Journal of Clinical and Experimental Neuropsychology, 2015 Vol. 37, No. 1, 102–112, http://dx.doi.org/10.1080/13803395.2014.1003533

Validation of the Cross-Linguistic Naming Test: A naming test for different cultures? A preliminary study in the Spanish population Mario Gálvez-Lara1, Juan Antonio Moriana1, Raquel Vilar-López2,3, Ahmed Fayez Fasfous3,4, Natalia Hidalgo-Ruzzante3,5, and Miguel Pérez-García2,3 1

Department of Psychology, University of Córdoba, Córdoba, Spain School of Psychology, University of Granada, Granada, Spain 3 Mind, Brain and Behaviour Reseach Center (CIMCYC), University of Granada, Granada, Spain 4 Faculty of Arts, Bethlehem University, West Bank, Palestine 5 School of Science Education, University of Granada, Granada, Spain 2

(Received 24 April 2014; accepted 29 December 2014) Background: Despite the consensus pointing out the importance of cultural variables in neuropsychological assessments, empirical studies within cross-cultural neuropsychology continue to be limited. The CrossLinguistic Naming Test (CLNT) is a naming test that is supposed to have no influence from cultural variables. The aim of this paper is to determine the psychometric properties of the CLNT and its discriminatory validity (Experiment 1) and to determine the performance of the CLNT in different cultures (Experiment 2). Method: Three groups followed the CLNT in Experiment 1: dementia patients, individuals with subjective memory complaints, and neurologically healthy volunteers. Three groups followed the CLNT in Experiment 2: Colombians, Moroccans, and Spaniards. Results: The results showed that the psychometric properties of the CLNT are appropriate and that this test obtains a high specificity but a low sensitivity. Furthermore, no differences were found in the CLNT among the three cultural groups. Discussion: The CLNT may be appropriate for the screening of naming impairment in Colombian, Moroccan, and Spanish cultures. Keywords: Cross-cultural neuropsychology; Naming; Boston Naming Test; Ethnic minorities; Dementia.

Nowadays, there is a need to develop new neuropsychological assessment instruments that can be used on individuals from different ethnicities and cultures. The majority of the neuropsychological tests have been developed and standardized for Caucasian, monolingual, English-speaking individuals from the US or Canada (Razani, Burciaga, Madore, & Wong, 2007). Therefore, the aptness of this same evaluation for individuals with diverse ethnic and language backgrounds is questionable (Harris, Tulsky, & Schultheis, 2003). The scarce research in cross-cultural neuropsychology has generally compared the performance between ethnic minorities and White Americans in different neuropsychological tests. The results

typically show a worse performance by the ethnic minorities (Byrd, Sánchez, & Manly, 2005). Those differences appear in cognitive skills such as attention, memory, executive functions, or language (Agranovich & Puente, 2007; Byrd, Touradji, Tang, & Manly, 2004; Cheie, Veraksa, Zinchenko, Gorvaya, & Visu-Petra, 2015; Kempler, Teng, Dick, Taussig, & Davis, 1998; Manly, Jacobs, Touradji, Small, & Stern, 2002; Razani, Murcia, Tabares, & Wong, 2006; Sobeh & Spijkers, 2013). Although some cognitive functions, such as episodic memory and visuospatial skills, decline in older age, language abilities remain relatively stable among older adults (Pekkala et al., 2013). Specifically, vocabulary has been found resistant to the effects of

Address correspondence to: Mario Gálvez-Lara, Facultad de Ciencias de la Educación, Universidad de Córdoba, 14071 Córdoba, Spain (E-mail: [email protected]).

© 2015 Taylor & Francis

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cognitive aging (Rabbitt et al., 2004). However, impaired language functions, including difficulties in naming, are among the core clinical criteria of Alzheimer’s disease (McKhann et al., 2011). It is thus paramount for neuropsychologists working with older adults to evaluate word-finding ability, which is typically completed through confrontation naming tests (Yochim, Kane, & Mueller, 2009). The Boston Naming Test (BNT; Kaplan, Goodglass, & Weintraub, 1983) is probably the most commonly used visual confrontation naming test (Barker-Collo, 2001) and has been adapted to numerous languages including Spanish (GarcíaAlbea, Sánchez-Bernardos, & del Viso-Pabón, 1986), Portuguese (Miotto, Sato, Lucia, Camargo, & Scaff, 2010), Swedish (Tallberg, 2005), and Dutch (Marien, Mampaey, Vervaet, Saerens, & De Deyn, 1998). Thus, most cross-cultural research on naming was conducted by means of this instrument (Baird, Ford, & Podell, 2007; Pedraza et al., 2009; Touradji, Manly, Jacobs, & Stern, 2001). However, this test was originally designed for monolingual English speakers and is not optimal for assessing the naming performance of monolinguals in other languages, or multilinguals (Gollan, Fennema-Notestine, Montoya, & Jernigan, 2007; Ivanova, Salmon, & Gollan, 2013; Kohnert, Hernandez, & Bates, 1998; Roberts, Garcia, Desrochers, & Hernandez, 2002). This is because the BNT has been developed in a particular cultural context, and it has been culturally and linguistically influenced. Thus, some images belong to typical American elements (for example: pretzel) or these are known just by people who live in certain areas of the world (for example: beaver; Ardila, 2007). Moreover, item difficulty in the BNT increases with item progression, but the order of difficulty varies from one culture to the next, and this was not considered in the different adaptations. For example, the final item is abacus, an item that is quite difficult in English, but as abacuses are more common in China than they are in the US, it is relatively easy to name them in Mandarin (Gollan, Weissberger, Runnqvist, Montoya, & Cera, 2012). Nevertheless, difficulties in cross-cultural administration of the BNT appear when it is utilized not only in subjects from non-English-speaking countries, but also in individuals from other Englishspeaking countries, such as New Zealand or Australia. Barker-Collo (2001) found that a sample of New Zealand university students scored significantly lower on the BNT than a sample from U.S. university students. Similar results were found in Australia by Cruice, Worrall, and Hickson (2000). Several studies have found a low performance by bilingual subjects on the BNT. Roberts and colleagues (2002) found that cognitively intact adult

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bilinguals, compared with monolinguals, name fewer pictures correctly in standardized naming tests such as the BNT. Similar results were found in both younger bilinguals (Kohnert et al., 1998) and older bilinguals (Gollan et al., 2007). Although the BNT is commonly used in the neuropsychological assessment of dementia (Salmon & Bondi, 2009), it is not clear whether this test is useful in bilinguals who are diagnosed with dementia, considering that cognitively healthy bilingual individuals perform more poorly on this test than monolinguals (Weissberger, Salmon, Bondi, & Gollan, 2013). Generally, the use of translated naming tests to evaluate speakers of other languages has been distorted because the translation of test items may modify the construct validity of the test (Márquez de la Plata et al., 2009). To overcome this limitation, Márquez de la Plata and colleagues (2008) developed the Texas Spanish Naming Test (TNT). To create the test, these authors used factors such as age of acquisition of a word and its frequency and familiarity to select the most culturally salient words for Spanish speakers. The TNT proved convergent validity and was able to detect differences between individuals with and without dementia. In addition, internal consistency of the TNT was superior to that of other naming tests, such as the Modified Boston Naming Test–Spanish (Pontón et al., 1992) and the naming subtest of the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) Battery (Morris et al., 1989) in individuals from the US, Colombia, and Spain, which suggests that a literal translation of test items may detract from their ability to assess a unitary construct (Márquez de la Plata et al., 2009). Despite the good results obtained by the TNT, this test can only be used to assess Spanish speakers. However, Ardila (2007) has proposed the development of a test that would assess visual confrontation naming in any language of the world, the CrossLinguistic Naming Test (CLNT). This test was based on the Swadesh Words List (Swadesh, 1952, 1967), which consists of concepts that have an adequate word in every language, independent of cultural differences. Ardila selected 40 words that could be clearly represented in a picture from this list, and he grouped them in six semantic categories: body parts (10 words), natural phenomena (5 words), external objects (5 words), animals (5 words), colors (5 words), and actions (10 words). These semantic categories were selected because only these categories can be clearly separated if departing from the Swadesh Words List. Ardila (2007) proposes some general guidelines for the administration of this naming test: (a) The items corresponding to each category are presented in sequence; (b) for each category, there are different

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instructions (see Instruments section); the semantic category is provided in order to minimize the effect of potential visuoperceptual difficulties; (c) to avoid the confounding of perceptual errors, 10 × 15-cm color photographs are included in the test; (d) there is not a discontinuous rule; all the 40 pictures are presented to the participants; (e) time is taken; immediate responses (within 5 s) are separated from slow responses (up to 20 s); time in naming is used for qualitative analysis, but it is not taken into account in the correct score; after 20 s, the initial syllable is presented (phonological cueing); however, words retrieved using phonological cueing are not included in the “correct” score; (f) three types of naming errors are distinguished: phonological paraphasias, semantic paraphasias, and circumlocutions. Nevertheless, the main feature of the CLNT is that it does not use a specific set of images, but any picture that clearly represents the concept, and it is easily recognizable by a majority of people (Ardila, 2007). Consequently, the pictures could be modified in order to adapt them to specific conditions of the test—for example, the ethnicity of the patient being assessed. The intention of Ardila (2007) was to make a test that will produce a perfect score in normal adults, and he warned that although the test is likely to be specific for anomia, it is not likely to be highly sensitive. The low ceiling of the test can be expected to result that individuals with significant loss of naming abilities may, nevertheless, obtain normal scores on this test. Indeed, this test seems suitable just for detecting severe naming impairment. Therefore, the CLNT could be used as screening test of language impairment. Regarding the CLNT as a promising strategy for the naming assessment of different cultures, to our knowledge no research has validated the CLNT or its capacity to evaluate individuals from different cultures because the CLNT has never been applied to individuals with any language pathology or groups from different ethnicities. Therefore, the aim of this study is to analyze the psychometric properties of the CNLT and its discriminative validity to detect naming deficits (Experiment 1) and to evaluate differences in the results of people from different cultures (Experiment 2). EXPERIMENT 1 Method Participants A total sample of 61 subjects was included in this study. It consisted of 24 patients diagnosed

with dementia, 17 individuals without dementia but with subjective memory complaints, and 20 volunteers older than 65 years old and cognitively normal. The ethnic background of all participants was Caucasian, born in Spain. The patients diagnosed with dementia or with subjective memory complaints were recruited from the nursing home “Ciudad de Granada” and the Cognitive Stimulation Service of the Association of Relatives of Patients with Alzheimer and Other Dementias of Granada, Spain. In order to include participants in the dementia (DEM) group, we considered the following inclusion/criteria: individuals diagnosed with Alzheimer’s disease (AD) dementia by their primary care physician according to the National Institute of Neurological and Communicative Disorders and Stroke–Alzheimer’s Disease and Related Disorders Association (NINCS-ADRDA) criteria (McKhann et al., 1984). Additional inclusion criterion was a score of ≤69 in the Revised Cambridge Cognitive Exam (CAMCOG-R; Roth, Huppert, Mountjoy, & Tym, 2003). In the case of the subjective memory complaints (SMC) group, we considered the following inclusion criteria: the presence of subjective memory complaints, the absence of a dementia diagnosis by a medical professional, and a score of >69 on the CAMCOG-R. Twenty-four patients were included in the DEM group, 6 men and 18 women, with a mean age of 78.12 years (SD = 7.49) and a mean of 5.58 years of education (SD = 3.78). Seventeen patients were included in the SMC group, 10 men and 7 women, with a mean age of 78.47 years (SD = 7.13) and an average education of 9.05 years (SD = 4.36). The control group participants were volunteers recruited in Granada, Spain, via a news release reproduced in several local newspapers. Inclusion criteria for the control group included: adults aged 65 or older, absence of subjective memory complaints explicitly declared by the subject, a score of ≥26 on the Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975), a score of 100 on the Barthel Index (BI; Mahoney & Barthel, 1965), and a clinical interview with a reliable informant (an immediate or close family member, such as partner, offspring, nephews, or nieces) to determine a normal cognitive state. Twenty participants were included in the control group, 8 men and 12 women, with an average age of 71.70 years (SD = 6.13) and an average education of 3.35 years (SD = 2.96). We obtained written consent from all participants in the study. In the case of the participants of the DEM and SMC groups, the informed consent was provided by the patient and the patient’s caregiver.

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We intended to select healthy subjects in the control group. Thus, although both the subject and the reliable informant confirmed the absence of cognitive impairment, we used the MMSE as a screening tool to filter and exclude candidates with any presence of cognitive impairment, as other authors did (Minett, da Silva, Ortiz, & Bertolucci, 2007). Conversely, participants included in the other two groups were recruited from a nursing home and a cognitive stimulation service and therefore expected to suffer cognitive impairment. For this reason, to group these subjects into two different groups we used the CAMCOG-R. This test is broader than the MMSE, and it has an accepted cutoff point to distinguish between subjects with and without dementia (Blessed, Black, Butler, & Kay, 1991; Roth et al., 2003). Instruments First, the following tests were administered in this order: 1. Barthel Index (BI; Mahoney & Barthel, 1965): This questionnaire evaluates basic activities of daily living and gives us information about a person’s degree of dependency. The individual receives a score based on whether they have received help while doing the task. A higher score means greater independence, with a maximum score of 100. 2. Mini Mental State Examination (MMSE; Folstein et al., 1975): This test briefly evaluates different cognitive capacities. The 30-point version of the Spanish adaptation of the test was applied in this study (Lobo, Saz, Marcos, & ZARADEMP group, 2002), establishing a cutoff point for dementia at 23/24. 3. Revised Cambridge Cognitive Exam (CAMCOGR): This neuropsychological battery, which is included in the Revised Cambridge Exploration Test for the Assessment of Mental Disorders in Old Age (CAMDEX-R; Roth et al., 2003), is used to evaluate the cognitive function of older people suffering from dementia. The maximum score was 105, establishing a cutoff point for dementia at 69/ 70 (Blessed et al., 1991). Secondly, the following naming tests were administered in a counterbalanced way: 4. Boston Naming Test (BNT): This is a test to evaluate naming for visual confrontation with 60 cards of line-drawings in black and white that the individual has to name. The Spanish adaptation of the test was used for

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this study (Quiñones-Úbeda, Peña-Casanova, Böhm, Gramunt-Fombuena, & Comas, 2004). The total score was the number of correct responses produced spontaneously and with the aid of semantic cue. The maximum score was 60. 5. Cross-Linguistic Naming Test (CLNT): This test evaluates naming for visual confrontation using 40 color images grouped into six semantic categories. In order to minimize the effect of potential visuospatial difficulties, the instructions mention the semantic categories of the words shown in the pictures and that differ within each category: (a) parts of the body: “What part of the body is this?”; (b) natural phenomena: “What is this?”; (c) external objects: “What is this?”; (d) animals: “What animal is this?”; (e) colors: “What color is this?”; (f) actions: “What is this person doing?” or “What is this bird doing?.” The maximum score was 40. Procedure The DEM and SMC groups completed the neuropsychological battery, lasting approximately 1 hour and 15 minutes. All the tests of the battery except the CAMCOG-R were performed by the control group, lasting approximately 30 minutes. The BI was administered to a reliable informant (an immediate family member, such as partner, offspring, nephews, or nieces) of each participant. Assessments were conducted by a neuropsychologist specifically trained for this project (M.G). Regarding the visual confrontation naming tests, the standard instructions of the BNT were not followed when it was administered to any of the three groups. Since it was expected that many DEM participants would make errors within eight consecutive questions of the 30 items, we made the decision to administer 60 items of the BNT to the three groups of participants. In the case of the CLNT, the 40 color pictures selected were presented to the participants on a 15.6-inch laptop screen. When administering the CLNT, the difficulty order of the items was not taken into account since the difficulty order varies from one language to another. The set of pictures utilized in the CLNT was piloted in a small sample (n = 19) of college students. Several color images obtained from Internet web pages were initially used for each item. Finally, for each word, we selected an image with 100% correct answers within the sample group. Additionally, based on the pool of answers from

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the sample group, we were able to identify correct responses (synonyms) for each of the pictures. Statistical analysis First, Chronbach’s alpha was performed as a measure of internal consistency of the CLNT. Second, Pearson correlations were conducted to determine both convergent and ecological validity of the CLNT. Third, either a one-way analysis of variance (ANOVA) or a contingency analysis (chisquared) was performed as appropriate to compare the principal demographic variables and the scoring on MMSE, CAMCOG-R, and BI among the three groups. Fourth, to determine differences among the three groups on the naming tests, the Kruskal– Wallis test was performed. Subsequently, the Mann–Whitney U test was used to prove the existence of significant differences among groups. Fifth, to study the possible influence of age and education on the naming tests, we used the Kruskal–Wallis test after dividing the nondemented participants (SMC and control) into four groups stratified by age and education. Finally, a binary logistic regression analysis by the enter method was realized in order to determine the sensitivity and specificity of the CLNT and the BNT. Results Psychometric properties Interitem reliability. The internal consistency of the 40 items that made up the CLNT was determined by obtaining Cronbach’s alpha with the three groups of participants. This analysis resulted in a high alpha (.934). Convergent validity. Convergent validity indicates positive correlations with other tests that measure the same. Pearson correlations were used

to compare the CLNT with the BNT. The results showed a statistically significant correlation between those tests (r = .822, p < .01). Ecological validity. Sbordone (1996, p. 16) defined the ecological validity as the “functional and predictive relationship between the patient’s performance on a set of neuropsychological tests and the patient’s behavior in a variety of real world settings.” To determine the ecological validity, Pearson correlations were obtained between the two naming tests (CLNT and BNT) and the BI in order to relate the scores of the naming tests with daily functions. The results showed very similar statistically significant correlations between the CLNT and the BI (r = .490, p < .01), as well as between the BNT and the BI (r = .507, p < .01). Discriminative validity In this research, discriminative validity was conducted to determine naming differences among the three groups and to establish whether the CLNT is able to distinguish between demented and nondemented individuals correctly. First, we compare the sociodemographic variables and the scoring on MMSE, CAMCOG-R, and BI among the three groups. The results indicate differences among the groups in age and education (see Table 1). The Kruskal–Wallis test was performed to determine differences among the three groups on the naming tests. The results of these analyses showed statistically significant differences among the groups for both the BNT and the CLNT (see Table 2). To test the existence of significant differences between specific groups, the Mann–Whitney U test was used. For both naming tests, the results showed not only that the scores of the DEM group were significantly lower than those of the two other groups (SMC and control), but also that the SMC and control groups did not differ from each other in the two measures (see Table 3).

TABLE 1 Demographic variables and score on MMSE, CAMCOG-R, and BI of the groups from Experiment 1 Group Variable Men/women Age Years of education MMSE CAMCOG-R BI

DEM (n = 24)

SMC (n = 17)

Control (n = 20)

F/χ2

p

6/18 78.12 (7.49) 5.58 (3.78) 15.45 (4.15) 47.33 (15.71) 78.12 (23.06)

10/7 78.47 (7.13) 9.05 (4.36) 25.41 (1.50) 82.70 (6.37) 95.00 (9.51)

8/12 71.70 (6.13) 3.35 (2.96) 27.50 (1.19)

4.776 5.978 10.918 114.97 76.703 12.306

.092 .004 .000 .000 .000 .000

100.00 (0.00)

Notes. DEM = dementia; SMC = subjective memory complaints; MMSE = Mini-Mental State Examination; CAMCOG-R = Revised Cambridge Cognitive Exam; BI = Barthel Index; χ2 = men/ women; F = age, years of education, MMSE, CAMGOG-R, and BI. Standard deviations in parentheses.

CROSS-LINGUISTIC NAMING TEST TABLE 2 Differences among groups on naming tests Group Test

DEM M

SMC M

χ2

Control M

p

BNT 21.20 (12.72) 43.29 (10.05) 43.85 (7.66) 28.133 .000 CLNT 32.00 (6.87) 39.17 (1.28) 39.30 (1.03) 24.484 .000 Notes. DEM = dementia; SMC = subjective memory complaints; BNT = Boston Naming Test; CLNT = Cross-Linguistic Naming Test. Standard deviations in parentheses.

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To determine the ability of the CLNT to differentiate correctly between demented and nondemented participants, a binary logistic regression analysis was conducted. This analysis was also done for the BNT. We found that the CLNT obtained a specificity of 94.6% and a sensitivity of 58.3% (B = –0.614; SE = .205; Wald = 8.945; DF = 1; p = .003), whereas the BNT obtained a specificity of 91.9% and a sensitivity of 75% (B = –0.151; SE = .035; Wald = 19.13; DF = 1; p = .0). EXPERIMENT 2

TABLE 3 Specific comparisons between groups

Method

Test BNT

Comparisons DEM vs. SMC DEM vs. control SMC vs. control

Mann– Whitney U 41.00 44.00 167.00

Participants

CLNT

p

Mann– Whitney U

p

.000 .000 .927

56.50 63.50 164.50

.000 .000 .853

Note. DEM = dementia; SMC = subjective memory complaints; BNT = Boston Naming Test; CLNT = Cross-Linguistic Naming Test.

To study the possible influence of age and education on the naming tests, we divided the nondemented participants (SMC and control groups) into four groups stratified by age and education, as other authors did (Marquez de la Plata et al., 2008; see Table 4). The Kruskal–Wallis test was done to determine differences among these four groups on the naming tests. The results showed no differences among groups on both tests, BNT (χ2 = 3.192, p = .363) and CLNT (χ2 = 1.704, p = .636).

TABLE 4 Mean scores for the naming tests stratified by age and education among nondemented participants (SMC and control groups) Age ≤75 years

Test

Education: ≤5 years (n = 11)

Education: ≥6 years (n = 7)

≥76 years Education: ≤5 years (n = 8)

Education: ≥6 years (n = 11)

CLNT 39.45 (0.68) 39.28 (1.49) 39.37 (0.91) 38.91 (1.44) BNT 46.18 (5.52) 45.42 (12.17) 42.25 (4.55) 40.81 (10.95) Notes. SMC = subjective memory complaints; CLNT = Cross-Linguistic Naming Test; BNT = Boston Naming Test. Standard deviations in parentheses.

In recent years, Spain has experienced a significant increase in the number of immigrants, among which exists a notable presence of Moroccans and Colombians (Instituto Nacional de Estadística– Spain, 2012). Therefore, for this study we selected a group of Colombians, a group of Moroccans, and also a group of Spaniards, all residing in Spain. The participants were recruited as volunteers from various nonprofit organizations working with immigrants in Granada and among the Granada University students. Fifty-seven neurologically healthy volunteers participated in this study: One group of immigrants with Colombian nationality (Colombians group) consisted of 17 individuals (7 men and 10 women) with a mean age of 28.47 years (SD = 6.76; range = 19–42) and a mean of 13.23 years of education (SD = 2.72); one group of immigrants with Moroccan nationality (Moroccans group) consisted of 20 individuals (11 men and 9 women) with a mean age of 26.15 years (SD = 4.19; range = 19–37) and a mean education of 14.50 years (SD = 2.52); and a group of Spaniards (Spaniards group) included 20 individuals (11 men and 9 women) with a mean age of 24.85 years (SD = 3.32; range = 20–35) and a mean education of 15.05 years (SD = 1.76; see Table 5). To select the participants, we considered the following inclusion criteria: a range between 18 and 55 years old; and no history of mental disorders, neurological disorders, or substance abuse. The participants received detailed verbal and written information about the study objectives and before giving their informed consent to their inclusion in the study. Instruments The CLNT, described in the previous study, was administered to all participants.

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GÁLVEZ-LARA ET AL. TABLE 5 Demographic variables and score on the CLNT of the groups from Experiment 2 Group Variable Men/women Age Years of education CLNT

Colombians (n = 17)

Moroccans (n = 20)

Spaniards (n = 20)

F/χ2

p

7/10 28.47 (6.76) 13.23 (2.72) 39.58 (0.71)

11/9 26.15 (4.19) 14.50 (2.52) 39.50 (0.82)

11/9 24.85 (3.32) 15.05 (1.76) 39.61 (0.70)

0.912 2.582 2.827 0.881

.634 .085 .068 .644

Note. CLNT = Cross-Linguistic Naming Test; χ2 = men/women and CLNT; F = age and years of education. Standard deviations in parentheses.

Procedure The CLNT was administered as part of an extensive neuropsychological battery of approximately three hours, including a 15-min break at the middle of the session and an initial interview to guarantee the inclusion criteria. This battery was part of a broader project of cross-cultural neuropsychology in which the BNT was not included. The CLNT was administered in Spanish to the Colombian and Spaniard groups and in Arabic to the Moroccan group. Two different assessors specifically trained for this project (M.G. and A.F.) conducted the evaluations. In order to avoid the differences between each evaluator, they received the same training and made several direct observations of each other supervised by a clinical neuropsychologist in order to ensure that the procedure was identical regardless of the examiner. By using the results obtained in the pilot study, the two assessors reached an agreement to determine the possible correct responses, taking into account language differences. Statistical analysis First, either a one-way ANOVA or contingency analysis (chi-squared) was performed as appropriate to compare the principal demographic variables. In order to determine whether there were differences among the naming scores of the three groups, the Kruskal–Wallis test was conducted with the scores of the CLNT as the dependent variable and the group (Colombians, Moroccans, and Spaniards) as independent variable.

Results No differences were found among the groups in sex, age, and education variables. Consequently, these variables did not influence the results of the study. The Kruskal–Wallis test showed no statistically significant differences among the three groups

in the scores of the CLNT (χ2 = 0.881, p = .644). Thus, the performance of Colombians, Moroccans, and Spaniards on the CLNT was very similar (see Table 5). Discussion The purposes of this research were to examine the psychometric properties of the CLNT as a measure of anomia in a sample of Spaniard older adults with and without dementia as well as to study the ability of this test to evaluate individuals from different cultures. The results above have shown that the CLNT meets the basic psychometric requirements for a psychological test, since the internal consistency and the convergent and ecological validity indexes are appropriate. Regarding the discriminative validity, the results showed that the participants with and without dementia obtained different scores on naming tests, and that the CLNT achieved a high specificity to distinguish between demented and nondemented individuals, but a low sensitivity. Furthermore, there were no differences in naming among Colombians, Moroccans, and Spaniards using the CLNT. The aim of Experiment 1 was to determine the psychometric properties of the CLNT and its discriminatory validity. Regarding internal consistency, the CLNT obtained good results with a Cronbach’s alpha above the level considered appropriate for the clinical context (.9; Nunnally, 1978). This suggests that different items that compose the test are interrelated to a large extent and measure the same construct. This internal consistency was similar or superior to that of other naming tests obtained in similar studies to ours, such as .912 for the BNT (Nebreda et al., 2010), between .923 and .933 for the TNT, .898 for the Modified Boston Naming Test– Spanish, and .776 for the naming subtest of the CERAD Battery (Marquez de la Plata et al., 2009). With respect to convergent validity, correlations between the CLNT and the BNT lead us to deduce that the CLNT actually measures the ability of

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naming. Furthermore, the correlation between the CLNT and the Barthel Index (BI) indicates that the CLNT has an adequate ecological validity; in other words, the scores on the CLNT seem to be a good predictor of an individual’s daily life activities. One fundamental goal of the present study was to determine whether the CLNT is able to distinguish between individuals with or without dementia—that is, to determine the discriminative validity of the test. The results have shown that individuals with dementia scored lower than those without dementia on the CLNT and BNT. This finding is consistent with the symptoms of anomia frequently found in the patients with dementia using the BNT (Bayles, Tomoeda, & Trosset, 1992; Lin et al., 2014; Salmon & Bondi, 2009), as well as with the results found in other studies using diverse naming tests (Brouillette et al., 2011; Goldman et al., 2001; Nebreda et al., 2010; Vigliecca, Aleman, & Jaime, 2007). With regard to the possible influence of age and education on the naming tests, we observed that, despite the low education of the control group, their score on the naming tests is similar to the score of the SMC group. Other results found in the literature suggest a better performance on naming tests among more educated individuals (Kaplan et al., 1983) and a poorer naming performance with advancing age (Albert, Heller, & Milberg, 1988). Since the age of the control group is lower than the age of the SMC group, it seems that the negative effect that low education can exert on naming ability may be countered by the younger age of the control group compared to the SMC group. The logistic regression analysis found that the BNT discriminated better than the CLNT between demented and nondemented individuals. Both tests, CLNT and BNT, showed high specificity (94.6% and 91.9%, respectively); however, while the BNT presented an acceptable sensitivity (75%), the CLNT obtained a low sensitivity (58.3%). These results are consistent with the assumption of Ardila (2007). The high specificity of the CLNT indicates that this test does not incorrectly classify healthy individuals as patients with dementia, which is consistent with the lack of differences found between the two groups of participants without dementia (SMC and control) on this test. However, due to the low sensitivity of the CLNT, individuals with loss of naming abilities may obtain normal scores on this test. This reaffirms its usefulness as a screening test, valid for detecting severe language impairments. Comparing the scores of the CLNT and the BNT, we can see that the percentage of success

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on the BNT (35.34% for the DEM group, 72.15% for the SMC group, and 73.08% for the control group) is much lower than that on the CLNT (80% for the DEM group, 97.94% for the SMC group, and 98.25% for the control group) in the different groups. We expected to find these discrepancies in the error percentage between the two tests for two reasons: first, because of the excessive difficulty of some of the BNT items (for instance, abacus or stethoscope); secondly, due to the ease of the CLNT items, which causes a low ceiling in the test, as we previously mentioned. However, despite the differences which exist in the percentage of correct responses between the two tests, individuals with and without dementia obtained significant statistically different scores on both CLNT and BNT. With regard to Experiment 2, its goal was to ascertain whether there were performance differences on the CLNT among different cultural groups—that is, to determine whether this is actually a neuropsychological test that can be used in a cross-cultural way, as Ardila (2007) hypothesized. The results have shown no differences on the CLNT score among Spaniards, Colombians, and Moroccans. These results differ from those found in other studies of cross-cultural neuropsychology with the BNT as measure of naming. Some studies suggest that the stimuli of the BNT are influenced by cultural variables, benefiting White American individuals. Thus, for instance Boone, Victor, Wen, Razani, and Pontón (2007) found differences on patients’ scores of different ethnicities and cultures on the BNT. In their study, American Caucasians scored an average about 10 points higher than African-American, Asians, and Hispanics. The findings of Baird and colleagues (2007) are similar. They found that, in an elderly sample, the American Caucasians scored an average about 7 points higher than African-Americans. Differences on the BNT scores were also observed between healthy individuals from the same ethnic group, but with different levels of acculturation (Manly et al., 1998). Considering both studies, Experiment 1 and Experiment 2, although the idea of Ardila (2007) is to make a test that will produce a perfect score in normal adults, in which any error can be considered as significant, the results have shown that, in all nondemented groups (SMC and control groups in Experiment 1; Colombians, Moroccans, and Spaniards groups in Experiment 2), some participants committed one or two errors. Consequently, despite the low ceiling of the test, individuals with intact ability of naming can obtain several errors on the CLNT.

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Despite the promising results, this research has some limitations. First of all, the small sample size in both studies encourages replication of the results. Secondly, only individuals from three different countries participated in the cross-cultural study of the CLNT, and two of them spoke the same language. Moreover, in the cross-cultural study only the CLNT was included and not the BNT, so it was not possible to compare the results of the different countries in both tests to check the superiority of the CLNT. Additionally, all participants included in the cross-cultural study were healthy adults, thus we cannot generalize our results to an older or a clinical sample. In future studies, it would be significant to obtain a profile of performance on the CLNT in different language pathologies as well as to realize cross-cultural studies with a large sample of countries. Thus, it would be interesting to study how individuals from different countries with language pathologies run the test. These studies should include, apart from the CLNT, other naming tests in order to compare whether the performance is similar in all of them across different countries. In short, to our knowledge, this is the first study focused on the implementation of the CLNT in patients with dementia and individuals from different countries. There are grounds for the belief that the CLNT may be a good instrument for the screening of naming impairment in Spanish speakers of Colombian and Spanish cultures and in Arabic speakers of Moroccan culture.

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Validation of the cross-linguistic naming test: a naming test for different cultures? A preliminary study in the Spanish population.

Despite the consensus pointing out the importance of cultural variables in neuropsychological assessments, empirical studies within cross-cultural neu...
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