Neurol Sci (2008) 29:000–000 DOI 10.1007/s10072-008-0864-y ORIGINAL ARTICLE Twenty years after Spinnler and Tognoni: new instruments in the Italian neuropsychologist’s toolbox Angelo Bianchi • Mirko Dai Prà Received: 18 January 2008 / Accepted in revised form 17 April 2008 © Springer-Verlag 2008 Abstract The aim of this article is to review neuropsycho- Introduction logical normative studies which – after Spinnler and Tognoni’s monograph of 1987 – were done on healthy In 1987 Spinnler and Tognoni [1] edited a vast collection of Italian adult subjects, and which either wholly or partially neuropsychological norms set on 321 healthy subjects over used the Equivalent Scores (ES) methodology proposed by the age of 40, chosen from several Italian regions, in col- Capitani et al. The independent norms settled for the same laboration with numerous centres specialized in the study tests have been compared in order to point out their agree- of cognitive deterioration. The collection consisted of 27 ment, measured by Cohen’s Kappa, which in most cases tests dealing with a wide range of cognitive functions: ori- resulted either excellent or good (>0.7). Available tests have entation, memory, attention, intelligence, language, praxia, been classified and arranged to facilitate the most suitable spatial cognition and visual perception. After the model of choice for different clinical purposes. Moreover, a simple covariance that best represented the contribution of demo- software program has been set up which adjusts and trans- graphic variable (sex, age, schooling) had been singled out forms raw scores into ES. As well as saving time and avoid- for every test, the raw scores were first adjusted and then ing errors, this simple aid is likely to improve the quality transformed into new standardized scores (named and clarity of the communication of neuropsychological Equivalent Scores, ES) on an ordinal scale ranging from 0 results. to 4, according to Capitani et al. [2–5]. The main point of ES methodology is to fix, with non- Keywords Neuropsychology · Assessment · Test · parametric techniques, the outer tolerance limit of the left Normative studies queue of the adjusted scores, so that it is possible to assess, with a known risk of error (<5%), the cut-off splitting the bottom 5% of the population: this segment of distribution is called ES=0, and represents pathological performance. At the other end of the scale, the adjusted scores higher than the median are called ES=4, while the remaining ES are used to divide the left half of the distribution into three approximately equivalent intervals. In addition, the methodology lets us accurately compare the performances from the various tests, so as to obtain, within the subject, a cognitive profile of the impaired and preserved functions. Spinnler and Tognoni’s work rapidly became a landmark for most Italian neuropsychologists, as has ES methodology. Besides the differential diagnosis between normal and patho- ౧ A. Bianchi ( ) · M. Dai Prà logical cognitive deterioration, the instrument has been Department of Mental Health, Via G. Monaco 13, increasingly applied in other clinical, rehabilitative and I-52100 Arezzo, Italy forensic settings. The complexities of these new applications e-mail: [email protected] – as well as the increasing development of neuropsychology 2 Neurol Sci (2008) 29:131–137 Table 1 Normative studies carried out on Italian samples A Studies adopting ES methodology integrally (n. 34) Study, Year Test or Battery Sample Size Age Range Reference Barigazzi et al., 1987 Prose memory 127 20-85 6 Orsini et al., 1987 Digit Span, Corsi 1355 20-99 7 Allamanno et al., 1987 Tower of London 131 40-88 8 Basso et al., 1987 Raven’s Coloured Progressive Matrices (CPM) 279 21-80 9 Capitani et al., 1988 Gottschaldt’s Hidden Figures Test 190 25-86 10 Borrini et al., 1989 Autobiographical Memory 157 55-89 11 Capitani et al., 1991 Corsi supraspan 495 25-85 12 Della Sala et al., 1992 Digit Cancellation Test 352 20-99 13 Capitani et al., 1992 Serial Position Curve 321 40-90 14 Brazzelli et al., 1993 Rivermead Behavioral Memory Test (RBMT) 231 18-70 15 Capitani et al., 1994 Prose Memory 228 40-80 16 Della Sala et al., 1995 Poppelreuter-Ghent’s Overlapping Figures Test 237 20-86 17 Papagno et al., 1995 Metaphor and Idioms Comprehension 322 19-94 18 Pomati et al., 1996 Odd-Man-Out Test, Classification and Recall of Figures 100 22-79 19 Giovagnoli et al., 1996 Trail Making Test 287 15-79 20 Carlesimo et al., 1996 Mental Deterioration Battery (MDB) 340 20-89 21 Mauri et al., 1997 Learning of Semantically Related and Unrelated Words 249 20-89 22 Barbarotto et al., 1998 Stroop Test 209 18-81 23 Laiacona et al., 2000 Wisconsin Card Sorting Test (WCST), Weigl Sorting Test 205 15-85 24 Caffarra et al., 2002 Rey’s Complex Figure (RCF) 280 20-89 25 Nichelli et al., 2002 Weight and Time Estimation Task (STEP) 121 20-79 26 Caffarra et al., 2002 Stroop Test (Short Form) 248 20-89 27 Rizzo et al., 2002 Famous Face Naming Test 187 21-70 28 Carlesimo et al., 2002 Rey’s Complex Figure, Short Story Recall 227 20-90 29 Caffarra et al., 2003 Raven’s Progressive Matrices 1938 (PM 38) 248 20-89 30 Caffarra et al., 2004 Modified Card Sorting Test (MCST) 248 20-90 31 Bizzozero et al., 2004 Past Famous Events Memory 96 46-75 32 Bizzozero et al., 2005 Famous Face Recognition Test 98 46-75 33 Rosci et al., 2005 Interpretation of a complex picture 196 20-89 34 Appollonio et al., 2005 Frontal Assessment Battery (FAB) 364 20-95 35 Bizzozero et al., 2007 Proper name comprehension 98 46-75 36 Bizzozero et al., 2007 Naming celebrities 98 46-75 37 Papagno et al., 2007 Metaphor Comprehension, figures 201 20-89 38 Anselmetti et al., 2008 BACS 204 20-89 39 B Studies adopting ES methodology partially (n. 17) Study, Year Test or Battery Sample Size Age Range Reference Measso et al., 1993 Raven’s Coloured Progressive Matrices (CPM) 894 20-79 40 Measso et al., 1993 Mini Mental State Examination (MMSE) 906 20-79 41 Brazzelli et al., 1994 Milan Overall Dementia Assessment (MODA) 217 20-97 42 Zappalà et al., 1995 Phonological Word Fluency, Benton Visual Retention Test 701 20-79 43 (BVRT), Associate Learning Test Ghidoni et al., 1995 Autobiographical Memory 99 15-80 44 Capitani et al., 1998 Phonological Word Fluency 503 18-81 45 Caterini et al., 1998 Object recognition and orientation 174 20-85 46 Della Sala et al., 1998 Physiognomic decision 183 20-79 47 Capitani et al., 2000 Milner Landmark Task 240 25-95 48 Bizzozero et al., 2000 Face apraxia 180 20-94 49 Mariani et al., 2002 General Knowledge of the World 175 20-60 50 Budriesi et al., 2002 Past Famous Events Memory 169 21-77 51 Barbarotto et al., 2000 Picture reality decision 140 18-75 52 Della Sala et al., 2003 Cognitive Estimation Task (CET) 175 18-87 53 Della Sala et al., 2004 Gait apraxia 182 20-92 54 Iavarone et al., 2004 Frontal Assessment Battery (FAB) 236 20-80 55 Nocentini et al., 2006 Symbol Digit Modalities Test 361 20-80 56 C Studies adopting other methodologies (n. 2) Study, Year Test or Battery Sample Size Age Range Reference Mondini et al., 2003 Short Neuropsychological Exam (ENB) 420 16-70 57 Heaton et al., 2000 Wisconsin Card Sorting Test (WCST) 560 6-70 58 Neurol Sci (2008) 29:131–137 3 as a specialist discipline – have fostered the research of new group B it is applied to the raw scores above the mean. The neuropsychological diagnostic tools, which have found a difference between the two parameters has constantly kind of “common language” in ES methodology. turned out to be irrelevant. This article aims to: ES=1, 2, 3: these divide the remaining left half of the 1. review the normative studies which – after Spinnler and distribution into three parts almost equivalent to percentile Tognoni’s monograph – were conducted on healthy intervals 5-20 (ES=1), 21-35 (ES=2), 36-50 (ES=3). In the Italian adult subjects. Most of these studies also exam- studies belonging to group B, which do not report the exact ined subjects under 40, filling an evident gap, mainly in non-parametric calculation of the middle ESs, they only neurotraumatology; represent an acceptable approximation of the “true” ESs. 2. compare the available norms in order to establish their Since ES 1 usually includes the inner tolerance limit, it can ratio of agreement; be labelled borderline. 3. propose some simple classifying standards to facilitate Finally, there is a third group of normative studies the choice of the most appropriate instruments in differ- (Table 1, C) which used completely different statistical ent settings; techniques. Normally, these studies utilize larger samples 4. illustrate the features of a simple scoring software pro- of subjects, do not adjust raw scores by regression equa- gram which both adjusts and transforms the raw scores tions and maintain stratified norms for age and schooling. into ES, saving time, avoiding errors and improving the For our purposes, only the studies that allow some sort of quality and clarity of the communication of results. comparison with the previous groups have been taken into consideration. For a complete review, see [59]. Although a purely descriptive comparison of the differ- Materials and methods ent norms is important, it is not enough to support or dis- claim the reliability of the method. It is necessary to Normative studies published since 1987 were collected. As demonstrate that the performance of the same subject even- not all studies were indexed, the principal biomedical and tually provides the same ES, when transformed by differ- psychological libraries were also surveyed, and some ent, independent norms.