The Halstead Category Test: a fifty year perspective

Demographically adjusted normative data for the Halstead category test in a Spanish-speaking adult population: Results from the Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS)

OBJECTIVE

The present study aimed to develop norms applicable to Spanish-speakers living in the United States (U.S.)- Mexico border region for the Halstead Category Test (HCT), a test of executive function.

METHODS

Healthy native Spanish-speakers (N = 252; Age: range 19-60 years, M = 37.28, SD = 10.24; Education: range 0-20 years; M = 10.65, SD = 4.33; 58.33% women) living in the U.S.-Mexico border region of California and Arizona completed the HCT as part of a comprehensive neuropsychological test battery. The univariable and interactive effects of demographic variables on HCT raw scores were examined. Total scores were normed using fractional polynomial equations, controlling for age, education, and gender. T-scores were also computed for HCT scores of the current Spanish-speaking normative sample using published, demographically-adjusted norms for English-speaking non-Hispanic Whites and Blacks. Impairment rates (T-Scores < 40) were calculated using published and current norms.

RESULTS

Age was significantly associated with increased number of errors, and education and male gender were associated with decreased number of HCT errors (total raw scores). Applying norms developed for English-speaking non-Hispanic Whites and Blacks resulted in overestimation of impairment rates in the current sample (impairment: 48% with White norms and 27% with Black norms). This pattern was evident across levels of education except in participants with 13+ years of education, where rates of impairment using non-Hispanic Black norms were comparable to those based on newly developed norms.

CONCLUSION

The present study presents norms for the HCT in a sample of U.S. Spanish-speakers, providing an important tool for identifying executive dysfunction in this population.

Psychometric Equivalence of the Computerized and Original Halstead Category Test Using a Matched Archival Sample

Objective: Investigate the equivalence of several psychometric measures between the traditional Halstead Category Test (HCT-Original Version [OV]) and the computer-based Halstead Category Test (HCT-Computerized Version [CV]). Method: Data were from a diagnostically heterogeneous, archival sample of 211 adults administered either the HCT by computer (n = 105) or cabinet (n = 106) as part of a neuropsychological evaluation. Groups were matched on gender, race, education, Full Scale Intelligence Quotient, and Global Neuropsychological Deficit Score. Confirmatory factor analysis was used to examine structural equivalence. Score, variability, and reliability equivalency were also examined. Differential item and test functioning under a Rasch model were examined. Results: An identified factor structure from research of the HCT-OV fit the HCT-CV scores adequately: χ²(4) = 8.83, p = .07; root mean square error of approximation = 0.10 [0.00, 0.20]; standardized root mean residual = 0.03; comparative fit index = 0.99. Total scores and variability of subtest scores were not consistently equivalent between the two administration groups. Reliability estimates were, however, similar and adequate for clinical practice: 0.96 for HCT-OV and 0.97 for HCT-CV. About 17% of items showed possible differential item functioning, though just three of these items were statistically significant. Differential test functioning revealed expected total score differences of <1% between versions. Conclusion: The results of this study suggest that the HCT-CV functions similar to the HCT-OV with there being negligible differences in expected total scores between these versions. The HCT-CV demonstrated good psychometric properties, particularly reliability and construct validity consistent with previous literature. Further study is needed to generalize these findings and to further examine the equivalency of validity evidence between versions.

Further validation of booklet category test subscales for learning, set loss, and memory in a mixed clinical sample

Although it has long been proposed that performance on the Booklet Category Test (BCT) relies on a number of different cognitive abilities, including executive functioning, perceptual reasoning, and memory, only a single total error score is typically derived and interpreted in clinical practice. BCT subscales based on factor analyses of subtest errors or designed specifically to measure specific cognitive domains have been proposed to better assess the multidimensional abilities underlying BCT performance. The aim of this study was to independently replicate and extend previous findings regarding the validity of these subscales. A mixed clinical sample of 137 patients completed the BCT and a number of additional measures used to assess neuropsychological domains of selective attention, various aspects of executive functioning, intellectual functioning, and memory. Correlation and regression analyses were used to explore the convergent and discriminant validity of each subscale. Subscales varied in the number and magnitude of their significant correlations with scores derived from traditional measures. In general, findings supported the convergent validity of BCT category learning, set loss, and memory subscales. However, findings regarding discriminant validity were more variable across subscales. Results provide additional support for the multidimensional nature of the BCT and the validity of derived subscales to measure specific aspects of cognitive functioning beyond what is measured by a total errors score. The recently proposed subscales examined in the current study appear to be worthy of further investigation by clinicians and researchers to determine their clinical utility.

The Category Test Perseveration, Loss of Set, and Memory Scales

The Category Test (CT) is a neuropsychological measure that taps into multiple domains of complex reasoning but yields a single error score, limiting the use of the test. In this study, three new CT scales were developed to assess specific aspects of executive dysfunction: Perseveration, Failure to Maintain Cognitive Set, and Inability to Recall and Re-Initiate Past Behavior. The relationship of these scales to well-established neuropsychological measures was examined in head-injured individuals and schizophrenia patients. The CT Perseveration score was correlated with the Wisconsin Card Sorting Test (WCST) Perseverative Responses score, but also with measures from the Wechsler Memory Scale-Revised and the California Verbal Learning Test. The CT Memory score correlated with other memory measures, but also with the WCST Perseveration measure. Although future studies designed to test discriminant and convergent validity are warranted, these scales may be useful in determining specific aspects of impaired CT performance.

ERP correlates of error processing during performance on the Halstead Category Test

The Halstead Category Test (HCT) is a neuropsychological test that measures a person's ability to formulate and apply abstract principles. Performance must be adjusted based on feedback after each trial and errors are common until the underlying rules are discovered. Event-related potential (ERP) studies associated with the HCT are lacking. This paper demonstrates the use of a methodology inspired on Singular Spectrum Analysis (SSA) applied to EEG signals, to remove high amplitude ocular and movement artifacts during performance on the test. This filtering technique introduces no phase or latency distortions, with minimum loss of relevant EEG information. Importantly, the test was applied in its original clinical format, without introducing adaptations to ERP recordings. After signal treatment, the feedback-related negativity (FRN) wave, which is related to error-processing, was identified. This component peaked around 250ms, after feedback, in fronto-central electrodes. As expected, errors elicited more negative amplitudes than correct responses. Results are discussed in terms of the increased clinical potential that coupling ERP information with behavioral performance data can bring to the specificity of the HCT in diagnosing different types of impairment in frontal brain function.

Concurrent Validity of New Subscale Scores for the Booklet Category Test

The Booklet Category Test (BCT) is a neuropsychological test of cognitive dysfunction that provides only one overall error score indicative of global impairment. It does not, however, delineate specific domains that might be impaired. The aim of this study is to concurrently validate 13 new BCT subscales using legacy instruments in patients with nonpenetrating traumatic brain injury (TBI). Eighty-nine patients with mild, moderate, and severe TBI completed a battery of neuropsychology tests. Partial correlations controlling for age were performed and there were significant correlations between the a priori selected scores from legacy measures of major cognitive domains and both BCT total errors and subscale scores. Additional analysis showed that several subscales were able to differentiate between performance levels on the legacy measures. Overall, our results showed that the subscales measured cognitive skills beyond global impairment, supporting the use of the BCT subscales in a population with TBI.

Effects of Marathi-Hindi bilingualism on neuropsychological performance

The present study aimed to examine if bilingualism affects executive functions and verbal fluency in Marathi and Hindi, two major languages in India, with a considerable cognate (e.g., activity is actividad in Spanish) overlap. A total of 174 native Marathi speakers from Pune, India, with varying levels of Hindi proficiency were administered tests of executive functioning and verbal performance in Marathi. A bilingualism index was generated using self-reported Hindi and Marathi proficiency. After controlling for demographic variables, the association between bilingualism and cognitive performance was examined. Degree of bilingualism predicted better performance on the switching (Color Trails-2) and inhibition (Stroop Color-Word) components of executive functioning; but not for the abstraction component (Halstead Category Test). In the verbal domain, bilingualism was more closely associated with noun generation (where the languages share many cognates) than verb generation (which are more disparate across these languages), as predicted. However, contrary to our hypothesis that the bilingualism "disadvantage" would be attenuated on noun generation, bilingualism was associated with an advantage on these measures. These findings suggest distinct patterns of bilingualism effects on cognition for this previously unexamined language pair, and that the rate of cognates may modulate the association between bilingualism and verbal performance on neuropsychological tests.

Clinical validity of the children's category test-level 2 in a mixed sample of school-aged children

The Children's Category Test (CCT) is a widely used measure of problem solving with adequate psychometric properties. Yet, Shriver and Vacc (n.d.) were fairly critical of the CCT in The Mental Measurement Yearbook and highlighted its limitations. Thus, to explore the clinical validity of the widely used CCT-Level 2 (CCT-2) version, results of that test were analyzed post hoc in a sample of 265 children with mixed etiology referred for neuropsychological testing at a private outpatient laboratory. Overall, the CCT-2 correctly classified 57.7% of the sample, with 72.2% accuracy in classifying the Neuropsychologically Normal Clinical Comparison group but only 54% for the Brain Injured group. Predictive power was further reduced when the Brain Injury group was subdivided. Predictive power fell to 27.2%, with the best predictions coming for the Mental Retardation (MR) group (58.3%) and the lowest for the Learning Disorder NOS group (2.5%). The current findings suggest that the CCT's clinical application should be used with caution.

Sensitivity of the Halstead Category Test factor scores to brain damage

Recent factor-analytic studies of the Halstead Category Test (HCT) indicate that its seven subtests form three factors including a Counting factor (subtests I and II), a Spatial Positional Reasoning factor (subtests III, IV, and VII), and a Proportional Reasoning factor (subtests V, VI, and VII). The sensitivity and specificity of these factors to heterogeneous forms of brain damage was examined in a large sample of patients and a normal comparison sample. A prorated Impairment Index, which excluded the HCT error score, was used to assign participants with brain damage into mild, moderate, and severe impairment groups. Also, groups with various forms of neuropathology were contrasted. Results indicated that both the Spatial Positional Reasoning and the Proportional Reasoning factors were sensitive to brain damage. However, in all of the brain-damage groups, a greater percentage of errors were made on the Spatial Positional factor, suggesting that of the two it was more difficult for those with brain damage. The sensitivity and specificity of the Spatial Positional factor score for detection of brain damage was comparable to that of the total error score, which has been previously demonstrated to be an excellent indicator of brain damage. Findings provide further support for the validity of the HCT factors, and are consistent with the view that factor scores may be useful in interpreting the HCT.

New scores for the Category Test: measures of interference for subtests 5 and 6

The Category Test is a well-known neuropsychological instrument used to assess concept formation and higher executive abilities. The present study investigated the utility of additional scores for the Category Test. We used principles developed in cognitive psychology to create several new measures for subtests 5 and 6 of this test. These scores were primarily designed to be sensitive to interference effects of learning decision rules from subtest 2, subtest 3, and subtest 4. The new scores as well as the total error scores from subtests 5 and 6 were used to discriminate subjects with documented brain injury from subjects who were neurologically normal based on neuroimaging and neurologic evaluation. The Category Test was given following Reitan's (1979) instructions, with the exception that no additional prompting was given to participants who struggled early with the test in order to reduce the "executive" guidance of the examiner. Because any "interference" from earlier subtests on performance of subtest 5 and subtest 6 should be related to mastery of these earlier subtests, the normal group was matched to the brain-impaired group on which subtest(s) they learned. This resulted in four learning groups: (a) learned subtests 3 and 4; (b) learned subtest 4 but not 3; (c) learned subtest 3 but not 4; and (d) failed to learn either subtest. ANOVA analyses revealed that the three measures of interference were significantly greater in the brain-damaged group than in the normal controls. Also, specific interference measures were related to specific prior subtest mastery, thus providing support for a proactive interference effect. In addition, we have evidence that our new measures may be selectively sensitive to frontal system dysfunction.

No evidence of the usefulness of eye blinking as a marker for central dopaminergic activity

This study aimed to evaluate eye blinking as a marker for central dopaminergic activity by investigating the effects of sulpiride (D2-antagonist) and lisuride (D2-agonist) on spontaneous eye blinks. Twelve healthy subjects were included in a randomized, double-blind, placebo-controlled, three-period crossover trial. They received sulpiride 400 mg, lisuride 0.2 mg and placebo on different occasions. Eye blinks, prolactin, finger tapping, eye movements and visual analogue scales were measured at baseline and regularly for 12 h after administration. No effect of sulpiride or lisuride was observed on the number of eye blinks. Sulpiride caused an increase in prolactin (643 U/ml) [confidence interval (CI) 549-737). Lisuride caused a decrease in smooth pursuit eye movements (-4.1%) (CI -7.3 to -0.9) and visual analogue scales for mood (-2.1 mm) (CI -3.7 to -0.4). Spontaneous eye blink rate was not affected by sulpiride and lisuride, which makes eye blinking not suitable as a marker for central D2 activity.

Computer-related anxiety: examining the impact of technology-specific affect on the performance of a computerized neuropsychological assessment measure

This study was conducted to examine the effect of impairment status and computer-specific anxiety on the performance of a computerized neuropsychological assessment measure. Computer related anxiety was measured using a standardized self-report measure tapping anxiety specific to computers and technology. Outcome on this measure was compared with error scores and response timing variables on a computerized version of the Category Test (CT) in both normal individuals and individuals with neurological, psychiatric, or substance abuse histories. Multivariate analysis results, controlling for psychomotor performance, revealed significant main effects for group status and computer-related anxiety. CT performance was significantly related to the level of computer-related anxiety, in that high anxiety resulted in higher CT error scores and longer response times, and the negative impact of computer-related anxiety on computerized neuropsychological assessment performance was stronger in individuals with impairment histories. Our results suggest that as computer-related anxiety increases, performance on computer administered neuropsychological assessment measures tends to decrease. Key words: computers, anxiety, computer-based task performance, clinical neuropsychology, Category Test

Clinical utility of the Category Test as a multidimensional instrument

The construct and criterion validities of the Category Test (CT) were evaluated in 162 participants who had sustained traumatic brain injury and had been screened carefully for confounding factors. Maximum likelihood factor analysis identified 2 latent constructs, consistent with previous research. However, only subtests associated with the Proportional Reasoning factor (Subtests V and VI) demonstrated consistent criterion validity in terms of sensitivity to injury severity. Performance of Subtest III, associated with the Spatial Positioning factor, was in the range of chance for more than a third of the sample, without any relationship to injury variables. It was concluded that the CT has construct validity as a multidimensional instrument but that only the Proportional Reasoning factor has criterion validity in the evaluation of sequelae of traumatic brain injury.