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NeuroRehabilitation 34 (2014) 463–471 DOI:10.3233/NRE-141057 IOS Press

Montreal-Toulouse Language Assessment Battery for aphasia: Validity and reliability evidence Karina Carlesso Pagliarina,∗ , Karin Zazo Ortizb , Maria Alice de Mattos Pimenta Parentec , Adriane Artechea , Yves Joanetted , Jean-Luc Nespoulouse and Rochele Paz Fonsecaa a Pontifical

Catholic University of Rio Grande do Sul, Porto Alegre, Brazil University of S˜ao Paulo, S˜ao Paulo, Brazil c Federal University ABC, S˜ ao Paulo, Brazil d Universit´ e de Montr´eal, Montreal, Canada e Universit´ e Toulouse II - Le Mirail, Toulouse, France b Federal

Abstract. BACKGROUND: In Brazil, no standardized instruments are available to assess language in patients with aphasia. OBJECTIVE: The aim of the current study was to search for reliability and validity evidence for the Montreal-Toulouse Language Assessment Battery (MTL-BR). METHODS: The sample was composed of 537 adults, of whom 463 were healthy individuals and 74 had neurological lesions (25 participants had right hemisphere brain damage, 21 had left hemisphere damage (LHD) with aphasia and 28 had LHD without aphasia). Reliability was assessed by internal consistency (Cronbach’s alpha) and test-retest analyses. Test-retest reliability was calculated using the Pearson correlation coefficient, and a repeated measures analysis of variance, with years of education as a covariate. Construct validity was verified by correlations between scores in MTL-BR subtest and similar tasks from other language assessment instruments. RESULTS: Internal consistency was satisfactory (Cronbach’s alpha between 0.79 and 0.90), as were correlations between test and retest scores (mean 0.52), and between the MTL-BR and scores in similar instruments. CONCLUSIONS: The present results suggested that the MTL-BR battery had adequate reliability and validity as a method for diagnosing and monitoring aphasia. Keywords: Language, assessment, test validity, adults

1. Introduction

∗ Address

for correspondence: Karina Carlesso Pagliarin, Pontifical Catholic University of Rio Grande do Sul, Faculty of Psychology. Av. Ipiranga 6681 - Pr´edio 11 – 9◦ andar, sala 932. Zip code: 90619900. Porto Alegre/RS. Brazil. Tel./Fax: +55 51 33203500; E-mail: karinap [email protected].

The Montreal-Toulouse Language Assessment Battery (MTL-BR) was developed to assess components of spoken and written language, praxis and arithmetical skill after brain damage, and has been recently translated and adapted from French to Brazilian Portuguese (Parente et al., in press). The main purpose of

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this instrument is to detect the presence of aphasia and examine linguistic profiles by assessing different language modalities (expression, comprehension, reading and writing) across varying levels of linguistic (phonological, syntactic, semantic and pragmatic) complexity. A growing interest in standardized language assessment instruments has been observed in the international literature over recent years (Calis, On, & Durmaz, 2013; Salter, Jutai, Foley, Hellings, & Teasell, 2006). However, there is a general scarcity of such instruments in Brazil (Pagliarin et al., 2013). The instruments available for language assessment after acquired brain injury in Brazilian populations generally consist of screening tools that provide a brief assessment of language as part of a general cognitive evaluation. Some of these instruments include: the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD; Bertolucci et al., 2001), the Brief Neuropsychological Assessment Instrument - NEUPSLIN (Fonseca, Salles, & Parente, 2008, 2009), the Mini Mental State Examination (MMSE; Chaves & Izquierdo, 1992), and the Alzheimer’s Disease Assessment Scale (ADAS-Cog; Schultz, Siviero, & Bertolucci, 2001). To the authors’ knowledge, only the Token Test (Fontanari, 1989), the Boston Diagnostic Aphasia Examination (BDAE; Mansur, Radanovic, Taquemori, Greco, & Ara´ujo, 2005) and the Boston Naming Test (BNT; Mansur, Radanovic, Ara´ujo, Taquemori, & Greco, 2006), focus specifically on the assessment of predominantly structural language skills more related to left hemisphere domain such as phonology, syntax, morphology and literal semantics abilities. Test batteries assessing predominantly functional aspects of language more related to right hemisphere domain specialization, such as pragmatic, prosody, non-literal semantics and discourse are also available. Among these tools, there is the Montreal Communication Assessment Battery (Fonseca et al., 2008) and the Montreal Communication Assessment Battery - brief version (Casarin et al., in press). Of the instruments cited, the latter two are the only ones that have been standardized and had their psychometric properties assessed. Furthermore, two of the language assessment batteries mentioned (BDAE and BNT) are not available for clinical use because they are not commercialized in Brazil. Therefore, these instruments can only be used for research purposes. As such, there do not appear to be any test batteries available with evidence of reliability and validity in a Brazilian sample that provide the scientific and clinical communities with a comprehensive assessment of language processes.

The lack of neurocognitive instruments for the assessment of language can compromise the diagnostic and therapeutic efficacy of the health system as a whole. The detailed and specific assessment of language impairment together with clinical observation contribute significantly to diagnostic precision, especially when dealing with neurological conditions where individual differences can lead to significant variability in task response (Ardila, 2010; Sabe et al., 2006; Vigliecca et al., 2011). When a standardized test is included as part of an assessment battery, its psychometric properties must be studied, as these will guide the assessment process and contribute to the interpretation of quantitative and qualitative data obtained. Therefore, it is important to consider psychometric properties pertaining to standardization, reliability and validity when selecting assessment instruments (Mitrushina, Boone, Razani, & D’Elia, 2005; Murray & Coppens, 2012). A number of studies have produced language assessment instruments with adequate reliability and validity (see Salter et al., 2006; Strauss, Sherman, & Spreen, 2006 for a review). Some of the instruments for which psychometric data are available include the BDAE (Goodglass & Kaplan, 1972), the Minnesota Test for Differential Diagnosis of Aphasia (Schuell, 1965), the Western Aphasia Battery (WAB; Kertesz, 1982), the Aachener Aphasie Test (Wilmes, Poeck, Weniger, Huber, 1980) and the Psycholinguistic Assessment of Language Processing in Aphasia (PALPA; Kay, Lesser, & Coltheart, 1996). The most common sources of evidence of the reliability of language assessment instruments for adults with acquired brain injury include test-retest and internal consistency methods, as well as agreement between judges (Flamand-Roze et al., 2011, Kalbe et al., 2005; Peristeri & Tsapkini, 2011; Shewan & Kertesz, 1980). Validity assessment is usually based on external criteria (Calis et al., 2013; Salter et al., 2006). The literature suggests the use of the BDAE and the WAB as goldstandards to validate language assessment tests. Although the MTL Battery, referred to in the international literature as the Protocole Montr´ealToulouse d’examen linguistique de l’aphasie (MT-86; Nespoulous, Joanette, & Lecours, 1986; Nespoulous et al., 1992), has been increasingly used in aphasiology and neuropsychology, no studies appear to have investigated its reliability and validity. The MTL-BR allows the possibility of analysis of dissociations between different inputs and outputs, and different levels of complexity (B´eland & Lecours, 1990; Parente et al., in

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press). Besides, it is one of the few instruments developed originally in Latin language. Given the many potential contributions of psychometric studies of language assessment batteries to the Brazilian literature, the present study aimed to provide evidence of the reliability and validity of the MTL-BR Battery.

2. Method 2.1. Participants The total sample was composed of 537 participants, of whom 463 were neurologically healthy adults, while 74 had suffered unilateral brain injury. Neurologically healthy participants were recruited through convenience sampling from university, organizational and community environments. All participants were native speakers of Brazilian Portuguese. A total of 308 (66.5%) women and 155 (33.2%) men aged between 19 and 75 years (M = 44.84, SD = 15.12), with complete primary (5–8 years of formal schooling, 33.7%), secondary (9–11 years, 33%) and higher education (12 or more years of education, 33.7%) took part in the study. Exclusion criteria for the control group were the presence of dementia (assessed by the MMSE, Chaves e Izquierdo, 1992 and clock drawing, Juby, Tench, & Baker, 2002), psychiatric diagnoses and neurological lesions (assessed by self-report on a sociocultural and health questionnaire, Fonseca et al., 2012). Exclusion criteria for the study were uncorrected sensory deficits (hearing or visual), current or prior alcohol or drug abuse (based on self-report during interview, Fonseca et al., 2012) and symptoms suggestive of depression (assessed by the Beck Depression Inventory – BDI, Cunha, 2001).

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The clinical group comprised 25 participants with right-hemisphere brain damage (RHD), 21 with lefthemisphere damage (LHD) and aphasia, and 28 patients with ischemic LHD without aphasia, recruited from hospitals and health care centers, and assessed at least one month after suffering a stroke. The majority of participants suffered a single stroke, but 3 participants suffered up to two strokes in the same hemisphere. Participants in the clinical group were aged between 20 and 85 years (M = 58.76, SD = 12.38), and had 2 to 30 years of formal education (M = 9.88, SD = 5.59). Only righthanded patients were included in the clinical group. Clinical participants were screened by the same exclusion criteria applied to the control group, except for the presence of stroke and symptoms of post-stroke depression. All clinical participants had been previously diagnosed with ischemic unilateral strokes, confirmed by neurological examination and computer tomography and/or magnetic resonance imaging. Participants’ sociodemographic and clinical data are displayed in Table 1.

2.2. Procedure and instruments The present study was approved by the Research Ethics Committee of the Pontifical University of Rio Grande do Sul (protocol number 04908/09). All participants or their legal representatives (relatives or caregivers) provided written informed consent prior to study participation. All participants were administered the MTL-BR battery. The main language functions assessed in the present study were: auditory comprehension, oral expression, reading, writing, praxis and arithmetical abilities. Auditory comprehension tasks involved a directed interview consisting of open questions,

Table 1 Socio-demographic and clinical data for participants in each group Participants variables Age Education Sex Female/Male Socioeconomic status MEEM Depression score Rankin Score Time since stroke (months)

Healthy n = 463

Stroke n =74

M (DP)

RHD n = 25 M (DP)

LHD n = 28 M (DP)

Aphasia n = 21 M (DP)

44.84 (15.12) 11.28 (4.44) 308/155 25.81 (6.78) 28.35 (1.69) 0.12 (0.33) – –

59.28 (14.22) 9.12 (5.01) 12/13 24.46 (6.86) 25.17 (3.32) 0.72 (0.84) 1.43 (1.33) 34.65 (40.03)

57.68 (12.48) 10.43 (5.65) 13/15 26.82 (5.76) 25.29 (3.02) 0.39 (0.83) 1.04 (1.08) 27.98 (32.50)

60.35 (10.57) 9.77 (5.71) 8/18 24.05 (6.81) 20.32 (6.75) 0.69 (0.84) 1.16 (1.12) 43.56 (45.37)

Note. RHD = right hemisphere damage; LHDna = left hemisphere damage non-aphasic; MMSE = Mini Mental State Examination; *=≤.05; **=≤0.001.

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the assessment of auditory comprehension of words, sentences and text, and instructions for object manipulation. Oral expression tasks assessed automatic speech, word, pseudoword and sentence repetition, verb and noun naming, oral narrative ability (scene description task) and verbal fluency. Reading subtests consisted of reading aloud words, pseudowords, sentences and numbers, as well as tasks assessing written comprehension of words, sentences and passages. Writing tests involved dictation, sentence copying, a written narrative and written naming (nouns and verbs). Praxis assessment involved spoken instructions for tongue and lip movements provided by the examiner. Arithmetical abilities concerning addition, subtraction, multiplication and division were assessed, as was the resolution of mathematical problems provided verbally and in written form. The battery was administered by trained health professionals with formal experience in the neuropsychology of language. Participants were individually assessed in well-lit, well-ventilated and quiet environments. The psychometric procedures conducted in the present study are described below. 2.2.1. Reliability Internal consistency was assessed with a sample of n = 537 participants, 463 of whom were neurologically healthy adults, while 74 had suffered unilateral stroke (25 RHD, 21 LHD with aphasia and 28 LHD without aphasia). Test-retest reliability was assessed on 71 participants from the initial sample, who were readministered the MTL-BR battery between one and 15 months after the initial assessment (M = 5.41; SD = 2.95). The test-retest sample was composed of individuals aged between 19 and 75 years (M = 41.04; SD = 14.55), of whom 56.3% were female while 43.7% were male. Participants had from 5 to 25 years of formal education (M = 14.65; SD = 4.32). The sociocultural questionnaire (Fonseca et al., 2012) was also readministered before the retest to investigate any changes in sociodemographic or medical characteristics since the initial assessment that could influence performance on the tasks. 2.2.2. Validity Evidence based on relations to other variables (Bornstein, 2011; Messick, 1989) was investigated on a subsample of 70 healthy and 27 clinical participants (11 RHD and 16 LHD without aphasia). As well as being administered the MTL-BR Battery, these participants completed four similar tasks

drawn from other standardized assessment instruments, namely: 1) Brazilian Brief Neuropsychological Assessment Battery – NEUPSLIN (Fonseca et al., 2008, 2009) – brief assessment battery, consisting of 32 subtests. The oral and written language subtests were used in the present study. The oral language subtest involves object and picture naming, word and pseudoword repetition, automatic speech and auditory comprehension of words and sentences. The written language subtest involves word and pseudoword reading, written word and sentence comprehension, as well as copy, spontaneous writing and writing to dictation. 2) Weschler Adult Intelligence Scales - WAIS III (Nascimento, 2004) – Composed of 13 subtests that assess general intellectual abilities (IQ). Subtests can also be grouped according to the cognitive abilities assessed, resulting in the following four indices: Verbal Comprehension (composed of the Vocabulary, Similarities and Information subtests), Perceptual Organization (including picture completion, block design and matrix reasoning tests), Working Memory (containing scores from the arithmetic, digit span and letter-number sequencing tasks) and Processing Speed (digit symbol-coding and symbol search subtests). Scores on the vocabulary and information subtests were used in the present study. 3) Montreal Communication Assessment Battery - MAC (Fonseca et al., 2008). Comprises 14 subtests, assessing lexical-semantic, pragmaticinferential, discursive and prosodic communication. The narrative discourse and semantic (clothing items) and phonemic (letter P) verbal fluency tasks were used in the present study. 4) Brief Montreal Communication Assessment Battery - Brief MAC (Casarin et al., in press). It is composed of 9 subtests, which assess the same constructs as the MAC Battery (Fonseca et al., 2008), as well as reading and writing. The conversational discourse, narrative discourse, reading and writing tasks were used in the present study. 2.3. Statistical analyses Reliability was assessed using Cronbach’s alpha, as recommended for samples assessed at only one point in time (Vogt, 2005). This analysis was only conducted

K.C. Pagliarin et al. / Montreal-Toulouse Language Assessment Battery for aphasia

on MTL-BR tasks with total and subtotal scores, as required for alpha calculation. Test-retest reliability was assessed using Pearson’s correlation coefficients, with years of education as a covariate. This analysis was only conducted on tasks whose scores had a minimum variation of 15%. A complementary repeated measures analysis of variance (ANOVA) was also conducted, with years of education as a covariate. Validity was assessed using Pearson correlations between scores on MTL-BR subtests and total scores in tasks from the MAC and Brief MAC batteries, standardized scores on WAIS III subtests and scores on the language tasks from the NEUPSILIN. Results were considered significant at p ≤ 0.05. Analyses were conducted using the SPSS Software, version 17.0 for Windows (SPSS Inc., Chicago, USA).

Table 3 Pearson correlation coefficients between test and retest scores on the MTL-BR Battery Tasks Auditory comprehension Oral narrative (number of words produced) Oral narrative (information units) Oral narrative (scene elements) Written comprehension Dictation Reading Semantic verbal fluency Naming Phonemic verbal fluency Written Naming Oral text comprehension Written narrative (number of words produced) Written narrative (information units) Written narrative (scene elements) Written text comprehension Calculation ∗∗ p

3. Results Results regarding the reliability of the MTL-BR battery are displayed in Table 2, which contains the internal consistency of the MTL-BR subtests. The high internal consistency, which ranged from 0.79 to 0.91, suggested adequate reliability. Test-retest reliability was assessed on the control group, and significant results were obtained for most of the tasks, except for the auditory text comprehension (Table 3). It is important to note that a ceiling effect was observed in scores on the directed interview, automatic speech (form and content), sentence copying, repetition, praxis, object manipulation, auditory comprehension (parts of the body and right-left orientation), number dictation and reading. Over 90% of the sample obtained the maximum score on these tasks, so that scores did not have the minimum variability (15%) required for test-retest analyses. Table 4 presents the results of test-retest analyses for the MTL-BR Battery. Table 2 Cronbach’s alpha for the MTL-BR Battery Tasks1 Auditory comprehension Written comprehension Repetition Reading Naming Written Naming Calculation

Cronbach’s Alpha 0.791 0.800 0.887 0.907 0.856 0.856 0.888

1 Only tasks with subtotal and total scores were selected for the present

analysis.

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r 0.499** 0.500** 0.521** 0.300* 0.601** 0.708** 0.437** 0.594** 0.939** 0.611** 0.775** 0.222 0.624** 0.515** 0.381** 0.290* 0.399**

≤ 0.001, ∗ p ≤ 0.05.

The analysis of variance (Table 4) controlled for a significant effect of education on scores on the oral narrative task (scene elements), praxis, object manipulation, number dictation and number reading. As expected, there were no statistically significant differences between test and retest scores on most tasks. Significant differences were observed in only five of the 22 tasks, namely: repetition, praxis, object manipulation, number dictation and number reading. However, there was very little variability in test and retest scores on these tasks. Moderate to strong correlations, ranging from 0.33 to 0.71, were found between scores on the MTL-BR Battery and on the other language tests administered (Table 5). Due to the low variability in scores on the oral and written naming tests from the NEUPSILIN battery, these tasks could not be included in the analyses. Scores on the praxis, object manipulation, number reading, number dictation, and parts of the body and right-left orientation tasks from the MTL-BR Battery were not analyzed for correlations with other instruments, due to low score variability, and a lack of similar instruments with which to correlate performance data. 4. Discussion The MTL-BR battery had adequate reliability and validity for the neuropsychological assessment of adults with language impairment. The instrument had satisfactory internal consistency and test-retest reliability, as well as adequate correlation with similar instruments.

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K.C. Pagliarin et al. / Montreal-Toulouse Language Assessment Battery for aphasia Table 4 Analysis of variance of test-retest scores on the MTL-BR Battery

Tasks

Directed interview Automatic speech (form) Automatic speech (content) Auditory comprehension Oral narrative (number of words produced) Oral narrative (information units) Oral narrative (scene elements) Written comprehension Sentence copying Dictation Repetition Reading Semantic verbal fluency Praxis Naming Object manipulation Phonemic verbal fluency Written Naming Oral text comprehension Number dictation Number reading Written narrative (number of words produced) Written narrative (information units) Written narrative (scene elements) Written text comprehension Calculation

Within-groups repeated measures

Education

Test Mean (SD)

Retest Mean (SD)

F

p

F

p

25.94 (0.29) 5.94 (0.23) 5.94 (0.23) 18.61 (0.80) 59.46 (26.52) 7.03 (1.79) 2.31 (0.73) 12.92 (0.33) 7.94 (0.23) 21.39 (1.20) 32.87 (0.41) 32.82 (0.46) 26.01 (6.36) 23.82 (0.66) 29.75 (0.73) 15.96 (0.26) 19.44 (5.52) 29.62 (1.09) 8.24 (1.02) 5.97 (0.17) 6.00 (0.00) 41.01 (18.02) 6.52 (2.25) 2.29 (0.75) 8.68 (0.58) 11.14 (1.42)

25.97 (0.17) 594 (0.23) 600 (0.23) 1863 (0.72) 5745 (25.75) 748 (1.86) 2.51 (0.69) 12.96 (0.26) 7.94 (0.29) 21.51 (1.05) 32.96 (0.26) 32.79 (0.63) 25.58 (6.76) 24.00 (0.00) 29.86 (0.46) 16.00 (0.00) 20.39 (6.14) 29.58 (1.20) 8.17 (1.07) 5.99 (0.12) 5.99 (0.12) 42.90 (18.30) 6.91 (2.27) 2.42 (0.73) 8.69 (0.62) 11.04 (1.46)

0.044 0.357 0.020 2.529 0.007 0.128 2,594 2,562 0,214 1,173 2,302 0,016 2,460 6,460 0,183 5,331 0,050 0.008 3,274 7,662 7,662 2,791 0,370 0,259 2,392 0,224

0.83 055 089 012 093 0.72 0.11 0.11 0.64 0.28 0.03 0.90 0.12 0.01 0.67 0.02 0.82 0.91 0.08 0.01 0.01 0.09 0.54 0.61 0.13 0.63

0.153 0.379 0.130 2.426 0.068 0.839 2,594 1,721 0,227 0,613 1,344 0,055 3,187 4,105 0,630 4,146 0,034 0.001 3,054 6,727 6,727 2,107 0,992 0,023 2,400 0,422

0.69 054 072 012 079 072 0.11 0.19 0.63 0.44 0.25 0.81 0.08 0.05 0.43 0.05 0.85 0,981 0.08 0.01 0.01 0.15 0.32 0.88 0.13 0.52

Reliability results were consistent with expectations for this type of instrument, with coefficients above 0.80, which are considered satisfactory (Enderby, Wood, Wade, & Langton, 1987; Sabe et al., 2008; Shewan & Kertesz, 1980; Vigliecca et al., 2011). As in the Boston Diagnostic Aphasia Examination (Goodglass, Kaplan, & Barresi, 2001), alpha coefficients for subtest scores in the MTL-BR were over 0.85, except for scores on the auditory and written comprehension tests (≤0.80). Test-retest reliability for language assessment instruments is usually assessed on clinical samples (Kalbe et al., 2005; Sabe et al., 2008; Shewan & Kertesz, 1980; Romero et al., 2012; Walker & Schwartz, 2012), and correlations between test and retest scores are high and significant (r > 0.65). The test-retest validity of the MTL-BR was assessed on a control sample, and most correlations were only moderate in strength. The difference in correlation strength may be due to the low score variability reported in the present study. Since the MTL-BR battery was developed to assess neurological samples, its tasks may be too easy for healthy control subjects, which exhibit a ceiling effect on most language tasks (Vigliecca et al., 2011). Furthermore, although mean scores were higher at retest (Table 4),

this increase was not significant. These results suggest that scores on the MTL-BR battery do not change significantly over time. The number of years of education moderated the correlation between test and retest scores, and therefore, was controlled in all statistical analyses, since participants with more years of schooling had a more significant learning effect between test and retest (Delaney, Prevey, Cramer, & Mattson, 1992). Correlation coefficients for external validity were moderate to significant for most tasks. However, a few surprising correlations were found. Scores on the MTLBR written comprehension task correlated with the oral rather than the written comprehension test from the NEUPSILIN battery. This unexpected finding suggests that performance in both tests relies largely on comprehension skills. Similarly, the total number of information units recalled in the oral narrative task displayed the highest correlation with the vocabulary subtest of the WAIS-III. Although this can be explained by the fact that the vocabulary task also assesses verbal comprehension (Nascimento, 2004) and semantic memory (Arroyo-Anll´o, Lorber, Rigaleau, & Gil, 2012; Rogers, Ivanoiu, Patterson, & Hodgers, 2006), it was expected that the oral narrative task from the MTL-BR

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Table 5 Pearson correlation coefficients between performance in the MTL-BR and in other assessment instruments MTL-BR

Tasks from other instruments

Directed interview (/26)

Conversational discourse - Brief MAC (/42) Conversational discourse (comprehension score) - Brief MAC (/8) Auditory comprehension - NEUPSILIN (/3) Written comprehension - NEUPSILIN (/3) Vocabulary - WAIS-III (/19) Narrative discourse essential information - MAC (/18) Narrative discourse total information - MAC (/29) Narrative discourse essential information - Brief MAC (/11) Narrative discourse total information - Brief MAC (/17) Narrative discourse total information - MAC (/29) Narrative discourse essential information - MAC (/18) Narrative discourse total information - Brief MAC (/17) Narrative discourse essential information - Brief MAC (/11) Information - WAIS-III (/19) Auditory comprehension - NEUPSILIN (/3) Dictation - NEUPSILIN (/12) Dictation - Brief MAC (/5) Semantic verbal fluency - MAC Phonemic verbal fluency - MAC Phonemic verbal fluency - MAC Semantic fluency - MAC Narrative discourse questions - MAC (/12) Narrative discourse questions - Brief MAC (/12) Full retelling - MAC (/13) Vocabulary - WAIS-III Narrative discourse essential information - MAC (/18) Narrative discourse total information - MAC (/29) Narrative discourse essential information - Brief MAC (/11) Narrative discourse total information - Brief MAC (/17) Narrative discourse total information - MAC (/29) Narrative discourse essential information - MAC (/18) Narrative discourse essential information - Brief MAC (/11) Information - WAIS-III Reading (comprehension) - Brief MAC (/8)

Auditory comprehension (/19) Oral narrative (information units) (/10)

Oral narrative (scene elements) (/3)

Written comprehension (/13) Dictation (/22) Semantic verbal fluency Phonemic verbal fluency Oral text comprehension (/9)

Written narrative (information units) (/10)

Written narrative (scene elements) (/3)

Written text comprehension (/9)

r 0.368* 0.404** 0.389** 0.377** 0.428** 0.371* 0.334* 0.367* 0.388* 0.324* 0.315* 0.327* 0.348* 0.374* 0.402** 0.715** 0.559** 0.670** 0.583** 0.600** 0.370* 0.250* 0.460** 0.325* 0.373* 0.422** 0.427** 0.363 0.327* 0.344* 0.312* 0.291* 0.396** 0.330*

Note: **≤0.001, *≤0.05; Maximum scores are presented next to the name of each instrument.

would correlate most strongly with the total information contained in responses to the narrative discourse task from the MAC/brief MAC batteries. The number of picture elements recalled in the oral and written narrative tasks correlated most highly with the information subtest of the WAIS-III, as both tasks demanded semantic memory. The demand for standardized language assessment instruments that allow for diagnostic and prognostic classification of aphasia across different sociocultural settings has been observed in scientific publications related to health and education in Brazil as well as in many Hispanic countries (Rey et al., 2001; Vigliecca et al., 2011). The limited availability of standardized assessment instruments can have a negative impact on patient assessment and, consequently, on the development of health intervention programs. Furthermore, a lack of standardized instruments prevents comparative analyses between populations (Sabe et al., 2008).

Only a few subtests from the MTL-BR could be correlated with scores on other assessment instruments, since, to the authors’ knowledge, there is no goldstandard among language assessment instruments in Brazil to evaluate all processes investigated by the MTL-BR. The low score variability in the tasks used in the present study may have negatively influenced the results obtained, as tests such as the NEUPSILIN are quite short and designed for clinical samples, so that they become quite easy for control subjects. Although the present study was conducted on a hybrid sample (composed of healthy and clinical subjects), participants in the clinical group did not have significant language impairment. Clinical participants were purposely limited to individuals with mild expression and comprehension problems, as these participants would still be able to respond to all formal tasks, but would also help to indicate whether the MTL-BR battery was sensitive enough to detect mild to moderate aphasia.

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K.C. Pagliarin et al. / Montreal-Toulouse Language Assessment Battery for aphasia

The present results suggested that the MTL-BR battery is applicable to the Brazilian population, and has adequate validity and reliability for the detection of aphasia. It is suggested that future sensitivity and specificity studies assess the psychometric properties of the MTL-BR using methods based on classical psychometry. There is also a need for studies based on item response theory, due to its applicability to shorter assessment instruments with large variability in scores, and to cases such as the present study, where a ceiling effect is observed in participants who are not part of the target clinical population which, in this case, is composed of patients with aphasia. Acknowledgments The authors thank CNPq and CAPES, whose scholarships contributed to the development of this manuscript. Declaration of interests The authors declare no conflict of interest. References Ardila, A. (2010). A proposed reinterpretation and reclassification of aphasic syndromes. Aphasiology, 24, 3, 363-394. Arroyo-Anll´o, E. M., Lorber, M., Rigaleau, F., & Gil, R. (2012). Verbal fluency in Alzheimer’s disease and aphasia. Dementia, 11, 5-18. Bertolucci, P. H. F., Okamoto, I. H., Bruki, S. M. D., Siviero, M. O., Neto, J. T., & Ramos, L. R. (2001). Applicability of the CERAD neuropsychological battery to Brazilian elderly. Arquivos de Neuro-Psiquiatria, 59, 532-536. B´eland, R., & Lecours, A. R. (1990). The MT-86 Aphasia Battery: A subset of normative data in relation to age and level of school education. Aphasiology, 4, 439-462. Bornstein, R. F. (2011). Toward a process-focused model of test score validity: Improving psychological assessment in science and practice. Psychological Assessment, 23, 532-544. Calis, F. A., On, A. Y., & Durmaz, Z. (2013). Validity and reliability of a new test for Turkish-speaking aphasic patients: Ege Aphasia Test. NeuroRehabilitation, 32, 157-163. Casarin, F. S., Fonseca, R. P., Parente, M. A. M. P., Cˆot´e, H., Ska, B., Ferre, P., & Joanette, Y. (in press). Bateria Montreal de Avaliac¸a˜ o da Comunicac¸a˜ o - vers˜ao abreviada - Bateria MAC Breve. S˜ao Paulo, Brasil: Pr´o-Fono. Chaves, M. L., & Izquierdo, Y. (1992). Differential diagnosis between dementia and depression: A study of efficiency increment. Acta Neurologica Scandinavia, 85, 378-382. Cunha, J. A. (2001). Escalas Beck. Casa do Psic´ologo, S˜ao Paulo. Brasil. Delaney, R. C., Prevey, M. L., Cramer, J., & Mattson, R. H. (1992). Test-retest comparability and control subject data for the Rey-Auditory Verbal Learning Test and Rey-Osterrieth/Taylor

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Montreal-Toulouse language assessment battery for aphasia: validity and reliability evidence.

In Brazil, no standardized instruments are available to assess language in patients with aphasia...
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