Examination of the Construct Validity of the Repeatable Battery for the Assessment of Neuropsychological Status Language Index in a Mixed Neurological Sample

Examination of the Construct Validity of the Repeatable Battery for the Assessment of... Abstract Objective We sought to examine the construct validity of the Language Index of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Methods Archival neuropsychological data were collected for 2,057 individuals of diverse neurological etiologies. Results Correlations were seen between the RBANS Language Index and its indices (Semantic Fluency r = .727; Picture Naming r = .786), between Semantic Fluency and both Category Fluency (r = .379) and the Controlled Oral Word Association test (r = .375), and between Picture Naming and both Visual Naming from the Multilingual Aphasia Examination (r = .447) and the Boston Naming Test (r = .519). Finally, Picture Naming predicted performance on both Visual Naming [F(1,495) = 123.36, p < .000] and the Boston Naming Test [F(1,262) = 96.28, p < .000]. Conclusion Given these results, support for the interpretation of RBANS Language Index appears warranted in a diverse clinical sample. Assessment, Language and language disorders, Professional issues, Test construction Introduction The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Randolph, 1998) was developed as a brief neuropsychological battery to characterize dementia. Over time, empirical research has expanded the utility of the RBANS into numerous clinical populations, including schizophrenia (Gold, Queern, Iannone, & Buchanan, 1999), traumatic brain injury (TBI; McKay, Casey, Wertheimer, & Fichtenberg, 2007), cerebral infarct (Larson, Kirschner, Bode, Heinemann, & Goodman, 2005), Parkinson’s disease (Beatty et al., 2003), and multiple sclerosis (Aupperle, Beatty, Shelton, & Gontkovsky, 2002), additionally receiving a normative expansion to include adolescents (Randolph, 2012). Furthermore, Duff and colleagues (2003) extended the RBANS normative range by offering age and education-corrected index and total scores across the measure, based a sample of community dwelling older adults. Today, the RBANS remains one of the most widely used assessment instruments across the field of neuropsychology (Rabin, Paolillo, & Barr, 2016). Some criticisms have been levied against the instrument, specifically questioning the interpretability of certain index scores including the RBANS Language Index (Strauss, Sherman, & Spreen, 2006). This limitation has important clinical significance as subtle language decline can be a precursor to later cognitive decline (Price et al., 1993). Thus, the purpose of the current study is to examine the validity of the RBANS Language Index relative to stand-alone measures of similar constructs within a clinical sample. Construct Validity Specific to language abilities, validation samples of the RBANS (Randolph, 1998, 2012) reported strong correlations between the Language Index and both the Boston Naming Test (BNT; Kaplan, Goodglass, & Weintraub, 2001; r = .75) and the Controlled Oral Word Association test (COWA; Benton, Hamsher, & Sivan, 1994a; r = .59). Correlational values for the Picture Naming and Semantic Fluency RBANS subtests was not reported within the RBANS manual (Randolph, 1998, 2012). Larson and colleagues (2005) examined the construct validity of the RBANS’ indices through comparisons with other measures across a sample of 158 stroke survivors. Low to moderate correlations were seen between the index score and the Boston Diagnostic Aphasia Exam (BDAE; Goodglass, Barresi, & Kaplan, 1983) Repetition subtest (r = .42), the BDAE Commands subtest (r = .38), and the Wechsler Adult Intelligence Test, Revised Edition (WAIS-r; Wechsler, 1981) Vocabulary subtest (r = .51). However, it should be noted that performances on these subtests do not directly relate to word retrieval (i.e., confrontation naming) or rapid word generation, as more directly assessed by the RBANS Picture Naming and Semantic Fluency subtests, respectively. Thus, these results should be interpreted with caution. Researchers McKay et al., 2007 additionally attempted to examine the construct validity of the RBANS, utilizing a sample of 57 individuals who had experienced a traumatic brain injury. Moderate to strong correlations were seen between RBANS Picture Naming and Visual Naming from the Multilingual Aphasia Examination (MAE; Benton, Hamsher, & Sivan, 1994b; r = .590) and between RBANS Semantic Fluency and the COWA (r = .456). Factor analytic support for the Language Index has been variable (see Duff et al., 2006; Emmert, Schwarz, Vander Wal, & Gfeller, 2016). This is partially due to the Picture Naming subtest exhibiting a low ceiling, where healthy individuals generally obtain raw scores approaching maximum values, with very few individuals scoring any inaccuracies (Strauss et al., 2006). This leads to the potential for highly skewed distributions across the Picture Naming subtest, limiting its comparative power to other subtests. Additionally, this can lead individuals with mild degrees of language impairment to score well on this subtest. As described earlier, the RBANS continues to be one of the most widely used cognitive assessment instruments (Rabin et al., 2016). Because subtle language deficits can be a precursor to some neurodegenerative illnesses (Price et al., 1993), it is important that the Language Index be sufficiently validated within diverse neurological samples. In the present study, it was hypothesized that performances on the Language Index, and the Picture Naming and Semantic Fluency subtests, would significantly correlate with supplemental assessment materials. That is, RBANS Picture Naming would correlate with both Visual Naming from the MAE, as well as the BNT, and RBANS Semantic Fluency would correlate with Animal Fluency (Strauss et al., 2006) and the COWA. It was further hypothesized that the Picture Naming subtest would significantly predict performance on relevant supplemental measures. Methods Procedures Archival neuropsychological test data were collected from a larger database from a private level I trauma hospital located in the Midwestern United States. Each outpatient in the current study underwent a clinical interview conducted by a licensed clinical neuropsychologist prior to testing. Assessment procedures were performed by a trained clinical neuropsychological assistant (psychometrist or clinical psychology graduate student). The length of the evaluations varied depending on numerous factors including presenting problem, selection of test battery, and tolerance. For the purpose of grouping individuals into broad categories for analyses, individuals were grouped based on their assigned International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM; World Health Organization, 1992) diagnostic code provided by the licensed clinical neuropsychologist (see Table 1) following evaluation completion. This code was further matched with presenting etiology within archival records to ensure diagnostic accuracy. Table 1. Diagnostic breakdown of utilized sample and cognitive performance   N  Age  Years of education  Mean  SD  Mean  SD  Dementia  332  75.56  10.90  12.72  2.89  TBI  900  56.69  22.45  12.51  2.64  Cardiovascular/Stroke/Aneurysm  273  64.55  15.27  12.95  2.95  PD/Movement Disorder  32  70.69  8.82  13.66  3.58  Multiple Sclerosis  21  61.24  16.88  12.90  2.68  Brain Tumor  56  61.86  12.65  13.82  2.66  Psychiatric Conditions  42  60.55  14.03  12.71  3.06  Encephalopathy  133  62.37  14.75  12.72  2.92  Seizure Disorder/Epilepsy  35  51.23  16.79  13.57  2.72  Other Cognitive Deterioration  140  66.29  16.86  13.00  2.52  Hydrocephalus  49  68.90  17.94  13.65  2.86  Anoxic/Hypoxic Event  44  54.75  20.03  13.21  2.65  Total Sample  2,057  62.44  19.64  12.77  2.79    N  Mean  SD  Minimum  Maximum  RBANS Language Index  1,992  77.08  15.61  40  134  Semantic Fluency  2,022  10.90  4.94  0  39  COWA  547  23.30  11.27  0  64  Animal Fluency  193  13.77  7.30  0  38  Picture Naming  2,057  8.77  1.46  4  10  MAE Visual Naming  496  44.37  8.94  10  64  BNT  263  46.72  10.06  14  60    N  Age  Years of education  Mean  SD  Mean  SD  Dementia  332  75.56  10.90  12.72  2.89  TBI  900  56.69  22.45  12.51  2.64  Cardiovascular/Stroke/Aneurysm  273  64.55  15.27  12.95  2.95  PD/Movement Disorder  32  70.69  8.82  13.66  3.58  Multiple Sclerosis  21  61.24  16.88  12.90  2.68  Brain Tumor  56  61.86  12.65  13.82  2.66  Psychiatric Conditions  42  60.55  14.03  12.71  3.06  Encephalopathy  133  62.37  14.75  12.72  2.92  Seizure Disorder/Epilepsy  35  51.23  16.79  13.57  2.72  Other Cognitive Deterioration  140  66.29  16.86  13.00  2.52  Hydrocephalus  49  68.90  17.94  13.65  2.86  Anoxic/Hypoxic Event  44  54.75  20.03  13.21  2.65  Total Sample  2,057  62.44  19.64  12.77  2.79    N  Mean  SD  Minimum  Maximum  RBANS Language Index  1,992  77.08  15.61  40  134  Semantic Fluency  2,022  10.90  4.94  0  39  COWA  547  23.30  11.27  0  64  Animal Fluency  193  13.77  7.30  0  38  Picture Naming  2,057  8.77  1.46  4  10  MAE Visual Naming  496  44.37  8.94  10  64  BNT  263  46.72  10.06  14  60  Note: TBI = Traumatic Brain Injury; PD = Parkinson’s Disease; Language Index = RBANS Language Index, Semantic Fluency (from RBANS); COWA = Controlled Oral Word Association Test, Picture Naming (from RBANS), Visual Naming (from the Multilingual Aphasia Examination); BNT = Boston Naming Test. Table 1. Diagnostic breakdown of utilized sample and cognitive performance   N  Age  Years of education  Mean  SD  Mean  SD  Dementia  332  75.56  10.90  12.72  2.89  TBI  900  56.69  22.45  12.51  2.64  Cardiovascular/Stroke/Aneurysm  273  64.55  15.27  12.95  2.95  PD/Movement Disorder  32  70.69  8.82  13.66  3.58  Multiple Sclerosis  21  61.24  16.88  12.90  2.68  Brain Tumor  56  61.86  12.65  13.82  2.66  Psychiatric Conditions  42  60.55  14.03  12.71  3.06  Encephalopathy  133  62.37  14.75  12.72  2.92  Seizure Disorder/Epilepsy  35  51.23  16.79  13.57  2.72  Other Cognitive Deterioration  140  66.29  16.86  13.00  2.52  Hydrocephalus  49  68.90  17.94  13.65  2.86  Anoxic/Hypoxic Event  44  54.75  20.03  13.21  2.65  Total Sample  2,057  62.44  19.64  12.77  2.79    N  Mean  SD  Minimum  Maximum  RBANS Language Index  1,992  77.08  15.61  40  134  Semantic Fluency  2,022  10.90  4.94  0  39  COWA  547  23.30  11.27  0  64  Animal Fluency  193  13.77  7.30  0  38  Picture Naming  2,057  8.77  1.46  4  10  MAE Visual Naming  496  44.37  8.94  10  64  BNT  263  46.72  10.06  14  60    N  Age  Years of education  Mean  SD  Mean  SD  Dementia  332  75.56  10.90  12.72  2.89  TBI  900  56.69  22.45  12.51  2.64  Cardiovascular/Stroke/Aneurysm  273  64.55  15.27  12.95  2.95  PD/Movement Disorder  32  70.69  8.82  13.66  3.58  Multiple Sclerosis  21  61.24  16.88  12.90  2.68  Brain Tumor  56  61.86  12.65  13.82  2.66  Psychiatric Conditions  42  60.55  14.03  12.71  3.06  Encephalopathy  133  62.37  14.75  12.72  2.92  Seizure Disorder/Epilepsy  35  51.23  16.79  13.57  2.72  Other Cognitive Deterioration  140  66.29  16.86  13.00  2.52  Hydrocephalus  49  68.90  17.94  13.65  2.86  Anoxic/Hypoxic Event  44  54.75  20.03  13.21  2.65  Total Sample  2,057  62.44  19.64  12.77  2.79    N  Mean  SD  Minimum  Maximum  RBANS Language Index  1,992  77.08  15.61  40  134  Semantic Fluency  2,022  10.90  4.94  0  39  COWA  547  23.30  11.27  0  64  Animal Fluency  193  13.77  7.30  0  38  Picture Naming  2,057  8.77  1.46  4  10  MAE Visual Naming  496  44.37  8.94  10  64  BNT  263  46.72  10.06  14  60  Note: TBI = Traumatic Brain Injury; PD = Parkinson’s Disease; Language Index = RBANS Language Index, Semantic Fluency (from RBANS); COWA = Controlled Oral Word Association Test, Picture Naming (from RBANS), Visual Naming (from the Multilingual Aphasia Examination); BNT = Boston Naming Test. Supplemental Measures Representing a subset of a larger neuropsychological evaluation, performance data were collected across language-based measures including the COWA (CFL version; Benton et al., 1994a), Category Fluency (Animals; Strauss et al., 2006), BNT (Kaplan et al., 2001), and the Visual Naming subtest of the MAE (Benton et al., 1994b), in addition to the RBANS (Randolph, 1998, 2012). For full descriptions of these measures, readers are referred to Strauss et al. (2006). Participants Participants were referred for neuropsychological evaluation between 2005 and 2016, in the context of assessing cognitive functions in patients with injury or neurological disease. Inclusion criteria included all participants who completed measures relevant to the current study (i.e., RBANS Language Index subtests). Exclusionary criteria included individuals under the age of 18. Due to focus of the current study being an examination the RBANS Language Index within a clinical sample, exclusions based on diagnosis or the potential for co-occurring diagnoses was not pursued. All data were analyzed following IRB approval and in accordance with institutional regulations. Sample Characteristics The sample utilized in this study contained 2,057 individuals who were administered the Picture Naming subtest of the RBANS at minimum. From this sample, a total of 496 individuals were administered both RBANS Picture Naming and MAE Visual Naming. Additionally, from this sample, a total of 263 individuals were administered both RBANS Picture Naming and the BNT. From the 2,057 individuals administered Picture Naming, 1,992 individuals received a RBANS Language Index score, indicating that the same value additionally completed the Semantic Fluency subtest. From this value, a total of 542 individuals were administered both RBANS Semantic Fluency and the COWA, while 190 individuals were administered both RBANS Semantic Fluency and Animal Fluency. Table 1 outlines basic demographic information and overall performance across cognitive measures. Of note, the 140 individuals classified as “other cognitive deterioration” included those with altered mental status, delirium, general memory complaints, and those seen to assess capacity to make complex medical decisions. Further, the 42 individuals classified as “psychiatric conditions” represent those with a primary psychiatric diagnostic code following evaluation (Psychosis/Schizophrenia [N = 16], Substance Abuse/Dependence [N = 11], Bipolar Disorder [N = 10], Major Depressive Disorder [N = 5]). With regard to gender, the sample was composed of 1,116 (54.3%) of individuals who identified as male, 1,852 (90.0%) of participants identified as Caucasian, with 165 (8.0%) identifying as African-American, and 1,401 (68.1%) reported that they were not currently in the labor force (e.g. unemployed, disabled, retired, or currently a student). A total of 1,837 (89.3%) identified as being right-handed. Additionally, 985 (47.9%) of individuals reported prior or current treatment for psychiatric difficulties (e.g., depression, anxiety, posttraumatic stress disorder, etc.). Statistical Approach Data were analyzed using IBM Statistical Package for Social Sciences (SPSS) Version 22. Consistent with accepted recommendations (Field, 2009), outliers were replaced with a value equal to 3 SDs from the mean. Assumptions of normality were checked via skewness and kurtosis values and by using visual inspection (e.g., histograms, scatterplots, etc.). While there was some mild evidence of negatively skewed data in both the Picture Naming and BNT variables, these values did not exceed established guidelines of ±2 (Field, 2009). It is believed that the presence of complex neurological conditions which often exhibit deficits in confrontation naming assisted in diminishing the presence of ceiling effects within the current study. Therefore, no transformations of the data occurred. Results Pearson correlations between the variables can be seen in Table 2. Correlations between all measures were found to be statistically significant, including many at the 0.01 level. As expected, strong correlations were found between the RBANS Language Index and the subtests which comprise this value (Semantic Fluency r = .727 and Picture Naming r = .786). Furthermore, relationships between the index and the supplemental measures were shown to be weak to moderate in strength, ranging from .263 to .473. With regard to the Semantic Fluency subtest, supplemental neurocognitive measures (COWA and Animal Fluency) showed moderate correlations with this subtest (r = .375 and r = .379, respectively). With regard to the Picture Naming subtest, supplemental measures (MAE Visual Naming and the BNT) also showed moderate correlations with this subtest (r = .447 and r = .519, respectively). Table 2. Pearson correlations between utilized neurocognitive measures   Language Index  Semantic Fluency  COWA  Animal Fluency  Picture Naming  Visual Naming  BNT  Language Index  —  .727** (N = 1992)  .290** (N = 532)  .263** (N = 188)  .786** (N = 1992)  .473** (N = 484)  .447** (N = 259)  Semantic Fluency    —  .375** (N = 542)  .379** (N = 190)  .380** (N = 2022)  .413** (N = 490)  .285** (N = 261)  COWA      —  .664** (N = 106)  .140** (N = 547)  .420** (N = 154)  .298** (N = 136)  Animal Fluency        —  .169* (N = 193)  .609** (N = 68)  .551** (N = 64)  Picture Naming          —  .447** (N = 496)  .519** (N = 263)  Visual Naming            —  .667* (N = 13)  BNT              —    Language Index  Semantic Fluency  COWA  Animal Fluency  Picture Naming  Visual Naming  BNT  Language Index  —  .727** (N = 1992)  .290** (N = 532)  .263** (N = 188)  .786** (N = 1992)  .473** (N = 484)  .447** (N = 259)  Semantic Fluency    —  .375** (N = 542)  .379** (N = 190)  .380** (N = 2022)  .413** (N = 490)  .285** (N = 261)  COWA      —  .664** (N = 106)  .140** (N = 547)  .420** (N = 154)  .298** (N = 136)  Animal Fluency        —  .169* (N = 193)  .609** (N = 68)  .551** (N = 64)  Picture Naming          —  .447** (N = 496)  .519** (N = 263)  Visual Naming            —  .667* (N = 13)  BNT              —  Note: Language Index = RBANS Language Index, Semantic Fluency (from RBANS), COWA = Controlled Oral Word Association Test, Picture Naming (from RBANS), Visual Naming (from the Multilingual Aphasia Examination), BNT = Boston Naming Test. *Indicates correlation significant at the .05 level. **Indicates correlation significant at the .01 level. Table 2. Pearson correlations between utilized neurocognitive measures   Language Index  Semantic Fluency  COWA  Animal Fluency  Picture Naming  Visual Naming  BNT  Language Index  —  .727** (N = 1992)  .290** (N = 532)  .263** (N = 188)  .786** (N = 1992)  .473** (N = 484)  .447** (N = 259)  Semantic Fluency    —  .375** (N = 542)  .379** (N = 190)  .380** (N = 2022)  .413** (N = 490)  .285** (N = 261)  COWA      —  .664** (N = 106)  .140** (N = 547)  .420** (N = 154)  .298** (N = 136)  Animal Fluency        —  .169* (N = 193)  .609** (N = 68)  .551** (N = 64)  Picture Naming          —  .447** (N = 496)  .519** (N = 263)  Visual Naming            —  .667* (N = 13)  BNT              —    Language Index  Semantic Fluency  COWA  Animal Fluency  Picture Naming  Visual Naming  BNT  Language Index  —  .727** (N = 1992)  .290** (N = 532)  .263** (N = 188)  .786** (N = 1992)  .473** (N = 484)  .447** (N = 259)  Semantic Fluency    —  .375** (N = 542)  .379** (N = 190)  .380** (N = 2022)  .413** (N = 490)  .285** (N = 261)  COWA      —  .664** (N = 106)  .140** (N = 547)  .420** (N = 154)  .298** (N = 136)  Animal Fluency        —  .169* (N = 193)  .609** (N = 68)  .551** (N = 64)  Picture Naming          —  .447** (N = 496)  .519** (N = 263)  Visual Naming            —  .667* (N = 13)  BNT              —  Note: Language Index = RBANS Language Index, Semantic Fluency (from RBANS), COWA = Controlled Oral Word Association Test, Picture Naming (from RBANS), Visual Naming (from the Multilingual Aphasia Examination), BNT = Boston Naming Test. *Indicates correlation significant at the .05 level. **Indicates correlation significant at the .01 level. Furthermore, as criticisms have been levied against Picture Naming specifically positing limited predictive power with regard to other stand-alone measures assessing confrontation naming (Strauss et al., 2006), additional linear regression analyses were performed to assess its ability to predict performance across other stand-alone measures of confrontation naming. A linear regression was calculated to predict scores on both Visual Naming from the MAE, as well as the BNT, based on performance on the Picture Naming subtest of the RBANS. With regard to Visual Naming, a significant regression equation was found [F(1,495) = 123.36, p < .000] with a R2 of .198. With regard to the BNT, a significant regression equation was additionally found [F(1,262) = 96.28, p < .000] with a R2 of .270. Discussion The RBANS (Randolph, 1998, 2012) was developed as a brief but comprehensive neuropsychological screener to characterize dementia in various forms of severity and continues to be one of the most frequently used neurocognitive assessments (Rabin et al., 2016). Despite its wide use across the medical field and in different neurological and psychiatric conditions, notable criticisms, especially in regard to the validity of the Language Index, have been noted (Strauss et al., 2006). As described earlier, previous studies attempting to validate the Language Index and included subtests have yielded mixed results. The original RBANS validation studies conducted by Randolph (1998, 2012) showed strong correlations between the Language Index and both the BNT and COWA. However, exact correlational values for the individual subtests are not reported in the technical manual. Additionally, McKay and colleagues (2007) found moderate to high correlations between the Language Index and both the COWA and Visual Naming test from the MAE. Despite this support, factor analytic support has been variable and these studies represent a narrow focus with regard to their examined sample. Thus, further examination of the relationships between common neurocognitive language measures and the RBANS, at both an index and subtest level, was warranted. The current study investigated the relationships between RBANS subtests and supplemental tests intended to specifically measure the same type of language ability (i.e., semantic fluency, confrontation naming). Previous studies supported the validity of the Language Index due to correlations with verbal tasks, but not necessarily language tests (see Larson, et al., 2005). The current study adds to the literature on the use of the RBANS in a mixed neurological sample. Many past studies narrowed their population of interest to individuals with a single type of brain injury or neurological disorder. While this method has its merits, it can potentially limit the external validity of findings to other clinical populations. Contrastingly, the current study’s results can be extrapolated to a wide range of neurological conditions and demographic characteristics due to the diverse nature of the study sample. Overall, results of the current study support the construct validity of the RBANS Language Index in a large, diverse, neurologically compromised sample. The current study found that RBANS Semantic Fluency was moderately correlated with supplemental measures of semantic/phonetic fluency, and RBANS Picture Naming was moderately correlated with other formal tests of confrontation naming. Furthermore, within expanded analyses specific to Picture Naming, evidence suggests that performance on this subtest can predict performance across other measures of confrontation naming. Despite issues with ceiling effects and the potentially low sensitivity of the Picture Naming subtest, the current study provides evidence that the Picture Naming subtest of the RBANS is a valid measure assessing this language ability. Given these results, as the RBANS is commonly given in abbreviated medical visits as a neurocognitive screener, there appears to be validity in its continued use to assess for language deficits. However, despite these supportive results, the screening nature of the RBANS cannot be ignored and the use of this measure should not take the place of a comprehensive neuropsychological evaluation when considering diagnosis and treatment plans. Study Limitations Although this study contributes to the literature supporting the overall use of the RBANS, there are several limitations which warrant examination. The current study was compromised of individuals from a level I trauma private hospital in the Midwestern United States who were referred neuropsychological testing. As data regarding the duration of injury (i.e., acute vs. chronic conditions) was unable to be determined within the archival review, this may limit generalizability. Furthermore, as detailed medical records were unavailable for review, individuals were grouped for the purpose of the current study (see Table 1) based on diagnoses provided by licensed clinical neuropsychologists, as well as examination of their initial presenting concern during evaluation procedures. While the purpose of this study was to assess the RBANS in a diverse clinical sample which mirrors referrals in neuropsychological settings, this creates a situation in which individuals with differing etiologies (e.g., mild traumatic brain injury vs. an expressive aphasia) are analyzed together, which may further limit the interpretation and generalizability of the current findings. Finally, as approximately half of the current sample identified some history of psychiatric illness, it remains unclear the extent to which this variable may or may not affect the current findings. Future Directions In line with the limitations of the current study, future research should examine similar constructs within samples derived from additionally diverse clinical samples. Future research may wish to limit their samples to individuals with a common diagnosis or clinical syndrome in order warrant more specific clinical implications. 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M., & Spreen, O. ( 2006). A compendium of neuropsychological tests: Administration, norms, and commentary . USA: Oxford University Press. Wechsler, D. ( 1981). WAIS-R manual: Wechsler Adult Intelligence Scale-revised. Psychological Corporation. World Health Organization. ( 1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines . Geneva: World Health Organization. Published by Oxford University Press 2017. This work is written by (a) US Government employee(s) and is in the public domain in the US. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Clinical Neuropsychology Oxford University Press

Examination of the Construct Validity of the Repeatable Battery for the Assessment of Neuropsychological Status Language Index in a Mixed Neurological Sample

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Oxford University Press
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Published by Oxford University Press 2017. This work is written by (a) US Government employee(s) and is in the public domain in the US.
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0887-6177
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1873-5843
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10.1093/arclin/acx115
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Abstract

Abstract Objective We sought to examine the construct validity of the Language Index of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Methods Archival neuropsychological data were collected for 2,057 individuals of diverse neurological etiologies. Results Correlations were seen between the RBANS Language Index and its indices (Semantic Fluency r = .727; Picture Naming r = .786), between Semantic Fluency and both Category Fluency (r = .379) and the Controlled Oral Word Association test (r = .375), and between Picture Naming and both Visual Naming from the Multilingual Aphasia Examination (r = .447) and the Boston Naming Test (r = .519). Finally, Picture Naming predicted performance on both Visual Naming [F(1,495) = 123.36, p < .000] and the Boston Naming Test [F(1,262) = 96.28, p < .000]. Conclusion Given these results, support for the interpretation of RBANS Language Index appears warranted in a diverse clinical sample. Assessment, Language and language disorders, Professional issues, Test construction Introduction The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Randolph, 1998) was developed as a brief neuropsychological battery to characterize dementia. Over time, empirical research has expanded the utility of the RBANS into numerous clinical populations, including schizophrenia (Gold, Queern, Iannone, & Buchanan, 1999), traumatic brain injury (TBI; McKay, Casey, Wertheimer, & Fichtenberg, 2007), cerebral infarct (Larson, Kirschner, Bode, Heinemann, & Goodman, 2005), Parkinson’s disease (Beatty et al., 2003), and multiple sclerosis (Aupperle, Beatty, Shelton, & Gontkovsky, 2002), additionally receiving a normative expansion to include adolescents (Randolph, 2012). Furthermore, Duff and colleagues (2003) extended the RBANS normative range by offering age and education-corrected index and total scores across the measure, based a sample of community dwelling older adults. Today, the RBANS remains one of the most widely used assessment instruments across the field of neuropsychology (Rabin, Paolillo, & Barr, 2016). Some criticisms have been levied against the instrument, specifically questioning the interpretability of certain index scores including the RBANS Language Index (Strauss, Sherman, & Spreen, 2006). This limitation has important clinical significance as subtle language decline can be a precursor to later cognitive decline (Price et al., 1993). Thus, the purpose of the current study is to examine the validity of the RBANS Language Index relative to stand-alone measures of similar constructs within a clinical sample. Construct Validity Specific to language abilities, validation samples of the RBANS (Randolph, 1998, 2012) reported strong correlations between the Language Index and both the Boston Naming Test (BNT; Kaplan, Goodglass, & Weintraub, 2001; r = .75) and the Controlled Oral Word Association test (COWA; Benton, Hamsher, & Sivan, 1994a; r = .59). Correlational values for the Picture Naming and Semantic Fluency RBANS subtests was not reported within the RBANS manual (Randolph, 1998, 2012). Larson and colleagues (2005) examined the construct validity of the RBANS’ indices through comparisons with other measures across a sample of 158 stroke survivors. Low to moderate correlations were seen between the index score and the Boston Diagnostic Aphasia Exam (BDAE; Goodglass, Barresi, & Kaplan, 1983) Repetition subtest (r = .42), the BDAE Commands subtest (r = .38), and the Wechsler Adult Intelligence Test, Revised Edition (WAIS-r; Wechsler, 1981) Vocabulary subtest (r = .51). However, it should be noted that performances on these subtests do not directly relate to word retrieval (i.e., confrontation naming) or rapid word generation, as more directly assessed by the RBANS Picture Naming and Semantic Fluency subtests, respectively. Thus, these results should be interpreted with caution. Researchers McKay et al., 2007 additionally attempted to examine the construct validity of the RBANS, utilizing a sample of 57 individuals who had experienced a traumatic brain injury. Moderate to strong correlations were seen between RBANS Picture Naming and Visual Naming from the Multilingual Aphasia Examination (MAE; Benton, Hamsher, & Sivan, 1994b; r = .590) and between RBANS Semantic Fluency and the COWA (r = .456). Factor analytic support for the Language Index has been variable (see Duff et al., 2006; Emmert, Schwarz, Vander Wal, & Gfeller, 2016). This is partially due to the Picture Naming subtest exhibiting a low ceiling, where healthy individuals generally obtain raw scores approaching maximum values, with very few individuals scoring any inaccuracies (Strauss et al., 2006). This leads to the potential for highly skewed distributions across the Picture Naming subtest, limiting its comparative power to other subtests. Additionally, this can lead individuals with mild degrees of language impairment to score well on this subtest. As described earlier, the RBANS continues to be one of the most widely used cognitive assessment instruments (Rabin et al., 2016). Because subtle language deficits can be a precursor to some neurodegenerative illnesses (Price et al., 1993), it is important that the Language Index be sufficiently validated within diverse neurological samples. In the present study, it was hypothesized that performances on the Language Index, and the Picture Naming and Semantic Fluency subtests, would significantly correlate with supplemental assessment materials. That is, RBANS Picture Naming would correlate with both Visual Naming from the MAE, as well as the BNT, and RBANS Semantic Fluency would correlate with Animal Fluency (Strauss et al., 2006) and the COWA. It was further hypothesized that the Picture Naming subtest would significantly predict performance on relevant supplemental measures. Methods Procedures Archival neuropsychological test data were collected from a larger database from a private level I trauma hospital located in the Midwestern United States. Each outpatient in the current study underwent a clinical interview conducted by a licensed clinical neuropsychologist prior to testing. Assessment procedures were performed by a trained clinical neuropsychological assistant (psychometrist or clinical psychology graduate student). The length of the evaluations varied depending on numerous factors including presenting problem, selection of test battery, and tolerance. For the purpose of grouping individuals into broad categories for analyses, individuals were grouped based on their assigned International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM; World Health Organization, 1992) diagnostic code provided by the licensed clinical neuropsychologist (see Table 1) following evaluation completion. This code was further matched with presenting etiology within archival records to ensure diagnostic accuracy. Table 1. Diagnostic breakdown of utilized sample and cognitive performance   N  Age  Years of education  Mean  SD  Mean  SD  Dementia  332  75.56  10.90  12.72  2.89  TBI  900  56.69  22.45  12.51  2.64  Cardiovascular/Stroke/Aneurysm  273  64.55  15.27  12.95  2.95  PD/Movement Disorder  32  70.69  8.82  13.66  3.58  Multiple Sclerosis  21  61.24  16.88  12.90  2.68  Brain Tumor  56  61.86  12.65  13.82  2.66  Psychiatric Conditions  42  60.55  14.03  12.71  3.06  Encephalopathy  133  62.37  14.75  12.72  2.92  Seizure Disorder/Epilepsy  35  51.23  16.79  13.57  2.72  Other Cognitive Deterioration  140  66.29  16.86  13.00  2.52  Hydrocephalus  49  68.90  17.94  13.65  2.86  Anoxic/Hypoxic Event  44  54.75  20.03  13.21  2.65  Total Sample  2,057  62.44  19.64  12.77  2.79    N  Mean  SD  Minimum  Maximum  RBANS Language Index  1,992  77.08  15.61  40  134  Semantic Fluency  2,022  10.90  4.94  0  39  COWA  547  23.30  11.27  0  64  Animal Fluency  193  13.77  7.30  0  38  Picture Naming  2,057  8.77  1.46  4  10  MAE Visual Naming  496  44.37  8.94  10  64  BNT  263  46.72  10.06  14  60    N  Age  Years of education  Mean  SD  Mean  SD  Dementia  332  75.56  10.90  12.72  2.89  TBI  900  56.69  22.45  12.51  2.64  Cardiovascular/Stroke/Aneurysm  273  64.55  15.27  12.95  2.95  PD/Movement Disorder  32  70.69  8.82  13.66  3.58  Multiple Sclerosis  21  61.24  16.88  12.90  2.68  Brain Tumor  56  61.86  12.65  13.82  2.66  Psychiatric Conditions  42  60.55  14.03  12.71  3.06  Encephalopathy  133  62.37  14.75  12.72  2.92  Seizure Disorder/Epilepsy  35  51.23  16.79  13.57  2.72  Other Cognitive Deterioration  140  66.29  16.86  13.00  2.52  Hydrocephalus  49  68.90  17.94  13.65  2.86  Anoxic/Hypoxic Event  44  54.75  20.03  13.21  2.65  Total Sample  2,057  62.44  19.64  12.77  2.79    N  Mean  SD  Minimum  Maximum  RBANS Language Index  1,992  77.08  15.61  40  134  Semantic Fluency  2,022  10.90  4.94  0  39  COWA  547  23.30  11.27  0  64  Animal Fluency  193  13.77  7.30  0  38  Picture Naming  2,057  8.77  1.46  4  10  MAE Visual Naming  496  44.37  8.94  10  64  BNT  263  46.72  10.06  14  60  Note: TBI = Traumatic Brain Injury; PD = Parkinson’s Disease; Language Index = RBANS Language Index, Semantic Fluency (from RBANS); COWA = Controlled Oral Word Association Test, Picture Naming (from RBANS), Visual Naming (from the Multilingual Aphasia Examination); BNT = Boston Naming Test. Table 1. Diagnostic breakdown of utilized sample and cognitive performance   N  Age  Years of education  Mean  SD  Mean  SD  Dementia  332  75.56  10.90  12.72  2.89  TBI  900  56.69  22.45  12.51  2.64  Cardiovascular/Stroke/Aneurysm  273  64.55  15.27  12.95  2.95  PD/Movement Disorder  32  70.69  8.82  13.66  3.58  Multiple Sclerosis  21  61.24  16.88  12.90  2.68  Brain Tumor  56  61.86  12.65  13.82  2.66  Psychiatric Conditions  42  60.55  14.03  12.71  3.06  Encephalopathy  133  62.37  14.75  12.72  2.92  Seizure Disorder/Epilepsy  35  51.23  16.79  13.57  2.72  Other Cognitive Deterioration  140  66.29  16.86  13.00  2.52  Hydrocephalus  49  68.90  17.94  13.65  2.86  Anoxic/Hypoxic Event  44  54.75  20.03  13.21  2.65  Total Sample  2,057  62.44  19.64  12.77  2.79    N  Mean  SD  Minimum  Maximum  RBANS Language Index  1,992  77.08  15.61  40  134  Semantic Fluency  2,022  10.90  4.94  0  39  COWA  547  23.30  11.27  0  64  Animal Fluency  193  13.77  7.30  0  38  Picture Naming  2,057  8.77  1.46  4  10  MAE Visual Naming  496  44.37  8.94  10  64  BNT  263  46.72  10.06  14  60    N  Age  Years of education  Mean  SD  Mean  SD  Dementia  332  75.56  10.90  12.72  2.89  TBI  900  56.69  22.45  12.51  2.64  Cardiovascular/Stroke/Aneurysm  273  64.55  15.27  12.95  2.95  PD/Movement Disorder  32  70.69  8.82  13.66  3.58  Multiple Sclerosis  21  61.24  16.88  12.90  2.68  Brain Tumor  56  61.86  12.65  13.82  2.66  Psychiatric Conditions  42  60.55  14.03  12.71  3.06  Encephalopathy  133  62.37  14.75  12.72  2.92  Seizure Disorder/Epilepsy  35  51.23  16.79  13.57  2.72  Other Cognitive Deterioration  140  66.29  16.86  13.00  2.52  Hydrocephalus  49  68.90  17.94  13.65  2.86  Anoxic/Hypoxic Event  44  54.75  20.03  13.21  2.65  Total Sample  2,057  62.44  19.64  12.77  2.79    N  Mean  SD  Minimum  Maximum  RBANS Language Index  1,992  77.08  15.61  40  134  Semantic Fluency  2,022  10.90  4.94  0  39  COWA  547  23.30  11.27  0  64  Animal Fluency  193  13.77  7.30  0  38  Picture Naming  2,057  8.77  1.46  4  10  MAE Visual Naming  496  44.37  8.94  10  64  BNT  263  46.72  10.06  14  60  Note: TBI = Traumatic Brain Injury; PD = Parkinson’s Disease; Language Index = RBANS Language Index, Semantic Fluency (from RBANS); COWA = Controlled Oral Word Association Test, Picture Naming (from RBANS), Visual Naming (from the Multilingual Aphasia Examination); BNT = Boston Naming Test. Supplemental Measures Representing a subset of a larger neuropsychological evaluation, performance data were collected across language-based measures including the COWA (CFL version; Benton et al., 1994a), Category Fluency (Animals; Strauss et al., 2006), BNT (Kaplan et al., 2001), and the Visual Naming subtest of the MAE (Benton et al., 1994b), in addition to the RBANS (Randolph, 1998, 2012). For full descriptions of these measures, readers are referred to Strauss et al. (2006). Participants Participants were referred for neuropsychological evaluation between 2005 and 2016, in the context of assessing cognitive functions in patients with injury or neurological disease. Inclusion criteria included all participants who completed measures relevant to the current study (i.e., RBANS Language Index subtests). Exclusionary criteria included individuals under the age of 18. Due to focus of the current study being an examination the RBANS Language Index within a clinical sample, exclusions based on diagnosis or the potential for co-occurring diagnoses was not pursued. All data were analyzed following IRB approval and in accordance with institutional regulations. Sample Characteristics The sample utilized in this study contained 2,057 individuals who were administered the Picture Naming subtest of the RBANS at minimum. From this sample, a total of 496 individuals were administered both RBANS Picture Naming and MAE Visual Naming. Additionally, from this sample, a total of 263 individuals were administered both RBANS Picture Naming and the BNT. From the 2,057 individuals administered Picture Naming, 1,992 individuals received a RBANS Language Index score, indicating that the same value additionally completed the Semantic Fluency subtest. From this value, a total of 542 individuals were administered both RBANS Semantic Fluency and the COWA, while 190 individuals were administered both RBANS Semantic Fluency and Animal Fluency. Table 1 outlines basic demographic information and overall performance across cognitive measures. Of note, the 140 individuals classified as “other cognitive deterioration” included those with altered mental status, delirium, general memory complaints, and those seen to assess capacity to make complex medical decisions. Further, the 42 individuals classified as “psychiatric conditions” represent those with a primary psychiatric diagnostic code following evaluation (Psychosis/Schizophrenia [N = 16], Substance Abuse/Dependence [N = 11], Bipolar Disorder [N = 10], Major Depressive Disorder [N = 5]). With regard to gender, the sample was composed of 1,116 (54.3%) of individuals who identified as male, 1,852 (90.0%) of participants identified as Caucasian, with 165 (8.0%) identifying as African-American, and 1,401 (68.1%) reported that they were not currently in the labor force (e.g. unemployed, disabled, retired, or currently a student). A total of 1,837 (89.3%) identified as being right-handed. Additionally, 985 (47.9%) of individuals reported prior or current treatment for psychiatric difficulties (e.g., depression, anxiety, posttraumatic stress disorder, etc.). Statistical Approach Data were analyzed using IBM Statistical Package for Social Sciences (SPSS) Version 22. Consistent with accepted recommendations (Field, 2009), outliers were replaced with a value equal to 3 SDs from the mean. Assumptions of normality were checked via skewness and kurtosis values and by using visual inspection (e.g., histograms, scatterplots, etc.). While there was some mild evidence of negatively skewed data in both the Picture Naming and BNT variables, these values did not exceed established guidelines of ±2 (Field, 2009). It is believed that the presence of complex neurological conditions which often exhibit deficits in confrontation naming assisted in diminishing the presence of ceiling effects within the current study. Therefore, no transformations of the data occurred. Results Pearson correlations between the variables can be seen in Table 2. Correlations between all measures were found to be statistically significant, including many at the 0.01 level. As expected, strong correlations were found between the RBANS Language Index and the subtests which comprise this value (Semantic Fluency r = .727 and Picture Naming r = .786). Furthermore, relationships between the index and the supplemental measures were shown to be weak to moderate in strength, ranging from .263 to .473. With regard to the Semantic Fluency subtest, supplemental neurocognitive measures (COWA and Animal Fluency) showed moderate correlations with this subtest (r = .375 and r = .379, respectively). With regard to the Picture Naming subtest, supplemental measures (MAE Visual Naming and the BNT) also showed moderate correlations with this subtest (r = .447 and r = .519, respectively). Table 2. Pearson correlations between utilized neurocognitive measures   Language Index  Semantic Fluency  COWA  Animal Fluency  Picture Naming  Visual Naming  BNT  Language Index  —  .727** (N = 1992)  .290** (N = 532)  .263** (N = 188)  .786** (N = 1992)  .473** (N = 484)  .447** (N = 259)  Semantic Fluency    —  .375** (N = 542)  .379** (N = 190)  .380** (N = 2022)  .413** (N = 490)  .285** (N = 261)  COWA      —  .664** (N = 106)  .140** (N = 547)  .420** (N = 154)  .298** (N = 136)  Animal Fluency        —  .169* (N = 193)  .609** (N = 68)  .551** (N = 64)  Picture Naming          —  .447** (N = 496)  .519** (N = 263)  Visual Naming            —  .667* (N = 13)  BNT              —    Language Index  Semantic Fluency  COWA  Animal Fluency  Picture Naming  Visual Naming  BNT  Language Index  —  .727** (N = 1992)  .290** (N = 532)  .263** (N = 188)  .786** (N = 1992)  .473** (N = 484)  .447** (N = 259)  Semantic Fluency    —  .375** (N = 542)  .379** (N = 190)  .380** (N = 2022)  .413** (N = 490)  .285** (N = 261)  COWA      —  .664** (N = 106)  .140** (N = 547)  .420** (N = 154)  .298** (N = 136)  Animal Fluency        —  .169* (N = 193)  .609** (N = 68)  .551** (N = 64)  Picture Naming          —  .447** (N = 496)  .519** (N = 263)  Visual Naming            —  .667* (N = 13)  BNT              —  Note: Language Index = RBANS Language Index, Semantic Fluency (from RBANS), COWA = Controlled Oral Word Association Test, Picture Naming (from RBANS), Visual Naming (from the Multilingual Aphasia Examination), BNT = Boston Naming Test. *Indicates correlation significant at the .05 level. **Indicates correlation significant at the .01 level. Table 2. Pearson correlations between utilized neurocognitive measures   Language Index  Semantic Fluency  COWA  Animal Fluency  Picture Naming  Visual Naming  BNT  Language Index  —  .727** (N = 1992)  .290** (N = 532)  .263** (N = 188)  .786** (N = 1992)  .473** (N = 484)  .447** (N = 259)  Semantic Fluency    —  .375** (N = 542)  .379** (N = 190)  .380** (N = 2022)  .413** (N = 490)  .285** (N = 261)  COWA      —  .664** (N = 106)  .140** (N = 547)  .420** (N = 154)  .298** (N = 136)  Animal Fluency        —  .169* (N = 193)  .609** (N = 68)  .551** (N = 64)  Picture Naming          —  .447** (N = 496)  .519** (N = 263)  Visual Naming            —  .667* (N = 13)  BNT              —    Language Index  Semantic Fluency  COWA  Animal Fluency  Picture Naming  Visual Naming  BNT  Language Index  —  .727** (N = 1992)  .290** (N = 532)  .263** (N = 188)  .786** (N = 1992)  .473** (N = 484)  .447** (N = 259)  Semantic Fluency    —  .375** (N = 542)  .379** (N = 190)  .380** (N = 2022)  .413** (N = 490)  .285** (N = 261)  COWA      —  .664** (N = 106)  .140** (N = 547)  .420** (N = 154)  .298** (N = 136)  Animal Fluency        —  .169* (N = 193)  .609** (N = 68)  .551** (N = 64)  Picture Naming          —  .447** (N = 496)  .519** (N = 263)  Visual Naming            —  .667* (N = 13)  BNT              —  Note: Language Index = RBANS Language Index, Semantic Fluency (from RBANS), COWA = Controlled Oral Word Association Test, Picture Naming (from RBANS), Visual Naming (from the Multilingual Aphasia Examination), BNT = Boston Naming Test. *Indicates correlation significant at the .05 level. **Indicates correlation significant at the .01 level. Furthermore, as criticisms have been levied against Picture Naming specifically positing limited predictive power with regard to other stand-alone measures assessing confrontation naming (Strauss et al., 2006), additional linear regression analyses were performed to assess its ability to predict performance across other stand-alone measures of confrontation naming. A linear regression was calculated to predict scores on both Visual Naming from the MAE, as well as the BNT, based on performance on the Picture Naming subtest of the RBANS. With regard to Visual Naming, a significant regression equation was found [F(1,495) = 123.36, p < .000] with a R2 of .198. With regard to the BNT, a significant regression equation was additionally found [F(1,262) = 96.28, p < .000] with a R2 of .270. Discussion The RBANS (Randolph, 1998, 2012) was developed as a brief but comprehensive neuropsychological screener to characterize dementia in various forms of severity and continues to be one of the most frequently used neurocognitive assessments (Rabin et al., 2016). Despite its wide use across the medical field and in different neurological and psychiatric conditions, notable criticisms, especially in regard to the validity of the Language Index, have been noted (Strauss et al., 2006). As described earlier, previous studies attempting to validate the Language Index and included subtests have yielded mixed results. The original RBANS validation studies conducted by Randolph (1998, 2012) showed strong correlations between the Language Index and both the BNT and COWA. However, exact correlational values for the individual subtests are not reported in the technical manual. Additionally, McKay and colleagues (2007) found moderate to high correlations between the Language Index and both the COWA and Visual Naming test from the MAE. Despite this support, factor analytic support has been variable and these studies represent a narrow focus with regard to their examined sample. Thus, further examination of the relationships between common neurocognitive language measures and the RBANS, at both an index and subtest level, was warranted. The current study investigated the relationships between RBANS subtests and supplemental tests intended to specifically measure the same type of language ability (i.e., semantic fluency, confrontation naming). Previous studies supported the validity of the Language Index due to correlations with verbal tasks, but not necessarily language tests (see Larson, et al., 2005). The current study adds to the literature on the use of the RBANS in a mixed neurological sample. Many past studies narrowed their population of interest to individuals with a single type of brain injury or neurological disorder. While this method has its merits, it can potentially limit the external validity of findings to other clinical populations. Contrastingly, the current study’s results can be extrapolated to a wide range of neurological conditions and demographic characteristics due to the diverse nature of the study sample. Overall, results of the current study support the construct validity of the RBANS Language Index in a large, diverse, neurologically compromised sample. The current study found that RBANS Semantic Fluency was moderately correlated with supplemental measures of semantic/phonetic fluency, and RBANS Picture Naming was moderately correlated with other formal tests of confrontation naming. Furthermore, within expanded analyses specific to Picture Naming, evidence suggests that performance on this subtest can predict performance across other measures of confrontation naming. Despite issues with ceiling effects and the potentially low sensitivity of the Picture Naming subtest, the current study provides evidence that the Picture Naming subtest of the RBANS is a valid measure assessing this language ability. Given these results, as the RBANS is commonly given in abbreviated medical visits as a neurocognitive screener, there appears to be validity in its continued use to assess for language deficits. However, despite these supportive results, the screening nature of the RBANS cannot be ignored and the use of this measure should not take the place of a comprehensive neuropsychological evaluation when considering diagnosis and treatment plans. Study Limitations Although this study contributes to the literature supporting the overall use of the RBANS, there are several limitations which warrant examination. The current study was compromised of individuals from a level I trauma private hospital in the Midwestern United States who were referred neuropsychological testing. As data regarding the duration of injury (i.e., acute vs. chronic conditions) was unable to be determined within the archival review, this may limit generalizability. Furthermore, as detailed medical records were unavailable for review, individuals were grouped for the purpose of the current study (see Table 1) based on diagnoses provided by licensed clinical neuropsychologists, as well as examination of their initial presenting concern during evaluation procedures. While the purpose of this study was to assess the RBANS in a diverse clinical sample which mirrors referrals in neuropsychological settings, this creates a situation in which individuals with differing etiologies (e.g., mild traumatic brain injury vs. an expressive aphasia) are analyzed together, which may further limit the interpretation and generalizability of the current findings. Finally, as approximately half of the current sample identified some history of psychiatric illness, it remains unclear the extent to which this variable may or may not affect the current findings. Future Directions In line with the limitations of the current study, future research should examine similar constructs within samples derived from additionally diverse clinical samples. Future research may wish to limit their samples to individuals with a common diagnosis or clinical syndrome in order warrant more specific clinical implications. Finally, future studies may wish to examine the psychiatric affect on performance across the RBANS broadly, as well as how it may relate to overall language abilities as assessed by the subtest of the RBANS Language Index. Acknowledgments No funding accompanied this study. Conflict of interest The authors have no conflicts of interest to disclose. References Aupperle, R. L., Beatty, W. W., deNAP Shelton, F., & Gontkovsky, S. T. ( 2002). Three screening batteries to detect cognitive impairment in multiple sclerosis. Multiple Sclerosis Journal , 8, 382– 389. Google Scholar CrossRef Search ADS PubMed  Beatty, W. W., Ryder, K. A., Gontkovsky, S. T., Scott, J. G., McSwan, K. L., & Bharucha, K. J. ( 2003). Analyzing the subcortical dementia syndrome of Parkinson’s disease using the RBANS. Archives of Clinical Neuropsychology , 18, 509– 520. Google Scholar PubMed  Benton, L. A., Hamsher, K. D., & Sivan, A. B. ( 1994a). Controlled oral word association test. Multilingual aphasia examination. Benton, A. L., Hamsher, K. D., & Sivan, A. B. ( 1994b). Multilingual aphasia examination: Manual of instructions. AJA Association. Duff, K., Patton, D., Schoenberg, M. R., Mold, J., Scott, J. G., & Adams, R. L. ( 2003). Age-and education-corrected independent normative data for the RBANS in a community dwelling elderly sample. The Clinical Neuropsychologist , 17, 351– 366. Google Scholar CrossRef Search ADS PubMed  Duff, K., Langbehn, D. R., Schoenberg, M. R., Moser, D. J., Baade, L. E., Mold, J., et al.  . ( 2006). Examining the Repeatable Battery for the Assessment of Neuropsychological Status: Factor analytic studies in an elderly sample. The American Journal of Geriatric Psychiatry , 14, 976– 979. Google Scholar CrossRef Search ADS PubMed  Emmert, N., Schwarz, L., Vander Wal, J., & Gfeller, J. ( 2016). RBANS factor structure in older adults with suspected cognitive impairment: Evidence for a 5-factor structure. Applied Neuropsychology: Adult , 1– 13. Field, A. ( 2009). Discovering statistics using SPSS . Thousand Oaks, CA: Sage Publications. Gold, J. M., Queern, C., Iannone, V. N., & Buchanan, R. W. ( 1999). Repeatable Battery for the Assessment of Neuropsychological Status as a screening test in schizophrenia, I: Sensitivity, reliability, and validity. American Journal of Psychiatry , 156, 1944– 1950. Google Scholar PubMed  Goodglass, H., Barresi, B., & Kaplan, E. ( 1983). The Boston diagnostic aphasia examination. Lippincott Williams & Willkins. A Wolters Kluwer Company. Kaplan, E., Goodglass, H., & Weintraub, S. ( 2001). Boston naming test. Pro-ed. Larson, E. B., Kirschner, K., Bode, R., Heinemann, A., & Goodman, R. ( 2005). Construct and predictive validity of the repeatable battery for the assessment of neuropsychological status in the evaluation of stroke patients. Journal of Clinical and Experimental Neuropsychology , 27, 16– 32. Google Scholar CrossRef Search ADS PubMed  McKay, C., Casey, J. E., Wertheimer, J., & Fichtenberg, N. L. ( 2007). Reliability and validity of the RBANS in a traumatic brain injured sample. Archives of Clinical Neuropsychology , 22, 91– 98. Google Scholar CrossRef Search ADS PubMed  Price, B. H., Gurvit, H., Weintraub, S., Geula, C., Leimkuhler, E., & Mesulam, M. ( 1993). Neuropsychological patterns and language deficits in 20 consecutive cases of autopsy-confirmed Alzheimer’s disease. Archives of neurology , 50, 931– 937. Google Scholar CrossRef Search ADS PubMed  Rabin, L. A., Paolillo, E., & Barr, W. B. ( 2016). Stability in test-usage practices of clinical neuropsychologists in the United States and Canada over a 10-year period: A follow-up survey of INS and NAN members. Archives of Clinical Neuropsychology , 31, 206– 230. Google Scholar CrossRef Search ADS PubMed  Randolph, C. ( 1998). RBANS manual: Repeatable battery for the assessment of neuropsychological status . San Antonio, TX: The Psychological Corporation. Randolph, C. ( 2012). RBANS update: Manual. Strauss, E., Sherman, E. M., & Spreen, O. ( 2006). A compendium of neuropsychological tests: Administration, norms, and commentary . USA: Oxford University Press. Wechsler, D. ( 1981). WAIS-R manual: Wechsler Adult Intelligence Scale-revised. Psychological Corporation. World Health Organization. ( 1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines . Geneva: World Health Organization. Published by Oxford University Press 2017. This work is written by (a) US Government employee(s) and is in the public domain in the US.

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Archives of Clinical NeuropsychologyOxford University Press

Published: Nov 28, 2017

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