Applied Neuropsychology

2002, Vol. 9, No. 4, 244248

Copyright 2002 by
Lawrence Erlbaum Associates, Inc.

BOOK AND TEST REVIEWS

Book and Test Review Editor: Nick A. DeFilippis

diagnosis, and formal language evaluation of these

disorders.
The first chapter of the book, Historical Aspects,
is well written and provides information on contrasting
historical arguments and controversies concerning
transcortical aphasias. From previous works, we have
read about borderzone aphasic syndromes (Benson,
1979) and extrasylvian aphasic syndromes (Benson &
Ardila, 1996). In this work, we can see a progression in
the sophistication of the analysis of the clinical characteristics and corresponding localization of these
transcortical aphasias.
The text is organized into additional chapters on
language testing, transcortical motor aphasia, transcortical sensory aphasia, and mixed transcortical aphasia.
Added bonuses are the final two chapters on echophenomena, automatic speech and prosody in transcortical
aphasias, and neuroanatomical correlates of transcortical aphasias.
Of particular interest to me was the discussion about
the right hemisphere mediation of automatic speech
versus automatic speech and transcortical aphasias in
general. The section on prosody highlights new ideas
on prosody in transcortical aphasias, which makes for
interesting comparisons with previously described
right hemisphere syndromes and prosody disturbances
(Pimental, 1989; Ross, 1981). Innovative thinking regarding damage to the left hemisphere and resultant
transhemispheric diaschisis and impairment of various
functions encourage the reader to expand their thinking about etiologic and diagnostic possibilities in language disturbances.
In summary, this text highlights both previously
known and new information on a topic that is clinically
significant for our continued understanding and treatment of language disorders secondary to brain dysfunction. In a relatively short text, the reader is brought
up to date on important developments in aphasiology,
specifically complex issues in the transcortical
aphasias.

M. Berthier, Transcortical Aphasias. Psychology Press, East Sussex, England, 1999

This text on transcortical aphasias fills a void in
the neurological and neuropsychological literature
concerning this most fascinating group of aphasic
disturbances. Although not an exhaustive and comprehensive review of all of the aspects of known
transcortical syndromes, which the author himself admits, it is by far one of the most clinically provocative
and useful.
As a clinical neuropsychologist who originally
trained as a speech-language pathologist some 25
years ago in the manner of the Boston school of aphasiology and the Boston Diagnostic Aphasia Examination (Goodglass & Kaplan, 1972), a great curiosity and
appreciation of the transcortical aphasias still lingers
with me. Although the author states that the text might
be seen as untimely because its publication coincides
with the progressive decline in the use of standard diagnoses in the classification of aphasias, he also
points out that it is not at odds with a cognitive neuropsychological model. I would argue further that in
terms of localization value and rehabilitation treatment
with ecological validity concerning language integrity,
that it would serve us well not to abandon the rich literature of the classical aphasia syndromes and what
this literature has taught us. Practically speaking,
transcortical aphasias are a commonplace diagnostic
finding in progressive neurodegenerative conditions
with cortical aphasia syndromes such as Alzheimers
disease, and, for this reason, it is clinically useful to
discuss them.
To the clinical neuropsychologist, behavioral neurologist, aphasiologist, speech-language pathologist,
and other cognitive rehabilitation specialists, this text
provides new information on transcortical aphasias
in tandem with recent advances in neuroimaging. It
also clarifies various aspects of the etiology, clinical
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BOOK AND TEST REVIEWS

References
Benson, D. F. (1979). Aphasia, alexia and agraphia. New York:
Churchill.
Benson, D. F., & Ardila, A. (1996). Aphasia: A clinical perspective.
New York: Oxford University Press.
Goodglass, H., & Kaplan, E. (1972). The assessment of aphasia
and related disorders. Philadelphia: Lea & Febiger.
Pimental, P. A., & Kingsbury, N. (1989). Neuropsychological aspects of right brain injury. Austin, TX: PRO-ED.
Ross, E. D. (1981). The aprosodias: Functional-anatomic organization of the affective components of language in the right hemisphere. Archives of Neurology, 38, 561569.

Patricia A. Pimental, Neurobehavioral Medicine Consultants, Ltd., Carol Stream, IL, and GlenOaks Hospital, Glendale Heights, IL, 60139, USA

M. D. Franzen, Reliability and Validity in Neuropsychological Assessment (2nd ed.), Kluwer

Academic/Plenum, New York, 2000

The second edition of Reliability and Validity in

Neuropsychological Assessment provides a valuable and
timely discussion of psychometric issues pertinent to
neuropsychological research and practice and a summary of research findings examining the reliability and
validity of a large selection of neuropsychological tests.
Franzens intentions for this volume were to (a) alert
clinical researchers of the need to conduct basic research into the psychometric properties of neuropsychological instruments, (b) inform clinicians choices when
selecting tests for particular patients in particular situations, and (c) provide students with a resource to learn
about instruments or to generate ideas for research. In
our view, Franzen has accomplished these goals. Although there are other books that incorporate some of
this material (e.g. Lezak, 1995; Mitrushina, Boone, &
DElia, 1999; Spreen & Strauss, 1998), Franzens psychometric sophistication with regard to issues of reliability and validity sets this book apart.
The first 5 chapters consider basic methodological
and theoretical considerations regarding test reliability and validity. These chapters are extremely well
written and could serve as essential reading for both
graduate students as well as practicing clinicians. The
author focuses not only on traditional conceptualizations of reliability and validity but also provides
important discussion of newer developments in psychometric theory (e.g., generalizability theory, item
response theory, ecological validity, and test bias).

Franzen encourages the incorporation of newer

methodologies, which would lead to a greater sophistication and understanding of the utility and limitations
of our tools.
Each of the next 16 chapters presents a review of research on the reliability and validity of particular tests
or test batteries. However, chapter organization is variable, such that some chapters cover a particular test or
test battery (e.g., Wechsler Adult Intelligence Scales,
Halstead-Reitan, and Luria-Nebraska Neuropsychological Batteries), whereas other chapters incorporate
tests of specific cognitive domains (e.g., tests of memory and tests of verbal functions) or for particular purposes (e.g., screening devices and methods for evaluating the validity of test scores). It was often difficult to
locate and identify the tests covered, and a more detailed table of contents or a test index would have been
useful in orienting the reader to the tests reviewed and
their placement within the book.
Franzen reviews a wide variety of tests, methods,
and domains in neuropsychological assessment. Indeed, we commend Franzen for the immense effort involved in carefully and thoughtfully reviewing the vast
psychometric literature, especially that which has
emerged since the first edition of the book was published in 1989. For the majority of the tests covered,
Franzen provides a nice, but not exhaustive, summary
of the psychometric literature to date, highlights important issues, and provides direction for future research.
His choice of tests, however, is somewhat idiosyncratic, with the selection ranging from the familiar
(e.g., California Verbal Learning Test) to the more obscure (e.g., Queensland Test). Furthermore, the
amount of discussion and review provided for each
test varies considerably. Although he goes into depth
for some of the older standards in the field (e.g.,
Wechsler scales and Bentons neuropsychological
tests), the amount of information provided on some
tests was less than optimal. Often the newer methods
are dealt with in a more cursory fashion, and some important reliability and validity information does not
appear to be included. For example, contrary to
Franzens claim, there are considerable reliability data
available for the Buschke Selective Reminding Test,
as well as data related to the tests predictive and concurrent validity. Also, given the rapid developments in
the testing enterprise, some of the test versions described are already dated (e.g., the Peabody Picture
Vocabulary TestRevised), and only brief discussions
of newer revisions are provided (e.g., the Wechsler
Adult Intelligence ScaleThird Edition). The coverage
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BOOK AND TEST REVIEWS

of tests of attention, executive functioning, and working memory could be expanded, as could the section
on child neuropsychological assessment.
A review of the first edition of this volume (Benedict, 1992) emphasized that while the book provided a
valuable summary for the practicing clinical neuropsychologist, the amount of information varied considerably among the tests covered, and some sections (e.g.,
measures of attention) required more extensive coverage. These concerns remain in the current volume.
Criticisms notwithstanding, in agreement with Benedicts earlier comments, we strongly recommend
Franzens book, as it will serve as an excellent reference on issues concerning the validity and reliability of
neuropsychological tests. The first 5 chapters provide a
concise and valuable summary on psychometric issues
as they pertain to neuropsychological assessment. The
remainder of the volume provides a helpful test resource that, in conjunction with other texts, will assist
in informing researchers and clinicians of the psychometric properties of the tests they employ.

References
Benedict, R. H. B. (1992). [Review of the book Reliability and validity in neuropsychological assessment]. Archives of Clinical
Neuropsychology, 7, 561562.
Lezak, M. D. (1995). Neuropsychological assessment (3rd ed.).
New York: Oxford University Press.
Mitrushina, M. N., Boone, K. B., & DElia, L. F. (1999). Handbook of normative data for neuropsychological assessment.
New York: Oxford University Press.
Spreen, O., & Strauss, E. (1998). A compendium of neuropsychological tests: Administration, norms, and commentary. New
York: Oxford University Press.

Nancy Wilde and Esther Strauss, Department of Psychology, University of Victoria, Victoria, BC V8W 3P5,
Canada

J. Tonkology, The Brief Neuropsychological

Cognitive Examination (BNCE), Western Psychological Services, Los Angeles, 1997

The Brief Neuropsychological Cognitive Examination (BNCE) is a well-conceived instrument for the
clinical neuropsychologist in a general clinical setting,
designed to evaluate the cognitive status of patients
with psychiatric disorders or psychiatric manifestations
of neurological diseases. This is an important niche to
246

fill in the evolving adaptations of neuropsychologists.

The test supplier makes many promises in the catalog
that are attractive: This convenient test assesses cognitive functions targeted in a typical neuropsychological
exam. In less than 30 minutes, it gives you a general
cognitive profile that can be used for screening, diagnosis, or follow-up. More efficient than a neuropsychological battery and more thorough than a screener. . . .
But does it live up to it promise?
When you first open the box, on the face of it, the
test does not appear to be convenient or simple. More
than a cursory examination of the materials is required
to get started. The test qualification required to purchase this test is not stated in the catalog, so I called
Western Psychological Services to ask. The doctoral
psychologist I spoke with stated that the BNCE would
be sold to individuals with a masters degree plus evidence of training in psychological testing. This is consistent with two similarly priced neuropsychological
screenersthe Repeatable Battery for the Assessment
of Neuropsychological Status and Cognistat. However,
I think that interpretation of the BNCE should be limited to users with a doctoral degree. Indeed, the manual
could be assigned reading in a graduate course on neuropsychological assessment, as it reflects a high level
of skill and competence by the author. Pay particular
attention to the case examples section of chapter 4 on
interpretation, where some valuable insights into cognitive functioning with respect to obtained BNCE results are given.
The details of administration, such as the instructions given to the patient or participant, are embedded
in the administration and scoring form (which is convenient), rather than in the administration and scoring
sections of the manual (which is expected). A closer
look at the structure of the test is needed to understand
just how it works and at what level of complexity. The
10 subtests of the BNCE are labeled as Orientation,
Presidential Memory, Naming, Comprehension, Constructive Praxis, Shifting Set, Incomplete Pictures,
Similarities, Attention, and Working Memory. These
10 subtests (a total of 50 items, with 39 items per
subtest) are grouped into two levels of difficulty, such
that the first 5 subtests (Orientation through Constructive Praxis) comprise part I (conventional information)
and the last 5 (Shifting Set through Working Memory)
comprise part II (Novel Information). In all, the test
yields 10 subtest scores, an aggregate score each for
part I and part II, and 1 total score. For each subtest,
the raw score is placed on a 4-point scale of impairment, ranging from 3 (none) to 0 (severe), and the five
ratings for each part are summed into an aggregate

BOOK AND TEST REVIEWS

score. Never mind that a lower score indicates greater

impairment. The total score is then the simple sum of
the two aggregate scores of impairment ratings. However, nowhere can I find the psychometric used to rate
a score of, say, 5 out of a total possible 8 on comprehension as mild impairment ( 2), and 6 out of 9 on
shifting set as moderate impairment ( 1). A closer
examination of the construct validity of the subtests
follows.
The total score ranges from 30 (no impairment) to 0
(maximal impairment). It is beyond question that people with no mental disorder will not lose more than 1
or, at most, 2 points. The total score is shown in the validity section of the manual to have pretty good classification accuracy using discriminant analysis (94% for
neurological versus psychiatric groups), but, of course,
this would not be particularly useful for individual
clinical decision making. A validity index, computed
as the ratio of the part I aggregate to the part II aggregate, is presented with the notation that values less
than 0.8 suggest an unlikely pattern of impairment (or
aphasia) because the simpler part I is too low relative
to the more difficult part II. Although this meets the
test of common sense, the validity index cutoff of 0.8
must be considered to be a rule of thumb, as there is no
validity study for it (and no validation of its application
as an indicator of aphasia either).
Data are presented in the manual to show that the relationship between BNCE total score and patient functional status is especially useful: 25 of 31 individuals
with total scores less than or equal to 21 were unable to
live independently, whereas 10 of 11 with total scores
of 28 to 30 were able to live independently. The discharge planning utility of this finding is of extreme importance. Furthermore, validity studies in the manual
reported correlations of part I and part II aggregate
scores with functional status that showed an interesting
pattern. In neurologicals, the part I functional status
correlation (0.71) is significantly greater than the part
II functional status correlation (0.59); in patients with
schizophrenia, the reverse was found, with the correlation of functional status with part I (0.47) significantly
less than the correlation with part II (0.64). But what
does this pattern mean? I think this finding belies a research pedigree of the author, and there are certain to
be further research findings that can be derived with
this instrument among these clinical populations.
The patient interface is nice. It lives up to its
promise of requiring less than 30 min in all but the
most impaired cases. Scoring is a snap, and the aggregate and total scores are quickly determined. A graphic
profile of subtest impairment ratings is easily plotted

on the scoring form, which is used in the demanding

process of interpretation. The test was able to hold the
interest of several low functioning people with chronic
schizophrenia whom I tested. Incomplete pictures, in
particular, is noteworthy because of its similarity to the
classic Gollin (1960) figures procedure to assess visual
perception. A very similar format has been shown to
differentiate those with Alzheimers disease from elderly controls (Lezak, 1995) and those with amnesia
from those considered normal (Warrington &
Weiskrantz, 1968). In this modern incarnation, the incomplete pictures subtest incorporates an interspersed
priming trial.
A careful consideration of the construct validity of
the subtests revealed that several of the subtest labels are
confusing as descriptors of the functions tested. Thus,
Naming (part I, C) is not confrontation naming like the
Boston Naming Test but rather is an assessment of autotopagnosia by naming four body parts. Comprehension
(part I, D) is not comprehension like verbal IQ testing
(e.g., Why do many foods need to be cooked?) but
rather is made up entirely of simple commands involving left-right orientation (e.g., Point to my right
hand.). Thus, more than a test of minimal language
comprehension, it is a test of body dysgnosia. Shifting
Set (part II, F) consists of eight items grouped into three
types: recurrent figures (figure copy and recall), reciprocal motor function, and months backward. This eclectic
subtest seems to require four cognitive functions
graphomotor skill and perseveration, visual memory,
motor inhibition, and working memorynone of which
assesses set shifting, at least not as taught in graduate
school. Attention (part II, I) has three types of items:
tracking, which is fairly equivalent to the Trail Making
Test and so would seemingly be a better candidate for
the Shifting Set label; Working Memory registration,
which is just the same as registration on the venerable
mini-mental state examination; and Calculation (simple
subtraction and serial threes). Lastly, Working Memory
(part II, J) is simply immediate recall of the three words
from working memory registration.
To be sure, it is tedious and picayune to argue, as I
am doing, that (a) the BNCE Naming and Comprehension subtests are really both tests of body agnosia,
(b) Shifting Set is really a test of movement organization and perseveration plus visual memory plus working memory, (c) Attention really is a test of set shifting
set plus working memory, and (d) Working Memory is
really a test of immediate recall. But is it important to
even bother? Here is why it may be important.
We want to know more than that this test has criterion validity (total score as predictor of functional
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BOOK AND TEST REVIEWS

status plus discriminant classification of neurological

versus schizophrenic groups). We want to know why
it workswhat it is doing. Thus, we want more understanding of the differential and dissociated correlations of part I and part II with functional status in
neurological versus schizophrenia standardization
groups. More empirical research is needed on this
point, and as a starting point, we can begin with hypothetical constructs of part I and part II. The proposed group labels of Conventional Information
(part I) and Novel Information (part II) seem inadequate because they lead to a perplexing conclusion
that types of information (conventional versus novel)
have differential functional value to different clinical
populations. More parsimonious is the suggestion
that there are differential impairments in cognitive
function in these populations that affect functional
outcome. Part I is made up largely of aphasia-related
items (body dysgnosa plus construction), with the
remainder being orientation and remote memory.
Part II is made up of items relating to processing of
external information plus regulating activity. That
part I is impaired to a greater degree than part II in
neurological patients, and the reverse in patients with
schizophrenia, is consistent with many clinical perceptions. More research could be used here.
In conclusion, the BNCE provides rich data that are
a bit troublesome to handle. Its flaws are irksome, yet

248

in both clinical and research settings, the results, when

properly interpreted, give the user valuable information about the patient. To realize the potential and correct the deficiencies of this instrument (labeling and
construct validity, impairment rating scale psychometric, and validity of validity index cutoff), research
questions need to be formulated and tested. But even
without a large-scale effort, the BNCE easily provides
useful data for clinical application. It deserves a respectable and well-used perch in the neuropsychologists collection of test instruments.

References
Gollin, E. S. (1960). Developmental studies of visual recognition
of incomplete objects. Perceptual Motor Skills, 11, 289298.
Lezak, M. D. (1995). Neuropsychological assessment (3rd ed.).
New York: Oxford University Press.
Warrington, E. K., & Weiskrantz, L. (1968). New method of testing
long-term retention with special reference to amnesic patients.
Nature, 217, 972974.

J. P. Ginsberg, Bryan Psychiatric Hospital and University of South Carolina School of Medicine, Department of Neuropsychiatry and Behavioral Science,
Columbia, SC 29229, USA