BECLA, a new assessment battery for acquired deficits of language: Normative data from Quebec-French healthy younger and older adults

Journal of the Neurological Sciences 361 (2016) 220–228

Contents lists available at ScienceDirect

Journal of the Neurological Sciences journal homepage: www.elsevier.com/locate/jns

BECLA, a new assessment battery for acquired deficits of language: Normative data from Quebec-French healthy younger and older adults Joël Macoir a,b,⁎, Caroline Gauthier c, Catherine Jean c, Olivier Potvin b a b c

Université Laval, Faculté de médecine, Département de réadaptation, Québec, Canada Centre de recherche de l'Institut universitaire en santé mentale de Québec, Québec, Canada CHU de Québec — Hôpital de l'Enfant-Jésus, Québec, Canada

a r t i c l e

i n f o

Article history: Received 27 October 2015 Received in revised form 7 December 2015 Accepted 1 January 2016 Available online 6 January 2016 Keywords: Assessment Acquired deficits of language Normative data

a b s t r a c t Compared to English, for which there exist numerous tests and batteries for the assessment of acquired deficits of language, the tools available to assess French-speaking individuals are much more limited. The Batterie d'Évaluation Cognitive du Langage (BECLA) was purposely developed to fulfill the need for French assessment tools based on theoretical models of cognitive psychology. It comprises 19 tasks, designed to assess each of the components and routes involved in single word processing in order to identify the functional locus/loci of impairment. In this article, we describe the BECLA and we present normative data for individuals 18–94 years of age (N = 248). The sample was stratified by age, gender, and years of education, according to the Institut de la statistique du Québec, in order to be representative of the French-Quebec population. Percentile scores were provided for each BECLA task in order to show the relative rank of each raw score according to significant correlates. The BECLA is a new clinical, theoretically based assessment battery, useful for identifying and characterizing acquired deficits of language in younger and older adults. © 2016 Elsevier B.V. All rights reserved.

1. Introduction The evaluation of speech and language is one of the most important tasks of speech-language pathologists and professionals from a variety of disciplines and backgrounds, such as neuropsychologists, physicians, nurses, etc. The assessment session is often the first contact with clients and also constitutes the starting point of all clinical interventions. Because of the absence of biological markers or simple assessment methods, the early detection or diagnosis of speech and language problems remains dependent on various indirect assessments (i.e., speech or language functioning must be inferred from the client performance in various tasks devised to explore the different areas of this functioning) performed to identify specific impairments and eliminate other possible causes. There are various purposes to conduct speech-language assessments. The main goal of screening is to determine whether or not a client has a problem. Based on an established criterion, the screening assessment yields a “pass” or “fail” result, which can then lead to an extensive or a follow-up assessment. Diagnosis and differential diagnosis assessments are usually performed to label the communication problem and/or to differentiate it from other disorders in which similar characteristics are usually reported. Finally, the assessment of functional ⁎ Corresponding author at: Faculté de médecine, Département de réadaptation, Université Laval, Pavillon F-Vandry, Québec, Québec G1K 7P4, Canada. E-mail address: [email protected] (J. Macoir).

http://dx.doi.org/10.1016/j.jns.2016.01.004 0022-510X/© 2016 Elsevier B.V. All rights reserved.

communication is highly useful to rate the efficiency of communication in real life situations. Another important purpose that evaluation provides clinicians with is a description of the client's baseline level of functioning in all communication areas. The latter allows to clearly identify the affected and preserved components essential for planning a proper treatment, establishing its effectiveness and tracking client's progress over time through periodic re-evaluations. These types of assessment require the clinician to consider all aspects of communication, including the various different speech (e.g., articulation, voice, resonance) and language (e.g., lexical access, comprehension, reading, written spelling) areas. Related abilities and components such as pragmatics, cognitive functions (e.g., attention, memory, visual perception), emotions, deficit awareness, etc., are also essential to include. The selection of evaluation tools is also conditioned by the specific assessment objectives. Screening for a speech or language disorder is usually performed with standardized screening measures whereas standardized norm-referenced tests are used for diagnosis and differential diagnosis assessments as well as for clinical treatment purposes (baseline, effectiveness, progress). The choice of a particular method of assessment, the selection of evaluation tools as well as the interpretation of results, is highly dependent not only on the clinician's own conception of speech and language functioning but also on the reference to a clinicopathological or cognitive model of assessment. In the clinicopathological model, speech and language problems are considered as essential characteristics of clinical

J. Macoir et al. / Journal of the Neurological Sciences 361 (2016) 220–228

syndromes. These clinical syndromes are organized and classified according to neurological-neuropathological characteristics (e.g., deterioration of cortical tissue in a specific brain area) and according to semiology (e.g., sensory and motor deficits, visuospatial deficits, language deficits, etc.). For the purpose of assessment, the emphasis is put on the precise identification of the diagnostic label that best corresponds to the observed deficits as well as to the identification of the possible etiology. Instead of resorting to a medical assessment model, clinicians may also use cognitive psychology models, directly derived from informationprocessing theories, to evaluate language. In these models, cognitive functions, including language, are sustained by specialized interconnected processing components, represented in functional architecture models. These components, sustained by different cerebral structures, are modular and operate independently of other components. An example of such a model, adapted from Patterson and Shewell [1], is depicted in Fig. 1. For example, according to cognitive psychology models of spoken production, words are retrieved and produced through the activation of specialized and interconnected components [2]. For naming, the word retrieval process involves three main levels of activation: (a) the concept corresponding to the object or idea to be expressed is first activated in the semantic system; (b) this nonverbal conceptual representation maps into a phonological lexical representation; and (c) at the third level, this phonological form is temporarily maintained in the phonological output buffer, until the end of the production of the target word. An assessment process based on cognitive psychology models consists of the localization of the impaired and preserved processing components for each language modality. This localization is performed through the administration of specific tasks or test batteries (e.g., Psycholinguistic Assessments of Language Processing in Aphasia [PALPA]; [3] aiming to evaluate each component and route of the model. For example, the evaluation of naming abilities in an aphasic person could be performed by the administration of tasks exploring the conceptual-semantic (e.g., semantic

221

matching), phonological output lexicon (e.g., picture-naming task controlled for frequency, familiarity, etc.), and phonological output buffer (e.g., repetition of words and nonwords manipulated for length) components. Important information regarding the level of impairments also arises from error analysis. Within this same example, an anomic behavior could arise from distinct underlying deficits (e.g., in the activation of conceptual-semantic representations or in retrieving phonological forms of words in the output lexicon), leading to distinct types of errors (e.g., semantic substitutions, phonemic errors) [4,5]. The complete cognitive assessment process should allow the clinician to understand the client's deficits (i.e., surface manifestations, underlying origins, affected components) as well as to identify the strengths and weaknesses in his/ her communication abilities. When recommended, the treatment may focus on the impaired levels of processing (i.e., function restoration) or on alternative processing routes (i.e., function reorganization) that will allow the client to communicate successfully. In the English language, numerous bedside and screening tests (e.g., [6]), as well as comprehensive batteries (e.g., [7,8]) have been developed to assess language functioning in adults and aged people. With respect to test batteries derived from the cognitive neuropsychology approach of assessment, English-speaking clinicians may resort to the PALPA [3] which consists of a set of resource materials comprising 60 rigorously controlled tests that enable the user to select tasks “that can be tailored to the investigation of an individual patient's impaired and intact abilities.” The scoring and analysis of errors give the clinician a detailed profile of language abilities, including reading and written spelling, which can be interpreted within current cognitive models of language. In other languages such as French, the range of possibilities is much more limited. For screening or clinicopathological assessments, clinicians may used the LAST-Q [9] and the Protocole Montréal-Toulouse d'examen linguistique de l'aphasie [10]. They also can select tests for the assessment of specific aspects of language such as the

Fig. 1. Functional architecture model of language processing for single words. Adapted from [1].

222

J. Macoir et al. / Journal of the Neurological Sciences 361 (2016) 220–228

DO-80 [11] for picture naming and the French adaptation of the Pyramids and Palm Trees Test [12,13] for semantics. However, in French, there exists no language assessment battery, based on theoretical models of cognitive psychology. The use of adapted versions of tests developed in other languages, although frequent, is not recommended, especially for the assessment of language functions, considering the possible psycholinguistic (e.g., word frequency, length) and cultural (e.g., vocabulary, familiarity of concepts) biases. Moreover, the importance of developing tests and norms adapted to a given culture has been highlighted by a recent study showing that local norms are more sensitive and accurate than non-cultural specific norms for identifying cognitive difficulties in older adults [14]. The aim of this study was to fill this important lack by developing a handy, sensitive and standardized French battery designed for the cognitive assessment of language disorders in adults. Moreover, the purpose of our study was to evaluate the effects of age, education, and gender in a representative sample of younger and older adults and, based on the results of these analyses, to provide normative data for community-dwelling individuals.

2. Methods 2.1. Subjects Two hundred and forty-eight (248) healthy, community-dwelling, French-speaking adults, whose mother tongue and usual language was French, were recruited by students in speech-language pathology as well as by speech-language pathologists through public advertisements and among their relatives. The province of Quebec is officially divided into 17 administrative regions. In order to control for geographic variation, subjects were recruited from 15 of these urban and rural regions (no participants from Outaouais nor from Nord-du-Québec). The majority of subjects were recruited from Capitale-Nationale and Montreal regions. Any person with a history of neurological illness (stroke, head trauma, tumor, etc.), untreated high blood pressure, a history of psychiatric illness (e.g., depression), a history of drug abuse (e.g., alcohol) was excluded. This information regarding the exclusion criteria was obtained from subjects' self reports, corroborated, in many cases, by family members. No formal screening test of cognitive functioning was administered. The sample was composed of 110 men (44%) and 138 women (56%), aged between 18 and 94, with an education level varying between 4 and 23 years. In addition to gender, we considered age and education level as demographic variables that may have influenced test performance. There were significant differences between men and women in terms of age (men: M = 42.42; SD = 16.88; women: M = 48.32; SD = 18.65; t = 2.58, p = .010) and years of education (men: M = 14.65; SD = 3.33; women: M = 13.60; SD = 3.33; t = 2.44, p = .015). With respect to the representativeness of the sample, highly educated individuals were overrepresented compared with actual Quebec demographics (Institut de la statistique du Québec, [30]; Table 1).

2.2. Material 2.2.1. Description of the BECLA: Batterie d'Évaluation Cognitive du Langage The Batterie d'Évaluation Cognitive du Langage1 ‘Cognitive assessment battery of language’ (BECLA) is a test battery designed to rapidly evaluate acquired language deficits in younger and older adults (i.e. language impairment caused by stroke, dementia, brain injury, brain tumor), following brain damage (e.g., stroke, head injury, neurodegenerative disease). The BECLA was developed within the cognitive language-processing theoretical framework [1]. This model comprises all of the cognitive components and connections involved in single word processing. Following cortical lesions, each of these components and connections can be independently impaired, leading to a large number of possible performance and impairment patterns. The BECLA comprises 19 tasks, designed to specifically and rapidly assess each of the components and routes of the language-processing model in order to identify the functional locus/loci of impairment. The number of stimuli varies across the tasks. It was determined according to the complexity of the task, as well as to ensure that the entire battery could be administered in a short time. The word stimuli used on these tasks were manipulated for various psycholinguistic parameters: lexical frequency [15], imageability [16], length, semantic category, phonological and orthographic complexity. The black and white pictures corresponding to object nouns were selected from three picture sets [17–19] and those corresponding to actions were selected from the picture set An object and action naming battery [20]. Black and white pictures were selected in order to minimize the possible effects of visual features on performance. Indeed, color and photographic detail is known to influence recognition and naming of visually presented objects [21]. For example, in a study conducted with Alzheimer’ s patients and normal controls, Zannino et al. have shown that color supports object naming by assisting semantic processing of the stimuli [22]. A pilot phase was first conducted with four French-speaking adults (2 men; age range 20–64 years; range of education level 11–17 years) in order to ensure the clarity of instructions, the adequacy of stimuli presentation, the ease of scoring, etc. Some adjustments were then carried out to develop the final version of the test battery. The 19 tasks of the BECLA, briefly described in Table 2, are the following: A) Recognition of spoken and written words. According to language cognitive models, word recognition involves two processing stages. In the spoken modality, the first stage is the auditory phonological analysis, which consists of the identification of speech sounds in the string of sounds heard. The second stage consists of the recognition of the word performed through a match between the string of phonemes and a stored representation in the phonological input lexicon. Similar stages are involved in the written modality: visual orthographic analysis to identify graphemes in the string of letters and recognition of the corresponding representation in the orthographic input lexicon. The following tasks of the BECLA were designed to assess these processing stages: 1. Auditory discrimination. The auditory phonological analysis is assessed with a same/different discrimination task in which subjects are requested to judge if the two elements of word or nonwords minimal pairs are identical (e.g., jour–jour ‘day–day’; *[tib–tib]) or not (e.g., miche-niche ‘loaf-doghouse’; *[piʃ]–[tiʃ]). 2. Auditory lexical decision. Spoken word recognition is assessed with a classical lexical decision task in which subjects are asked to judge if a heard stimulus corresponds to an existing word (e.g., clé ‘key’) or not (e.g., *[fru]).

Table 1 Comparison of demographic data between the province of Quebec (%) and our study sample (number and %). Years of education

18–35 years 36–55 years 56 + years Total

Province of Quebec

Study sample

0–12

13+

0–12

13+

60.4 56.99 71.5 62.6

39.6 43.01 28.5 37.4

22 (23.2) 31 (38.75) 33 (45.2) 86 (34.68)

73 (76.8) 49 (61.25) 40 (54.8) 162 (65.32)

1

The BECLA is available on request from the first author ([email protected]).

J. Macoir et al. / Journal of the Neurological Sciences 361 (2016) 220–228

223

Table 2 Overview of the tasks of the BECLA battery. Task

Name of the task

N

Stimulus types and psycholinguistic variables

A) Recognition of spoken and written words 1 Auditory discrimination

36

2

Auditory lexical decision

20

3

Letter matching

26

4

Written lexical decision

20

Stimulus type: 18 monosyllabic word pairs and 18 monosyllabic nonword pairs Position of the change in dissimilar pairs: 6 initial; 6 final; 6 metathesis Modified distinctive feature in dissimilar pairs: 6 voicing; 6 manner of articulation; 6 place of articulation Lexical frequency in word pairs: 6 high; 6 low Stimulus type: 10 words; 10 nonwords Imageability in words: 5 high; 5 low Lexical Frequency of words: 5 high; 5 low Word and nonword length: 6 monosyllabic; 8 bisyllabic; 6 trisyllabic Phonological complexity: 10 simple; 10 complex Phonological similarity between nonwords and existing words: 5 low; 5 high Stimulus type: 13 upper-case; 13 lower-case letters Visual proximity between target and distractor: 15 close; 11 distant Stimulus type: 10 words; 10 nonwords Imageability in words: 5 high; 5 low Lexical Frequency of words: 5 high; 5 low Word and nonword length: 6 monosyllabic; 8 bisyllabic; 6 trisyllabic Spelling similarity between nonwords and existing words: 5 low; 5 high

B) Semantic processing 5 Semantic association of pictures

20

6

Spoken word-picture matching

20

7

Semantic association of written words

20

C) Spoken production 8 Spoken picture naming

20

9

Rhyme judgment on pictures

10

10

Rhyme judgment on written words

20

11

Word repetition

15

12

Nonword repetition

10

13

Delayed word repetition

10

14

Delayed nonword repetition

10

D) Reading and written production 15 Word reading

10

16

Nonword reading

10

17

Written picture naming

20

Stimulus type: 60 pictures of objects (20 stimuli; 20 targets; 20 distractors) Semantic category of objects: 10 living; 10 non-living Stimulus type: 100 pictures of objects; 20 spoken words Semantic category of objects: 10 living; 10 non-living Nature of picture distractors: 20 semantic; 20 visual-semantic; 20 visual; 20 neutral Stimulus type: 60 written names of objects (20 stimuli; 20 targets; 20 distractors) Lexical frequency of triplets: 10 high; 10 low Semantic category of objects: 10 living; 10 non-living

Stimulus type: 10 object nouns; 10 action verbs Lexical frequency: 10 high; 10 low Semantic category of nouns: 5 living; 5 non-living Argument structure of verbs: no argument 1; 4 one-argument; 5 two-arguments Stimulus type: 10 pairs of pictures Similarity of the orthographic/phonological ending: 3 similar/rhyming; 2 similar/non-rhyming; 2 dissimilar/rhyming; 3 dissimilar/non-rhyming Stimulus type: 20 pairs of written words Lexical frequency: 10 high; 10 low Similarity of the orthographic/phonological ending: 5 similar/rhyming; 5 similar/non-rhyming; 5 dissimilar/rhyming; 5 dissimilar/non-rhyming Stimulus type: 15 words Lexical frequency: 8 high; 7 low Imageability: 7 high; 8 low Syllable length: 5 monosyllabic; 5 bisyllabic; 5 trisyllabic Phonological complexity: 7 simple; 8 complex Stimulus type: 10 nonwords Syllable length: 3 monosyllabic; 4 bisyllabic; 3 trisyllabic Phonological complexity: 5 simple; 5 complex Phonological similarity between nonwords and existing words: 5 low; 5 high Stimulus type: 10 words Lexical frequency: 5 high; 5 low Imageability: 5 high; 5 low Syllable length: 3 monosyllabic; 4 bisyllabic; 3 trisyllabic Phonological complexity: 5 simple; 5 complex Stimulus type: 10 nonwords Syllable length: 3 monosyllabic; 4 bisyllabic; 3 trisyllabic Phonological complexity: 5 simple; 5 complex Phonological similarity between nonwords and existing words: 5 low; 5 high

Stimulus type: 10 words Lexical frequency: 6 high; 4 low Imageability: 5 high; 5 low Syllable length: 3 monosyllabic; 4 bisyllabic; 3 trisyllabic Phonological complexity: 5 simple; 5 complex Spelling regularity: 5 regular; 5 irregular Stimulus type: 10 nonwords Syllable length: 3 monosyllabic; 4 bisyllabic; 3 trisyllabic Phonological complexity: 5 simple; 5 complex Phonological similarity between nonwords and existing words: 5 low; 5 high Stimulus type: 10 object nouns; 10 action verbs Lexical frequency: 10 high; 10 low Semantic category of nouns: 5 living; 5 non-living Argument structure of verbs: no argument 1; 4 one-argument; 5 two-arguments Spelling regularity: 10 regular; 10 irregular (continued on next page)

224

J. Macoir et al. / Journal of the Neurological Sciences 361 (2016) 220–228

Table 2 (continued) Task

Name of the task

N

Stimulus types and psycholinguistic variables

18

Word spelling to dictation

20

19

Nonword spelling to dictation

10

Stimulus type: 20 words Lexical frequency: 10 high; 10 low Imageability: 10 high; 10 low Syllable length: 6 monosyllabic; 8 bisyllabic; 6 trisyllabic Spelling regularity: 10 regular; 10 irregular Stimulus type: 10 nonwords Syllable length: 3 monosyllabic; 4 bisyllabic; 3 trisyllabic Phonological similarity between nonwords and existing words: 5 low; 5 high

3. Letter matching. In the written modality, the visual orthographic analysis is assessed with a letter matching task in which subjects are presented with a single upper- (e.g., M) or lower-case (e.g., m) letter and are asked to identify among two, the corresponding letter presented in a similar or different graphemic format. 4. Written lexical decision. The recognition of written words is assessed with a classical lexical decision task in which subjects are asked to judge if a written stimulus correspond to an existing word (e.g., avis ‘opinion’) or not (e.g., *mitoir).

B) Semantic processing. Once the phonological or orthographic form of the word has been recognized/activated in the lexicon, the information is transferred to the semantic system. This central component encodes the meaning of words, as well as conceptual knowledge about non-verbal information (e.g., non-verbal sounds, objects, famous people).2 The following tasks of the BECLA were designed to test the activation of semantic representations from pictures and from spoken and written words:

5. Semantic association of pictures. The activation of semantic representations from non-verbal information is assessed with a task in which subjects are shown a picture stimulus (e.g., os ‘bone’) and asked to match it to either of two images: A target (e.g., chien ‘dog’) or a distractor (e.g., chat ‘cat’). Subjects are required to use explicit semantic information of encyclopaedic or functional/associative nature to select the correct match. 6. Spoken word-picture matching. The activation of semantic representations from spoken words is assessed with a task in which subjects are requested to match a heard word (e.g., clou ‘nail’) with the corresponding picture, presented along with semantic (marteau ‘hammer’), visual-semantic (vis ‘screw’), visual (crayon ‘pencil’) and neutral (pêche ‘peach’) distractors. 7. Semantic association of written words. The activation of semantic representations from written words is assessed with a task in which subjects are shown a written word (e.g., rideau ‘curtain’) and are asked to match it to either of two other written words: A target (e.g., fenêtre ‘window’) or a distractor (e.g., porte ‘door’). Subjects are required to use explicit semantic information of encyclopaedic or functional/associative nature to select the correct match.

C) Spoken production. In the spoken modality, the information is transmitted from the semantic system to the phonological output system. This system involves three main processing stages. During the first stage, the representation corresponding to the semantic information

2 There exist various competing theoretical propositions to account for the meaning of words. For example, according to the non-decompositional view, the meaning of all types of words is encoded in a unitary way in the lexical-semantic system [28], while, according to the feature-based, non-linguistic, conception, word meanings are decomposable into conceptual features (e.g., [29]).

is retrieved in the phonological output lexicon. This long-term memory store encodes the phonological forms of known words, including grammatical information (e.g., gender) and phoneme characteristics. Compared to cognitive processing, the neuromuscular and articulatory processes are particularly slow, and the second stage of the spoken production system consists of a rehearsal process, performed in the phonological buffer, whose role is to maintain temporarily the activated phonological information until the end of the word production. Finally, the third stage consists of the activation of articulatory gestural programs, which converts phonemes into neuromuscular commands. However, this lexical-semantic route cannot operate for nonwords, which must be processed sublexically. The language-processing model comprises therefore a non-lexical route, involved in nonword repetition, requiring the activation of a phonological input (auditory phonological analysis output) to phonological output (phonological buffer output) mechanism. The following tasks of the BECLA were designed to test the integrity/ impairment of the phonological output system: 8. Spoken picture naming. This task recruits all the processing components of the phonological output system. It simply consists of requesting subjects to name orally the target word corresponding to the object presented on picture. 9. Rhyme judgment on pictures. In this task, subjects are requested to judge if the nouns corresponding to two pictures rhyme (e.g., rateau ‘rake’ — robot ‘robot’) or not (e.g., nez ‘nose’ — chaise ‘chair’). This task has the advantage to test the activation of sound forms in the phonological output lexicon from the semantic system, without recruiting subsequent production components. 10. Rhyme judgment on written words. In this task, subjects are requested to judge if two written words rhyme (e.g., gâteau ‘cake’ — domino ‘domino’) or not (e.g., cuiller ‘spoon’ — collier ‘necklace’). This task has the advantage to test the activation of sound forms in the phonological output lexicon from written forms, without recruiting subsequent production components. 11. Word repetition. The activation of the phonological output system is also assessed with a simple repetition task in which subjects are requested to immediately repeat the word pronounced by the examiner. 12. Nonword repetition. The non-lexical route of spoken production is assessed with a repetition task in which subjects are requested to immediately repeat the nonword pronounced by the examiner. 13. Delayed word repetition. Imposing a delay before repetition is known to exacerbate the effects of phonological impairment because of the decay of the phonological form in the output buffer over time [23]. In this task, subjects are instructed to wait until the examiner knocks on the table, after a 5 second delay, before repeating the word heard. 14. Delayed nonwords repetition. An even more important effect of delayed repetition is expected on nonword repetition due to the impossibility of relying on the lexical-semantic route to compensate for phonological difficulties. In this task, subjects are instructed to wait until the examiner knocks on the table, after a 5 second delay, before repeating the nonword heard. D) Reading and written production. According to the dual-route cognitive model of reading [24], the pronunciation of written words

J. Macoir et al. / Journal of the Neurological Sciences 361 (2016) 220–228

can be generated via two routes functioning in parallel: a) a lexical-semantic route, in which the word's graphemes first map their corresponding representation in the orthographic input lexicon, which in turn can be used to directly activate the corresponding concept in the semantic system and then, the processing components involved in spoken production; and b) a non-lexical route, through the application of specific linguistic rules that convert each grapheme (output of the visual orthographic analysis) into its corresponding phonological representation (i.e. grapheme-to-phoneme rule-governed correspondences) in the phonological buffer. Nonwords have no lexical correspondences and their pronunciation can only be generated via the nonlexical route. A similar functional organization is proposed for written production: a) a lexical-semantic route that passes from the phonological input lexicon (in a writing to dictation task) to the semantic system and then to the orthographic output lexicon; and b) a non-lexical route, through the application of specific linguistic rules that convert each phoneme (output of the auditory phonological analysis) into its corresponding graphemic representation (i.e. phoneme-to-grapheme rule-governed correspondences) in the graphemic output buffer (temporary maintenance of the activated graphemic information until the end of the written production), through the mediation of the phonological buffer. Nonwords have no lexical correspondences and their spelling can only be generated via the non-lexical route. The following tasks of the BECLA were designed to assess reading and written production abilities:

15. Word reading. The lexical-semantic route of reading is assessed with a simple task in which subjects are requested to read aloud written words. 16. Nonword reading. The non-lexical route of reading is assessed with a simple task in which subjects are requested to read aloud written nonwords. 17. Written picture naming. This task recruits all of the processing components of the written output system. It simply consists of the presentation of object pictures that the subjects are requested to write down on a sheet of paper. 18. Word spelling to dictation. The lexical-semantic route of spelling is assessed with a simple task in which subjects are requested to write words read out by the examiner.

225

19. Nonword spelling to dictation. The non-lexical route of spelling is assessed with a simple task in which subjects are requested to write nonwords read out by the examiner. 2.2.2. Procedure All subjects were tested individually in a quiet room of their home. Tasks were given without any time constraint. All visual stimuli (pictures, written words) were presented using PowerPoint or Keynote software. The average time to complete the battery was 60 min. Written protocols of the tests were collected and entered in the analyses. 3. Results 3.1. Statistical analysis For the sake of parsimony and consistency, we adopted a global stratification strategy (i.e. common stratification categories for all dependent variables) and set the minimum of individuals within each cell to 20. Actually, when strata are made according to multiple variables (i.e. age gender, education), the number of individuals within each cell dramatically diminishes and norms are no longer valid. Data were entered and analyzed using the Statistical Package for the Social Sciences (SPSS) version 19 for Windows (SPSS Inc., Chicago, IL). All data were examined for normality, skewness, and range restriction. All scores of the BECLA were found to have non-normal distributions and partial Spearman rank correlation coefficients were calculated to assess the relationship between independent sociodemographic variables and performance scores. Then, stratified percentiles for each score were calculated (gender: M/F; age: ≤35/36–55/N56; education level: ≤12/N13) according to significant sociodemographic variables. Percentiles are not affected by skewness and are thus, as argued by Crawford and Garthwaite [25], the best approach for neuropsychological normative data. Table 3 presents the effects of age, gender and education level on each task of the BECLA. As shown in Table 3: two tasks (Delayed word repetition, Word reading) were not correlated with any of the sociodemographic variables; three tasks (Written lexical decision, Semantic association of pictures, Nonword reading) were correlated with education level only; four tasks (Auditory discrimination, Semantic association of written words, Rhyme judgment on pictures, Nonword repetition) were correlated with age only; eight tasks (Auditory lexical decision, Letter matching, Spoken word to picture matching, Spoken picture naming,

Table 3 Effects of age, gender and education level on the performance for each BECLA task. Age

Gender

Education

Task name

Partial rs

p-Value

Partial rs

p-Value

Partial rs

p-Value

1. Auditory discrimination 2. Auditory lexical decision 3. Letter matching 4. Written lexical decision 5. Semantic association of pictures 6. Spoken word-picture matching 7. Semantic association of written words 8. Spoken picture naming 9. Rhyme judgment on pictures 10. Rhyme judgment on written words 11. Word repetition 12. Nonword repetition 13. Delayed word repetition 14. Delayed nonwords repetition 15. Word reading 16. Nonword reading 17. Written picture naming (lex. access) 18. Word spelling to dictation 19. Nonword spelling to dictation

−.279 −.138 −.218 −.007 .125 −.183 −.164 −.266 −.175 −.231 −.197 −.348 −.073 −.305 .049 −.064 −.232 .025 −.203

.000*** .030* .001*** .917 .051 .004** .010** .000*** .006** .000*** .002** .000*** .251 .000*** .446 .316 .000*** .695 .001***

−.115 −.061 −.065 .073 .037 −.067 −.021 .034 .090 −.120 −.103 −.084 −.054 −.137 −.063 −.073 .051 −.206 −.009

.071 .342 .308 .254 .565 .293 .743 .599 .159 .059 .106 .191 .396 .032* .328 .257 .427 .001*** .885

.124 .165 .232 .227 .216 .144 .102 .173 .098 .219 .164 .074 .114 .035 .076 .214 .177 .353 .138

.052 .010** .000*** .000*** .001*** .024* .111 .006** .125 .001*** .010** .247 .074 .586 .233 .001*** .005** .000*** .030*

*p b .05; **p ≤ .01; ***p ≤ .001.

226

J. Macoir et al. / Journal of the Neurological Sciences 361 (2016) 220–228

Table 4 Percentiles for BECLA raw scores according to significant correlations with sociodemographic variables. Percentiles Task (number of items)

Age

Gender

Education

1

2

5

10

15

25

50

95

1. Auditory discrimination (36)

≤35 36–55 N56 ≤35

– – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – F M F M F M – – – – – – – – – F

– – – 0–12 N13 0–12 N13 0–12 N13 0–12 N13 0–12 N13 0–12 N13 0–12 N13 0–12 N13 0–12 N13 0–12 N13 0–12 N13 – – – 0–12 N13 0–12 N13 0–12 N13 – – – 0–12 N13 0–12 N13 0–12 N13 0–12 N13 0–12 N13 0–12 N13 – – – – – – – – – – – 0–12 N13 0–12 N13 0–12 N13 0–12 N13 0–12 N13 0–12 N13 0–12

34 32 25 19 18 18 19 19 19

34 33 25 19 18 18 19 19 19

34 34 28 19 19 19 19 19 19

35 34 31 19 19 19 19 19 19

35 34 32 19 20 19 19 19 19

35 35 33 20 20 19 20 20 20

36 36 36 20 20 20 20 20 20

36 36 36 20 20 20 20 20 20

24

24

25

26

26

26

26

26

25 25 17 18 17 18

25 25 18 18 17 18

25 26 18 18 18 19

25 26 19 19 19 19

25 26 19 19 19 19

26 26 19 20 19 19

26 26 20 20 20 20

26 26 20 20 20 20

19 19 18 19 18 18 17 17 17 18 18 14 17 8 7 7 16 14 17 16 14 15 14 14 14 13 14 13 9 8 5 9 8 9 8 8 6 4 8 8 8 19 18 18 18 17 17 11 17 9 16 7

19 19 18 19 19 19 17 17 17 18 18 14 17 8 7 7 16 15 17 16 14 15 14 14 14 13 14 13 9 8 5 9 8 9 8 8 6 4 9 8 9 19 18 18 18 17 17 11 17 9 16 7

19 20 18 20 19 19 18 17 18 19 18 15 17 9 8 8 16 18 17 17 14 17 14 15 14 14 14 13 9 9 7 9 9 9 9 9 7 4 9 9 9 19 18 19 18 17 18 14 18 13 17 7

20 20 19 20 19 19 19 18 18 19 19 16 18 9 9 8 18 19 17 18 15 17 14 15 14 15 14 14 10 9 8 10 10 9 9 9 8 6 9 9 10 19 19 19 19 17 18 16 18 16 18 8

20 20 20 20 20 20 19 18 19 19 19 17 18 9 9 8 19 19 18 19 16 17 15 15 14 15 14 15 10 9 8 10 10 9 10 9 8 6 10 9 10 19 19 19 19 18 19 17 19 16 18 8

20 20 20 20 20 20 20 19 19 19 19 18 19 10 9 9 19 20 19 19 17 19 15 15 15 15 15 15 10 10 9 10 10 10 10 9 9 9 10 10 10 19 19 19 19 19 19 17 19 17 19 9

20 20 20 20 20 20 20 20 20 20 20 19 19 10 10 10 20 20 20 20 18 20 15 15 15 15 15 15 10 10 10 10 10 10 10 10 10 10 10 10 10 20 20 20 20 19 20 19 20 18 19 10

20 20 20 20 20 20 20 20 20 20 20 20 20 10 10 10 20 20 20 20 20 20 15 15 15 15 15 15 10 10 10 10 10 10 10 10 10 10 10 10 10 20 20 20 20 20 20 20 20 20 20 10

2. Auditory lexical decision (20)

36–55 N56 3. Letter matching (26)

≤35* 36–55 N56

4. Written lexical decision (20) 5. Semantic association of pictures (20) 6. Spoken word-picture matching (20)

– – – – ≤35* 36–55 N56

7. Semantic association of written words (20)

8. Spoken picture naming (20)

≤35 36–55 N56 ≤35 36–55 N56

9. Rhyme judgment on pictures (10)

10. Rhyme judgment on written words (20)

≤35 36–55 N56 ≤35 36–55 N56

11. Word repetition (15)

≤35 36–55 N56

12. Nonword repetition (10)

13. Delayed word repetition (10) 14. Delayed nonword repetition (10)

≤35 36–55 N56 – ≤35 36–55 N56

15. Word reading (10) 16. Nonword reading (10) 17. Written picture naming (20)

– – – ≤35 36–55 N56

18. Word spelling to dictation (20)

19. Nonword spelling to dictation (10)

– – – – ≤35

M –

J. Macoir et al. / Journal of the Neurological Sciences 361 (2016) 220–228

227

Table 4 (continued) Percentiles Task (number of items)

Age 36–55 N56

Gender

Education

– – – – –

N13 0–12 N13 0–12 N13

1

2 6 8 8 2 4

6 8 8 2 4

5 8 8 8 3 8

10

15

25

50

95

8 8 8 4 8

9 9 9 5 8

9 9 9 8 8

10 10 10 9 10

10 10 10 10 10

*Performance is perfect (i.e. no error) for tasks (No 3 and 6) not reported in the table.

Rhyme judgment on written words, Word repetition, Written picture naming, Nonword spelling to dictation) were correlated with age and education level; one task (Delayed nonword repetition) was correlated with age and gender; one task (Word spelling to dictation) was correlated with gender and education level. Percentile scores were provided for each task of the BECLA in order to show the relative rank of each raw score according to significant correlates (see Table 4). 4. Discussion The assessment of linguistic abilities is one of the most important clinical activities of speech-language pathologists. By resorting to the cognitive psychology framework, the clinician interprets the assessments results, including the characterization of errors and influence of psycholinguistic variables, in order to identify the functional locus/loci of impairment (e.g., semantic memory; lexical access; phonological output buffer). When recommended, he may then choose a therapeutic approach (e.g., restoration; reorganization; compensation) [26,27] and treatment method (e.g., reactivation of phonological representations; relearning of grapheme-to-phoneme conversion rules) specifically adapted to the impairment as well as to patient's communication needs and wishes. Compared to the English language, for which there exist numerous tests and batteries to assess acquired language deficits, the tools available to assess French-speaking individuals are much more limited. The BECLA was explicitly developed to fulfill the need for assessment tools based on theoretical models of cognitive psychology in French. This test battery, developed to rapidly evaluate language deficits in younger and older adults, comprises 19 tasks, designed to assess each of the components and routes involved in the processing of single words. The results of the present study provide norms for the BECLA, culturally adapted to the French-Quebec population. The normative scores for the BECLA have been computed from a study sample composed of 248 French-speaking adults, aged between 18 and 94, with an education level varying between 4 and 23 years, recruited from 15 out of the 17 administrative regions of the province of Quebec. As mentioned above, culture has an impact on cognition and therefore, it is important to use normative data specific to the population to which they are applied. This is particularly true for the assessment of language functions, considering the possible psycholinguistics (e.g., word frequency, length) and cultural (e.g., vocabulary, familiarity of concepts) biases. In this regard, BECLA fills an important void in Quebec's speech-language pathology practice. The large group of participants (N = 248) is a considerable strength of the present study. Despite this significant number, the stratification of data according to multiple variables (i.e. age, gender, education) forced the adoption of a global stratification strategy in order to have enough individuals in each cell. Additional strata according to age could improve the generalizability of the normative data, especially to elders, and further studies are therefore needed. In the same vein, further studies are also required to establish cut-off scores for each task of the BECLA. This study also has few limitations, such as the overrepresentation of highly educated individuals in the sample. In fact, compared to current Quebec demographics (Institut de la statistique

du Québec, [30]), this sample includes more individuals with at least 13 years of formal education. Ideally, a random sampling method would have increased the representativeness of this sample. Therefore clinicians should interpret percentile ranks carefully since some age groups with low education do not comprise enough participants, especially for younger adults. Considering that the BECLA is a new assessment battery, we believe that our sampling method is, at the very least, a practical starting point in the establishment of norms for the Quebec-French population. Another limitation is the ceiling or almost ceiling effects observed for the majority of the BECLA tasks in some age groups and/or education level. In fact, in 14 out of the 19 tasks, producing a single error corresponds to the 5th percentile, which is close to one and a half standard deviations below the mean on a normal distribution. It should be recalled that the BECLA was created to rapidly assess language processing and some tasks comprise relatively few stimuli. Therefore, impaired performance in one or more tasks should be interpreted as a “clinical alarm” for which a more extensive assessment should be performed to confirm the presence of a deficit. Because of these ceiling effects, the BECLA is also not suitable to measure language improvement (i.e. low sensitivity to change). A third limitation is associated with the administration of the BECLA at the participants' home, in various set-ups and conditions. However, such a testing method also has the advantage of avoiding sample bias linked to the recruitment of highly dedicated volunteers who may not be representative of the general population. To conclude, this study provides normative data for the BECLA, a new clinical battery for the assessment of language processing in younger and older adults. These norms, established from a wide sample of 248 French-speaking adults selected from the community, will be useful for identifying and characterizing acquired deficits of language, within the theoretical framework of cognitive models of language processing. Further research is needed to establish the reliability and the validity of the BECLA. Moreover, considering the ceiling effect observed in the performance of healthy Quebecers on some tasks of the battery, further studies are also needed to directly address the question of the instrument's sensitivity to mild language impairments. Conflict of interest The authors report no conflict of interest. References [1] K. Patterson, C. Shewell, Speak and spell: dissociations and word-class effects, in: C. M, J. R, S. G (Eds.), The Cognitive Neuropsychology of Language, Lawrence Erlbaum Ass., Hillsdale, N.J 1987, pp. 273–294. [2] A. Caramazza, How many levels of processing are there in lexical access? Cogn. Neuropsychol. 14 (1) (1997) 177–208, http://dx.doi.org/10.1080/026432997381664. [3] J. Kay, R. Lesser, M. Coltheart, Psycholinguistic Assessments of Language Processing in Aphasia (PALPA), Hove, UK, Lawrence Erlbaum Ass., 1992 [4] L. Nickels, D. Howard, A frequent occurrence? Factors affecting the production of semantic errors in aphasic naming, Cogn. Neuropsychol. 11 (3) (1994) 289–320, http://dx.doi.org/10.1080/02643299408251977. [5] A.E. Hillis, A. Caramazza, The compositionality of lexical semantic representations: clues from semantic errors in object naming, Memory 3 (3/4) (1995) 333–358, http://dx.doi.org/10.1080/09658219508253156.

228

J. Macoir et al. / Journal of the Neurological Sciences 361 (2016) 220–228

[6] R.M. Reitan, Aphasia Screening Test, Tucson, Reitan Neuropsychology Laboratory., 1991 [7] H. Goodglass, E. Kaplan, B.A. Barresi, Boston Diagnostic Aphasia Examination, third ed. Lippincott Williams & Wilkins, Philadelphia, 2001. [8] A. Kertesz, Western Aphasia Battery, Grune & Stratton, New York, 1982. [9] J. Bourgeois-Marcotte, C. Flamand-Roze, C. Denier, L. Monetta, LAST-Q: adaptation and normalisation in Quebec of the Language Screening Test, Rev. Neurol. 171 (5) (2015) 433–436, http://dx.doi.org/10.1016/j.neurol.2015.03. [10] J.-L. Nespoulous, A.R. Lecours, D. Lafond, A. Lemay, M. Puel, Y. Joanette, et al., Protocole Montréal-Toulouse d'examen linguistique de l'aphasie. MT-86 Module Standard Initial: M1A. 2nd Edition Revised by Renée Béland & Francine Giroux, L'Ortho-Édition, Isbergues, 1992. [11] G. Deloche, D. Hannequin, Test de dénomination orale d'images-DO 80, Éditions du Centre de Psychologie Appliquée, Paris, 1997. [12] D. Howard, K. Patterson, The Pyramids and Palm Trees Test: A Test for Semantic Access from Words and Pictures, Bury St Edmunds, Thames Valley Test Company, 1992. [13] B.L. Callahan, J. Macoir, C. Hudon, N. Bier, N. Chouinard, M. Cossette-Harvey, et al., Normative data for the pyramids and palm trees test in the Quebec-French population, Arch. Clin. Neuropsychol. 25 (3) (2010) 212–217, http://dx.doi.org/10.1093/ arclin/acq013. [14] G. Arsenault-Lapierre, V. Whitehead, S. Belleville, F. Massoud, H. Bergman, H. Chertkow, Mild cognitive impairment subcategories depend on the source of norms, J. Clin. Exp. Neuropsychol. 33 (5) (2011) 596–603, http://dx.doi.org/10. 1080/13803395.2010.547459. [15] J. Baudot, Fréquences d'utilisation des mots en français écrit contemporain, Les Presses de l'université de Montréal, Montréal, 1992. [16] A. Desrochers, M. Bergeron, Valeurs de fréquence subjective et d'imagerie pour un échantillon de 1,916 substantifs de la langue française, Can. J. Exp. Psychol. 54 (4) (2000) 274–325, http://dx.doi.org/10.1037/h0087347. [17] J.G. Snodgrass, M. Vanderwart, A standardized set of 260 pictures: norms for name agreement, image agreement, familiarity, and visual complexity, J. Exp. Psychol. 6 (2) (1980) 174–215, http://dx.doi.org/10.1037/0278-7393.6.2.174. [18] P. Bonin, R. Peereman, N. Malardier, A. Méot, M. Chalard, A new set of 299 pictures for psycholinguistic studies: French norms for name agreement, image agreement, conceptual familiarity, visual complexity, image variability, age of acquisition, and naming latencies, Behav. Res. Methods Instrum. Comput. 35 (1) (2003) 158–167, http://dx.doi.org/10.3758/BF03195507.

[19] F.X. Alario, L. Ferrand, A set of 400 pictures standardized for French: norms for name agreement, image agreement, familiarity, visual complexity, image variability, and age of acquisition, Behav. Res. Methods Instrum. Comput. 31 (3) (1999) 531–552, http://dx.doi.org/10.3758/BF03200732. [20] J. Druks, J. Masterson, An Object and Action Naming Battery, Psychology Press, Hove, UK, 2000. [21] J. Tanaka, D. Weiskopf, P. Williams, The role of color in high-level vision, Trends Cogn. Sci. 5 (5) (2001) 211–215, http://dx.doi.org/10.1016/S1364-6613(00)01626-0. [22] G.D. Zannino, R. Perri, G. Salamone, C. Di Lorenzo, C. Caltagirone, G.A. Carlesimo, Manipulating color and other visual information influences picture naming at different levels of processing: evidence from Alzheimer subjects and normal controls, Neuropsychologia 48 (9) (2010) 2571–2578, http://dx.doi. org/10.1016/j.neuropsychologia.2010.05.003. [23] L. Cohen, A.-C. Bachoud-Levi, The role of the output phonological buffer in the control of speech timing: a single case study, Cortex 31 (3) (1995) 469–486, http://dx. doi.org/10.1016/S0010-9452(13)80060-3. [24] M. Coltheart, K. Rastle, C. Perry, R. Langdon, J. Ziegler, A dual route cascaded model of visual word recognition and reading aloud, Psychol. Rev. 108 (2001) 204–256, http://dx.doi.org/10.1037/0033-295X.108.1.204. [25] J.R. Crawford, P.H. Garthwaite, Percentiles please: the case for expressing neuropsychological test scores and accompanying confidence limits as percentile ranks, Clin. Neuropsychol. 23 (2) (2009) 193–204, http://dx.doi.org/ 10.1080/13854040801968450. [26] D. Howard, F.M. Hatfield, Aphasia Therapy: Historical and Contemporary Issues, Lawrence Erlbaum Associates, London, 1987. [27] A. Whitworth, J. Webster, D. Howard, A Cognitive Neuropschological Approach to Assessment and Intervention in Aphasia: A Clinician's Guide, second ed. Psychology Press, New York, 2014. [28] W.J.M. Levelt, A. Roelofs, A.S. Meyer, A theory of lexical access in speech production, Behav. Brain Sci. 22 (1999) 1–75, http://dx.doi.org/10.1017/S0140525X99001776. [29] R.A. McCarthy, E.K. Warrington, Evidence for modality-specific meaning systems in the brain, Nature 334 (1988) 428–430, http://dx.doi.org/10.1038/334428a0. [30] Institut de la statistique du Québec, Population de 25 ans et plus, selon le plus haut degré de scolarité atteint, le sexe et le groupe d’âge . Québec, 2006. Retrieved November 13, 2013, from http://www.stat.gouv.qc.ca/donstat/societe/education/etat_ scolr/tab1_niv_sco_2006.htm.