of the NAB Naming Test in a sample of patients with acquired brain injury. The current study provides independent validation supporting the utility of the NAB Naming Test for patients with acquired brain injury. The internal consistency (form 1: α = 0.82; form 2: α = 0.70) and alternate forms reliability (r = .73) of the NAB Naming Test using the current sample were found to be consistent with values provided from the NAB standardization data and prior independent analyses using clinical and non-clinical samples. Correlations found between scores from the BNT and forms 1 and 2 of the NAB Naming Test were large and significant (form 1: r = .80; form 2: r = .74) establishing the convergent validity of the NAB Naming Test in the current study sample.

For tests of memory, significant, although moderate, correlation coefficients were found between scores from each confrontation naming test and the delayed recall trial of the Hopkins Verbal Learning Test-Revised, but not with the total learning scores of this measure. Further, scores on a test of verbal working memory (Digits Span Backward) were significantly correlated with form 2 of the NAB Naming Test and the BNT, but not with form 1 of the NAB Naming Test. Yochim and colleagues (2009) reported moderate and significant associations between scores from the NAB Naming Test and the BNT and the total (not delayed) recall scores from both the California Verbal Learning Test-II (Delis, Kaplan, Kramer, & Ober, 2000) and the Brief Visuospatial Memory Test-Revised (Benedict, 1997). The only exception was a lack of a statistical significant correlation between form 1 of the NAB Naming Test and total recall scores from the California Verbal Learning Test-II. Overall, the lack of consistent findings within the memory domain was not expected given the underlying verbal memory component in recalling names of objects.

Given the nature of a visual confrontation naming test (i.e., visual examination of a line drawing or photograph to be subsequently named), one would anticipate there to be a relationship with tests that assess visuospatial skills. In the current study, we found significant correlations between scores on the NAB Naming Test and the BNT and two separate tests of visuospatial skills (Judgment of Line Orientation Test and Matrix Reasoning) with one exception being a lack of a significant relationship between form 1 of the NAB Naming Test and the Judgment of Line Orientation Test. Yochim and colleagues (2009) reported weak to moderate associations between scores on the NAB Naming Test and the Judgment of Line Orientation Test (form 1, r = .35, p < .01; form 2, r = .20, p > .05). Further, they reported that the magnitude of the correlation coefficient between the Judgment of Line Orientation Test and the BNT (r = .49) was significantly greater than that found between the NAB Naming Test (form 2) and the Judgment of Line Orientation Test (r = .20), which led them to suggest that the BNT may rely more heavily on visuospatial skills than the NAB Naming Test which they attributed to the color photographs of the NAB Naming Test. The current study showed a similar association between the Judgment of Line Orientation Test and the BNT (r = .44), but in contrast to findings reported by Yochim and colleagues (2009) raw scores from the Judgment of Line Orientation Test was significantly associated with scores from form 2 of the NAB Naming Test (r = .37, p < .01), but not form 1 (r = .25).

As would be expected, tests of naming ability should maintain associations with other tests of language. In an independent analysis using a neurologically impaired sample of patients, Sachs and colleagues (2011) reported that scores from both the NAB Naming Test and the BNT were correlated with scores from a test of semantic fluency (NAB form 1, r = .53; NAB form 2, r = .45; BNT, r = .56) and to a lesser degree correlated with scores from a test of phonemic fluency (NAB form 1, r = .18; NAB form 2, r = .30; BNT, r = .35). In the current study, only form 1 of the NAB Naming Test (r = .29) was significantly correlated with a test of verbal fluency (animal naming). The differences in the associations between tests of visual confrontation naming and tests of verbal fluency (semantic or phonemic) may be related to differences in the underlying neural correlates and retrieval processes (i.e., search strategies) utilized when executing such tasks (Szatkowska, Grabowska, & Szymanska, 2000). Neuropsychological tests that assess semantic fluency and confrontation naming ability appear to share a common thread as they both rely on search strategies that tap conceptual knowledge followed by a search within a given semantic category. For instance, on a visual confrontation naming test, an individual may identify a picture of a “canoe” as a “boat.” In contrast, performance on a test of phonemic fluency appears to rely on an effective search strategy for lexical representations. The latter is typically viewed as a more difficult task (Lezak et al., 2012).

For divergent validity, we assessed the relationship between scores on the NAB Naming Test (forms 1 and 2) and tests of attention and visuomotor processing speed which appear to be less related to visual confrontation naming ability. The correlation coefficients obtained between the scores for the tests of attention and processing speed and each confrontation naming test were weak and not significant. Similarly, Yochim and colleagues (2009) reported weak and non-significant correlation coefficients between scores on the NAB Naming Test or the BNT and the Processing Speed Index from the Wechsler Adult Intelligence Scale-III (Wechsler, 1997).

Prior work assessing the influence of demographic variables on the BNT suggests that BNT performance can be greatly influenced by age and/or education, particularly for older individuals with lower levels of education (e.g., Hawkins & Bender, 2002; Ross & Lichtenburg, 1998; Zec, Burkett, Markwell, & Larson, 2007). Stern and White (2009) reported that a proportion of the variance in NAB Naming Test scores can be attributed to demographic factors; however, measures were taken in the development of the test to minimize the influence of educational attainment. Thus, in the current study, we assessed the associations between scores on the NAB Naming Test and the BNT with demographic variables of age, education, and estimated premorbid intelligence (NAART). We found that scores from the BNT, but not the NAB Naming Test, were significantly associated with education. Scores from each confrontation naming test were significantly associated with an estimate of premorbid full-scale intelligence; however, the magnitude of the correlation coefficient between the BNT and the NAART (r = .65) was significantly greater than correlation coefficients found between each form of the NAB Naming Test and the NAART (form 1, r = .44; form 2, r = .36). Further, the correlation coefficients calculated between age and scores from each confrontation naming test were non-significant. This latter finding may be attributable to the fact that our sample of patients is considerably younger than those used in prior studies (Sachs et al., 2011; Yochim et al., 2009) in which age was found to be significantly related to scores on the NAB Naming Test. Overall, these findings appear to suggest that the NAB Naming Test may be influenced less by demographic variables than the BNT in a sample of patients with acquired brain injury.

There are several limitations to the current study that limit generalizability of our results. First, our small sample of patients with acquired brain injury predominantly included Caucasian males. Replication of the current study in a larger representative sample of individuals with brain injury (with and/or without a specific disorder of language) would be helpful in this regard. Second, due to the large number of statistical analyses performed in the current study, the possibility of Type I errors cannot be ruled out. Third, the influence of ethnic and cultural factors on the performance of the NAB Naming Test was not addressed in the current study. Fourth, the current study only demonstrated relationships between the NAB Naming Test and a select group of neuropsychological tests without a motor component. Hence, future work should examine the relationship between the NAB Naming Test and a variety of other neuropsychological tests, test batteries, and/or visual confrontation naming tests other than the BNT (e.g., Visual Naming Test; Benton et al., 1994). Lastly, based on the current analysis, as well as prior independent analyses, the significance of the correlations between performances on forms 1 and 2 of the NAB Naming Test and other neuropsychological tests varied. Despite NAB standardization data suggesting that the two forms of the NAB Naming Test are highly equivalent the variable findings observed in the current study may be attributed to a sample size effect that negatively influenced statistical power. Future exploration of possible differences between the alternate forms of the NAB Naming Test using larger sample sizes of patients with acquired brain injury and/or more advanced statistical methods (e.g., Rasch analysis) is paramount.

Funding

This work was supported by the Moody Endowment, Galveston, TX.

Conflict of Interest

None declared.

Acknowledgements

We gratefully acknowledge Renee Pearcy, Jason Duncan, MA, and Alexandra Tellez, MA, for editorial assistance and to Kimily Lawson and Kari Moore for data collection.

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