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Psychometric Properties of the Taiwanese (Traditional Chinese) Version of the Frontal Assessment Battery: A Preliminary Study a

b

Tzu-Lan Wang , Yi-Hsiang Hung & Chi-Cheng Yang

b

a

Department of Neurology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan b

Division of Clinical Psychology, Master of Behavioral Science, Department of Occupational Therapy, College of Medicine, Chang-Gung University, Taoyuan, Taiwan Published online: 21 May 2015.

To cite this article: Tzu-Lan Wang, Yi-Hsiang Hung & Chi-Cheng Yang (2015): Psychometric Properties of the Taiwanese (Traditional Chinese) Version of the Frontal Assessment Battery: A Preliminary Study, Applied Neuropsychology: Adult, DOI: 10.1080/23279095.2014.995792 To link to this article: http://dx.doi.org/10.1080/23279095.2014.995792

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APPLIED NEUROPSYCHOLOGY: ADULT, 0: 1–10, 2015 Copyright # Taylor & Francis Group, LLC ISSN: 2327-9095 print/2327-9109 online DOI: 10.1080/23279095.2014.995792

Psychometric Properties of the Taiwanese (Traditional Chinese) Version of the Frontal Assessment Battery: A Preliminary Study Tzu-Lan Wang

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Department of Neurology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan

Yi-Hsiang Hung and Chi-Cheng Yang Division of Clinical Psychology, Master of Behavioral Science, Department of Occupational Therapy, College of Medicine, Chang-Gung University, Taoyuan, Taiwan

The Frontal Assessment Battery (FAB) is commonly used to evaluate executive functions. Although psychometric properties have been examined in Western studies, data on the FAB in Eastern societies are limited. This study thus aims to examine psychometric properties of the Taiwanese FAB (TFAB). A total of 301 healthy participants were recruited. All participants were evaluated with the TFAB. Thirty participants were retested 3 months after the 1st examination for test–retest reliability. The Verbal Fluency Test was used for criterion-related validity. Although the TFAB had an unacceptable Cronbach’s alpha, its test–retest reliability was good. The criterion validity was also good, while the factor analysis revealed that the TFAB may be represented as a 2-factor or 3-factor structure. The TFAB score was significantly associated with age and education level. This study comprehensively re-examined the psychometric properties of the TFAB for Chinesespeaking people, and it merited more validations for the TFAB with clinical samples in the future.

Key words:

Frontal Assessment Battery, psychometric properties, Taiwan, Traditional Chinese

INTRODUCTION For the past three decades, executive function has been viewed as a rubric concept (Baddeley, 1986; Norman & Shallice, 1986). There is still no complete definition for executive function; however, in clinical terms, it is usually understood as an ability that involves four major components: volition, planning, purposive actions, and effective performances (Lezak, Howieson, & Loring, 2004). Much of the literature (Cummings, 1993; Fuster, 2000; Godefroy, 2003) provides evidence for a strong connection between Address correspondence to Chi-Cheng Yang, Ph.D., Division of Clinical Psychology, Master of Behavioral Science, Department of Occupational Therapy, College of Medicine, Chang-Gung University, No. 259, Wen-Hua 1st Rd., Taoyuan City, Taiwan. E-mail: ccyang@ mail.cgu.edu.tw

executive function and the frontal lobe. Indeed, many neurological diseases associated with frontal lesions may result in profound impairments in executive function (Brandt et al., 2008; Chow & Cummings, 1999; Ciaramelli, Serino, Di Santantonio, & Ladavas, 2006; Levin, Goldstein, Williams, & Eisenberg, 1991; McKinlay, Grace, Dalrymple-Alford, & Roger, 2010). In cases of severe traumatic brain injury that involve frontal-lobe damage, cognitive abnormalities may occur such as perseveration in thoughts or responses (common manifestations of executive dysfunction). Alternatively, neurodegenerative diseases such as Huntington disease or Parkinson disease cause profound impairments in logical reasoning and mental flexibility due to lesions affecting the frontal-subcortical circuitry. Many studies (Ponsford, 1995; Varney & Menefee, 1993; Wood & Liossi, 2006) have also highlighted executive dysfunction as one of

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WANG, HUNG, & YANG

the most important factors contributing to patients’ lifetime disability. Because neurobehavioral disturbances related to executive dysfunction are frequently observed following frontal-lobe lesions, a wide variety of instruments for measuring executive function have been developed (Dubois, Slachevsky, Litvan, & Pillon, 2000; Heaton, 1981; Luria, 1966; Nelson, 1976; Reitan & Wolfson, 1985; Royall, Mahurin, & Gray, 1992; Shallice, 1982; Wilson, Alderman, Burgess, Emslie, & Evans, 1996). In general, these methods can be divided into three categories. Firstly, a “comprehensive assessment” usually evaluates multiple aspects of executive function in a single neuropsychological test battery. For example, the Behavioral Assessment of the Dysexecutive Syndrome (Wilson et al., 1996), one of the most popular instruments for examining executive function, consists of six subtests that cover diverse aspects of executive function. Secondly, a “specific assessment” is usually aimed at testing only one aspect of executive function (rather than providing a comprehensive examination of overall executive function). The Wisconsin Card-Sorting Test (WCST; Heaton, 1981), a representative instrument that mainly evaluates two major components of executive function—conceptual formation and mental shifting—provides an example of a specific assessment method. Thirdly, a screening test such as the Frontal Assessment Battery (FAB; Dubois et al., 2000) usually aims to provide a more efficient evaluation of executive function. This type of test usually takes only a few minutes and provides an initial glance regarding the potential severity of executive dysfunction. Although the FAB was developed primarily for screening purposes, previous studies (Dubois et al., 2000; Kim et al., 2010; Kugo et al., 2007; Mok et al., 2004) have revealed its utility for evaluating the extent of executive dysfunction in patients with frontal injuries or neurodegenerative diseases. Indeed, the FAB has significant advantages for providing an efficient and effective assessment of executive function. Firstly, the FAB saves time; compared with specific tests or neuropsychological test batteries of executive function, the FAB can be performed in 10 min to 15 min, resulting in significant reductions of clinicians’ time loadings. Secondly, the FAB is a multidomain test that examines six aspects of executive function, including conceptualization, mental flexibility, motor programming, sensitivity to interference, inhibitory control, and environmental autonomy. Moreover, these six domains encompass almost each component of executive function (Dubois et al., 2000). Unfortunately, the psychometric properties of the FAB are only available from limited studies undertaken in different cultural populations (Appollonio et al., 2005; Dubois et al., 2000; Kim et al., 2010; Kugo et al., 2007; Lima, Meireles, Fonseca, Castro, & Garrett, 2008; Mok et al., 2004). For example, the internal consistency of the FAB

has been evidenced as fair (Dubois et al., 2000) when evaluating a larger sample of patients with frontal lesions. A recent study from Japanese researchers (Nakaaki et al., 2007) revealed that the internal consistency of the FAB was also fair when examining patients with frontotemporal dementia. In an Italian population, Appollonio et al. (2005) recruited 364 healthy participants who were aged 20 to 94 years old. The investigators showed that the test–retest reliability of the FAB was good, and they tried to establish a clinical cutoff score adjusted by age and education level. Contrasting with the Western studies, only a few researchers have tried to examine performance on the FAB for Chinese people—who make up approximately 20% of the world’s population. For example, Mok et al. (2004) compared performance on the FAB between 30 patients with small subcortical infarcts and 40 healthy participants and found the FAB had good reliability and was well correlated with specific tests of executive function. Recently, Chong et al. (2010) further compared 80 participants who suffered from mild cognitive impairment to 100 healthy participants and developed age- and education-adjusted cutoff points of the FAB score for clinical use. Even though the clinical feasibility of the FAB has been examined in those studies, the psychometric properties were still questionable. Obviously, even though the FAB has been evidenced as an appropriate instrument for assessing executive function, the cultural differences in the various societies with Chinese-speaking people (e.g., Singapore, Hong Kong, Taiwan, and China) may influence performance on the FAB. Thus, the need to develop a Taiwanese version of the FAB is still necessary. Before establishing the normative data for the Taiwanese population, the present study was therefore undertaken to preliminarily examine the psychometric properties of the Taiwanese (Traditional Chinese) version of the FAB (TFAB). In addition, the study was performed with the following two specific objectives: (a) to examine psychometric properties including the reliability and validity of the TFAB; and (b) to explore the associations between scores of the TFAB and demographic variables (including gender, age, and number of years of formal education). METHODS Participants A total of 301 healthy participants (176 women and 125 men) aged 15 to 86 years old and who had received formal education for 0 to 16 years were recruited in this study. All participants were community-dwelling (the recruitment information was posted on the bulletin board in the community recreational areas, exercise centers, etc.) and lived independently, either working, studying, or otherwise engaged in community-based activities. Consent was obtained for all participants after they had

TAIWANESE FRONTAL ASSESSMENT BATTERY

3

TABLE 1 Number of Participants in Each Group Subdivided by Age and Formal Education Years Formal Education Years 0

1–6

7–9

10–12

13

Total

0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (0.33%) 16 (5.32%) 17 (5.65%)

0 (0.00%) 0 (0.00%) 1 (0.33%) 1 (0.33%) 3 (1.00%) 24 (7.97%) 26 (9.63%)

0 (0.00%) 0 (0.00%) 3 (1.00%) 3 (1.00%) 8 (2.66%) 8 (2.66%) 22 (7.31%)

12 (3.99%) 0 (0.00%) 4 (1.33%) 4 (1.33%) 17 (5.65%) 13 (4.32%) 50 (16.61%)

12 (3.99%) 73 (24.25%) 26 (8.64%) 26 (8.64%) 28 (9.30%) 18 (5.98%) 183 (60.80%)

24 (7.97%) 73 (24.25%) 34 (11.30%) 34 (11.30%) 57 (18.94%) 79 (26.25%) 301 (100%)

Age (Years)

15–19 20–29 30–39 40–49 50–59

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≥60 Total

been informed of the study rationale and its purposes. The study protocol was in compliance with the Helsinki Declaration of ethical principles for medical research involving human participants (World Medical Association, 2008). According to the census data from the annual national statistics of “the age distribution of the population” and “the formal education level above the age of 15” (Ministry of the Interior, 2011), participants were subdivided into eight age groups (15–19 years, 20–29 years, 30–39 years, 40–49 years, 50–59 years, 60–69 years, 70–79 years, and 80–89 years); meanwhile, five educational level groups (0 years, 1–6 years, 7–9 years, 10–12 years, and more than 13 years) were subdivided following the present education system in our country (Table 1). Based on this subdividing procedure, no participants were recruited in some specific groups (e.g., groups of 0 formal education years aged 15–49 years old) because the 9-year universal compulsory education began almost five decades ago in our country. Before administering the TFAB, medical and demographic information were evaluated by a brief semistructured interview, and individuals who voluntarily reported the following conditions were excluded from the study: (a) those with a history of head injuries, psychiatric illnesses,

or other diseases of the central nervous system; and (b) those taking antidepressants (of any type), antipsychotics, or sedative drugs. However, older participants who may have been suffering from various latent diseases, such as hypertension, diabetes mellitus, or mild cardiovascular disease, were not excluded because these diseases are prevalent in the elderly population of Taiwan. Participants’ age, education, and their scores on the TFAB are shown in Table 2. Measures TFAB. With the agreement of the investigators who developed the FAB (Dubois et al., 2000), this test battery was translated into Taiwanese (Traditional Chinese). The translation process followed the “back-translation” method. Firstly, the original FAB, which includes the instructions and the answer sheets, was translated into Taiwanese. The translated Taiwanese version of the FAB was edited by an expert in clinical neuropsychology and a Taiwanese expert in English translation. After editing, this Taiwanese version of the FAB was translated again into an English version, which was further verified by the author of the original FAB. Based on this translation process, the final version of the TFAB was developed.

TABLE 2 All Participants’ Age, Education, and Scores on the TFAB (N ¼ 301) TFAB Scores Age (Years) Median Mean (Standard Deviation)

— 44.58 (19.01)

Education (Years) — 12.84 (4.47)

Total

CON

MF

MP

SI

IC

EA

16.00

2.00

2.00

3.00

3.00

3.00

3.00

14.89 (2.75)

1.73 (1.00)

2.13 (0.91)

2.84 (0.53)

2.78 (0.58)

2.44 (0.91)

2.97 (0.27)

TFAB ¼ Taiwanese version of the Frontal Assessment Battery; N ¼ number of participants; CON ¼ score of the Conceptualization subtest; MF ¼ score of the Mental Flexibility subtest; MP ¼ score of the Motor Programming subtest; SI ¼ score of the Sensitivity to Interference subtest; IC ¼ score of the Inhibitory Control subtest; EA ¼ score of the Environmental Autonomy subtest.

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WANG, HUNG, & YANG

Similar to the original FAB, the TFAB consists of six subtests (only a single item in each subtest), which include Conceptualization (CON), Mental Flexibility (MF), Motor Programming (MP), Sensitivity to Interference (SI), Inhibitory Control (IC), and Environmental Autonomy (EA). The CON subtest mainly examines the ability of verbal abstraction; participants have to conceptualize the links between two objects from the same category. The MF subtest mainly evaluates the ability of productivity; in a 1-min trial, participants are required to recall as many words as they can that begin with a given Chinese orthographical feature (such as a word with the left-right orthographical pattern). The MP subtest examines the ability of temporal organization, maintenance, and executive functioning related to successive actions, based on Luria’s motor series (Luria, 1966). The SI subtest examines the ability to reconcile conflicting information; participants are required to provide an opposite response to the examiner’s alternating signal. The IC subtest mainly evaluates the ability to withhold inappropriate responses; participants must inhibit responses that have already been given in a prior occurrence of the same stimulus. The EA subtest examines the spontaneous tendency to adhere to environmental stimuli. In this subtest, the examiner touches both palms of the participant’s hands to see if the participant spontaneously takes the examiner’s hands. Overall the TFAB score varies from 0 to 18; the score of each subtest ranges from 0 to 3 (a score of 0 indicates that the participant has failed to give an answer or has responded inappropriately). The administration time of the TFAB is approximately 15 min. Semantic association of the Verbal Fluency Test (Hua, Chang, & Chen, 1997). To examine the criterion-related validity of the TFAB, the Verbal Fluency Test (VFT) was performed. This test consists of the following three semantic categories: fruit, fish, and vegetables. Participants were asked to report as many items within a category as possible in 1 min. Scoring was based on summation of correct responses in the three categories. Evidence has

highlighted this ability of semantic fluency as one of the most important domains of executive function (Troyer, 2000; Troyer, Moscovitch, & Winocur, 1997) and has also shown (Henry & Crawford, 2004) that patients with frontal lesions have significantly poor performance on this test. Data Analysis For the item-level analysis, the Pearson correlation was used to determine the association between individual subtest scores and the total score of the TFAB. If the correlation coefficient between the scores of each subtest and the total score of the TFAB was lower than .30, that subtest might be considered unacceptable for the TFAB. The Cronbach’s a and test–retest reliability were used to evaluate the reliability of the TFAB. In addition, three aspects of validity were analyzed. Firstly, the Pearson correlation was used to evaluate the association between the TFAB and the VFT to assess concurrent validity. Secondly, the significance of differences across the eight age groups was analyzed to examine the construct validity of the TFAB. Finally, an exploratory factor analysis (EFA) was undertaken to determine the factor structure of the TFAB. Factor loadings were estimated with the principal axis method, and the factor structure was rotated by the Promax method. Factor numbers were primarily chosen according to the theoretical construct of the FAB (Dubois et al., 2000). If the factor loadings of individual subtests were greater than .40, they were then designated on the specific factor. Statistical significance was defined at p < .05. The commercially available software package Statistical Package for the Social Sciences Version 19.0 was used for statistical analyses.

RESULTS Item Analysis Our results (Table 3) show that the associations between the scores of six individual subtests and the total score of

TABLE 3 Pearson Correlation Between the Scores of Individual Subtests and the Total Score of the TFAB TFAB

Total

CON

MF

MP

SI

IC

EA

AGE

EDU

Total CON MF MP SI IC EA AGE EDU

1 .74** .58** .62** .61** .79** .30** .59** .71**

1 .30** .32** .33** .41** .07 .49** .57**

1 .13* .11 .29** .01 .27** .33**

1 .34** .53** .20** .35** .45**

1 .44** .30** .31** .49**

1 .20** .52** .58**

1 .11 .12*

1 .56**

1

TFAB ¼ Taiwanese version of the Frontal Assessment Battery; CON ¼ Conceptualization; MF ¼ Mental Flexibility; MP ¼ Motor Programming; SI ¼ Sensitivity to Interference; IC ¼ Inhibitory Control; EA ¼ Environmental Autonomy; EDU ¼ Formal education years. *p < .05. **p < .01.

TAIWANESE FRONTAL ASSESSMENT BATTERY

the TFAB were significantly correlated (the correlation coefficient is ranging from .30 ~ .79).

TABLE 4 Two-Factor Structure of the TFAB TFAB

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Reliability According to the guidelines (Cicchetti, 1994; Cicchetti & Sparrow, 1990) of the clinical significance for the internal consistency of a given psychological assessment instrument, the results show that the internal consistency of the TFAB total score seems to be unacceptable (Cronbach’s a ¼ .68). However, if the EA subtest, which was not significantly correlated with the other two subtests (Table 3), was removed from the TFAB, the internal consistency of this five-subtest TFAB would be fair (Cronbach’s a ¼ .70). In addition, the test–retest reliability of the TFAB—revealed by the Pearson correlation between two evaluations (mean period between these evaluations ¼ 95.87 days) for 30 participants selected randomly from the original sample—was good for the total score of the TFAB (r ¼ .88, p < .001). Validity The Pearson correlation showed a significant association between the total score of the TFAB and the score of the VFT (r ¼ .38, p < .001). After the Bonferroni correction, the p value was set at < .008 for multiple comparisons when analyzing the correlation between the score of the VFT and one of each subtest in the TFAB. The associations between three subtests of the TFAB and the VFT are significant (CON, r ¼ .29, p < .001; MF, r ¼ .40, p < .001; IC, r ¼ .22, p < .001), whereas the score of the VFT and the scores of the EA subtest (r ¼ –.01, p ¼ .849), MP subtest (r ¼ .13, p ¼ .028), and SI subtest (r ¼ .12, p ¼ .049) were not significantly correlated. This result represented acceptable concurrent validity of the TFAB. Because previous studies (Troyer et al., 1997) have indicated that frontal lobe-dependent functions may deteriorate with the normal aging process, we therefore examined the Pearson correlation between age and the total TFAB score; the analyses revealed a significantly negative association for these two variables (r ¼ –.54, p < .001). This result, which revealed that the older participants may have a lower TFAB total score, also represented good construct validity of the TFAB. Because the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy (KMO ¼ .73) and the Bartlett’s test of sphericity (v2 ¼ 310.10, p < .001) are acceptable, the factor analysis of the TFAB was then analyzed. The specific factors were extracted following the rule of “eigenvalues greater than 1” (Kaiser, 1960). In addition, according to the original theoretical basis of the FAB, the EFA with principal axis extraction of factors presented a two-factor structure (Table 4), which explained 37.09% of the variance. Rotated pattern matrix factor loadings showed that the CON, MF, and IC subtests were designated to Factor 1 (30.93% of the variance) and the SI, EA, and MP subtests

5

Cognitive Control

Behavioral Control

.63 .62 .50 .02 .29 .23

.27 .01 .35 .63 .63 .42

Mental Flexibility Conceptualization Inhibitory Control Sensitivity to Interference Environmental Autonomy Motor Programming

Note. The bolded text represents those TFAB subtests belong to the specific factors. TFAB ¼ Taiwanese version of the Frontal Assessment Battery.

were designated to Factor 2 (6.16% of the variance). In addition, a three-factor structure (Table 5), which was able to explain 43.98% of the variance, was also explored in this study. Rotated pattern matrix factor loadings showed that the SI and EA subtests were designated to Factor 1 (32.31% of the variance), the CON and MF subtests were designated to Factor 2 (7.15% of the variance), and ‘the MP and IC subtests were designated to Factor 3 (4.53% of the variance). Demographic Variables and Scores of the TFAB (Tables 6 and 7) The Pearson correlation showed that both age (r ¼ –.54, p < .001) and educational level (r ¼ .65, p < .001) were significantly associated with the total TFAB score, whereas there was no significant association between gender and the total TFAB score (r ¼ –.10, p ¼ .105). The one-way analysis of variance was further used to analyze differences in total TFAB scores between age and educational-level subgroups. The results showed that the main effects of both age, F(7, 293) ¼ 29.81, p < .001, and educational level, F(4, 296) ¼ 85.31, p < .001, on total TFAB scores were significant. The post-hoc Scheffe test was subsequently used for pairwise comparisons between age and TABLE 5 Three-Factor Structure of the TFAB

TFAB Sensitivity to Interference Environmental Autonomy Mental Flexibility Conceptualization Motor Programming Inhibitory Control

Automatic Behavioral Control

Cognitive Control

Monitored Behavioral Control

.84

.04

.08

.41 .16 .06 .00 .11

.19 .66 .53 .10 .29

.12 .09 .06 .82 .46

Note. The bolded text represents those TFAB subtests belong to the specific factors. TFAB ¼ Taiwanese version of the Frontal Assessment Battery.

6

WANG, HUNG, & YANG TABLE 6 Scores of the Taiwanese Version of the Frontal Assessment Battery (TFAB) by Age Subgroups TFAB

Age (Years) Subgroups

N

Age (Years)

15–19 20–29 30–39 40–49 50–59 60–69 70–79 80–89

24 73 34 34 57 46 22 11

18.04 24.29 34.00 44.44 54.67 63.71 74.05 81.90

(1.04) (2.52) (2.99) (3.05) (2.90) (3.05) (2.98) (2.17)

Education (Years) 12.04 16.18 14.65 14.41 12.89 10.20 5.71 7.60

Total

(1.16) (1.15) (2.96) (2.80) (3.34) (4.73) (5.54) (4.80)

16.04 16.45 15.88 15.62 15.19 13.13 11.00 10.60

CON

(1.43) (1.34) (1.65) (1.72) (2.18) (2.76) (3.49) (2.54)

2.08 2.34 1.97 1.65 1.75 1.18 .71 .80

MF

(0.72) (0.71) (0.83) (1.10) (0.79) (0.99) (0.88) (0.87)

2.25 2.41 2.35 2.21 2.19 1.64 1.81 1.70

MP

(0.80) (0.74) (0.81) (0.91) (0.93) (0.97) (0.79) (1.01)

2.96 2.95 2.97 3.00 2.95 2.73 2.29 1.80

(0.20) (0.28) (0.17) (0.00) (0.29) (0.71) (0.88) (1.08)

SI 2.92 2.93 2.82 2.97 2.89 2.62 2.10 2.30

(0.28) (0.30) (0.52) (0.17) (0.36) (0.68) (1.07) (1.01)

IC 2.83 2.82 2.76 2.79 2.44 2.02 1.24 1.00

(0.38) (0.45) (0.50) (0.54) (0.85) (1.04) (1.07) (1.10)

EA 3.00 3.00 3.00 3.00 2.96 2.93 2.86 3.00

(0.00) (0.00) (0.00) (0.00) (0.27) (0.44) (0.64) (0.00)

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Note. The score in each cell is the mean, and the standard deviation is in parentheses. N ¼ number of participants; CON ¼ score of the Conceptualization subtest; MF ¼ score of the Mental Flexibility subtest; MP ¼ score of the Motor Programming subtest; SI ¼ score of the Sensitivity to Interference subtest; IC ¼ score of the Inhibitory Control subtest; EA ¼ score of the Environmental Autonomy subtest.

TABLE 7 Scores of the TFAB by Education-Year Subgroups TFAB Education-Year Subgroups 0 1–6 7–9 10–12 >12

N 10 36 22 50 183

Age (Years) 73.00 66.92 55.09 46.46 36.85

(4.37) (1.62) (11.87) (19.27) (15.47)

Education (Years) 0.00 5.42 8.91 11.78 15.77

(0.00) (1.32) (.29) (.58) (1.31)

Total 7.30 11.78 13.64 14.96 16.06

(2.63) (2.10) (2.44) (1.77) (1.75)

CON 0.10 0.69 1.45 1.54 2.11

(0.32) (0.71) (0.80) (0.86) (0.86)

MF 1.80 1.58 1.41 2.02 2.37

(0.92) (0.94) (0.91) (0.82) (0.83)

MP 1.20 2.64 2.77 2.96 2.94

(0.79) (0.72) (0.75) (0.20) (0.30)

SI 1.20 2.36 2.86 2.90 3.91

(1.03) (0.83) (0.35) (0.36) (0.35)

IC 0.30 1.50 2.27 2.54 2.74

(0.68) (1.13) (0.94) (0.76) (0.56)

EA 2.70 3.00 2.86 3.00 2.99

(0.95) (0.00) (0.64) (0.00) (0.15)

Note. The score in each cell is the mean, and the standard deviation is in parentheses. TFAB ¼ Taiwanese version of Frontal Assessment Battery; N ¼ number of participants; CON ¼ score of the Conceptualization subtest; MF ¼ score of the Mental Flexibility subtest; MP ¼ score of the Motor Programming subtest; SI ¼ score of the Sensitivity to Interference subtest; IC ¼ score of the Inhibitory Control subtest; EA ¼ score of the Environmental Autonomy subtest.

FIGURE 1

TFAB score by different age groups.

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TAIWANESE FRONTAL ASSESSMENT BATTERY

FIGURE 2

7

TFAB score by different educational-level groups.

educational-level subgroups. In terms of age, no significant differences were found between the subgroups aged 60 to 69 years, ’70 to 79 years, and ’80 to 89 years. In addition, total TFAB scores for the subgroup aged 60þ years were significantly lower than were those for all other age subgroups. In terms of number of educational years, the TFAB total scores for the subgroup with an educational level of 13þ years were significantly higher than those of the other four educational subgroups. TFAB scores for the subgroups with educational levels of 7 to 9 years and ’10 to 12 years were significantly higher than those of the subgroups with educational levels of 0 years and 1 to 6 years (Figures 1 and 2).

DISCUSSION Psychometric Properties of the TFAB Reliability. The reliability of the TFAB, represented by the internal consistency, was not acceptable. This result was not supported by previous studies (Dubois et al., 2000; Kim et al., 2010). For example, a recent study by Kim et al. (2010), who also examined healthy participants, revealed that the Korean version of the FAB (KFAB) had a good internal consistency (Cronbach’s a ¼ .80). One possible reason, which might account for this controversial finding, is that the EA subtest of the TFAB might not be statistically acceptable for the Taiwanese healthy participants in this study. Actually, the results have shown a remarkable ceiling effect of the score on the EA subtest (M ¼ 2.97, SD ¼ 0.27). This effect reflected that the healthy participants can minimally make any mistakes

on this subtest; hence, the score of EA could not be easily correlated with the scores of other subtests. In fact, when comparing the correlations between the total score of the TFAB and other subtests, the EA seemed to be correlated with the total score of the TFAB at a lower level (r ¼ .30) and could not even be correlated with other two subtests significantly. Indeed, after removing the score of the EA subtest, the internal consistency of the five-subtest TFAB became fair (Cronbach’s a ¼ .70). However, the theoretical basis of the EA subtest has to be carefully considered before deciding its presence on the TFAB. In fact, the EA subtest was designed to examine the problem of environmental dependency, which is not uncommon in patients with frontal lesions (Dubois et al., 2000; Lagarde et al., 2013; Lhermitte, 1986). In an earlier study, Dubois et al. (2000) clearly evidenced that the FAB has a fair internal consistency (Cronbach’s a ¼ .78) in a larger sample of patients with frontal lesions. Hence, to explore different aspects of neurobehavioral dysfunctions after frontal-lobe pathology, the EA subtest in the TFAB might still be needed to reveal specific problems when assessing patients with frontal lesions. On the other hand, the test–retest reliability of the TFAB was good, and this result confirmed the findings of previous studies (Appollonio et al., 2005; Dubois et al., 2000; Kim et al., 2010; Kugo et al., 2007; Mok et al., 2004; Nakaaki et al., 2007). For example, Kim et al. (2010) examined healthy participants to assess the reliability of the KFAB and found good test–retest reliability (r ¼ .82, p < .001). Validity. Three aspects of the validity of the TFAB were examined in this study: concurrent validity, construct validity, and factor structure. The concurrent validity of the

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TFAB was good based on a significant correlation between the TFAB scores and the VFT. This result is consistent with a previous study (Kim et al., 2010), which also showed that the FAB is highly correlated with the VFT. In addition, attempts have been made in other studies to use various tests to verify the validity of the FAB (Dubois et al., 2000; Kugo et al., 2007; Mok et al., 2004; Nakaaki et al., 2007). For example, Kugo et al. (2007) evaluated 105 patients with mixed neurodegenerative diseases and found that the FAB was significantly correlated with the completed categories (r ¼ .65, p < .001) and numbers of perseverative errors (r ¼ –.48, p < .001) in the Keio version of the WCST. The authors of this study therefore concluded that the concurrent validity of the FAB is good. Construct validity was established based on the association between age and the TFAB score in this study. Evidence from several studies (Ardia & Rosselli, 1986; Crawford & Channon, 2002; Mayr, Spieler, & Kliegl, 2001; Mejia, Pineda, Alvarez, & Ardila, 1998) indicates that executive function deteriorates as part of the normal aging process. For example, a study undertaken by Mejia et al. (1998) revealed a significant negative association between age and executive function in healthy participants with ages ranging from 50 years to 85 years. Moreover, Crawford and Channon (2002) compared executive function, measured by the WCST, the Trail-Making Test, and the Dysexecutive Questionnaire, in two groups of healthy participants: one with an age range of 19 to 37 years old and the other with an age range of 60 to 80 years old. The results also showed that the former group outperformed the latter group and confirmed deterioration in executive function that accompanied normal aging. Moreover, our results revealed that the TFAB has good construct validity, given that performance on the TFAB was also found to decrease with age in healthy individuals. In addition to concurrent validity and construct validity, the factor structure of the TFAB was explored in this study. Even though the FAB was developed more than 10 years ago, no previous studies have established its factor structure; we therefore decided to investigate this important aspect in the present study (using the TFAB). These investigations suggested a two-factor and/or a three-factor structure of the TFAB. Assuming a two-factor structure, the first factor is assigned as a “cognitive control” factor, which includes the CON, MF, and IC subtests. Clearly, these three subtests primarily examine abilities related to performing mental operations (such as verbal abstraction and inhibition of inappropriate responses). The other factor is assigned as a “behavioral control” factor, which includes the MP, SI, and EA subtests. These three subtests mainly evaluate the abilities of motor regulation, such as motor sequencing and withholding of automatic movements. Indeed, this structure is well consistent with the theoretical construct of the original FAB proposed by Dubois et al. (2000), which is composed of “cognitive” and “behavioral” aspects

of executive function. Accordingly, the two-factor solution of the TFAB in the present study further confirms this theoretical construct. Interestingly, the three-factor structure explored in this study could reveal more information about the TFAB. Indeed, our results show that a three-factor solution explains more of the variance of the TFAB than does a two-factor solution. Assuming the three-factor structure, the first factor includes the SI and EA subtests, with the second factor including the CON and MF subtests and the third factor including the MP and IC subtests. These three factors appeared to remain consistent with the “cognitive” and “behavioral” dichotomy of the two-factor structure; more importantly, “behavioral control” in the two-factor structure could be further divided into “automatic control” and “monitored control” factors (Table 5). In fact, this differentiation of behavioral control seems to be compatible with the past theoretical concept of executive function proposed by Norman and Shallice (1986). These authors proposed that behaviors are controlled by two major systems, the contention scheduled system (CSS) and the supervisory attention system (SAS). “Automatic behavioral control” is like the CSS, which mainly deals with routine and/or rehearsed behaviors, such as daily conversations or simple problem-solving tasks. On the other hand, “monitored behavioral control” is like the SAS, which mainly relates to behaviors concerned with the novel and/or unexpected, such as setting goals and monitoring. Accordingly, the present study provides clear evidence that the factor structure of the TFAB is closely related to the theoretical background of executive function. Demographic Variables and the TFAB In this study, associations between the TFAB and demographic variables, which mainly included age and educational level, were analyzed. The relationship between age and the TFAB has already been discussed in the section on “Construct Validity.” In terms of educational level, a significant positive association was found between the TFAB score and number of formal educational years; thus, participants with a greater number of educational years obtained higher TFAB scores. Indeed, these results are supported by previous findings (Kim et al., 2010; Lima et al., 2008; Mok et al., 2004). For example, Mok et al. (2004) evaluated Chinese-speaking people in Singapore and found the FAB score of 41 healthy participants (Mage ¼ 69.6 years; Mnumber of educational years ¼ 5.4), and they demonstrated a significant positive correlation between educational level and the FAB score. In a larger sample size (635 healthy participants) with ages ranging from 55 years to 96 years, Kim et al. (2010) demonstrated a striking association between KFAB score and educational level. Accordingly, people with younger age and higher educational level will have a higher total score on the TFAB.

TAIWANESE FRONTAL ASSESSMENT BATTERY

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Limitations Even though psychometric properties for the TFAB have been reexamined and established in this study, some methodological drawbacks may weaken the representativeness of these results. Firstly, to be compatible with the distribution of age and educational levels of the whole population, the participants were subdivided in terms of age and formal education years in this study. Unfortunately, this subdividing procedure made the sample size of some subgroups (e.g., older, less-educated participants) too small to achieve the appropriate representativeness. Secondly, only a single test—the VFT—was used to validate the concurrent validity of the TFAB. Indeed, this test might be associated with semantic abilities, which are more related to temporal-lobe functions (Chertkow & Bub, 1990; Henry & Crawford, 2004). Meanwhile, the scores of the VFT and TFAB would be correlated with age, education, or other general cognitive abilities, which can further confound the association between the scores of the VFT and TFAB. Indeed, because executive functions depend on heterogeneous aspects of cognitive abilities, many other tests, such as the WCST and the Stroop test, could be used as assessment criteria for examining the validity of the TFAB in future studies. In addition, because this study was population-based, studies aimed at further verifying the feasibility of the TFAB in clinical samples were not performed. Future studies based on the cutoff score of the TFAB established in the present study, aimed at examining patients with diseases or injuries to the central nervous system, are therefore warranted.

Conclusions This study aimed to reexamine the psychometric properties for the FAB in Chinese-speaking people. According to our results, the TFAB is mostly acceptable in reliability and validity. In addition, the factor structure of the TFAB was also established. Further studies aimed at obtaining data for the TFAB from clinical populations are now warranted.

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Psychometric Properties of the Taiwanese (Traditional Chinese) Version of the Frontal Assessment Battery: A Preliminary Study.

The Frontal Assessment Battery (FAB) is commonly used to evaluate executive functions. Although psychometric properties have been examined in Western ...
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