Applied Neuropsychology 2001, Vol. 8, No.

3, 161166

Copyright 2001 by Lawrence Erlbaum Associates, Inc.

COWAT Metanorms Across Age, Education, and Gender

Ann S. Loonstra, Alison R. Tarlow, and Alfred H. Sellers
Center for Psychological Studies, Nova Southeastern University, Fort Lauderdale, Florida, USA Norms for the Controlled Oral Word Association Test (COWAT; Benton & Hamsher, 1976) have been published as summary statistics from many relatively small samples. The purpose of this study was to combine statistics from these samples to produce metanorms broken down by age, gender, and level of education. Means and standard deviations of letters F, A, and S (FAS) totals from normative samples and samples of normal controls were gathered from a wide variety of research studies and then stringently selected based on factors such as adequacy of the sample and presence of the appropriate statistics. The resulting aggregate statistics for FAS totals suggest differences may exist in verbal fluency task performance, depending on a persons age, gender, and level of education. Key words: verbal fluency, norms, COWAT, FAS The Controlled Oral Word Association Test (COWAT; Benton & Hamsher, 1976) has been used since its inception as an aid in determining neurocognitive ability. It has been used to detect verbal communication deficits after brain lesions, to monitor delays in language development in children, and to assess an individuals ability to communicate in daily life (Spreen & Strauss, 1991). Although normative data for the letters F, A, and S (FAS) version of the COWAT currently exist in published form, these data have been accumulated a little at a time, piece by piece across numerous studies. As a result, no large sample of comprehensive norms exists for this test across age, education, gender, and IQ. Word fluency testing as a measure of neurocognitive functioning is often used to compare neurologically impaired participants with normal controls. A fundamental difficulty encountered in this type of research is the procurement of an adequate sample size. Small samples have a propensity for distortion or bias due to sample demographics. Because patterns have been found to be inconsistent among groups (Margolin, Pate, Friedrich, & Elia, 1990), it is crucial that normative data be extracted and compiled carefully. This preliminary study is a beginning toward such an end. We combined infor-

LOONSTRA,COWAT METANORMS TARLOW, & SELLERS

mation from diverse studies containing samples of normal performance of total words produced from the letters F, A, and S of the COWAT.

Method Selection of Studies A literature search was conducted to locate published studies containing normative samples of performances on the COWAT. These studies were either normative studies or studies in which a control group of normal participants was used. Collection methods included the close examination of any study using a word fluency test. Studies were included only if participants were required to orally generate words in accordance with Bentons administration criteria (Spreen & Strauss, 1991), beginning with the letters F, A, and S in a 60-sec time span (see appendix for detailed rules confirming standard procedure). The total number of words produced in response to all three letters were the reported scores. Only samples that contained normal participants and for which both means and standard deviations were reported were used. The means and standard deviations of the various test performances in the samples were then combined to produce aggregate summary statistics. Studies in which the COWAT was administered in a language other than English were excluded. Studies containing word fluency measures uti161

Requests for reprints should be sent to Ann S. Loonstra, Center for Psychological Studies, Nova Southeastern University, 3301 College Avenue, Fort Lauderdale, FL 33314, USA. E-mail: loona@nova.edu

LOONSTRA, TARLOW, & SELLERS

lizing more than three letters or letters other than FAS were also excluded, as were tests using categories instead of initial consonants.

Procedures for Combining Sample Statistics To calculate the total number of members (N) in all samples of the test score, the numbers in each valid sample (ns) were summed. To calculate the aggregate means of the test scores, each test mean of each valid sample was multiplied by the number (n) of the sample, resulting in the sum of that samples scores. The sum was then simply divided by the total number of the sample (N) to give the aggregate mean. To calculate the aggregate standard deviation, each sample standard deviation was first squared, then multiplied by the degrees of freedom of that sample, yielding a sum of squared deviations (SS) for that sample. These were then summed across samples. This result represents the SS within the samples. The SS between the samples was calculated by adding the weighted squared differences between sample means and overall composite mean. The SS between the samples was added to the SS within the samples to produce the total SS across all samples. This value was then divided by the total degrees of freedom (N 1) yielding the aggregate variance. The square root of this is the aggregate standard deviation.

der, and 40- to 60-year category was derived from data published by Cerhan et al. (1998). Table 1 shows the studies, their sample statistics, and the aggregate of these, for the overall FAS across both age and gender. Contributing samples and metanorms broken down by gender are shown in Table 2; Table 3 shows these statistics broken down by age groups. Table 4 provides the sample and aggregate statistics for the FAS totals by level of education, and Table 5 summarizes the aggregate statistics for the total FAS across all groupings. The increased sample sizes thus resulted in more stable score norms. The significance of increased stability provided by compiling aggregate statistics is that there is an increased level of confidence that similar results will be
Table 1. Sample and Aggregate Statistics for Overall Mean and Standard Deviation of FAS Totals Study Axelrod et al. Bolla et al. Boone Boone et al. Boone et al. Cerhan et al. Clark et al. Coen et al. Crossley et al. Dalrymple et al. Demakis Eslinger et al. Friedman et al. Geffen et al. Goethe et al. Gordon et al. Hoff et al. Joyce et al. Klimczak et al. Kozora et al. Lafleche et al. Norris et al. Nyberg et al. Parkin et al. Parkin et al. Parkin et al. Poreh et al. Shogeirat et al. Simkins et al. Tombaugh et al. Yeudall et al. Zec et al. Aggregate Year 1992 1990 1999 1990 1995 1998 1997 1996 1997 1994 1999 1984 1995 1993 1989 1986 1996 1996 1997 1995 1995 1995 1997 1991 1994 1999 1995 1990 1994 1999 1986 1999 M 38.63 44.50 40.15 41.28 40.45 33.90 41.40 29.50 25.00 41.00 37.80 38.62 44.29 30.00 44.17 42.27 43.70 46.95 40.15 43.65 51.90 38.43 42.10 49.15 36.90 49.45 51.80 38.00 43.58 37.50 45.80 36.60 34.78 SD 11.08 11.72 10.86 10.60 11.12 12.55 10.30 8.91 11.60 2.80 11.10 11.04 12.50 8.50 7.58 11.10 10.00 2.72 11.43 12.23 10.99 9.32 9.77 9.64 10.70 12.35 7.90 7.50 9.63 13.10 5.83 13.10 12.83 N 80 199 151 61 110 13,775 92 16 628 8 21 19 24 10 18 250 54 16 14 174 11 94 39 40 22 60 19 31 19 1,300 225 45 17,625

Results We identified 32 studies comprising a total of 92 separate samples that met our basic criteria for inclusion in this study. In several of these studies the criteria of normality were quite vague or based only on self-report. Demographic data are also incomplete in a number of cases. Only 17 of the studies provided information about the educational level of their samples, and just 10 studies provided information regarding IQ. Of these 10 studies, only 1 (Boone, 1999) stratified FAS data by IQ groupings (average, high average, and superior). Hence, it was not possible to stratify the metanorms on IQ. However, all but six samples provided gender information, and age was provided for all samples. Thus, we were able to stratify the metanorms on age (< 40 years, 4059 years, 6079 years, and > 80 years), level of education, and gender, although cross-classification was not possible. The large proportion of the metanorms for the overall, gen162

COWAT METANORMS Table 2. Sample and Aggregate Statistics for FAS Totals on Males and Females Males Study Bolla et al. Cerhan et al. Crossley et al. Goethe et al. Gordon et al. Hoff et al. Klimczak et al. Poreh et al. Tombaugh et al. Yeudall et al. Aggregate Note: Year 1990 1998 1997 1989 1986 1996 1997 1995 1999 1986 M 42.15 32.70 23.20 44.17 40.76 43.70 45.00 51.80 37.00 45.08 33.28 SD 11.70 12.68 12.10 7.58 11.46 10.00 11.69 7.90 13.00 5.90 12.96 N 80 6,098 258 18 90 54 7 19 559 127 7,310 M 46.08 34.86 26.20 43.12 35.29 37.80 44.43 35.14 Females SD 11.51 12.37 11.00 10.84 9.57 13.10 5.73 12.59 N 119 7,677 370 160 7 741 98 9,172

Dashes indicate data were not reported.

obtained when the test is administered neurocognitively intact individuals.

to

Discussion The aggregate statistics for FAS totals per age group suggest that there may be a progressive age-related decline in performance on oral measures of word fluency. This is in contrast to numerous studies that reported no effect of age (Axelrod & Henry, 1992; Bolla, Lindgren, Bonaccorsy, & Bleecker, 1990; Boone, 1999; Boone, Miller, Lesser, Hill, & DElia, 1990; Parkin & Java, 1999). The difference could in part be due to the possible influence of verbal IQ on overall FAS performance (Boone, 1999) and the fact that a number of individual samples that did not show an age effect may have used a population with a higher overall verbal intelligence (e.g., Bolla et al., 1990; Boone et al., 1990). Earlier studies using participants of low ability, due to poor education, low intelligence, or both, showed substantially lower scores (Spreen & Strauss, 1991). The absence of FAS normative data for individuals with lower than average IQ and education in many of the more recent normative studies is an issue raised by Mitrushina, Boone, and DElia (1999), who suggested that the use of those data alone could turn out to be problematic in clinical practice. The aggregate statistics for FAS totals according to gender indicate that women may slightly outperform men on this verbal fluency task. This is consistent with results garnered by Bolla et al. (1990). Other studies did not find a significant gender difference (Tombaugh, Kozak, & Rees, 1999; Yeudall, Fromm, Reddon, &

Stefanyk, 1986). Lezak (1995) reported in her review of FAS test characteristics that no difference in performance exists between men and women. Yeudall et al. (1986) noted the inherent difficulty in making inferences about gender differences in a data set derived from diverse biological and environmental sources. Tombaugh et al. (1999) found less than 1% of the variance to be accounted for by gender in administration of the FAS to a sample of 1,300 cognitively intact individuals. The aggregate statistics for FAS totals by level of education show an increase in verbal fluency performance between those who continued beyond high school and those with an education of 12 years or less. This confirms the suggestion of previous studies that FAS scores tend to increase with increasing education (Tombaugh et al., 1999). Although it appears that age, education, and gender play a role in verbal fluency performance on the COWAT, it is as yet unclear how many of these differences should be attributed to these factors and how many should be attributed to verbal intelligence. The role of verbal intelligence as a predictor of verbal fluency is an area that merits further research and analysis.

References
Axelrod, B. N., & Henry, R. R. (1992). Age-related performance on the Wisconsin Card Sorting, Similarities, and Controlled Oral Word Association Tests. The Clinical Neuropsychologist, 6, 1626. Benton, A. L., & Hamsher, K. (1976). Multilingual aphasia examination (2nd ed.). Iowa City, IA: AJA Associates. Bolla, K., Lindgren, K., Bonaccorsy, C., & Bleecker, M. (1990). Predictors of verbal fluency (FAS) in the healthy elderly. Journal of Clinical Psychology, 46, 623628.

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Table 3.

Sample and Aggregate Statistics for FAS Totals by Age Group Age FAS Total Group < 40 < 40 < 40 < 40 < 40 < 40 < 40 < 40 < 40 < 40 < 40 < 40 < 40 < 40 < 40 < 40 4059 4059 4059 4059 4059 4059 4059 4059 4059 6079 6079 6079 6079 6079 6079 6079 6079 6079 6079 6079 6079 6079 6079 > 80 > 80 > 80 > 80 > 80 > 80 M 37.80 44.17 46.95 45.00 35.29 40.50 49.45 51.80 39.30 41.20 43.10 41.83 44.92 44.58 49.72 43.51 41.10 43.56 35.39 34.01 33.17 41.23 43.50 42.10 34.24 39.60 36.00 42.33 36.00 31.70 32.37 24.00 41.00 30.00 41.23 45.76 36.90 51.25 32.31 37.80 24.00 46.49 28.90 28.20 29.37 SD 11.10 7.58 2.72 11.69 9.57 7.80 14.55 7.90 12.00 9.20 11.40 6.72 6.53 5.69 5.87 9.44 9.90 6.51 12.26 12.46 12.37 12.10 12.20 11.10 12.48 10.70 9.30 14.21 8.93 12.80 12.34 12.00 2.80 8.50 12.10 14.26 10.70 10.94 12.70 14.00 10.80 10.46 11.70 11.00 13.05

Study Demakis et al. Goethe et al. Joyce et al. Klimczak et al. Klimczak et al. Norris et al. Parkin et al. Poreh et al. Tombaugh et al. Tombaugh et al. Tombaugh et al. Yeudall et al. Yeudall et al. Yeudall et al. Yeudall et al. Aggregate Axelrod et al. Boone et al. Cerhan et al. Cerhan et al. Cerhan et al. Kozora et al. Tombaugh et al. Tombaugh et al. Aggregate Axelrod et al. Axelrod et al. Boone et al. Boone et al. Cerhan et al. Cerhan et al. Crossley et al. Dalrymple et al. Geffen et al. Kozora et al. Kozora et al. Parkin et al. Parkin et al. Aggregate Axelrod et al. Crossley et al. Kozora et al. Tombaugh et al. Tombaugh et al. Aggregate

Year 1999 1989 1996 1997 1997 1995 1999 1995 1999 1999 1999 1986 1986 1986 1986 1992 1990 1998 1998 1998 1995 1999 1999 1992 1992 1990 1990 1998 1998 1997 1994 1993 1995 1995 1994 1999 1992 1997 1995 1999 1999

N 21 18 20 7 7 40 20 19 19 106 132 62 73 48 42 634 20 25 1,519 3,780 3,552 41 121 144 9,202 20 20 21 15 1,710 3,219 139 8 10 43 47 22 20 5,294 20 146 43 200 24 433

Range 1538 1829 3039 1722 1722 1828 2032 1825 1619 2029 3039 1520 2125 2630 3139 1539 5059 5059 4549 5054 5559 5059 4049 5059 4059 6069 7079 6069 7079 6569 6064 6574 6070 6079 6069 7079 6079 6372 6079 8089 85+ 8089 8089 9095 8095

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COWAT METANORMS Table 4. Sample and Aggregate Statistics for FAS Totals by Level of Education Years of Education Study Crossley et al. Crossley et al. Tombaugh et al. Geffen et al. Dalrymple et al. Tombaugh et al. Crossley et al. Aggregate Crossley et al. Tombaugh et al. Tombaugh et al. Aggregate Year 1997 1997 1999 1993 1994 1999 1997 1997 1999 1999 N 140 170 163 10 8 664 202 1,357 115 392 81 588 Range 06 79 08 712 812 912 1012 012 13+ 1316 1721 1321 Group 012 012 012 012 012 012 012 012 > 12 > 12 > 12 > 12 M 16.20 23.70 24.90 30.00 41.00 36.70 27.00 30.07 34.20 42.60 43.90 41.14 FAS Totals SD 6.90 9.90 10.70 8.50 2.80 12.20 10.20 13.09 12.60 11.60 12.30 12.37

Table 5. Category Gender Males Females Age < 40 4059 6079 8095 Education 012 > 12 Overall

Summary of Aggregate Statistics for FAS Totals N M SD

7,310 9,172 634 9,202 5,294 433 1,357 588 17,625

33.28 35.14 43.51 34.24 32.31 29.37 30.07 41.14 34.78

12.96 12.59 9.44 12.48 12.70 13.05 13.09 12.37 12.83

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Original submission May 3, 2000 Accepted January 19, 2001

Appendix COWAT Administration Administer the test as follows:

Use a stopwatch and have the patient comfortably seated before giving the following instructions: I will say a letter of the alphabet. Then I want you to give me as many words that begin with that letter as quickly as you can. For instance, if I say B, you might give me bad, battle, bed. I do not want you to use words that are proper names such as Boston, Bob, or Brylcreem. Also do not use the same word again with a different ending such as eat and eating. Any questions? (Pause.) Begin when I say the letter. The first letter is F. Go ahead. (Begin timing immediately.) Allow one minute for each letter (F, A, and S). Say Fine or Good after each one-minute performance. If patients discontinue before the end of the minute, encourage them to try to think of more words. If there is a silence of 15 seconds, repeat the basic instructions, and the letter. For scoring purposes, write down the actual words in the order in which they are produced. Administer all three letters: F, A, and S. The test administration takes about five minutes. The score is the sum of all admissible words for the three letters. Inadmissible words produced under these instructions are not counted as correct. (Spreen & Strauss, 1991, p. 222)

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