Upload
others
View
16
Download
0
Embed Size (px)
Citation preview
379 A/&/J 3C3i
THE ASSESSMENT OF COGNITIVE FUNCTIONING AMONG PATIENTS
WITH UNILATERAL VISUAL NEGLECT: EFFECTS OF
FIELD OF PRESENTATION AND CUEING
DISSERTATION
Presented to the Graduate Council of the
University of North Texas in Partial
Fulfillment of the Requirements
For the Degree of
DOCTOR OF PHILOSOPHY
By
Vicki Marlene Soukup
Denton, Texas
August, 1992
379 A/&/J 3C3i
THE ASSESSMENT OF COGNITIVE FUNCTIONING AMONG PATIENTS
WITH UNILATERAL VISUAL NEGLECT: EFFECTS OF
FIELD OF PRESENTATION AND CUEING
DISSERTATION
Presented to the Graduate Council of the
University of North Texas in Partial
Fulfillment of the Requirements
For the Degree of
DOCTOR OF PHILOSOPHY
By
Vicki Marlene Soukup
Denton, Texas
August, 1992
Soukup, Vicki Marlene, The Assessment of Cognitive
Functioning among Patients with Unilateral Visual Neglect:
Effects of Field of Presentation and Cueing. Doctor of
Philosophy (Clinical Psychology), August, 1992, 122 pp.,
11 tables, 3 illustrations, references, 122 titles.
Prior evidence has shown a reduction of neglect on line
bisection tasks as a function of altered hemispace
presentation and left cueing. The present study was
conducted to examine the effect of these factors in reducing
symptoms of neglect on measures of general cognitive
functioning.
To examine proposed changes, revised versions of the
Raven's Coloured Progressive Matrices and the Memory-for-
Designs (MFD) Test were constructed by placing the target
stimuli in the right hemifield. Two experimental
presentations, a right hemispace condition and a right
hemispace plus left cue prompt condition, were compared to
the standard presentation format. The primary hypotheses
predicted that RBD neglect patients would reveal enhanced
performance on the criterion measures as a result of these
manipulations. Significant correlations were predicted
between the neglect measures and between the two scoring
systems for the MFD.
The sample was comprised of 54 hospitalized patients,
assigned to either a RBD neglect group (N = 18), a RBD
nonneglect group (N = 18) , or an orthopedic control group (N
= 18) . Both RBD groups were administered the Mini Inventory
of Right Brain Injury, to document the presence and severity
of right brain injury. Presence of neglect was assessed via
the Schenkenberg Line Bisection Task and the Bells Test for
Visual Neglect. Subjects were examined under all three
conditions by administering one third of the items for each
condition.
Neglect subjects demonstrated significantly poorer
performance on both criterion measures than the two
comparison groups. However, no significant improvement in
performance was revealed with right hemispace presentation
of stimuli or left cue prompts combined with the right
hemispace version. Ancillary predictions concerning
correlations for the neglect measures and MFD scoring
systems were confirmed.
Results are interpreted in terms of increased
attentional demands and task complexity. These results
suggest that, despite the frequent clinical use of these
manipulations in the cognitive assessment of this
population, support for the efficacy of these procedures is
lacking.
TABLE OF CONTENTS
Page
LIST OF TABLES iv
LIST OF ILLUSTRATIONS V
Chapter
I. INTRODUCTION 1
Anatomical Correlates Animal Literature Theories of Neglect Incidence of Neglect Recovery of Function Assessment of Neglect Factors Affecting the Manifestation of Neglect Independent Deficit or Global Cognitive
Deterioration Defective Performance on the Raven's Coloured
Matrices Memory-for-Designs Test Summary and Statement of Hypotheses
II. METHOD 4 0
Subjects Procedure Instruments
III. RESULTS 50
IV. DISCUSSION 59
APPENDICES 68
REFERENCES 107
i l l
LIST OF TABLES
Table Page
1. Sample Characteristics and Group Performance
on Screening Measures 72
2. Clinical Data for Neglect Subjects 74
3. Clinical Data for RBD W/0 Neglect Subjects . . 75 4. Correlation Matrix for Subject Characteristics,
Screening Measures, and Dependent Variables . . 76
5. Group Means and Standard Deviations for the Raven's Coloured Progressive Matrices (RCPM) and the Memory-for-Designs (MFD) Tests . . . . 79
6. Tests for Equality and Compound Symmetry for the Dependent Variables 80
7. Analysis of Variance with Repeated Measures on One Factor for Raven's Coloured Progressive Matrices (RCPM) Scores 81
8. Analysis of Variance with Repeated Measures on One Factor for Memory-for-Designs (MFD) Test (Graham-Kendall Scoring) 82
9. Analysis of Variance with Repeated Measures on One Factor for Memory-for-Designs (MFD) Test (Modified Taylor Scoring System) 83
10. Components Found to Influence the Expression of Neglect 84
11. Comparison of RCPM Group Performance for RBD Patients and Controls 87
IV
LIST OF ILLUSTRATIONS
Figure Page
1. Raven's Coloured Progressive Matrices Group Means for Each Presentation 55
2. Memory-for-Designs Mean Error Scores (Graham-Kendall Scoring System) 56
3. Memory-for-Designs Mean Error Scores (Modified Taylor Scoring System 57
CHAPTER I
INTRODUCTION
Converging evidence from neurophysiological and
clinical studies points to the presence of a neuronal
apparatus in each hemisphere which functionally mediates the
shift of attention and of head and eye movements to the
contralateral space. This mechanism implements its scanning
as soon as a novel stimulus appears; however, if this
mechanism is disrupted by a unilateral lesion, the patient
is no longer aroused by events occurring in that space and
will not respond to them (De Renzi, Gentilini, Faglioni, &
Barbieri, 1989). This phenomenon is known as unilateral
neglect, but has also been referred to in the literature as
unilateral spatial neglect, hemispatial agnosia,
hemi-inattention or hemi-neglect (Fox, 1983).
Initially described by Oppenheimer (1883) and by Holmes
(1919), and then discussed in detail by Brain (1941),
unilateral spatial neglect was regarded as a disorder of
attention confined to one-half of space. In Brain's three
patients, large right parietal lesions were present. Brain
(1941) concluded that visual neglect was usually seen after
damage to the right hemisphere, and was thus encountered as
left visual neglect. He indicated that the symptom was not
due to visual-field or oculomotor abnormalities.
1
Brain damaged patients demonstrating neglect are
unaware of body side or extrapersonal space contralateral to
the site of the lesion. In severe cases, the affected
individual persistently lacks awareness of sensory stimuli
in the affected hemifield (Critchley, 1966). In other
cases, lack of awareness is manifest episodically, only when
there are simultaneous competing sensory stimuli in the
normal hemifield (eg., Heilman & Valenstein, 1972b).
Typical behavioral manifestations have been described in
terms of failure to complete the left side of drawings
(Colombo, De Renzi, & Faglioni, 197 6), to respond to oral
commands from the left side of space (Heilman & Valenstein,
1979), to eat food from the left side of the plate, and to
recognize the limbs on the left side as his/her own
(Friedland & Weinstein, 1977).
Neglect can occur for stimuli presented in the visual,
auditory, or tactile modalities, but Riddoch and Humphreys
(1983) contend that patients rarely demonstrate neglect in
all of these modalities. Conceptual neglect has been
documented in the studies by Bisiach and Luzzatti (1978) and
a distinct, nonsensory form of motor neglect has been
described by Laplane and Degos (1983). Halsband, Gruhn, and
Ettlinger (1985) identified 30 individuals as having neglect
from a sample of 84 unilaterally injured patients, with 20
of these patients showing only one form of neglect and 10
subjects revealing various combinations of neglect.
Analysis of patient performance indicated that mixed neglect
seems to differ qualitatively from unimodal neglect. Mixed
neglect, tactile, and motor neglect were reported as easy to
discriminate from other kinds of neglect; whereas, visual
and auditory neglect were less easy to discriminate,
particularly from patients without neglect.
Anatomical Correlates
Instances of neglect have traditionally been considered
to occur following lesions in the right parietal lobe
(Brain, 1941; Critchley, 1966). More recent case studies,
however, have reported virtually identical and in certain
instances, more persistent and severe inattention to the
left extrapersonal space after right hemisphere lesions in
the frontal lobe (Heilman & Valenstein, 1972b; Stein &
Volpe, 1983), the thalamus (Watson & Heilman, 1979; Watson,
Valenstein, & Heilman, 1981) and the basal ganglia (Damasio,
Damasio, & Chui, 1980). These findings are consistent with
models that propose multiple cerebral structures, including
the posterior parietal and the frontal cortex, are involved
in a neural network responsible for the modulation of
directed spatial attention (Mesulam, 1981).
The data presented by Vallar and Perani (1986), using
CT-scans of 110 right hemisphere stroke patients, has
provided support for the traditional view that neglect is
more frequently associated with retrorolandic damage. Their
results indicated that the inferior parietal lobule was the
area most frequently involved in patients with cortical
lesions showing signs of neglect. In their analysis,
frontal lesions and damage confined to the subcortical white
matter were rarely found to be associated with neglect.
When the lesion was confined to deep structures, neglect
occurred much more frequently when grey nuclei such as the
thalamus and basal ganglia were damaged.
On the other hand, evidence presented by Spiers and
colleagues (1990) lends support for the role of frontal
activity in neglect symptomatology. These researchers
examined hemispheric asymmetries in the spatial distribution
of attention using a rather unique paradigm involving the
artificial induction of neglect via intracarotid sodium
amobarbital tests. Scanning performance was correlated with
EEG activity, in an effort to identify the anatomic locus of
control for directed attention to extrapersonal space. The
results indicated that disruption of scanning and
contralateral neglect occurred only after right hemisphere
suppression and seemed specifically related to changes in
right frontal lobe EEG activity. The resolution of neglect
appeared to coincide most closely with the resumption of
normal electrophysiological activity in the frontal areas.
This pattern of performance was revealed for right handed
and left handed subjects, as well as those who had right
hemisphere language dominance. While this study provides
strong support for the presence of a lateralized attentional
network, further investigation with a nonCNS impaired
sample, as opposed to epileptic patients, is warranted.
Also, consistent findings revealed via PET neuroimaging
would provide strong confirmatory evidence to resolve these
anatomical foci disputes.
Animal Literature
The experimental evidence provided by ablation studies
in animals has yielded some interesting findings concerning
the lesion site controversy. In monkeys, contralateral
multimodal sensory neglect has often been produced by
unilateral dorsolateral frontal damage (Bianchi, 1895;
Kennard & Ectors, 1938). Acutely, animals demonstrate
spontaneous circling to the side of the lesion, with disuse
of the contralateral upper extremity and face. They do not
orient to visual or somatosensory stimuli contralateral to
the lesion. Recovery from neglect proceeds spontaneously.
After small removals in the superior limb of the arcuate
sulcus, recovery is complete within two weeks (Welsh &
Stuteville, 1958); whereas, larger lesions comprising
frontal "polysensory" associative cortex show recovery in 4-
10 weeks (Deuel & Dunlop, 1979; Deuel, Collins, & Caston,
1980).
Despite various implications to the contrary, visual
neglect has never been observed as a consequence of parietal
ablations in monkeys. The report by Heilman and colleagues
(1970), often cited as evidence for neglect in parietal
monkeys, in reality describes extinction, i.e., failure to
respond to a unilateral stimulus exclusively in the
condition of bilateral simultaneous stimulation. Other
reports have documented neglect in animals as a result of
lesions in the anterior cingulate gyrus (Watson, Heilman,
Cauthen, & King, 1973), the lateral hypothalamus (Deuel,
1980), superior colliculus (Flandrin & Jeannerod, 1981), and
mesencephalic reticular formation (Watson, Heilman, Miller,
& King, 1974) .
Deuel and Collins (1983) have provided direct evidence
that a network of specific foci, rather than a single center
or wide expanses of heterogeneous neural tissue, undergoes
metabolic depression in neglect. Differences in 2-deoxyl
14C glucose (DG autoradiography) utilization were reported
following removal of the right frontal associative cortex of
the macaque monkeys. During the acute phase, utilization
was selectively decreased in the damaged hemisphere;
specifically, in the striatum, motor nuclei of the thalamus,
nucleus medialis dorsalis, and the deep layers of the
superior colliculus (i.e., in subcortical structures rather
than in cortical regions to which frontal cortex projects).
After recovery, there was decreased metabolic activity only
in the nucleus medialis dorsalis. No consistent glucose
utilization changes appeared in cortex or in primary motor
or sensory pathways. Brains from unoperated control animals
did not exhibit these changes, nor did brains from operated
animals with behavioral recovery from neglect. These
findings suggest that in frontal monkeys, neglect is based
on depression of neuronal activity in widespread uninjured
subcortical structures with synaptic relations to the
ablated cortex; return of neuronal activity in these
structures parallels recovery from manifestations of
neglect.
Theories of Neglect
The cerebral mechanisms underlying neglect and
hemi-inattention have been the subject of intense
speculation. Early theories revolved largely around
afferent sensory defects, including altered sensation
(Battersby, Bender, Pollack, & Kahn, 1956), impaired sensory
integration (Denny-Brown, Meyers, & Horenstein, 1952), or
disordered body schema.
Denny-Brown and colleagues (1952) related neglect to
poor integration of sensory information from the
contralateral side of the body, a function deranged by a
lesion of either parietal lobe. Battersby et al., (1956)
argued that neglect stems from decreased sensory input in
patients with generally impaired mental function. Eidelberg
and Schwartz (1971) hypothesized that neglect is a result of
quantitatively asymmetrical input to the two cerebral
hemispheres.
Pure sensory theories of neglect, however, have had
difficulty accounting for other symptomatology observed in
these patients; specifically, the impaired motor acts (e.g.,
the omission of the left side of a drawing) and denial of
hemiparesis (Kirshner, 1986). Furthermore, since neglect
can be demonstrated in the absence of any sensory impairment
(Albert, 1973; Ettlinger, Warrington, & Zangwill, 1957) and
because there is no one-to-one relationship between neglect
and sensory deficit (Costa, Vaughn, Horwitz, & Ritter, 1969;
Gainotti, 1968), alternative theories have been proposed.
De Renzi, Faglioni, and Scotti (1970) suggested that
neglect may be the result of a "mutilated representation of
space". They suggested that patients with right-hemispheric
lesions who could not find a marble when it was in the
contralateral corner of a tactile finger maze, appeared to
be unaware that the left side of space existed. This idea
has been supported by Bisiach and colleagues who found that
patients with right-hemispheric lesions and left
visuospatial neglect omitted the left sides of images
retrieved from long-term memory (Bisiach, Capitani,
Luzzatti, & Perani, 1981; Bisiach & Luzzatti, 1978) and the
left sides of images mentally constructed from immediate
external input (Bisiach, Luzzatti, & Perani, 1979). The
notion that contralateral neglect also occurs in internally
generated representations implies that at some level of
processing in the intact brain, images are represented
analogically in the two hemispheres, at least with respect
to their left and right sides. More recent findings from a
visual imagery task described by Ogden (1987) provide
support for the idea that deficits in the processing of
visuospatial mental images underlie some forms of neglect.
Given that neglect has been observed in all modalities, but
few if any patients have demonstrated a generalized neglect
that encompasses all modalities, Ogden (1987) suggests that
the term unilateral spatial neglect covers a number of
neglect disorders, each of which conceivably results from
one or more deficits at different levels of perceptual and
cognitive processing.
More recent theories have conceptualized the neglect
phenomenon in terms of an attentional disorder, resulting
from unilaterally defective arousal. Although the
importance of right hemisphere function in maintaining
attention has been cited among early investigators (eg.,
Brain, 1941; Critchley, 1966), Heilman and colleagues, in a
series of animal and human studies, extended this theory
into an attention-arousal hypothesis. From their
perspective, the arousal mechanisms constitute the
dysfunctional component in unilateral neglect patients.
According to their theory, each side of the brain contains
its own activating system, a cortico-limbic-reticular loop
which mediates orientation (Heilman & Watson, 1977a, 1977b).
When this system is destroyed, half of the brain cannot
properly process the incoming sensory information and
organize the appropriate motor responses to it. Such a
10
unilateral decrease in arousal is thought to result in the
selective loss of the orienting response to the space
contralateral to the lesion, since it is assumed that each
cerebral hemisphere subserves orienting responses to the
opposite half space. However, in order to explain the fact
that neglect occurs more frequently following right than
left hemisphere lesions (Ogden, 1987), Heilman and Van Den
Abell (1979, 1980) further assume that the left hemisphere
only controls orienting to the right side of space, whereas
the right hemisphere can produce orienting to both sides
(Ladavas, Del Pesce, & Provinciali, 1989).
Anatomically, the frontal and inferior parietal
cortical areas associated with neglect have abundant
connections both to each other and to the reticular
activating system (i.e., the ascending system of neurons in
the brainstem and thalamus which alerts the brain). Lesions
anywhere in this circuit may impair the alerting or
orienting responses to contralateral stimuli. Damage to
this ascending system may explain the neglect seen with
thalamic and other subcortical lesions (Watson & Heilman,
1979; Watson, Valenstein, & Heilman, 1981).
Heilman, Schwartz, and Watson (1978) presented
experimental evidence for this decreased arousal in right
hemisphere lesions by recording the galvanic skin response
(GSR) in the hand ipsilateral to the lesion after
stimulation of this same hand. GSRs were less in patients
11
with right hemisphere lesions and neglect than in either
normal controls or patients with left hemisphere lesions and
aphasia. Similarly, electroencephalographic (EEG)
desynchronization in the parietal lobe of normal subjects,
another measure of arousal, occurred in the right parietal
lobe after stimulation of either side of the body, whereas
the left parietal lobe desynchronized only after right-sided
stimulation (Heilman & Van Den Abell, 1980).
Another cerebral mechanism related to neglect is
unilateral hypokinesia, or decreased spontaneous motor use
of either the left limbs or of all limbs in the left side of
space. This mechanism can be thought of as the motor aspect
of neglect. Valenstein and Heilman (1981) indicated that
even in the absence of weakness or sensory extinction,
occasional patients with neglect have clinically evident
hypokinesia of the left limbs. Hemiakinesia may also
explain the omission of left-sided details in the
spontaneous drawings of patients with right hemisphere
lesions. Experimental evidence from monkeys with either
right frontal or right temporoparietal cortex also favors
motor akinesia as a factor in neglect behavior (Watson,
Miller, & Heilman, 1978; Valenstein, Van Den Abell, Watson,
& Heilman, 1982).
Mesulam (1981) has attempted to synthesize the
behavioral and neuroanatomical data on neglect in a
"network" approach. In this model, the right inferior
12
parietal region contains the sensory schema for the
contralateral body, and hence right parietal lesions produce
sensory inattention, extinction, and abnormalities of
spatial and topographical function. The frontal lobe
subserves movement and exploration in contralateral space,
and hence, right frontal lesions produce inattention and
hypokinesia. The cingulate gyrus, a limbic structure also
implicated in neglect (Heilman & Valenstein, 1972b), relates
to the motivation to explore or attend to contralateral
space. The cingulate gyrus has extensive connections to
other limbic structures thought to be related to motivation
and rewards. Finally, the reticular activating system in
the brainstem and thalamus is necessary for arousal,
vigilance, and attention, especially as direct to the
contralateral body and space. This "network" theory brings
together the three mechanisms of sensory alteration,
inattention, and hypokinesia, and takes into account much of
the clinical and experimental evidence relating to neglect.
Incidence of Neglect
There is considerable discrepancy in the literature
concerning the incidence and severity of neglect exhibited
by brain damaged patients, especially with respect to the
involved hemisphere (Friedland & Weinstein, 1977). Numerous
studies have found hemineglect to be more frequent and more
severe in right than in left hemisphere lesions (Brain,
1941; Critchley, 1966; Battersby, et al., 1956; Denes,
13
Semenza, Stoppa, & Lis, 1982? Gainotti, 1968; Costa et al.,
1969; Colombo, De Renzi, & Faglioni, 1976; Schenkenberg,
Bradford, & Ajax, 1980). Others have suggested that the
apparent association of neglect with right hemisphere
lesions is artifactual in that aphasic deficits caused by
left hemisphere lesions prevent detection of the neglect
syndrome (e.g., Ogden, 1987).
Studies to ascertain the extent of unilateral neglect
in right versus left hemisphere lesions have generally
reported a milder form (if found at all) in left side damage
(Colombo et al., 1976; Gainotti, Messerli, & Tissot, 1972;
Gainotti & Tiacci, 1971; Oxbury, Campbell, & Oxbury, 1974,
Schenkenberg et al., 1980). Colombo et al., (1976) reported
that no left brain damaged subject failed to complete the
right side of drawings in the way many right brain damaged
subjects omitted the entire left side; however, mild but
significant neglect was observed for the former on some
tasks relative to controls. Gainotti et al., (1972) also
reported drawing asymmetries as definitely more severe in
right than left hemisphere involvement. Oxbury et al.,
(1974) found unilateral neglect exclusively in their right
brain damaged subjects.
Schenkenberg, Bradford, and Ajax's study (1980) showed
as many as 90% of right brain damaged subjects exhibited
unilateral neglect, depending on the evaluation procedure;
whereas, only an occasional person with other lesion sites
14
manifested symptoms of neglect. Early estimates of the
incidence of neglect among right brain damaged patients
range from 33% (Benton, 1969) to 66% (McFie & Zangwill,
1960). With Albert's (1973) test, Fullerton, McSherry, and
Stout (1986) observed neglect in 49% of patients with
nondominant hemisphere lesions and 25% of patients with
dominant hemisphere lesions. Observations reported by Wade,
Wood, and Hewer (1988) on stroke patients from a community
register indicated that 11% of their sample had some visual
neglect, with neglect being more frequent (14%) in patients
with right sided symptoms. Similar results were reported in
a study restricted to patients with right hemisphere stroke
(Meerwaldt, 1983).
In a review of studies of spatial neglect, Ogden (1987)
proposed several factors to account for the wide variation
in incidence of right and left-sided neglect. In addition
to the methodological argument of excluding many left
hemisphere lesioned patients due to aphasia, Ogden (1987)
cites definitional issues of neglect and the varying
sensitivities of tests used to assess neglect as
contributing to differential frequencies observed in these
studies. Furthermore, the etiology of the lesions and the
recency of the lesions may be different. Given that the
more striking symptoms of hemineglect often diminish in the
weeks directly following a brain lesion (Campbell & Oxbury,
197 6; Gainotti, 1968) and assuming that neglect following
15
left-hemispheric lesions tends to be less severe anyway than
that following right-hemisphere lesions (Vallar & Perani,
1986), then one might expect a greater right-left difference
in incidence as the time interval between the sustaining of
the lesion and the assessment of neglect increases.
Recovery of Function
A number of authors have reported that the
manifestations of neglect tend to be transitory, with the
acute and more obvious neglect of contralateral information
being most pronounced in the first few weeks post injury (De
Renzi, 1982; Heilman, Valenstein, & Watson, 1985). Although
asymmetries in reading and drawing may persist (Friedland &
Weinstein, 1977), recovery is relatively rapid, compared to
other behavioral abnormalities observed in right hemisphere
injury (Hier, Mondlock, & Caplan, 1983). A recent study of
recovery of function among right hemisphere stroke patients
indicated that 85% of the sample manifested unilateral
spatial neglect on drawing and 46% showed visual and
auditory neglect of left hemispace (Hier et al., 1983).
Their results revealed that half of these patients recovered
in 8-9 weeks with a 90% probability of recovery 20 weeks
post-stroke. Similarly, Wade, Wood, and Hewer's (1988)
study of recovery of cognitive function following stroke
indicated that 24% of their sample who survived three months
showed more or less rapid recovery to normal function within
10 weeks.
16
Levine, Warach, Benowitz and Calvanio's (1986) analysis
of 29 left neglect patients showed that both size of the
infarct and degree of premorbid cortical atrophy were
important determinants of severity and improvement of left
spatial neglect after stroke. In general, severity was not
found to be related to damage in any single area of the
right hemisphere. However, in patients with moderate to
severe neglect, there was a higher incidence of
frontotemporal (FT) lesions and tempoparietal (TP) lesions
than in patients with mild to no neglect. Lesion location
was confounded by lesion size, since FT and TP patients had
medium to large infarcts whereas central gyri lesion size
was more uniformly distributed. More importantly, premorbid
diffuse cortical atrophy acted independently of lesion size
to influence severity and persistence of neglect. In the
presence of a right cerebral infarct, cortical atrophy
augmented left neglect and retarded recovery. These
findings strongly support the notion that amount of reserve
brain tissue is critical in determining the course of left
neglect.
Assessment of Neglect
Currently, there is no single, standard test used by
all researchers who investigate visual hemi-neglect
(Johnston & Diller, 1986), and few studies have attempted to
quantify the severity of this symptom. Consequently, the
nature and subtlety of the tasks presented to the patient
17
and the degree of asymmetry in the patient's performance
required to diagnose neglect have contributed to discrepant
findings regarding the incidence and prevalence of neglect
associated with right versus left hemisphere lesions.
Copying and spontaneous drawings of houses, stars,
geometric figures, human figures, clocks, wagonwheels and
daisies have been used (Campbell & Oxbury, 1976; Colombo et
al., 1976; Lezak, 1983), with omissions or incomplete
representations of the figures indicative of neglect.
Simple line bisection tests (e.g., Schenkenberg et al.,
1980) have been used to indicate neglect when patients show
a tendency to incorrectly estimate the center of the line to
the right of true center, neglecting the left end of the
line.
Cancellation exercises are perhaps more commonly used,
and reveal neglect when performance yields relatively more
omissions on the side of the page contralateral to the
lesion than on the side which is ipsilateral. Such
exercises have included crossing out lines according to the
method of Albert (197 3), or specific letters (or numbers,
words, or geometric figures) from an array of distractors
(Diller et al., 1974).
To eliminate the strong praxic effort required by
patients in these tasks, Massironi, Antonucci, Pizzamiglio,
Vitale, and Zoccolotti (1988) developed a diagnostic test of
hemi-inattention using a modified version of the
18
Wundt-Jastrow area illusion. They reported that 40.4% of
RBD patients showed responses inconsistent with the visual
illusion when the determinant features of the illusion
pointed to the left visual field. No LBD patients or
controls showed unexpected responses to the stimuli. The
Wundt-Jastrow test scores correlated with clinical ratings
of neglect severity, (yielding a Spearman correlation
coefficient of .83), and demonstrated a .64 correlation with
the Albert test.
Weinberg and co-workers (1977) have used a number of
reading and writing tasks for evaluation of neglect. More
recently, Caplan's (1987) Indented Paragraph Reading Test
has been designed to detect left-sided visual neglect. The
task not only provides a measure of "real world" relevance,
but also revealed instances of neglect that visual
perceptual tests failed to identify.
To provide more information about everyday problems
than existing measures of neglect, Wilson, Cockburn, and
Halligan (1987) developed a behavioral test of visuospatial
neglect. The Rivermead Behavioral Inattention Test (RBIT),
consisting of nine items sampling activities of daily
living, has been found to correlate well with conventional
tests of copying, drawing, cancellation, reading, and
arithmetic but was not significantly correlated with line
bisection tasks.
19
Several researchers have employed observation of
patients' scanning behavior to evaluate evidence of neglect.
The rationale for recording ocular movement is that it
allows a precise measurement of the time devoted to the
exploration of the right and left halves of space.
Proponents of this technique contend that the degree of
asymmetry in exploration provides a direct measure of
unilateral inattention.
The electro-oculographic recordings reported by Chedru,
Leblanc, and Lhermitte (1973) yielded the following results
among their brain damaged subjects: (1) longer search times
than that of normal subjects, especially for images situated
contralateral to the lesion, (2) abnormal ocular movements,
(3) unsystematic, irregular exploration patterns, and (4) a
unilateral defect of ocular exploration. Specifically, in
the case of right hemisphere lesions, the left side of space
is explored for a shorter period than the right side. In
contrast, Locher and Bigelow (1983) found that neither right
nor left brain damaged patients in their sample exhibited an
asymmetry of visual exploration as they viewed visual
perception cards. However, irregular scanning strategies
and increased scanning time were reported. These
researchers interpreted their results in accord with other
research demonstrating that various conditions influence the
occurrence of neglect (Colombo et al., 1976).
20
Johnston and Diller (1986) compared eye movement
behavior to severity of visual hemineglect among right
hemisphere stroke patients and age-matched normal controls.
A severity index was obtained from scores on letter
cancellation and visual matching tests. A strong negative
correlation was obtained between the severity index and eye
movement exploration time of the left visuospatial field for
stroke patients, but not for controls. These findings
support Chedru's et al. (197 3) conclusions that exploration
time does not distinguish brain lesioned individuals with
mild neglect from individuals who do not manifest this
symptom.
Analyses of the performance of patients with unilateral
cerebral lesions on the Raven Coloured Progressive Matrices
(RCPM) (Raven, 1965) have revealed that in addition to
providing an index of cognitive reasoning capacity, the
format of the RCPM provides an opportunity to assess
specific spatial factors which may contribute to impaired
performance (Piercy & Smyth, 1962; Gainotti, 1968). The
test not only requires discrimination of forms of varying
complexity, but because of the spatial arrangement of the
response alternatives (on the left, center and right of the
page below the stimulus pattern), it permits identification
of response position preference as a behavioral index of
unilateral neglect.
21
Raven (19 65) reported that normal subjects do not
prefer response alternatives on either the left or right
side, but may tend to respond slightly more frequently to
the center alternatives on the RCPM. Piercy and Smyth
(1962) observed that patients with right cerebral lesions
showed a preference for response alternatives in the right
positions. Gainotti (1968) subsequently developed the
initial system for identification of neglect on the basis of
position preference, but Costa et al., (1969) refined the
technique to provide an improved, empirically derived
response position preference score to measure visual spatial
neglect. Costa's et al., (1969) results revealed that right
cerebral lesioned patients showed poorer RCPM performance
and a higher incidence of response position preference for
the side ipsilateral to their lesions than did patients with
left lesions. While these findings provided support for the
measure's usefulness as an index of neglect, Caltagirone,
Gainotti, and Miceli (1977) showed that this tendency to
neglect the response alternatives lying on the half sheet
contralateral to the damaged hemisphere is an important
factor in lowering the scores of both right and left brain
damaged patients. Essentially, these findings suggest that
the assessment of global cognitive functioning among these
patients becomes obscured by the influence of unilateral
neglect.
22
Factors Affecting Manifestations of Neglect
It would appear then, that unilateral neglect is a
heterogeneous syndrome. Indeed, several researchers have
shown variability in the expression of a neglect syndrome
when the nature of the stimuli, or strategy induced by a
task, chang€is.
For excimple, Heilman and Watson (1978) reported changes
in the symptoms of neglect as a function of varying task
strategy. Six male right hemisphere damaged subjects with
left side unilateral neglect were presented with
visuospatial and verbal cancellation tasks. Results
revealed that the symptoms of neglect were less severe with
the visuospatial than with the verbal tasks; i.e., subjects
displayed a smaller degree of neglect when the task required
them to cross out lines than when the targets were words.
The authors reported clinical observations that neglect can
be improved by manually turning a patient's head and eyes to
the neglected side or by moving a stimulus card from the
neglected field to the normal field, but did not provide
experimental data to support this claim.
Caplan (1985) extended and refined Heilman and Watson's
(1978) approach by equating the verbal and visuospatial
cancellation tasks and comparing performance on single and
double target tasks. Contrary to Heilman and Watson's
(1978) finding that degree of neglect varied as a function
of stimulus characteristics, Caplan's (1985) neglect
23
subjects omitted targets to a comparable degree on both
verbal and nonverbal tasks. The greatest amount of neglect
was seen on the single-target verbal tasks. These results
raised a question concerning the robustness of the
stimulus-specific effect reported by Heilman and Watson.
Under conditions in which stimuli and task-induced
strategy remained the same, Joanette, Brouchon, Gauthier,
and Samson (1986) examined the visual detection capacities
of three left neglect subjects, using a visual pointing task
to elicit differences in the expression of a hemispatial
neglect syndrome. The hypothesis was based on the postulate
that the use of a given hand will enhance (or activate) the
right hemisphere's readiness to respond to incoming stimuli.
Results showed better detection performances when manual
pointing was executed with the left hand (i.e. contralateral
to the lesion) than when made with the right hand. These
results demonstrate that the manifestation of a neglect
syndrome may differ, not only according to the nature of the
task and/or stimuli employed, but also according to the
laterality of the motor response. This finding coincides
with the literature demonstrating that selective attention
for each hemifield can be manipulated by a variety of
peripheral maneuvers that affect activation balance between
the two hemispheres (Kinsbourne, 1977). Furthermore, these
results suggest that studies which use a motor response
24
paradigm in evaluating the expression of neglect will have
to control for the laterality of a motor response.
Mark, Kooistra and Heilman (1988) examined the
proposition that the deficit in neglect occurs as a result
of difficulties in disengagement from the right hemispace
and that the manifestations of neglect are influenced by the
presence of stimuli in the nonneglected hemispace. In their
paradigm, the standard version of line cancellation was
contrasted with one that required erasing lines rather than
marking over them. Performance dramatically improved with
line removal, supporting hypotheses related to an impaired
disengagement process.
Ishiai and colleagues (1990) suggested that
insufficient motivation for visuospatial searching may be a
factor in deficient performance on line cancellation tasks.
In their sample of eight CVA neglect patients, a significant
reduction of neglect occurred as a function of numbering
rather than crossing-out the lines. The beneficial effect
of numbering was interpreted as a process which enhanced the
general level of attention or arousal and activation.
Additional support for the defective arousal and
activation model was presented by Fleet and Heilman (1986).
Fatigue resulting from repetitive trials was found to
exacerbate symptoms of neglect on a letter cancellation
task; whereas, when patients were provided with knowledge of
errors, performance improved. These results suggest that
25
procedures that increase arousal reduce the symptoms of
neglect.
In a line bisection task, Heilman and Valenstein (1979)
evaluated performance changes associated with forced
reporting of endpoints and altered hemispatial field of
presentation. Prior to bisecting the line, RBD subjects
were required to identify a letter at either end of the line
to ensure their seeing the left/right side of the line. The
task was given with the lines placed at either the right,
center, or left of the body midline. Performance in trials
when subjects were required to look to the left did not
differ from when they were required to report letters at the
right end of the line. However, line bisection performance
was significantly better when the line was placed to the
right side of the body than to the left.
Similar observations were reported by Samuels, Butters,
and Goodglass (1971) in a study of visual memory deficits
among right parietal and Korsakoff patients. The
researchers reported that field of presentation was a
critical variable in the visual deficits exhibited by right
parietal lesioned patients. Specifically, poor performance
was due to rapid decay for items presented to the left
visual field. Normal subjects showed fast decay for items
presented to the right visual field, but little loss for
material presented to the left visual field, indicating
26
better retention for visual material transmitted directly to
the right than the left hemisphere.
For the most part, the literature examining the effect
of cueing in altering symptoms of neglect has been
inconsistent. An effect of cueing would suggest that some
processes governing the conscious orienting of visual
attention are intact, and that neglect is due to a more
specific impairment in automatically orienting to stimuli on
the side of space contralateral to the site of lesion.
Posner, Cohen, and Rafel (1982) used a simple reaction time
task in which patients were cued to attend to the probable
spatial location of the stimulus prior to its presentation.
On 80% of the trials, the stimulus appeared in the cued
location while on 20% of the trials, it appeared in the
opposite location. For valid trials (when the target
appeared in the cued location), there was a small but
consistent advantage for targets occurring on the side
ipsilateral to the lesion over those occurring contralateral
to the lesion. In contrast, on the invalid trials, there
were marked differences to stimuli occurring ipsilaterally
and contralaterally to the lesion. For stimuli occurring
ipsilaterally, responses were slightly slower on the invalid
trials than on the valid ones. For stimuli occurring
contralaterally, however, there was a marked effect of
validity, with responses being very substantially slower on
the invalid trials than in any of the other conditions.
27
Indeed, in this instance, when the cue preceded the target
stimulus by a short interval, patients usually failed to
detect the target stimulus. Thus, for this study, there was
a large effect of cueing, demonstrating that patients with
neglect can attend to stimuli contralateral to the side of
lesion.
Riddoch and Humphreys (1983) speculated that Heilman
and Valenstein's failure to reduce neglect by cueing
occurred because patients were presented with competing
stimuli in their neglected and nonneglected fields. Since
two cues were available at either end of the line, attention
would most likely have been drawn to the right hemisphere by
the presence of a right side cue, even if subjects had to
report only one of the stimuli. This may have interfered
with attention being allocated to the left side cue,
minimizing any effect of cueing on the line bisection task.
Consequently, Riddoch and Humphreys (1983) investigated
single cue effects and hemispace effects on a line bisection
task with neglect patients. A "no cue" condition and a dual
cue condition were included for baseline in order to assess
the differential effects of single left or right side cues.
Their results indicated that cueing to the left hand side
produced a marked decrease in neglect. In contrast, the
effect of forcing subjects to report only a right side cue
was to increase neglect relative to when no cues were
present. Although there was no effect of hemispace of
28
stimulus presentation, the authors reported that there was a
trend for patients to neglect the left ends of the lines
more when the stimuli were in the left hemispace than when
they were in the middle hemispace, and more in the middle
hemispace than when they were in the right hemispace.
Somewhat different results were obtained by Robertson
(1989), using a computer task requiring recognition of
geometric stimuli and word reading. Among 10 neglect
patients, an increase in right sided omissions was observed
as a function of (1) double, but not single stimulus
conditions and (2) cueing to the left.
In an effort to resolve some of the empirical and
theoretical controversies about the efficacy of cueing in
left neglect, Halligan and Marshall (1989) sought to "glue"
the spatial cue to the line bisection task by use of a
"mouse", attached to a computer display of lines for
bisection. A small bisection arrow is under the motor
control of the subject and thus, cue and bisection are
merged into one task. With the methodology deployed in this
study and N = 1, the results showed that left perceptual
cueing was efficacious in reducing (but not eliminating)
left neglect on line bisection.
In a more extensive analysis of hemispace, cueing, and
motor components, Reuter-Lorenz and Posner (1990) examined
two versions of the line bisection task in nine posterior
CVA patients. The traditional line bisection task (directed
29
manual version) was compared to an altered version (directed
visual task), in which subjects observed the experimenter
move the pen along the line and verbally indicated the
subjective midpoint. Patients only showed significant left
neglect in the manual task and visual scanning towards the
left. When the manual response was eliminated, scan
direction determined the presence or absence of neglect on
bisection. In contrast, controls showed no consistent
biases or influence of scanning direction. No effect of
hemispace wcis observed, but right and left cues biased line
bisection for both groups. Specifically, greater right
deviation was observed with a right cue and greater left
deviation was revealed with a left cue. The results are
consistent with the attentional and visual orienting
deficits ascribed to neglect.
Independent Deficit or Global Cognitive Deterioration
Taking into consideration data regarding the recovery
course of nejglect, the functional mechanism proposed to
account for the symptoms, and the variability in the
expression of neglect (as a function of the nature of the
stimuli and strategy changes), the evidence has theoretical
as well as practical implications in the assessment of
cognitive functioning of RBD patients. Specifically, the
data lend support to the controversial issue that unilateral
visual neglect is an independent deficit not uniquely
associated with general mental deterioration. From a
30
practical standpoint, if various mechanisms could be
identified as reducing the deleterious effects of neglect on
measures of global intellectual functioning, the results
would yield a more accurate, undiluted measure of residual
cognitive reasoning capacity.
In a recent study to determine whether hemi-inattention
is an independent deficit or associated with general or
specific cognitive deficits, Vilkki (1989) observed that the
degree of inattention was unrelated to other cognitive
deficits among left-hemisphere damaged patients. However,
in the right-hemisphere damaged group, the degree of
inattention to the left side was significantly correlated
with inaccurate line orientation perception and slowness of
simple verbal performances. These results do not support
prior contentions that hemi-inattention is associated with
general mental deterioration (Battersby et al., 1956;
Weinstein & Friedland, 1977). Rather, these findings
suggest that left hemisphere lesions result in discrete and
dissociated defects with associated hemi-inattention being
unrelated to other cognitive deficits; whereas, right
hemisphere lesions reveal diffuse deficits with
hemi-inattention being related to generalized attentional
deficits such as slowness and inaccuracy in simple spatial
and verbal functioning.
31
Defective Performance on RCPM
Although evidence is conflicting and inconclusive (eg.,
Gainotti, D'Erme, Villa, & Caltagirone, 1986), numerous
investigations using the RCPM to obtain estimates of
residual intellectual capacity have revealed substantially
lower scores among right brain damaged individuals (Piercy &
Smyth, 1962; Gainotti, 1968; Costa et al., 1969). The poor
performance of RBD patients on the RCPM has raised concerns
as to whether the relative deficit is due to general
intellectual deterioration or more specific defects, such as
defective discrimination of visual patterns and/or a
defective exploration of space. Both Gainotti (1968) and
Costa et al., (1969) have provided evidence that a certain
number of brain-damaged patients, particularly those with
right hemisphere injury, neglect the alternatives on the
side of the page contralateral to the lesion as a
consequence of their spatial hemi-inattention. This finding
emphasizes the need for controlling the degree of impairment
in visual perception and space exploration, when the RCPM
test is used to evaluate intelligence in brain damaged
patients.
In a series of classical papers, Zangwill and
co-workers (Paterson & Zangwill, 1944; McFie, Piercy, &
Zangwill, 1950; Ettlinger et al., 1957) proposed that
patients with posterior lesions of the right hemisphere may
present signs of visual spatial agnosia at every level of
32
psychological response, in absence of defects of general
intelligence. Gainotti and Tiacci (1971) reported that
patients with unilateral spatial neglect perform worse than
nonneglecting RBD subjects on tasks of visual spatial
analysis. With similar findings revealing defects of
spatial analysis and visual perception occurring
predominantly among right hemisphere damaged patients with
left neglect, the Oxbury, Campbell, and Oxbury (1974) report
concluded that this disability could not be attributed to
general intellectual deterioration.
In a. subsequent study examining performance changes on
various cognitive tasks, Campbell and Oxbury (197 6) revealed
additional support for the notion that defective performance
among neglect patients reflects specific deficits rather
than global decline in higher level cognitive processes.
Patients who had demonstrated neglect via drawing and
copying tasks at three to four weeks post-stroke were
reassessed five months later on various measures of spatial
analysis, visual perception, and verbal cognitive abilities.
On re-examination, even though drawings were more complete,
neglect patients still performed significantly worse than
non-neglecting RBD subjects on Block Design, cube counting,
incomplete figures, visual recognition, and the Raven's
Matrices. Only the Matrices scores and verbal fluency tasks
revealed significant improvement over time. The remaining
tests of verbal cognitive abilities revealed no significant
33
changes for either groups. Position preference for right
sided responses on the visual recognition test remained
unaltered. The authors concluded that the improved
performance on the Matrices and drawings could not be
attributed to a recovery of general cognitive functioning,
given the stability over time of six out of the seven verbal
measures.
Gainotti, Caltagirone, and Miceli's (1977)
investigation revealed that right hemisphere-damaged
patients obtain significantly lower scores on the RCPM than
patients with damage restricted to the left hemisphere. The
tendency to neglect information on the half sheet
contralateral to the damaged hemisphere was dramatically
more evident in right hemisphere damaged cases. As with
prior studies, their data suggested that the poor
performances obtained on the RCPM by right brain-damaged
patients seemed due to the detrimental effect of unilateral
spatial neglect rather than indicative of a general
intellectual impairment.
In a subsequent project, Gainotti and associates (1979)
further explored the meaning of poor RCPM performance by
patients with posterior right hemisphere lesions. Using two
verbal tests and a test of visual-spatial analysis in
addition to the RCPM, these investigators concluded that the
deficits found with RBD patients with unilateral spatial
34
neglect were found to be related more to specific
disabilities than to a general intellectual deterioration.
Consequently, Gainotti, D'Erme, Villa, and Caltagirone
(1986) constructed a new version of the Matrices,
purportedly to minimize the influence of spatial neglect
without changing the essential features of the original
task. Their new format consisted of (1) arranging all the
response alternatives in a single column below the stimulus
pattern in the center of the response plate and (2)
orienting the stimulus pattern so that the space to be
filled would always be placed in the half space
contralateral to the damaged hemisphere. Although their
rationale weis not explicated, the authors noted that the
structure of the original stimulus pattern appears to favor
inattention to the left side of the pattern since the space
to be filled in with the response alternative is always on
the lower right hand portion of the design and as such, RBD
patients are not induced to thoroughly explore the stimulus
pattern. Unfortunately, their design did not include a
comparison between the standard and revised versions with
brain damaged patients to ascertain if indeed, the changes
yielded the expected improved performance that would be
predicted by minimizing the effects of unilateral neglect.
Furthermore, while their approach represents a reasonable
attempt to expand visual exploration of the stimulus field,
their strategy is not consistent with evidence presented
35
earlier in this review concerning a reduction in the
expression of neglect as a result of field of presentation
and left side cueing.
In view of these concerns, the present study
constructed a revised version of the RCPM and examined
whether these changes reduced the deleterious effects of
neglect with results of higher estimates of general
cognitive capacity among neglect patients. In accordance
with prior evidence of a reduction in neglect as a function
of hemispace manipulations, the current revision placed the
response alternatives in a column located in the right
hemispace of the stimulus field. Additionally, since left
sided cueing has yielded contradictory results in terms of
efficacy among this population, the effects of left sided
cueing, employed in conjunction with the right hemispace
version, were also examined.
Memorv-for-Desiqns (MFD) Test
A second measure, characterized as one of the most
widely used of any single psychological test for the
diagnosis of perceptual, motor and memory deficits (Dustman
& Beck, 1980), was also investigated in the context of
changes in hemispace presentation and left sided cueing.
Specifically, as with the RCPM, this study constructed a
revised version of the Memory-for-Designs (MFD) Test (Graham
& Kendall, 1960) by placing each design in the right
hemifield (RH condition) to examine proposed performance
36
changes. A second experimental condition, a left cue prompt
employed with the right hemispace version (RH + L) was also
investigated. For this condition, the patient was shown the
RH version and reminded on each item, to look to the left.
The MFD is credited as a short, easily administered,
highly reliable measure to assess impaired cognitive
functioning (Dustman & Beck, 1980). The task requisites,
such as visual functioning, nonverbal memory, and nonverbal
visual constructive skills, make the MFD a particularly
suitable comparison measure, since the primary functions
tapped by the measure are those considered sensitive to
impairment of the nondominant hemisphere and the posterior
cortex (Webster, Scott, Nunn, McNeer, & Varnell, 1984).
Aside from reports concerning age effects in the MFD or
its utility as a screening measure, much of the recent
literature has evaluated the two scoring procedures
developed for the MFD. The original scoring procedure
(i.e., the Graham-Kendall (GK) system) has incurred
criticism for the severe penalties associated with reversals
and rotations, yielding less than adequate separation of
normal and brain damaged groups (Grundvig, Needham, & Ajax,
1970). Although Kendall (1966) proposed modifications, no
change was initiated by the test developers in the scoring
procedures. Taylor (1961) developed a system consisting of
six error categories for each design and one for the entire
group. He found this system to provide more effective
37
discrimination between normal and brain impaired groups than
the GK method. A modified version of Taylor's method (MT),
incorporating the GK method of grading distortion from zero
to three, was also suggested. Subsequent research has since
confirmed that the Taylor (T) and Modified Taylor (MT)
scoring methods are essentially comparable in ability to
discriminate, while the GK system is somewhat less effective
(Grundvig et al., 1970; Grundvig et al., 1973; Bradford,
1978) . Therefore, as a secondary focus of the study, the
relationship between the two scoring procedures for this
population was investigated.
Summary and Statement of Hypotheses
The studies reviewed thus far have indicated that
neglect RBD patients exhibit significantly poorer
performance on various cognitive measures. These
performance decrements have been ascribed to the deleterious
effects of visual neglect, rather than to a global
deterioration of cognitive functioning. A related body of
research in the neurology literature has revealed that the
manifestations of neglect are influenced by a variety of
external factors, such as the nature of the stimuli, task
strategy, hemispace presentation, and cueing. However, the
methodology to examine changes in symptoms of neglect has
been confined to visual detection paradigms or tasks
requiring line bisection or cancellation. The current
investigation sought to examine whether performance changes
38
are revealed on general cognitive measures when hemispace
manipulations and verbal prompts to "look to the left" are
employed. Specifically, this study examined whether right
hemispace presentation of stimuli and left side cues in
conjunction with right hemifield presentations reveal
improved performance on two general cognitive indices, the
RCPM and the MFD. These criterion measures were selected
because of their reported sensitivity to the effects of
neglect and frequent use with this population. Revised
versions of these measures were constructed to examine the
proposed performance changes. The following hypotheses were
examined:
(1) RBD patients with neglect will exhibit
significantly poorer performance on the criterion measures
(i.e., the RCPM and the MFD) than RBD patients without
neglect and hospitalized control subjects.
(2) Neglect subjects will show significantly higher
RCPM scores when response alternatives are aligned in the
right hemifield of the stimulus array (Right Hemifield
condition) than when response alternatives are placed below
the stimulus in the standard version (Standard presentation
condition).
(3) Neglect subjects will demonstrate significantly
higher scores on the RCPM when left side cueing is employed
with the right hemifield version (RH + L condition) than
under standard administration conditions.
39
(4) Neglect subjects will reveal significantly lower
mean error scores on the MFD when examined under the two
experimental conditions (i.e., the RH condition and RH + L
condition) than when examined under the standard
presentation condition.
In addition to these primary predictions, several
ancillary hypotheses were formulated and examined within the
context of this study:
(1) Neglect patients will demonstrate greater
impairment on a measure of right brain injury than RBD
patients without neglect, as evidenced by significantly
higher scores on the Mini Inventory for Right Brain Injury
(MIRBI).
(2) Significant correlations will be observed between
measures of neglect (i.e., for the Bells Test of Visual
Neglect and the Schenkenberg Line Bisection Task) across all
groups.
(3) Significant correlations will be revealed between
the two scoring systems of the MFD Test.
CHAPTER II
METHOD
Subjects
The sample was comprised of 54 hospitalized patients,
recruited from the rehabilitation units of two area
hospitals. The criterion group of neglect subjects (RBD-N)
consisted of seventeen right cerebral vascular accident
(CVA) patients, ranging in age from 4 6 to 84 years, and one
37 year old right parietal tumor patient. The criteria for
inclusion in this group consisted of defective scores on two
out of the three indices of neglect, a current diagnosis of
right brain injury, and impaired performance on the
screening assessment for right brain injury. Scores on the
indices of neglect were rated as defective if patient
performance revealed 6 or more omissions on the Bells Test,
two or more omissions on the Schenkenberg Line Bisection
(SLB) Task, or line bisection scores greater than +/- 10%
average deviation from midpoint on the SLB.
The RBD without neglect (RBD-NN) group consisted of 17
right CVA patients, ranging in age from 55 to 87 years, and
one 33 year old patient, hospitalized for a hematoma
evacuation. Patients assigned to this group had a current
diagnosis of right brain injury and exhibited impaired
40
41
performance on the right brain injury screening measure.
However, in contrast to the criterion group, the RBD-NN
group displayed negative results on two out of the three
indices for neglect. In this study, negative results were
operationalized as protocols exhibiting fewer than six
omissions on the Bells Test, less than two omissions on the
SLB, or line bisection scores less than +/- 10% average
deviation on the SLB. These scores are in accordance with
the respective authors' recommendations and validation data.
A second comparison group consisted of 18 patients
(ranging from 65-90 years of age), who had been hospitalized
for orthopedic conditions and presented with no reported
history of focal central nervous system (CNS) injury or
disorder. Thirteen of these individuals had undergone hip
replacements and five were hospitalized for knee surgery.
Patients in this group exhibited no abnormal performance on
the Bells Tests for neglect or revealed any SLB omissions.
All subjects were right-handed. Individuals presenting
a history of alcoholism or psychiatric treatment and persons
unable to provide informed consent, due to severe dementia
or language deficits, were excluded from participation.
Procedure
All subjects were advised of the nature of the study
prior to securing written consent (Appendix A).
Specifically, each patient was asked to participate in a
research project designed to identify the instrument that
42
most accurately depicted their current level of functioning.
In exchange for their voluntary participation, the
information obtained in the study was included in the
patient's medical record to assist in treatment planning.
Upon securing consent, participants completed a series of
neuropsychological screening instruments, a nonverbal,
visuospatial measure of global cognitive functioning, and a
memory-drawing task. Subjects were assessed individually
and administered the instruments described below in the
order listed. Except for the initial screening instrument
designed to identify prospective RBD subjects, all measures
were administered by the author, a clinical psychology Ph.D.
doctoral candidate, under the supervision of a licensed
clinical neuropsychologist. Total testing time ranged from
60-90 minutes.
For the criterion instruments, all subjects were
examined under each of the three conditions. For the
standard presentation condition, target items were presented
at the midline. In contrast, for the right hemifield
condition, target items were presented along the right side
of the page. For the right hemifield plus left cue
condition, the right hemifield version of the stimuli was
presented and the patient was reminded to "look to the left"
when shown each item.
43
Instruments
Mini-inventory of Right Brain Injury (MIRBI)• The
MIRBI (Pigmental & Kingsbury, 1989) was developed for the
purpose of identifying adults who exhibit deficits in areas
known to be compromised in right hemisphere brain injury and
to determine the relative severity of right brain injury.
This screening measure was used to identify potential
participants in the RBD groups. By adding the total number
of points received on the 27 item inventory, a total MIRBI
score is obtained. According to the standardization data,
scores of 38-43 are within normal limits and scores of 37
and below are considered brain injured. The total MIRBI
score can also be converted to a seven-scale severity rating
provided in the summary and profile sheet of the test
booklet. After correcting for age effects, the test
publishers report an alpha reliability coefficient of .92,
indicating a high level of internal consistency. Interrater
reliability estimates range from .65 to .87 and the standard
error of estimate is small (0 to 5.5 SEm), providing further
support of satisfactory reliability. Concurrent validity
studies using CT scan results have yielded a diagnostic
accuracy of 99.97% in differentiating normals, left, and
right brain injured groups.
Schenkenberq Line Bisection Test (SLB). As one of the
most common methods used to identify the presence and
severity of neglect, the bisection of horizontal lines was
44
formally evaluated by Schenkenberg and colleagues (1980) to
provide systematic normative data. The task requires the
patient to bisect a total of twenty lines (2 sample lines
and 18 scored lines) that are represented on a 21.5 x 28 cm
white sheet of paper, parallel to the long axis. Line
lengths of 100 - 200 mm are organized in three sets of six
lines, with each set positioned on the left, center, and
right side of the page. Scoring involves two components:
(1) noting the number and position of unmarked or omitted
lines and (2) measuring the deviation of the attempted
bisection of each of the marked lines from the true center.
Average percent deviation scores were computed according to
the method described by Schenkenberg et al.,(1980).
Test-retest correlations have yielded reliability
coefficients in the range of .84 to .93. Total neglect of
more than two lines has been found to discriminate between
RBD patients and patients with left or diffuse damage as
well as hospital controls. Additional normative data with
an elderly nonbrain damaged population has been presented by
Van Deusen (1983). In this study, defective performance
indicative of visual neglect on this measure was
operationalized as either two or more line omissions and/or
line bisection scores greater than +/- 10% average deviation
from line midpoint. A sample is provided in Appendix C.
The Bells Test. This measure, developed by Gauthier,
Dehaut, and Joanette (1989), was devised to provide a
45
quantitative and qualitative evaluation of visual neglect.
It is a cancellation task that allows a rapid visualization
of the location of omissions as well as of the scanning
pattern used by subjects, permitting the detection of mild
and moderate visual neglect. Prior to administration of the
actual test, the subject is presented with a sheet
containing an oversized version of the target (bell) and
each of the distractor items, and is asked to name the
elements to ensure proper object recognition. Instructions
are given to the subject to circle all the bells, and then
the task sheet is placed in front of the subject. On the
score sheet, the examiner marks the order of circling the
bells by successive numbering as the subject encircles the
bells. The maximum score is 35. In the preliminary
normative study, half of the normal controls obtained a
perfect score, with a maximum number of 3 omissions in this
group. Omissions of six or more bells in the contralateral
half of the test is suggestive of visual neglect. A sample
of the demonstration sheet, Bells Test, and examiner's
scoring sheet is provided in Appendix D.
Raven's Coloured Progressive Matrices (RCPM). This
measure was administered to provide an index of an ability
that has been alternately described as "clear thinking",
11 intellectual capacity", and "reasoning" (Raven, 1962,
1965). Developed initially as a children's version of a
culturally-reduced measure of intellectual functioning, the
46
RCPM is considered the best of all the nonverbal tests of
"g", i.e., the superordinate ability which, according to the
hierarchical theory of intelligence (Spearman, 1946), enters
into all intellectual performances (Burke & Bingham, 1969;
Jensen, 1982) . The test provides a measure of what Cattell
(1971) called fluid intelligence, i.e., the ability to make
inferences, draw relations, and develop hypotheses. In view
of the relative ease of administration and minimal
requirements for overt verbalization, the RCPM has been
described as the test of choice for the assessment of
intellectual disorders among brain damaged individuals
(Gainotti et al., 1986).
The test consists of 3 6 geometric designs in which
there is a missing piece. Six alternative pieces are
located below the design, one of which correctly completes
the design. The subject's task is to point to or verbalize
the correct response alternative for each test item.
Although the common practice is to administer all 36 items,
a modification in standardized administration procedures was
necessary in the present study in order to obtain RCPM
scores for each subject across all three experimental
conditions. Specifically, to avoid practice effects
associated with repeated administration of the test, three
sets of stimulus cards (i.e., 12 cards per set) were
selected for use in the standard administration condition
(Std), the right hemifield condition (RH), and the right
47
hemifield plus left cue condition (RHL). Every third card
was selected for each set, such that Set 1 consisted of Al,
A4, A7, A10, AB1, AB4, AB7, AB10, Bl, B4, B7, BIO; Set 2
consisted of A2, A5, A8, All, AB2, AB5, AB8, AB11, B2, B5,
B8, Bll; Set 3 consisted of A3, A6, A9, A12, AB3, AB6, AB9,
AB12, B3, B6, B9, B12. The order of presentation for the
experimental conditions and card sets was counterbalanced
across groups to eliminate practice or sequencing effects
and control for item difficulty level. A sample of the
standard version and the modified version for the RH and RHL
conditions can be found in Appendix E.
Memory for Designs (MFD). The MFD, developed by Graham
and Kendall (1960), is a neuropsychological instrument,
consisting of 15 geometric designs that vary in complexity
from an equilateral triangle to complicated, unfamiliar
designs. Individual designs are shown to the subject for 5
seconds and after each presentation, the subject is asked to
draw the design from memory.
The MFD was originally developed as a screening
instrument for discriminating brain impairment among
psychiatric populations, but in more recent years, has been
widely used to assess functions sensitive to impairment in
the nondominant, posterior cortex. The measure evaluates
several cognitive skills; specifically, visual functioning,
nonverbal memory, and nonverbal visual constructive skills.
The MFD was selected as a second criterion measure not only
48
for its sensitivity to RBD, but also because it evaluates a
compendium of cognitive functions similar to and yet
slightly different from the RCPM. Both measures require
visual perceptual skills and associative functions; however,
the MFD entails an additional nonverbal memory factor and a
constructional-motor component as well.
Two scoring methods have been developed for use with
the MFD, both of which were evaluated in the present study.
The original methodology (GK), proposed by Graham and
Kendall (1960), assigns each design a score of 0, 1, 2, or
3, which are then summed for a total score. Faults which
are more frequently observed in brain impaired populations,
such as rotations, are given an error score of 3; whereas,
incomplete items are not penalized. Detailed scoring
instructions and scoring samples are described in Graham and
Kendall's (1960) manual.
The alternative scoring system, the Modified Taylor
method (MT) (Bradford, 1978), entails scoring each design
for the presence or absence of each of six errors (i.e.,
embellishment, perseveration, reversal, rotation,
distortion, and omission). The omission category is scored
0, 1, or 2, depending on the proportion of the design which
is omitted. A seventh error category, organization, is
scored 0, 3, or 6, according to how disorganized the entire
set of figures appears on the page. The scores for each
49
design are summated to yield a total score. More explicit
instructions for MT scoring are detailed in Appendix F.
Interrater agreement for these two methods is commonly
found to be greater than .90. For example, independent
scoring of individual designs by Howard and Shoemaker
(1954), using the GK method, resulted in a 93% agreement,
lending favorable support to Graham and Kendall's (1960)
correlation of .99 between independent ratings of total
scores. Bradford (1978) reported estimates of .97 for the
GK method and .99 for the MT system. Similarly, Grundvig,
Needham, and Ajax (1970) indicated Pearson correlations
ranged from .90 to .98 for interscorer performance with both
scoring systems.
For this study, the same procedures employed with the
RCPM were applied to the MFD; i.e., the 15 geometric designs
were subdivided into 3 card sets, with one card set
administered to the subject for each of the three
experimental conditions. Set 1 consisted of MFD designs 1,
4, 7, 10, and 13. Set 2 was composed of MFD designs 2, 5,
8, 11, and 14 and Set 3 included MFD designs 3, 6, 9, 12,
and 15. As with the RCPM, the order of presentation for the
experimental conditions and card sets was counterbalanced
across groups to eliminate practice or sequencing effects
and control for item difficulty level. A sample of the
standard presentation and Right Hemispace revision of the
MFD are displayed in Appendix G.
CHAPTER III
RESULTS
The primary hypotheses of the study proposed improved
cognitive performance among neglect subjects as a result of
right hemispace presentation and left cue prompts. Neglect
subject performance was contrasted with two comparison
groups: right brain damaged patients without neglect and
hospitalized orthopedic controls. Two measures of cognitive
functioning, the Raven's Coloured Progressive Matrices
(RCPM, Raven, 1962) and the Memory-for-Designs (MFD, Graham
& Kendall, 1960), were employed as dependent variables.
Scoring of the MFD yielded two separate scores; one score
reflecting the criteria defined by the Graham and Kendall
methodology (MFD-GK) and the other score representing the
more recent Modified Taylor scoring revisions (MFD-MT).
Thus, for the primary analyses of the study, a 3 x 3 ANOVA
with repeated measures on one factor was conducted for the
RCPM scores, the MFD-GK scores, and the MFD-MT scores.
A preliminary analysis of the demographic data revealed
significant age effects (F (2,51) = 5.71, p < .01). Post
hoc comparisons, using the Newman Keuls procedure, indicated
that orthopedic controls were significantly older than
neglect patients. However, no significant age differences
50
51
were obtained between neglect and nonneglecting RBD subjects
or between nonneglecting RBD subjects and hospitalized
orthopedic patients. A significant sex difference between
the groups was observed (Chi square likelihood ratio =
12.56, p = .002). The table indicated a higher frequency of
males in the neglect group and a greater number of females
in the orthopedic group. Table 1 (Appendix B) displays
relevant sample characteristics and group performance on the
various screening measures. Specific clinical data for
individual neglect and nonneglecting RBD patients are listed
in Tables 2 and 3 (Appendix B), respectively.
Screening Measures for RBD and Neglect
A comparison to assess differences in severity between
the two RBD groups on the Mini Inventory of Right Brain
Injury (MIRBI) yielded significant differences (t = 3.04, df
=34, g < .01). As predicted, the neglect group revealed
significantly greater impairment than the nonneglecting RBD
subjects on the screening measure for right brain injury.
Correlations between subject characteristics, screening
measures and dependent variables are shown in Table 4
(Appendix B). As predicted, significant correlations were
obtained between the two measures of neglect. The Bells
Test correlated .90 with left side omissions on the SLB and
.68 with SLB center omissions. The Bells showed a .79
correlation with the average percent deviation (APD) score
of left lines on the SLB and a .65 correlation with the SLB
52
APD score for center lines. Total APD score on the SLB
yielded a .72 correlation with the Bells Test.
The neglect group omitted a mean number of 17.94 (SD =
8.56) bells (out of a possible 35) on the cancellation task.
In contrast, the nonneglect RBD individuals and orthopedic
controls omitted an average of 2.28 (SD = 1.53) bells and
1.0 (SD = .84) bell, respectively. With a ceiling of 6
lines per hemifield on the SLB task, the neglect group
averaged 2.83 (SD = 1.86) omissions for left lines and 1.28
(SD = 1.71) omissions for center lines. In contrast, the
nonneglect RBD group omitted a mean of .06 (SD = .23) left
lines and no center line omissions. Only one neglect
patient failed to cross lines in the right hemifield, no
nonneglecting RBD patients omitted lines in the right
portion of the SLB, and all orthopedic patients bisected all
18 lines.
To adjust for variations in line length on the SLB, all
scores for each bisected line were converted to a
standardized score, using Schenkenberg's et al., (1980)
formula. Specifically, a percent deviation score was
obtained for each line by subtracting the true midpoint
distance from the subject's mark (measured to the nearest
millimeter), dividing by the true midpoint distance, and
multiplying by 100. This transformation yielded positive
numbers for marks placed to the right of center and negative
numbers for marks placed to the left of center. Average
53
percent deviation (APD) scores were computed for the 6 left,
center, and right lines on the page and for the entire 18-
line page.
As expected, neglect subjects demonstrated marked right
biases with a mean APD of 34.91 (SD = 26.19) for left lines,
a mean APD of 21.94 (SD = 27.82) for center lines, and a
mean APD of 2.47 (SD = 26.79) for right lines. In contrast,
both comparison groups revealed mean APDs ranging from .37
to 4.10 (SD = 4.73 to 8.78).
Analyses of Criterion Measures
Group means and standard deviations for the dependent
variables are provided in Table 5 (Appendix B). Prior to
conducting the primary analyses, tests for equality and
compound symmetry of the variance-covariance matrices were
performed to ensure that the data satisfied the assumptions
for factorial repeated measures analyses (Winer, 1971). Chi
square values, computed for each of the dependent measures,
are shown in Table 6 (Appendix B). Results reveal
nonsignificant chi square values, indicating that the data
conform to the assumptions necessary for the repeated
measures analysis and that subsequent ANOVAs are justified.
The repeated measures ANOVA on RCPM scores demonstrated
a main effect for group, F(2,51) = 18.29, p < .001 (Table 7,
Appendix B). Subsequent comparison of the group means,
using the Newman Keuls procedure, showed that neglect
subjects scored significantly lower across all treatment
54
conditions than nonneglecting RBD patients or hospitalized
controls. Contrary to expectations, however, no significant
condition effect, F(2,102) = .22, p = .80, or group by
condition interaction, F(4,102) = .39, p = .82, was
obtained. Figure 1 presents a graphic display of the group
means across the three presentation conditions.
The second dependent variable under investigation, the
Memory-for-Designs (MFD) Test, revealed similar results.
The repeated measures ANOVA on the MFD scores, using the
Graham-Kendall scoring (MFD-GK), yielded a main effect for
group, F(2,51) = 11.82, p < .001 (Table 8, Appendix B). A
Newman Keuls comparison indicated that neglect subjects
demonstrated significantly higher errors than either of the
two comparison groups. No significant condition effect,
F(2,102) = .03, p = .97, or significant group by condition
interaction, F(4,102) = .66, p = .62, was obtained. The
repeated measures ANOVA on the MFD scores, according to the
Modified Taylor scoring system, revealed a main effect for
group, F(2,51) = 20.15, p < .001, but no significant
condition effect, F(2,102) = .08, p = .93, or significant
group by condition interaction, F(4,102) = .73, p = .57
(Table 9, Appendix B). The MFD group means, scored
according to the GK method, are graphically presented in
Figure 2 and the MFD group means using the MT scoring system
are displayed in Figure 3.
55
9.5
Legend
- Neglect - RBD w/o Neglect • Controls
C cd <D
<D > *</) CO o k. O) O l .
CL
<D L» D O O O c <D > CO (X
8.5
8
7.5
7
6.5 H
5.5
4 . 5 -
Standard Presentation
Right Hemispace
Method of Presentation
Right Hemispace + Left Cue
Figure 1. Raven's Coloured Progressive Matrices Group Means for each Presentation.
56
8
Legend
- Neglect - RBD w/o Neglect - Controls
1 7.5 "o c CD *
I
E CO jc CO V-0
w V-o v_
HI c CO a>
7 -
6.5-
6 -
5.5
(0 c D) "(0 <1> Q I
4.5
o E 0
3.5 J
3 -I
2.5
Standard Presentation
Right Hemispace
Right Hemispace + Left Cue
Method of Presentation Figure 2. Memory-for-Designs Mean Error Scores
(Graham-Kendall Scoring System)
57
9 i
8.5-
"U o
sz
8 -
0 2
7.5-
o >1 CO h-
7 -
l CO
6.5-
o u. L.
Lil 6 -
c CO o 5.5-
co c U) 5 -CO 0 Q i
4.5-i*. o M— 1 >* IL
4 -o e CD
2 3.5-
2.5
Legend
- Neglect - RBD w/o Neglect - Controls
Standard Presentation
Right Hemispace
Right Hemispace + Left Cue
Method of Presentation Figure 3. Memory-for-Designs Mean Error Scores
(Taylor Scoring System)
58
As predicted, the two scoring systems revealed significant
correlations, ranging from .68 to .90 (e < .01). The
correlation matrix in Table 4 (Appendix B) displays the R
values for the various conditions and scoring systems.
CHAPTER IV
DISCUSSION
In view of prior research which has demonstrated that
various strategies can reduce the deleterious effects of
neglect (see Table 10 for a review), the current
investigation was conducted to determine if such changes in
performance would be manifested on measures of cognitive
functioning. Specifically, the primary question was whether
changes in hemispace presentation of stimuli as well as left
sided cueing served to reduce the cognitive performance
decrement frequently observed in the RBD neglect population.
The initial hypothesis predicted that RBD neglect
individuals would demonstrate significantly lower scores on
the RCPM and MFD than nonneglect RBD patient's and orthopedic
control subjects. The results indicated a significant
performance decrement among the criterion group on both
measures of cognitive functioning relative to the comparison
group. These findings are consistent with prior evidence
that has revealed greater cognitive impairment among this
group (Piercy & Smyth, 1962; Gainotti, 1968; Costa et al.,
1969; Campbell & Oxbury, 1976). Contrary to expectations,
however, the present study failed to reveal any significant
improvement in neglect performance as a result of right
59
60
hemispace presentation of stimuli or left sided cueing.
This evidence was consistent for both measures. These
results suggest that, in contrast to the reported changes
observed in line bisection or cancellation task performance,
hemispace manipulations and cueing do not provide the
compensatory assistance needed for improved performance on
these measures.
One explanation that could account for this finding is
the notion that perhaps some improvement occurs, but is
mediated by neglect severity. It may be that performance
improves as a function of hemispace manipulation and cueing
among neglect subjects with mild to moderate levels of
severity, whereas a negligible change or performance
decrement is observed among the more severely impaired
neglect subjects. Since the current neglect sample was
primarily comprised of moderate to severe levels of
impairment, minimal improvement would be predicted to occur.
Indirect support for this idea is provided in studies that
have revealed the size of the infarct and integrity of
residual brain tissue to be important determinants of
recovery (Levine et al., 1986; Hier et al., 1983). Prior
research provides little assistance in addressing this issue
since few studies have differentiated samples in terms of
severity of neglect. Furthermore, the available data are
characterized by small samples with divergent operational
measures of neglect, which make comparisons difficult.
61
Unfortunately, the counterbalancing paradigm of the current
study does not permit such an analysis and further research
is needed to confirm this relationship.
A more parsimonious explanation for the results centers
on the nature of the criterion stimulus. A synthesis of
existing findings and evidence from recent sources suggest
that these strategies are not sufficient to promote enhanced
performance, particularly as task complexity is increased.
Rapcsak, Verfaellie, Fleet, and Heilman (1989) have recently
demonstrated that increased demands on visual selective
attention adversely affected both exploration of the left
side of space and visual discrimination. In a geometric
figure cancellation task that systematically varied the
level of selective attention, results indicated that left
neglect was more severe with complex visual tasks than with
targets that required minimal perceptual discrimination.
Under conditions of greater focusing of attention, incorrect
responses were equally likely in both hemispaces. From this
perspective, the argument can be made that the stimulus
features in the current study reflected an increased number
of distractors and higher demands for selective visual
attention, relative to the demands of line bisection and
cancellation tasks.
On another note, the failure to obtain significant
improvement in performance does not necessarily confirm that
such differences do not exist. Indeed, certain design
62
characteristics may obscure the detection of changes in
performance as a function of the experimental manipulations.
However, close examination of these factors does not provide
strong support for such a conclusion. The sample size in
the current study is considerably larger than previous
studies which have demonstrated significant improvement via
these manipulations (as shown in Table 10). The data
conform to the assumptions of equality and symmetry,
indicating no evidence of gross violations with respect to
sample variances. Concerns about the power of the measures
in detecting significant differences are not appertaining,
given that overall group differences were obtained between
neglect subjects and the comparison groups. In effect,
there is minimal evidence to argue for a Type II error.
The consistency of the results from both measures
provides additional confirmatory evidence to argue against
spurious findings. The data obtained in the present sample
are, for the most part, relatively consistent with prior
research findings. That is, the neglect RBD patients
exhibited significantly more impairment on criterion
measures than the nonneglecting RBD patients and the
orthopedic controls.
One anomalous result that has been difficult to
reconcile is the relatively high level of performance
exhibited by the nonneglecting RBD subjects. Their
performance was not significantly different from the
63
hospitalized orthopedic controls in this study.
Furthermore, when compared to undifferentiated RBD group
means reported by prior investigators, the current sample of
nonneglecting RBD patients exhibited substantially higher
performance. One plausible explanation that may be inferred
from these results is that when neglect is ruled out as a
component in the manifestation of right brain injury, the
cognitive performance associated with lateralized
dysfunction more closely approximates the cognitive
efficiency of cortical functions exposed to diffuse aging
effects. Further research is warranted, however, to confirm
this hypothesis.
The current findings are not entirely unexpected, given
the conflicting outcomes reported for rudimentary line
bisection and cancellation tasks. To date, such mediating
factors as the presence of double cues (Heilman &
Valenstein, 1979; Riddoch & Humphreys, 1983; Robertson,
1989), involvement of a motor response (Joanette et al.,
1986; Reuter-Lorenz & Posner, 1990; Bisiach et al., 1990),
the nature of the task (Heilman & Watson, 1978; Caplan,
1985; Rapcsak et al., 1989), the direction of visual scan
(Reuter-Lorenz & Posner, 1990; Mark et al., 1988), cognitive
load capacity (Rapcsak et al., 1989), and motivational or
conversely, fatigue effects (Ishiai, et al., 1990; Fleet &
Heilman, 1986) have been implicated as potential influences
which alter performance on measures of neglect.
64
These results suggest implications on several levels.
Clearly, the finding that no discernable performance changes
emerge as a function of stimulus modifications and verbal
prompts to explore the contralesional space is of practical
importance. These manipulations are frequently employed in
a clinical context to maximize patient performance, although
empirical support for such procedures is lacking. While the
present study does not presume to prove the null,
replication of these results would provide substantive
evidence for the utility or futility of these tactics. From
a psychometric standpoint, these results underscore the
importance of multiple measures in the assessment of
neglect. And with the multiple factors that have been
delineated as impacting neglect, studies utilizing larger
sample sizes will be necessary to evaluate how these factors
interact to change or improve the symptom picture of
unilateral visual neglect.
Theoretically, the results suggest that while the
phenomenon of neglect may be manifested as a visual
perceptual disorder or directed attentional deficit, the
deficit appears to impact multiple cognitive systems,
limiting the capacity for processing. The implication is
that if general cognitive functioning is defined as multiple
cognitive systems and encompasses processing capacity, then
these results would lend support to theories that relate
65
neglect to a generalized cognitive decline, rather than a
specific deficit.
Although the primary focus of the study examined
proposed cognitive changes among neglect patients as a
function of hemispace and cue manipulations, several
ancillary findings merit review. Specifically, predictions
concerning the screening measures and the relationship
between the two scoring systems for the MFD were
investigated. The two measures employed for detection of
neglect (i.e., the Bells Test and the SLB) yielded
substantial correlations, ranging from .65 to .90. These
results not only confirm the predictions generated in this
study, but also provide additional validation data for the
recently introduced Bells Test. According to the test
developers, this measure is sensitive for detection of mild
and moderate neglect and is more suitable for use during the
rehabilitation period of recovery (Gauthier et al., 1989).
In contrast, the less complex visual scene, like Albert's
Test (Albert, 1973) is routinely used to elicit striking
neglect in severe cases and more commonly employed during
acute stage assessment. Results from the present study
suggest that, in spite of apparent differences in task
requirements or level of perceived difficulty, the two
measures demonstrate marked agreement in their ability to
tap manifestations of neglect. Furthermore, the congruence
between the two instruments exists not only for those
66
patients examined at different stages of recovery, but also
for those patients exhibiting varying degrees of severity.
Similarly, a secondary concern of this study predicted
significant correlations between the two MFD scoring
systems. The findings support the proposed relationship,
revealing correlations ranging from .68 to 90. Contrary to
speculations concerning the deficiencies of the initial
system, these results suggest that the two scoring systems
provide a relatively consistent picture of the perceptual,
motor, and memory deficits associated with brain
dysfunction. Furthermore, these similarities are revealed
in samples that have traditionally been characterized as
exhibiting inconsistent performance (i.e., the RBD
patients), pronounced variability within the sample (i.e.,
the elderly control subjects), and substantial dysfunction
in this cognitive domain (i.e., the neglect group).
There are several limitations of the study that deserve
mention. Due to time constraints, no formal estimates of
premorbid IQ were obtained. More importantly, considerable
neglect group variability characterized the current neglect
sample. While the overall RBD severity level of the neglect
sample was in the moderate to severe range of impairment,
all levels of severity were represented in the neglect
group. On the other hand, the nonneglecting group revealed
an average RBD impairment rating of mild to moderate, and by
definition, represented a less impaired RBD group. The
67
failure to equate the RBD groups on degree of impairment and
premorbid intellectual factors may have posed limitations in
interpretation. Also, since admissions were screened for
participation in the study, there may have been a selection
factor in operation. Attempts were made, however, to
procure a representative sample, since patients were
selected from both a full-service medical facility as well
as a rehabilitation hospital. Finally, data pertaining to
lesion location and extent of damage were relatively crude
and nonspecific, restricting speculations about anatomical
correlates.
At the present time, replication studies designed to
confirm these initial findings are warranted. Future
studies that address the extent and course of recovery
following stroke, according to levels of severity, are
recommended.
APPENDIX A
INFORMED CONSENT
68
69
Informed Consent Form
I, , agree to participate in a study designed to identify the test instrument which most accurately identifies my current level of functioning. The information obtained in this study will be used to improve current assessment devices that fail to compensate for various brain traumas.
I understand that I will be given a series of paper and pencil tasks and shown various geometric designs to complete. Total participation time should be approximately 60-90 minutes. I understand that the information obtained from this study can be used to supplement my medical records and that there will be no charges or additional fees incurred as a result of patient involvement in this study. Further, I understand that this information may be added to my medical records to assist the treatment team in rehabilitation planning, pending patient consent.
I have been informed that any information obtained in this study will be recorded with a code number to ensure that all information remains anonymous. At the completion of the study, the key that relates to the identity of each participant will be destroyed to safeguard confidentiality concerns. Under this condition, I agree that any information obtained from this research may be used in any way thought best for publication and education.
I understand that there are no personal risks or discomfort directly involved with this research and that I am free to withdraw my consent at any time. A decision to withdraw from the study will not affect the services available to me on the rehabilitation unit at St. Joseph's Hospital.
If I have any questions or problems that arise in connection with my participation in this study, I should contact Vicki Soukup or the project director, Dr. Ernest Harrell, at 336-9371 (ext. 6577).
Date Participant
Date Investigator
Date Witness
THIS PROJECT HAS BEEN REVIEWED BY THE UNIVERSITY OF NORTH TEXAS COMMITTEE FOR THE PROTECTION OF HUMAN SUBJECTS.
70
Informed Consent Form
I, , agree to participate in a study designed to identify the test instrument which most accurately identifies my current level of functioning. The information obtained in this study will be used to improve current assessment devices that fail to compensate for various brain traumas.
I understand that I will be given a series of paper and pencil tasks and shown various geometric designs to complete. Total participation time should be approximately 60-90 minutes. I understand that the information obtained from this study can be used to supplement my medical records and that there will be no charges or additional fees incurred as a result of patient involvement in this study. Further, I understand that this information may be added to my medical records to assist the treatment team in rehabilitation planning, pending patient consent.
I have been informed that any information obtained in this study will be recorded with a code number to ensure that all infprmation remains anonymous. At the completion of the study;, the key that relates to the identity of each participant will be destroyed to safeguard confidentiality concerns. U;nder this condition, I agree that any information obtained from this research may be used in any way thought best for publication and education.
I understand that there are no personal risks or discomfort directly involved with this research and that I am free to withdraw my consent at any time. A decision to withdraw from the study will not affect the services available to( me at the Baylor Institute for Rehabilitation.
If I haye any questions or problems that arise in connection with my participation in this study, I should contact Vicki Soukup or the project director, Dr. Ernest Harrell, at 336-9371 (ext. 6577).
Date ; Participant
Date Investigator
Date ; Witness
THIS PROJECT! HAS BEEN REVIEWED BY THE UNIVERSITY OF NORTH TEXAS COMMITTEE FOR THE PROTECTION OF HUMAN SUBJECTS.
APPENDIX B
TABLES
71
72
Table 1
Sample Characteristics and Group Performance on Screening
Measures
Neglect RBD w/o Neglect
Controls
Age
(range)
64.39
37-84
69.33
33-93
76.33
65-90
Sex Male
Female
13
5
10
8
3
15
Mean Days Post Onset 3 5.44
(range) (9-108)
18.39
(3-39)
16.83
(5-31)
Admission Diagnosis 17 CVA 17 CVA 13 Hip
1 Tumor 1 Hema Evac 5 Knee
Mini Inventory of Right Brain Injury (MIRBI)
Total Score 19.22
(5.56)
26. 56
(8.60)
Severity Rating 3.94 2.50
(1.06) (1-54)
Bells Test
Mean Number of Omissions 17.94
(8.56)
2 . 2 8
(1.53)
1.0
(.84)
73
Neglect RBD w/o Controls Neglect
Schenkenberq Line Bisection (SLB)
Left Omissions 2.83 .06 -0-
(1.86) (.23)
Center Omissions 1.28 -0- -0-
(1.71)
Right Omissions .06 -0- -0-
(.24)
Average Percent Deviation (APD)
Left Lines 34.91 4.10 1.39
(26.19) (8.78) (5.18)
Center Lines 21.94 2.68 .37
(27.82) (5.02) (4.72)
Right Lines 2.47 3.69 .48
(26.79) (6.96) (5.56)
Total APD 20.93 3.59 .74
(24.17) (4.79) (4.75)
74
Table 2
Clinical Data for Neglect Subjects
Pt. Age Sex Post Onset (days)
Source of
Lesion
Location b RBDC
Severity Omissions
Bells Line Bisection
1 63 F 11 k
CVA OP, BG 2 23 5
2 67 M 14 CVA 3 11 0
3 58 M 11 CVA 4 5 3
4 76 F 31 *k
CVA BG 4 27 4
5 69 M 16 •k
CVA T 4 29 5
6 76 F 27 •k
CVA MCA 5 27 9
7 66 M 28 CVA* F 2 16 3
8 46 F 64 CVA* MCA 4 6 3
9 66 M 53 -k
CVA FP 4 24 5
10 67 M 9 k
CVA MCA 4 17 1
11 65 M 22 CVA* MCA 4 6 2
12 58 M 32 CVA 5 23 9
13 56 M 56 CVA* FP 3 13 1
14 56 M 66 CVA* MCA 4 11 2
15 79 M 13 CVA 5 30 12
16 70 M 41 CVA * MCA 6 26 7
17 84 M 36 CVA* FP 5 20 2
18 37 F 108 k
G1ioma FT 3 9 2
Confirmed via CAT Scan. •jjf
Location: BG = Basal Ganglia; F = Frontal; FP = Frontoparietal;
FT = Frontotemporal; MCA = Middle Cerebral Artery;
OP = Occipitoparietal; T = Temporal.
Severity rankings according to MIRBI: 1 = Mild; 2 = Mild-
Moderate; 3 = Moderate; 4 = Moderate-Severe; 5 = Severe;
6 = Profound.
75
Table 3
Clinical Data for RBD Without Neglect Sub.iects
Pt. Age Sex Post Onset (days)
Source of
Lesion
Location b RBDC
Severity Omissions
Bells Line Bisection
1 67 F 21 CVA* U 2 2 0
2 69 M 9 CVA U 3 0 0
3 33 F 11 1 HemaEvac P 1 1 0
4 74 M 8 *
CVA Pons 3 2 0
5 71 F 20 CVA BG,Th 1 2 0
6 55 M 19 *
CVA P 1 2 1
7 72 M 19 *
CVA P 5 1 0
8 67 M 15 CVA Pons 1 1 0
9 77 F 21 CVA U 2 2 0
10 80 F 13 CVA 1 1 0
11 69 F 12 CVA 5 5 0
12 60 M 15 CVA P,T 5 3 0
13 62 M 36 CVA* BG 3 1 0
14 87 M 3 *
CVA U 4 4 0
15 80 F 19 CVA 1 1 0
16 64 M 38 CVA* FTP 2 4 0
17 68 M 13 CVA 1 5 0
18 93 F 39 CVA 4 4 0
•jjjf
Confirmed via CAT Scan. *$c 'jt
Location: BG = Basal Ganglia; FTP = Frontotempoparietal;
P = Parietal; T = Temporal; Th = Thalamic; U = Unspecified. icitjc
Severity rankings according to MIRBI: 1 = Mild; 2 = Mild-
Moderate; 3 = Moderate; 4 = Moderate-Severe; 5 = Severe;
6 = Profound.
76
0 01 <
N- CO ro r - ON «— a N. O O O N. NO f\J CO ON N- O
a. <
N» O
f\J ro
(M si-
o o
CO o
* K *
<- in oo N-
O CO
O O
C CJ T3 C Ctf a d> o
T3 C (D
:e o
o N-
CO CO
CO o
NO o
0) s:
oi c
:e o co
CO o
u 00
:e o
N--J-
c n
x CD
-O D
CD h-
CQ
ct:
3e:
s:
_Q ro
2: o
o to
o CO
£ o o
a Q. <
o CL <
77
se: a
r- OJ « - N- vt 0 ro r- O Kl r\j 0 r~ 00 r_ O vO O O
O m LA sr oj 0 -J* CM O hO in >4- IA O N- O N» O O
* T~ SO -J" 00 ro hO * - O ro CO tn -vt O 0 O in 0
LA -d" ro OJ « - « - OJ vi- V* ro NO O NO N- 0
r~ * - m ro ro LA O NJ OJ K N- sO la r- N- LA 0 O Nj- K 0 tn r\j LA m 0 Kl 3" in 00 N- K 0
K)
CD O
ro *— OJ 0 0 N- -J" hO <t 1*0 0 CO OJ O O 0 ro in •<r ro r~ O ro OJ 0 OJ LA v* N- N. O
O CO O •O 00 *0 IA 0 0 K) 0 N. r- 0 0
O N"> N") OJ m tn 0 OJ <— "st >fr ro h- 0
<J O CO vt O 00 OJ co OJ 0 0 * - OJ T - O K> vO LA -J" K1 0 O LA LA O
N LA 00 CO * - f-0 r- r» Sf Sf OJ O co 0 O O O LA fO r- O N- sf 0
OJ ST NO f-n LA N- tn 0 OJ NO -4- OJ OJ O
0 * " vt •st -cr OJ «— ro 0 tn LA O
Q. O
OJ O N- CO OJ -4" T— LA O 00 O <r~ OJ sO LA LA O LA 0 Nt O
O CO
3E o
*— OJ K) «— OJ K1 *— OJ ro h- •—
—I 0 0£ O 2: £ X 0 0 CD 21 2: 3E: O 0 O CL CL Q. CL Q 0 Q O O 0 CL CL CL < U O CJ U- IX. Uu LX. u_ < < < K Q£ o; Of 2: s; X JE 3E 2:
Q> r~ 13) 21 1 C ItJ CL 1 O i_ CJ CO c O on CD
CO CO > O co c < •M •« ' r— £_ 0 c I— 03 CD < — li CD Cfl 4-*
CD CO O ro CD +j CO .J L_ >— £ JC II • t— O CD D> E CL a. c GJ
00 O < 0 > Q£ •—1 0 • >—
X £_ •« D) •M V)
H- O •2* CD O t/)
O co t_ <u O
-J c <0 0 Cfi t->S LU CD H- > <•- D) L. CD U < CD O O ir L. +J • k II 0 il QJ CL c CD "r- C 0 t— O +J on -r- "O > O 00 O 0 —J CD c U •—» <u CL C_
00 3E CO < CT> 3 0 »r« i_ O
•f- > 00 D3 • * CD -c: •M _J CO JD O »»- 00 O CD C u
x L. C c QJ CD •« . •r- «(— -V CO
11 > _J _l U QJ <0 CD c
- j 00 <0 cn £_ JC CD DC: 1 H- L. CD O > »—4 1 CJ •M 00 CD CO >> C c (X
Q£ O c: CD CD 3 >r- QJ U JC H
2L +J jii +J c u U L. 00 • » *~l 0 QJ O c 3E CD CO -c: 0 a. t_ c •r- 0 0 O >r- CQ c/> c c OL
O C0 0 0 00 t_ QJ c: • r-
CD C 0 <0 +-1 C — ' •<- <r- CD O to •M -J co > 'r-•M x: c: QJ > •M O CD CD 0 O QJ CD h~ • r~ u •— CJ +J 1 Qe: CD CO +-» C 1 X! CO C 4-> CD >> H— C >.-• GJ c y) £_ O CD E: u CD CD D -V O [_ O U.
.—t >- O CD i_ CL C L. CD CL CD <—« O JC x: CL T3
+-» U CD CL> t_ c c 00 U) CD CD QJ a: CD D) "D
(0 > c L. CD C £_ C 0 11 QJ t_ CD CD •~4 > CD +J
V) CK: < > 00 •M c 00 <C 1 JC c 0 *—. II , CD •r- Z. —i CO X 00 O 0 CD <u D£ CO CO Q •M 0
II -J CL O • r-H- E 00 < •— t-O > O +->
yj •... • ~ 11 CD X CO Cfl £ £_ •—< H— CO CD O O CD cd CD c CL CD
c
2:
II
CD £_ O O 00
1-. Q£
>» I-D C
CO 3E o CD _J 00
e o
-D C cd
CT> o
"D CD
o u
0 , H-1 . ...
QJ > — ; O) C D CO c O O O TJ >r~ >r-
E C •M <M CD O CD H- r V O +-•
CD 1 CO C 11 E
CO L. CD to .
CO CM JC O (D c D CO —J L. 0
O L. CL >r-CL O O CD +-«
u_ V/ h~ CD CO O X O •M O CO TJ CO C CD •» C O a CD a C CT) <r- CO CO CO O .1— H- • r- O
•<— .p~ CO >r- E £_
E +-» QJ T3 QJ CL CD CD a O 3C 3C +J 1 X CD
C L. vy •M D +-» QJ O jC U JC CO 4- CO D) CD CD 1 c • r- +J •r- I_ >- CD CkT H-
CC CL C_ O CO 1 GJ
_J 1 "O E CD CO CD • CD CO CD CD z: t C D 0 "D L. •r- — *
«r- C «i O C- CL t- (D H- 0 +-' 1 u CD CD 00 ef X 00 U
X 1 O t_ CD 1 O O L. a
CD /-v u. E O CO > CT) JE QJ —J >•—
C z; >- E CO >«— • h CD <D CO L. C it »— 3= QJ O O t_ O >r- r~ "D •M ai to +-• h- GJ JZ 0 CD 21 D) t_ •M O M- •F~ a. — . c LL. >r- 0£
CD CD X ~o 1 ~o U CO 0 1 CD C CD • * z L. CD t_ c W CD D Ql 0 C O 1 • r> CO • r-— ' E QJ +-> C £_
O CD U CO D> 0
O JC CO 4-J <r- a CD CL c CO 00 CO £— CO CD 0)
•« O >>— CO O L. C w E CD 1 0 OJ <D i_ L. > CO 3T CL O X CD C H- CD Cd o> 4-J QJ 1 1—
• <- JC D >*
tt CO o> O L. T3 CD •r- O GJ ro O cc +-> E >r-z 1 1 s- CD 4—
CL I— 1 QJ 3E: • r-u O —J "U Q£ «+- O)
c CO 11 0
2: • » X D CNJ W C 1_ L. t— O O O CL X CO
E U O C O CO QJ u. CD
CD z: O X • r~ 4-> — ' CO co C 11 a aj QJ CD CO C 0 CO r— "D • r- O 1 CD C E <r- £_
O O QJ •M O CL Q
LL. x: CO
•M H-QJ £ E 4-> c >s O CO JC CD £_ CD » «. JC CD CO O CL c CO • r- CD E CO 0 L. Qi t_ 0)
O 1 a. z: E •M V-* 1 CD CO x> n •c •M CO CT< t_ c c C (0 ro *-> CD CO -r- "D 1— jC CO L. C z: CR CD CO O CD 0 t_ CD O 4-* i •
oc CL CJ CO 00 z;
79
Table 5
Group Means and Standard Deviations for the Raven's Coloured
Progressive Matrices (RCPM^ and the Memorv-for-Desian fMFDl
Tests
Neglect RBD w/o Neglect
Controls
RCPM (Mean number correct on 12 items)
Standard* M 4.67 7.89 8. 06
SD 1.41 2 . 63 2 . 01
RH** M 5. 39 7.72 8.11
SD 2 .17 1.96 2.25
RH + L*** M 5.11 7.94 8 . 00
SD 1.78 2.46 2 . 28
MFD Errors (Graham-Kendall Scoring)
Standard* M 6.83 2.83 2 . 61
SD 3.31 3.15 2 . 09
RH** M 6.72 3 . 11 2.67
SD 3.46 2.85 2.77
RH + L*** M 6.33 3 .72 2.50
SD 4.23 3.49 2 . 01
MFD Errors (Modified Taylor Scoring)
Standard* M 8 .17 3 . 83 3.44
SD 3.11 2.46 2 . 01
RH M 8.28 3.56 3.22
SD 3 . 08 2.73 2.37
RH + L M 7.78 4.44 3 .17
SD 4 .49 3 .11 1.72
Note. =
Condition;
Standard Presentation; ***
* * = Right Hemispace
Right Hemispace Plus Left Cue Condition,
80
Table 6
Tests for Equality and Compound Symmetry for the Dependent
Variables
Dependent Variables
RCPM MFD-GK MFD-MT"
Test for Equality
Chi Square* 9.07
df 12
Test for Compound Symmetry
Chi Square** 4.31
df 4
24.75
12
2 .18
4
18 . 61
12
6.83
4
1
Raven's Coloured Progressive Matrices
^Memory-for-Designs Test (Graham-Kendall Scoring)
3Memory-for-Designs Test (Modified Taylor Scoring) *Critical value (.99) = 26.2 ** Critical value (.99) = 13.3
81
Table 7
Analysis of Variance with Repeated Measures on One Factor
for Raven's Coloured Progressive Matrices (RCPM} Scores
Source Sum of Squares
df MS F E
A (group) 303.49 2 151.75 18.29* <.001
Subjects Within Group 423.15 51 8.30
B (condition) o CM •
rH 2 . 60 . 22 .80
AB 4 .17 4 1. 04 . 39 .82
B X Subjects Within Group 273.96 102 2 . 69
82
Table 8
Analysis of Vciriance with Repeated Measures on One Factor
for Memory-for-Designs CMFD) Test (Graham-Kendall Scoring)
Source Sum of Squares
df MS F E
A (group) 509.48 2 254.74 11.82* <.001
Subjects Within Group 1098.96 51 21. 55
B (condition) .26 2 . 13 . 03 .97
AB 9.93 4 2.48 . 66 . 62
B X Subjects Within Group 381.81 102 3 . 74
83
Table 9
Analysis of Variance with Repeated Measures on One Factor
for Memory-for—Designs (MFD) Test (Modified Tavlor Scoring
System
Source Sum of Squares
df MS £ P
A (group) 729.05 2 364.52 20.15* <.001
Subjects Within Group 922.70 51 18.09
B (condition) .53 2 .27 . 08 .93
AB 10.17 4 2 . 54 . 73 . 57
B X Subjects Within Group 353.96 102 3 . 47
84
•M
o a>
w
e n
cu z
H -
o
c o
CO
t o OJ £_ Q
X LU
o>
x 4-»
a t
o c a 3
H-
C
O •4—'
" O c 3 O
u _
CO •M
o C 1— GJ
c a t o
—* a - Q E to o H— o
Q . co E —
"U 3
+-< CO H- CO <D co flj _J a
c/) (1) o . •» CO CT) (13 L- X J <L> -V <d c <r- a i o c 00 x <D co flj • £_ <0 a 4-J > 0 c L. u 3 •M CO CO (0 c CO as +-» o > X .p- c o C c
X I — ' E CO -M J* : • r - o CD CO CO 4> £_ o t o o •M « u X c SI x CO cd *-> a c •M DC
L. CT) —> c x <D c 0 ) V a» •M CO CD a> X • r - 0 X 4>
> H— a> • — C- •M "U L_ (U c 4~> —< o •M o 4-J _J C CO CO ro c CO
M— m o T 3 a. , r - 0 ) . a o X T J «>- —» + J > OJ , +-> •M a> +-J 4~i co — CO -M w ID
L_ o (0 • r - o CL •M C o C o < 3 > a t CO o o o cts o a CD "0 • f - >r- —- • r - a i a . w c a * u o -M E CO E H - « D ) CO </) 3 o t_ o 0> a> fl> a ) o <D • r - <L> CO E a t o X z X " 0 i~ Z 00
C •-o
c OJ CO
<D (0 D at •M CO X (0 L. -r- T3 X X c_ -M a "O • a; 4-> <D o> o co c 0) (U c > to u CO «r- X <u >r- •r- D5 > o <D a - Qe; o E L. o — CO CO CO +-J T 5 CO o •M CO L. 4-J
o to c c CJ a x O . +J a a CD D 0? <r~ E CO 0) 4-> E a> t_ CO L. •r- 4-* 4- a •— +J O
>r_ •M •M >r- O E X *+- OJ O at E > o CO —> H- a t CO <D - > > T J
oi a 3 C_ X • f- D) CT) CO c —1 E a> QC O C •M at CTJ CO CO CT) •r- • a •M C C • r- c o 3 ! X a* c •M "0 H- L. 01 CO C
*-> r z >•- CO CO a> O "D CO D O CO •M c 0 ! •M - j (0 c O E O —( • - L. CO c i_ X • p~ H- i_ 0) fD 00 D c M— 0) c a> o T 3 o —< XI 4~> • r- • r- •1— •M CO 3 >r~ C M-CTJ (_ CO > E c a> -a - D) L. (U o CD X o CJ (0 CO cu D <L> CO • - 0)
2 > +J x s E X a. u O L- > CO Q .
—>
CO /-N • > •M H - T 5 ' >— CO JU; X CD O
T 5 CO o —* CO t_ t o t o T J •M co a . O 1— <D 0» H - > CO 2 o u 0 ) o> c o w + J •M t o E . r -3 CO CO —> CO — ' _! " D a £_ + J
CO •«— CO a t (A O > CO > X J c_ L. (U c
t ~ i_ c - r - <U o " D H - OJ o 3 + J <U £_ .
c O > •>~ C J •M 3 CD •M . O -M cu a t iZ o t o c CO O i_ —» CO c <1- CO >
+-> o > 0) CD o to CO CO CO c u t_ * u — ' <<— M- >«— <r- CJ — ' £_ 00 CO o • r - E 0 ) u cu CTJ 0) CO Q> 4-J + J w CD o a C J * a t •—> C •« X X a a c E •— 00 c A 0 ) " U O ) 13 E E to O —> CO 3 " D c •i— O O
o u (/) •— QJ a ; JQ CO o
o N-O
CO 3 N-O oo T- CD
c : cu CO z : o — ' C CO < CT) o» <
+ J > CU > > t o u c <0 u 3 >
a —- o o<5 CO CD o d m
oc " D cm C O C CO >» E (0 . * E o E NO — ' •M > •p- II —i >•— II QJ
z i 3 a>
3C z i E • r 2=1
c t o > - CD CD —>
( 0 ID O <L> C X —
U c • -O 4-» •— <u •M X
O) < -Q
CO X 0J LU
C OJ
O O
c r s i « oo o o
c . o 4~>
O o 4-* 0) +J o o —-
•M 1 c o C CT) —• <0 o OJ
L_ at H- • r- C CO 4-J X 'r- +J
4- C •M o CO H~ (0 o 01 > O
« o o 00 a >>-+-> •r- • a CO •M CO c +-> at T J +-» • o E CL> CO X —« <0 < t o o
-i- E 4-> u CO 4-» +J O • r- •r- o a to 4-> c H- -0 t- •f- E D . 3 •<- c at >.
t o —• +-• 0) CO •M t o to X o •M c to E a CO o C 3 o C_ CO L. — ' <u E •<— 4-f •M 0 CT) »>- •r- 00 c CO E +-> <D L •M CD o X OJ __/
Z o CO u +J X CO
CO +J u CO L.
T 3 a> • 3 O • » O X 1 H-a> O CD CO 4-" 3 u 3 tD CO E CO T J C CO c •r- O a O CO 0 •M o at > 00 L. c —> CO c CO
•— Q . • r- " D cn X I E Oi 0) CO • , a» £-at a> o CO C c O
X 3 CO t o •r- T J o > O CO a t C <D c c
Q) L. >*- s - • r- o o 4-» l_ o H - M - H— c ,
M - o c O 01 Ot 00 +-> CJ a t *<- O U 00 c o -J T 5 c +-» o c > o CD •M o • r- CD • r-
H— at • u o T 3 H - £_ > •M H - —< 0) OJ •M 0) • r- <D CO a> CD —» o — ' U M- X I T 3
C CD c • r- a t H - t _ C o •»- CO 0) 3 co Q . .r- 0) O
z 00 E z u- CO T 5 > O
Q . C <d
CO 00 CD o> 3 t-O Q.
CU 4- T J U at c 0) CO C - j o —* O CD •r~ C\J U) >« J 2 -E •» *-> CD CO 3 (_ •M o t o 1 T J h - CO O OJ O X • o o 1 C C E " U >
H - CT) CO CO •I— c t o >r- C 3 t_ >r-L. «r- a> CL —> o O O O 00 4-J
0 ) a ; 3 CO a CO —- • f - • r - •F- <+- > • r -CL o "~ o> + J t o +-J H - c
0) E L_ t o X J 3 t o M— OJ CT) c —* o CD 3C L. E . • r - <D O o CT) c X " O 0> T 3 - CT) u
C c Od > +J 0 ) —- C . • r - £_ " O t o CO o C CO • r~ L. CO
o 0 0 o 0 ) c t \ l c • r> L. CO o c cu 1 c c t o —• CO to o CO » •» <r- o E T J t o u • D a T J 00
CO —* E >r~ O X ! CD i OJ co CO a> CO CO t o • «— c £_ —i *-> i C •M (_
3 3 X c a> • r - 0 ) t o CO •r~ OJ CO a> u a UJ at • c E > 3 3 OJ E CT) a c +-» t o c CO CT > t o L. E
» « X H - X o CD 01 X to O < CO U J O UJ c > w — ' tD u
hO CO O
00 >S o
a e •
CO
<D
N-sO
Q od CD
4- 3 CD to _J I—
T J to
— c > o
LA —'
o o
T J "D
CD CO 00 00
<L> z j X
CM O O i n NO C J O o o
o o C i If >* II <r— CO CO < I X -J cu c_ OJ
*. CT) co a> CT) c r s j o <C > T J < co t \ i *— . —> c UJ C a it tl CO (0 CO CD m OJ
o z | Z i 2 : « - 3E
85
C CD O H—
oo •r- o c 4->
o TO (D C/5 a «+- > O) E CO O • — TO O CD 4~> • •. <D L. CO CJ T3 a
c TO <U O E t_ o N 4-> c >. o • i— —> £_ »»- CO •M 4-' TO o o to CO Q. •M <D E •M 3 a TO O
CO O D JZ D CD £_ to •M TI
o H- TO <D 'r- C/5 U5 £_
X c CD <r- CD
4-» TO > £_ • r- E » >r- <u D —» +-• 4-> JZ * • TO TO V) o o +-> (D CO t_ i_ CL) CD o O D CD CD —- H_ a O O 4~> •M CD CD > L. c_
TO —* CD o JZ D. TO 1 TO C
CD CO JC u TO 4->
c 3 •r- •M
TO A E J D A> o T> E •M H— TO "D o ii- <J v4- JD (D
H- CD <u TJ 3 L. —- <D O CD CD (U CD JC a TO <D 13 H- CO
C C CT> c O •r- c w o >>— 4- <D +_l
•>- to o TO > C 4-J CD 4-» «+- <>- <D O C c D> ft) TO •r- o O *-> o • r- Z C TO <L> •M CL 4-> CD a TJ C TO • ». _C
O O JQ 0) 3 L. O 4-> L, D L. CD CD CD "U CD
C TJ U lr-
<D JZ 4-> CD <D TO +J 4-J *-> CD .C CO X TO O TO 00 3 3 LLI M- c
<D
o . C •M "O CD
TO .C CD U
E CD c c £_ • — TO o s- TO o •r- o E H - U +-» L. L. CO o TO <D o CD > CO —- U) 4-Q . CO T3 t—
TO CD CD o C u —- CL o CD CO C 3
._J 4-J TO O CO 4-> o u C 4-J u c "a CD (J CD CD 0) 4- L. o 4-> JC 00 4 - CD 3 M-CD 3 3 <D O H -
TJ •M JZ TO I'Ji co 0) <D —» 4) 3 —i
m h (A
A3 CD CD y> L. 3 C X ! •r- JC .v: O CO at C •M +-» YJ t_
><— JZ CD TO >r- TO L. > U x : u_ 3: -M <D
CD 3 c <r_ «r-
JC • <D O •r- L_ <J X •M O JZ CD u> u TO JQ
c CD D c CO T5
CD o C/5 c o
s -a TO TJ U E CO TJ TJ •M 3 C CO U
CD TO —> —1 •r- i u O O CO 4-* , O a c •M (D <• D co TO CD JC aj » CO C CO C *-> o C H- CO +J o o TO 4~> <D D o • — x : 4-J O c o CL C C D E E H- •r- o CO JC • r— TO CO CD L. a O CD
—» <r- o >r- o 4-» CO •M +J E a D •F-4-> JC o C H- +-> •r- O CO c C- CO 4~>
c CO «r- +J CD <D DC o TO CD • r- TJ c TO «r- TJ s~ c +J "U CD J— > r- TO a> CO <D a •+- CD <D CD - J c • r~ CD •M a TJ •M
co o +J T3 E CD •M •r- • *U CD E —> C 4-* 4-* •<— O <D C O CO co a Q CD TO U
o CD W CD W CD •M o c CD . —J CD u +-< to •M E w o +-> C •M •M £_ •M TJ
o c 0) c_ D) (_ >S CD TO • - L. • r~ O O CD c . „ CD o> 4) OJ <D O C O O C CD 00 o CD CD +J o 00 U <L>
—» y) C a CD a —» •»— t- CO a o CD u Jk£ D c o> CD c a CO CL a CD O a . a CD O) CD
u CO TJ
<D L. o D «•- • CD D C E D CD CD L. u TO CD c CL c 00 TJ w TJ O 'r- O 00 -C C Z CO o +-J L.
" * —J T j JC O •M TO C •M
to L. CD +-» T3 4-J c U TO CD TO c CJ C O <+- CD CD CO 3 c +-> CD JC O CD O C TJ D H- 4—' CD D •r- CD ,
CD JC +J —- o <D O O c t_ > JZ TJ CD CD
3 CD 3 TO CD CD a "D CD JQ D> 4~> ,» J_ L. TO C.
CD C_ CD +-» o> D • f - C +J ZJ TO C c o m C CD D
L. D CD TJ C • r- c O co CD c L. L. o o JQ O > CD TJ CO O CD QL • r- i» t JC CD CD TO o c 4-» CD
TO C TJ CO O 00 TJ CD •M 3 E C a CO o TJ *+- +-" CO H— C U TO CD U •M CD x : CD O E c "D ,r~ CD CD TO <D E > (U c CD L. CD C U U o >r- c 4-* •M C CD X
C- O E T> L. CD L- TO C o TO c O u CD CO C o E 0) CD JZ u CD O C0 E CD CD VJ_ E O c TO *4— CD D CO TJ •M a C CO TO CD H~ O E a o JZ L. L. • CO C 3 L. O TJ •M CO TO TJ H- L. E
+-> CD TJ c >r- o CD TO <r~ c 3 JD TO TO c o CO O CO a . CD CD i_ -M D 3 • - a TJ " I— • cn o to TO o CO t - j*: CD C E CD TO C TJ c c CD > 3
• — "D CD L. 4-J O • r- CD TJ c • TJ •M O t_ o > +-> TJ CL) E CD CD 3 TO +-» O +-• +J >•— +J o •M L. c TO -r- CO • p- <D TO •M l_ o +-* > E TO CO TO to CO H- TO 4-> 3 +-> TO 4-> CO £- o O
CD o CO a a c_ C </> CD 3 o •r- -M •r- O o L. O TO CD E
CD t- £_ CD C D 4~> 3 4-> o CO — ' 4-J CL TJ JZ TJ i_ CD CD D t- CD a C CD o o H— O M- E H- TJ c CD c o > CL CO CD <D o > E •r- JZ 3 u CD U CD <D E O CD "r- o • r- o c CD TJ X CD JC 3E O •M t— CD - J TO —1 TJ o +-< - J E o L_ o » - CO TO <D > Z *->
— '
CD CO U > c
TO L. CJ CD >
s - O O •
CD co CO C CD C •r- C c IX- L. —• co TO C- E O )
CD i c > i •«-
JX 00 O CO TO 3 TO L. h- 4-> CD
H~ CD
O — ED
C C O TO
TO CD 4-> (_
c CD L. CO O OH \ t- T> a c
TO TJ CD co
U 00 O O
CD CO
C CD i u
T5 O cts a sz
TJ 3 S-
o CD o TJ 3 4-i CD CD i 3 JZ i_ . a CD 4~> a O CO E CD 3 —< CD O L. 4-> o o D o CJ TO o o U
—< >p-
TO TO CO D 3 •M C a *r- > CD _Q l-O U co £_ £_ -V CD 4_ CD o CO .. C O . CL 4-> TO c i u 1— CD CO L. CO o
TO L. TO >•-
TO 4— C > 3 4-> 3 CD 4->
D O CD CD CT > c CO L. U c CD CD CD
»r- o +J >r- vf- o L. i -M > +-» o > 1 -
o CD o O 4-> «, "0 TO TJ E to TJ <r- TO CO CD CD (1) c CO TJ
£_ CD >S •M —< o TO CD
TO a CD CD CD <D CO —• CD E O 00 L. 3 O TJ C O C L. U O CO c 3 CD TO CD C O
•-« TO a O CJ > • r- H-
CD — ' -M
CL 00 E — TO £-CO CD
>* TO
TJ £—
3 £0
CO CO E •M —i
O o /-S sO u
lr_ CO CD c o CD CD 4-> o CO a —- x : to 00 <— o> CD T— CD 4-» CD
CD h - CD &15 o h-•» z •> Z CD » CO c co
— ' < TO < TO CD
TO 4~> E > L. CD 4—' LJ L_ —« o 4_j Z t_
CD CO CD a> O JD • CD Q - r - o X J
• 3 —' x : 00 o £ 0 CD Of < o; o a; < 4-1 oes •M • «• CD o CD O C 4-» LA C C CD CO
TO II CO 4> 11 CO ii CO O
z l 3 —i
z | TO a - 3 - 3 z l u- z | s: z !
to CD QC
T J O C L. TO TO 4-"
C > 4-J O O o JD o CD c CO
a —< T J CO o TO 00 o> CD CO +J o CD CD CO «— C £0 c T J
—* to o CD •> O TO TO N
c CD 4-* CO •r~ o ct: 4-* CO £_ to CL o • f CD
O to CD E +-> L. *— o —i o 3 <D JC CD CL
X ) IS CD T> E O
z [ o Z c O
z [ r_ w TO u
L_ CD JW: CO UL. c , „ CO CO
TO o 4-J O
o c o
- 4-> £_ aj CD 4->
•i— 4-> 4-> • r— —J TO 4-J c o C C W CD CJ CD CD O o ' 0) —• CD
O — ' o CD O Z CD CO c O o> 4-» CD CO O • r-• — a CD TO —. H~ o «c C X! E r— z TO 1_ T— > TO CD —. E CD u O CD O «• Q CD t , > C
<r- CO G O c Q CD * C QC C z TO CD C
JZ O TO E IX. CJ O t n O o TO -TO CO <r-
r- CO 00 o 3 TO O CD TO s .
CO fX tl TJ a 3C n • r> TJ »r-
z f > C TO z {
> C CD o d z f TO QC o d z { TO
86
to •M <D £_ a <_ <u •M c
—> ca to co U D 4) O C t-O TO O) C/i C <D O > .r-O 4-> t— c a <u e -M
CO w c *+-—• o L. Q> — JQ CD E > D &
a> -M c c
CD •M C t- o O CL a E a o D O a> • * CD c c o c
TO R3 > >
"D <u CD —-
JD 03 CO D 4->
C O TO H- CO H-O CO O TJ
cr» +-> o c c
- - — CD c o a E o o
O V- -M a — c CL U (D D <U
CL L. « O
CD "D 0) (D (/) c o
c C 4i D) C O D C O TO
— — 3 ^ P +J (fl
u c c a CD •— CJ 0 >
C E
C -A3 -M +J U t- o o —» Q. O)
CD - C
TJ . —/ U aj a> * — ' cu c to CD CO u •r- CD 3
•M o D —i TO TO •M ce: D <0 •1- C CD 4-> a U U C
0) «<• • r- 4-» TO <D O) tu (_ o 3 OO o to E C c •r- M- (D •M >r_ <L> 4) o > TO E 4- •M x: 4-J H— C CO •»- C -M O tD TO to O) to
C/J •M •r- c CO JZ CD • r- •<-
"O —- fO o TO « L. ctr > CJ E •M O -M 4— CJ CD CD +-> O) c D) O • — H— o D x: TJ •M c • — c "U at Hh- (D O +-> • «— • II— • r- CD —J • r- —J QJ • i «r— +J E L. •M JC o O) C O • % aj 2 H-O <D c o c <D CD C C +J o CJ -Q (D (_ to C •r- • r- GJ O c C _J Ui E E (0 JZ 00 D 4) to o 4-» 3 <D CJ c L_ u - w E • r- L. o C > CO CD CD • « CD 4- O) £_ +-* CD CD o o +-J CO CD c CD o TO 4~>
•—* c c_ D -C 03 £_ »— C 4- • r- TO XI 4) Q. CO +-J CD 00 a> £_ > CJ 3 -C E • r- t» TO E o c CJ a> L. CO
" "
> 3 O *-> CD 2T o A TJ U>
, TJ 00 i CD CD ro • •M 3
00 CO O o — ' od CD CJ to C TJ L. » o • r- * ~ CO >1— CD <r- 1 c L. > —J «• •M "D CO -M —> Jki CQ O {_ 00 to to O) CO —J <D c CJ > o ro >»- OJ c TO £_ TO XI
C •>- H- H- •r- a E •M c h- •«- O "D CO D JC o
»• — ' <D C 1 C o> • r-±-> JD o CO
lr- •M co 4~> E • r- c TO to <D £_ • r- CD Ci c: D D •M o • D L. co O H» O C a •1- C CO Q O) o to
>r~ » CD to TO «r- 2 > a a CO C0 a> i co t_ E > CO
*» CD c OJ • 1- CD C/5 •M CD •O •f- QQ > l-N CJ S- c E L. U) —' v— <M D <D •r- CD <L> < to <0 <D OJ w w CJ JZ JD 013 o <r~ C —• < J_ £_ • r- . , , < u >— < DO U
<D /—N L. c o (— (0 > O) a» 4~> S o O CD •k c c a (_ CO a co C •r- crt OJ CD o o 3 o •M h-<r— © • 1- to Q- CD 4-> u
+-» 4-> (D 0)
CL E •
>* T3 D
03 <0
CJ 01 13 O
- E <o oo
CD in w -G —
+J QD O It CD CD
CD C O) Q) •-a> cd _J
c £ II < (13 W > Q) — zl o 3E 03
CJ
u a-<D O Q£
® £ in w vj — a o —' so
to ii E it "D o> «
oo XI » E < D
c
O) C D) TO (O
o c c 03 It CO CD CL)
SE Z L 3E
87
"O C
XI (0
a 3
£ Cl
C o
a E O
--CJ «M so «M CO o o C T-
flj CD *U O CO 0^
c«S
Jk! t-CD O c c <0 o CL +->
CO
•M CO <U N .
a CO «— tt) c -Q> » O —
(0
- M O <L> N-
N-•r- (> +J «r-+->
O « c •
CD 4-> nO U) N-o o
ro K
0) (>
co — ' CD fC
O \ 0
a> c>
St N- N- O
N- in
O N-
00 O N- f\l
K1 sO
O sf O 00
in in o j
o j o j sf in
CM sO in O O CO N- 00 0 0 <>, O a st NO in CO 00 N- o K
II • • • . • , „ z l
OJ <— vO sO K (M •vj- OJ r-z l SO
K1 N- 00 o T~ m •<*
II O vO
z | T
z |
in OJ CM o O K1 CO vj" r\j vj- o oo
o a OJ hO r\j x— «- hO 00 >d-it • . • • • ,
o OJ N- CO N . in ro *st z l tn <r- r-
in r\j
n
z l
.84
m CO
sr o j
. 79 O NS-
m f\j tn N - m
in r\j
n
z l in f*"5 N-
f\l in o o f\j
o m K1 CO
N- OJ
ro so
z l
co
CK
z |
ro ro K ) o *— o a nO
o in O N-it
r\j T- <3 N-ii
2r| in t— « - asl
O in <\J
K ) O st <r-
CO N-m ->t
K in eg
<D —> O a ill E —- 00 (13 13) *— K ) O N- O sO CO 00 <D hO O O O in OJ
ZZ 11 • • « •M
2 i O K ) fO N- O oo
c O 2 i sO T— ro o %«N £_ 3 L. D o
E O t_ 4-» 00 H- O *— O *— o vt o
Q K1 in O OJ tn <D « * II * > , •M C31 sf T— vtf- -4" N - St A3 2=1 sO T— r— Q 3E
in
0 0 *— K1 in st SO
ro r— *— o o n • . •
sO sO v* o o =ci N- OJ r -
co N-
N-vO
hO hO
eI Q ! w l
I 3 E l o | s e I q ! I oo! co I
a d o l a d o ) x l o l 2:1 o j col 001 co[ 001
(D DO </) +-» < 00 —< o <
o l~ 4-J 4-> •M CD Q) +J z: <U CO (Si c OJ Q. 00
o D> CJ o < cm
a d o l d o !
Q)
<L) O
4-> O TO
a
OJ
jD
O) <u c
T3 4-J CL> o —J a> <0 —r <u O) > G> 0> Z L_
CO fD • r- D co > • r-
> * (D
CO C ' c A3 tu E u • <D
<Z> o 4J <0 o 4- —-
<L> •r-c c • r- Z)
T3 C H-CD O o -M C 00 CO o> <D • flj CO CO o o c i_ H- o <D a o C D
a> —t L.
<u 4-* <L> c > 4~ • r-
t- H— 4-> cu • r- 0) <D > T3 N C 0) >P L. CO X E <3J (D
CO C —> o •r~ fD O E
W) C JC E O +J J- -D 4-i • r- <u <D 3f +-J "D
<0 0) 2; c CD a CL -r- > o u OJ ac: T3 L. <1)
<L> > c +-» <D Of o A3 O ~u
<r_ 3 C CO cr *0 * L. <L> E X
J- CL o u
z: xi CL CJ
<0 t-<L> "O
oo a . a> CL GO D X — O CL >
aj < X O QC i
cd -Q u "u a>
APPENDIX C
SCHENKENBERG LINE BISECTION TEST
88
89
APPENDIX D
THE BELLS TEST
90
91
4
• *
* •
92
*~jV"t £&**}***'** 1* f\ ?y*»nt
v • v «-•* /Vs* u . |» 'K f «- >| */ c * 4- f 9-^ 7 «-
r£V* f~ *tv/ » ***. r * it pj*/*}* ** *• ;• ti * Vi.«»<•/** *\ t i«h« *l L « */ * ^ * Vef»
- 'MCvkYti1'' Ui-^i+Xri-n *Kw','«*'"& (-'•*
93
«s.
O u
E5 C o u
E-CO
ffl o <y
>4 § c nj
Cd Q tr>
0 l-H -u W 0 3 < LQ H >
U o
§ w a.
APPENDIX E
RAVEN'S COLOURED PROGRESSIVE MATRICES (RCPM)
SAMPLE ITEM FROM ORIGINAL VERSION AND REVISED VERSION
94
B 8 95
W)
r -
I -
i
5
J
96
1) 3 CM CO
CD
00 00
II
(D 3
APPENDIX F
MODIFIED TAYLOR SCORING INSTRUCTIONS
MEMORY-FOR-DESIGNS (MFD) TEST
97
98
Memory-for Designs Test
(Modified Taylor Scoring System)
General Instructions
Judging the figures one at a time, tally the appropriate
number of points for each error. Note that any individual
figure may score in several of the error categories. Points
may be given to a single figure for errors of rotation and
omission and distortion, etc., or any figure may be found to
score in only one category, or in no category.
After scoring all figures for each of the first six
categories, then score for Organization.
Total the number of tallies in each of the seven
categories and sum them. This grand total is the subject's
Total score.
Omission:
Distortion:
Scoring Categories Defined
If half or more of the figure is omitted,
score 2 points. If any part or line (but
less than half the figure) is omitted,
score 1 point.
If the overall gestalt of the figure does
not agree with the stimulus figure, or if
any portion of a figure is out of
proportion by more than about 50%, score
1 point. Do not score this category if
the discrepancy between reproduction and
99
3. Rotation:
4. Reversal:
Perseveration:
stimulus is caused solely by omission,
rotation, or reversal, etc.
Score 1 point in this category when the
figure as it is reproduced represents the
stimulus as though it were rotated about
its central axis. Rotation must be 45
degrees or more to be scored.
Score 1 point for reversal if the figure
or a proportion of the figure is drawn as
though the stimulus had been "flopped
over," either horizontally or vertically.
Note. Rotation represents the
figure as having been "spun around"—
reversal as though it had been "flopped
over." Generally there are fewer
possibilities of reversal, and reversal
must not be scored on Figures 1, 2, 7, or
8. When in doubt, check the illustrated
sample errors, and remember that the same
reproduction may contain both rotation
and reversal errors.
This might be called "carry-over effect"
and is scored for uncalled for
reproduction or partial reproduction of
any previous stimulus figure. No
perseveration score may be given on Figure
100
#1, as it represents the initial
stimulus.
6. Embellishment: Score 1 point for any addition of
uncalled for lines, loops, flags, boxes,
etc. to the figure, except where such
additions are clearly preservations from
previous figures.
Note. Distortion changes the
gestalt of the figure from that of the
stimulus; Embellishment maintains the
general gestalt, but adds extra frills or
adornments.
7. Organization: This category is based on the arrangement
of the figures on the paper relative to
numerical order of presentation. Only
scores of 0, 3, or 6 may be given in this
category.
For figures in orderly column or row
sequence with no more than one deviation,
score zero (0) points. For irregular
arrangement in which there is some order
but the figures do deviate more than once
from sequential column or row
presentation, score three (3) points.
For confused presentation score six (6)
points. This is for helter-skelter
101
distribution in which there appears no
pattern or sequential order of
presentation.
8. Total: This is the grand total of all points
scored in each of the preceeding seven
categories.
Bradford, D. C. (1978). Differences between groups of brain
damaged patients on the Memory-for-Designs test: A
comparison of two scoring systems. Unpublished doctoral
dissertation, University of Utah.
APPENDIX G
MEMORY-FOR-DESIGNS (MFD) TEST
SAMPLE ITEM FROM ORIGINAL VERSION AND REVISED VERSION
102
103
104
APPENDIX H
RAW DATA
105
106
X LS_ O X H- <*O o O ( ^ ^ c c ^ r O T a 3 a ? w < j D C s i 0 ^ c n ^ o o ^ ( r j 0 ^ c D C > / ^ c ^ r \ j c n ^ ( o c n u n o ^ ^ < N c o r ) r o i j r ) i n c N j r ) , < c r u ^ o - H ( N i * - f r ) f s ! i n c \ j < j D L n *-4 «-4 *-4 —4 -H
X u . O X •— f \ f c n ^ c n u ^ c ^ ^ r c o r ^ — i r v j i / ^ c o a s r s j — 4 < X J O 3 C \ I — i O O ~ H i n i n c o ^ o c o ^ c g c o c s j c g c \ j c 0 L n ^ r ' ^ ( \ j r o - H ( o r s J t v ( o c o » - 4 O < * O c o O <-H *H »H »—I <—4 ^ —4
l u - Q S t - H * t c n ^ Q i j n c o < D i x » c N j c r r c s i a > ^ ^ O i n — i t n — i r o r s j c o - < c N j c » c N ^ c \ m a > c o < o c o c o — < c o c \ j ^ ^ o n c o c o L n — l O c o i n L n c g u o c s j c o — i W - H - 4 - H —I - H
l u - D O ^ n Q — < ^ « j n < T i C v j u i < 0 c o ^ — < o r s J t o r ^ c » r g 0 D O O 0 0 O - 4 O ~ 4 — 4 r 0 — 4 C o r ^ c o n c \ j H < x > < N J u ^ c ^ « f O H ^ c o O O t \ i c w O t f " > c o t o i , s r *>H W *H H H *-4
X L i - O O ^ f N i c & u ^ c 0 ^ o ^ ^ ^ c o < n c o e o n ^ c o c \ i t 0 i n u o - < o a o o c o c o e o c ^ o r ^ c o ( s j i / > — i c o c N h ^ o i ^ r ^ c \ i w o u " ) O O r o c o < \ i a » - t o r x . c > *-4 *-4 *-H
I i l O O ^ H « > ^ c o a ) Q L n o ^ r \ i c o c o c n O h - c s / < o o r o — < — < q c o o ^ W — t — < r \ i r o u 3 * t c o O — i - H L r t c o u " ) u - > c s i r \ i r N i C N j u " > o o < C N J C D O ^ O I / I O *H «-H •—( «H *—*
o c O CL X <*> u > c o ' * t ' t * L n c v ) h - ( r > o > ' * f t D * f c o « « 3 ' * t < o o , > f < > . o o - - - t ^ - i ^ . c D O ( D * H O * H < D t n o o i n i n ' H ' H L n o o o r ^ . i n i n O ( o o c ^ c w c n c r i L n c o o o f ^ o j c o *-4 —4 <-H »-4 •—4 —( —4 —» •—4 *H - H —4
O C Q C U X C S J tf>c^t^^i/jOO<Dknir)cv)<DootDi^,**tDtoinoo«-ttDtno),*toocooor^.oTir^-N>i,-»*-<oojtDN-f^{DUDoo»-^cooc3,)tDrvjLr)OcocvOf^ *H —< — 4 W —I «-* —1 —I —« —»
a : o c l X *—* tf>oinr^co"«Jincoh--iri<oroir)C,>in,**CDCDh«.*HcniftLnc?>'«j''Heo(McDi«3,r-CDOo>csir^Oh»«3meioooocn o o — < u n c r ) *H '<-4 i-H »H »H *—I «H *—4 •—I
O o < D » < » c N ^ o o O N u ^ ^ O i n ^ t n v n r v i r a a ) 0 0 r w o ^ a > i t N O « H 0 > c s i O O 0 5 r , ) r 0 i r j O - H 0 > < c f « E t ^ r c s < r , > i n ( v > f - * ' C n c r > * f - H O « 5 t ' - < c u O C N < » i n c r > < o c t t c o ^ r \ i c s j T f c ^ c o o > ^ r o i n C T > r \ i c v c r > ^ ^ - 4 i » o c \ j — i r ^ e o — i — < — 4 r ^ ^ t o e o c o ^ u 5 r ) c o w o — < u n O r ^ < ^ u o i j - > o o
h - t D C O a j O h - O O C O C O ? - - f < 0 — < f M t O ( N ( O r - » * e J ' - - 4 —i —I «-< f-» I CM r - O -H CN CO *H CMtD i n u i i d h c m »-«"a - C\J o —• W i f ) r s j —4 <M —I I * t ( CO t D —« «H —4 —4 <—I I | ! I t I I ( I f r-4
c t - t o o o o i n o o m i n o a i O ) N 0 0 5 ( o ^ * J H C o e o i n N n f M o e o i / i N W i n O ' - t t D < t f < D t \ i o o ^ N < » 0 ( o o ) c o H O ( D 0 3 N H ^ m r ) * t O c o c o o ^ c r > ( o < o ( 0 ^ c \ i ^ o c » a > < ^ r ^ ^ o o — 4 ^ — i r o o r ^ ^ ' t f i / i ^ r g o ^ t t o o " ' ? } ' — < « " H O c \ t , < a i ' C O ( o i n o , i > ^ c n c N j O r g L n c \ j ' * t o D — < o o
< t n o o ' t j f - ^ o r o m r N j i o n c o r s i o ^ t r s j c o — i c o t o r - - l o —< r - . u o <» c o r-- r - - i o o m r o c \ j c o o o i i n M h h h i c c o i o u n I <NI »H - H CO UO —4 I •—I i —4 CO "*t I "H 1 -H I I l i t I t I —i
t * i i
O i n i N r g O ^ t f ^ t o ^ f o o o C T s — • m o H M H i D N ' j n M - i N c o o o t o c o N f s i o o c i o a i ' ^ o o o ^ O i f i i t H U j ^ N O ' ^ c D ' H D H r ) Q — < c o t r ) O O L D h ^ T j - o o ( o n — o o n t c i c ^ f N O O m - H N N c o o o H t D m O N ' t f i n r o i ^ o o i t f © o - * i n c o
<£ H < D ( N < 0 O n O H N f 0 0 0 < - t t / l L O h - 0O CO CO < I ( I S C J I I O H H l/"> i/> t CM "<t CM —I I LO —4 CO CO 0 0 f \ l *—5 *-4 C\! CO CO CO CD CO ! I LO I f - . - H — I I - H I ) I I I | I I I I [ H
»
—J i n c o o> o <n i c n c D f M C N j ^ - H f s i O i ^ f N j c s i - ^ i / x o i n i j D i r j - H c o o — i n o c D m r o ! D O H O w o * t H H o n a - i o 5 © N * J © O H N d n O cr> t o c o o > O f o t o — i w — i • l O f ^ r - . c o r s f L n r - ^ r s f i ^ . o o c N i c o c o c n ' - H i r x o r o i n a j o D - H O t o — m D f M ^ O ' H L O O r -
< o m w w r o t c — • <n t o <*h - h o> o i n —f t o r o t o <cf cm *? — » c o c o e o cr< c© <o —i t o <sf t o r o i M i n i / i H N s i d ^ r g c \ i *3- t o r o c\ i --f ( N H O t O O O H ( £ ) ( \ J H H O n S f l H I - 4 t —1—4 1 _ 4 I i t i l l I I I
X O O O O O O O O ^ O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O o CO - J CO
a CO t—I
X h o - t o o r o - H o r s i o — t T f O — " t o r o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o
0 0
X f O N ^ i / ) ( C N n N H H i n H H ( C l t f f M M O O O O O H O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O
CO
O ( v 5 « - H L O r ^ o ) f * - - t j ( 5 i x j * 3 - r ^ t o c o r o — l O t o o a x M O - H r j c s i c N — i — i c s j — i m n - H t j - — - i ^ i n ^ O O M N H O O i N M H ^ N H O O ' - J C J ' - t CNf CM CM - H N H ( \ l - t - H n fNJ f \ )
_ i U J CD > U J CO n c g < ' o ^ r i « e r < « c j ' L r ) r j * t T f ' 5 f ' d ' L n f O ' 5 3 - L n t o m c o c \ f c o - H c o — ( - > t L A - H C s i — t m L n c o * 3 - - H C s ( * H * j CO
X
X *—< e d CO t-H CK: —i i n ( j D t o r s j c y ) f o r ^ - f ^ . r o f o i r j c \ i u i 0 4 C v > c o L n * t m t o o o < x i a ) < » c \ f O i N ^ c o - H * i - t o i r > c o o r ) c n r ^
Z H Q ; £ D H I - O H M , « j ' 0 ) f f l h . * J O O O i D c r i i r ) ( 0 t » a ) N ^ ^ M ) 0 ( D ( N « a ' N t D ^ r j r v * j r v j ( M i n ( D i n O t D O •I«HO")C\JCNJ—«—<—4(NJ—i — 4 — i r s i C N t r s t r o c - j c o c o — < t " o c s i c o " - H ' — i r s i — I C O C O C O C N J
< Q X Q X t — l - H - H
X < 2 ! O
- t c o r o r o r o f o c o , < j p T « ^ - > t j c o c o c o ' ^ " < ? c o c o c o
Q - O O O - t o i - H c o r - c o ^ c o O T r s i C N J c o t o c o - H t o c o - H i o i - H c o o c n C T m — < c o < x i u ^ t o r o c ^ o o r o C T > 0 ( O L n , < 3 - c o a w < » c o u " > c r > C D O , « j f ' ^ C M * H c r i - 4 » H - H O - H { N C N I C O i r ) CM CO iTS t O •—(*J O O l N J —t CM —<—t —l CM —< — i n n •—( CO "H CO •—t *H *—4 *—i >—4 CM —< •—( «—4 •—< — K M - H C N J C O - h
< O U J ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ » ^ ^ o ^ o ^ r - ^ c n r o ^ r - H u ^ c s i r ^ r - - O c r i O c g r - - o < t c o o o o r g ( o c o r o a ) c o t o c o ^ O r ^ c » t o L r > 0 - - t O c o ( i > u ^ r ^ < o r ^ i X ) ^ c o t O { £ j L n u i u n r ^ r ^ c o o " > t o c i D r i ^ i ^ i ^ ^ u 5 ^ o o u ? o c x j o D c o c j D c o c r 5 w o o o r - - r - c o f - . h > h v f ^ f > > c n r - - r ~ . t O ( X 3 f ^ o o r -
CO 3 o a i—< Q ^ r J ^ ^ ^ f ^ ' ^ T O c ^ o ^ r ^ i c ^ ^ L ^ ) c o ^ - ^ ^ c s J r ; ^ u o u ^ ^ ^ c u c ^ ) 0 * - ^ c ^ J ^ O ' ^ r ^ u n o ^ ^ c o • - ^ r s ( f o ^ ^ L r ) t o ^ « . c o c r ^ o • - ^ c ^ J c o ' s J ' L A ^ x > ^ - o o
CD c c O Z3 cl- ^ h h - i ~ i h - h h w ^ m ^ r j r j r g r \ i r j c j o j ( \ i r j : j - \ j f \ .--j < \ (M n n c o r - ' s r o n c o c o c o r o c o f o r o r o c o r o c o t o
REFERENCES
Albert, M. (1973). A simple test of visual neglect.
Neurology. 23. 658-664.
Basso, A., De Renzi, E., Faglioni, P., Scotti, G., &
Spinnler, H. (1973). Neuropsychological evidence for
the existence of cerebral areas critical to the
performance of intelligence tasks. Brain. 96, 715-728.
Battersby, W., Bender, M., Pollack, M., & Kahn, R. (1956).
Unilateral "spatial agnosia" ("inattention") in patients
with cerebral lesions. Brain, 79, 68-93.
Benton, A. L. (1969). Disorders of spatial orientation. In
P. J. Vinken & G. W. Bruyn, (Eds), Handbook of clinical
neuropsychology, Volume 3. (pp. 212-228). Amsterdam:
North-Holland.
Bianchi, L. (1895). The functions of the frontal lobe.
Brain, .18, 497-522.
Bisiach, E., Capitani, E., Luzzatti, C., & Perani, D.
(1981). Brain and conscious representation of outside
reality. Neuropsvchologia. 19. 543-551.
Bisiach, E. & Luzzatti, C. (1978). Unilateral neglect of
representational space. Cortex. 14. 129-13 3.
Bisiach, E., Luzzatti, C., & Perani, D. (1979). Unilateral
neglect, representational schema and consciousness.
Brain. 102. 609-618.
107
108
Bradford, D. C. (1978). Differences between groups of
brain-damaged patients on the Memory-for-Designs Test: A
comparison of two scoring systems. Unpublished doctoral
dissertation, University of Utah.
Brain, W. R. (1941). Visual disorientation with special
reference to lesions of the right cerebral hemisphere.
Brain. 64., 244-272.
Burke, H. R. & Bingham, W. C. (1969). Raven's progressive
matrices: More on construct validity. Journal of
Psychology. 72, 247-251.
Caltagirone, C., Gainotti, G., & Miceli, G. (1977). Una
nuova versione delle matrici colorate elaborata
specificatamenta per i pazienti con lesioni emisferiche
focali. Minerva Psichiatrica. 18. 9-16.
Campbell, D., & Oxbury, J. (1976). Recovery from
unilateral visual neglect. Cortex. 12, 303-312.
Caplan, B. (1985). Stimulus effects in unilateral neglect.
Cortex. 21. 69-80.
Caplan, B. (1987). Assessment of unilateral neglect: a new
reading test. Journal of Clinical and Experimental
Neuropsychology. 9, 359-364.
Cattell, R. B. (1971). Abilities: Their structure.
growth, and action. Boston: Houghton Mifflin.
Chedru, F., Leblanc, M., & Lhermitte, F. (1973). Visual
searching in normal and brain damaged subjects
109
(contribution to the study of unilateral inattention).
Cortex. 9, 94-111.
Colombo, A., DeRenzi, E., & Faglioni, P. (1976). The
occurrence of visual neglect in patients with unilateral
cerebral disease. Cortex. 12, 221-231.
Costa, L. D., Vaughn, H. G., Horwitz, M., & Ritter, W.
(1969). Patterns of behavior deficit associated with
visual neglect. Cortex, 5, 242-263.
Critchley, M. (1966). The parietal lobes. New York:
Hafner Press.
Damasio, A. R., Damasio, H., & Chui, H. D. (1980). Neglect
following damage to frontal lobe or basal ganglia.
Neuropsvcholoqia • 18., 123-132 (685-696).
De Renzi, E. (1982). Disorders of space exploration and
cognition. Chichester: Wiley.
De Renzi, E., Faglioni, P., & Scotti, G. (1970).
Hemispheric contribution to the exploration of space
through the visual and tactile modality. Cortex. 6,
191-203.
De Renzi, E., Gentilini, P., Faglioni, P., & Barbieri, C.
(1989). Attentional shift towards the rightmost stimuli
in patients with left visual neglect. Cortex. 25,
231-237.
Denes, G., Semenze, C., Stoppa, E., & Lis, A. (1982).
Unilateral spatial neglect and recovery from hemiplegia.
Brain. 105. 543-552.
110
Denny-Brown, D., Meyers, J., & Horenstein, S. (1952). The
significance of perceptual rivalry resulting from
parietal lobe lesion. Brain. 75, 433-471.
Deuel, R. K. (1980). Sensorimotor dysfunction after
unilateral lateral hypothalamic lesions in rhesus
monkeys. Neurology, 30. 358.
Deuel, R. K. & Collins, R. C. (1983). Recovery from
unilateral neglect. Experimental neurology. 81, 733-748.
Deuel, R. K., Collins, R. C., & Caston, T. (1980). The
functional anatomy of neglect: Behavioral and
quantitative 2DG studies in the monkey. Neurology. 30.
390.
Deuel, R. K., & Dunlop, N. (1979). Role of frontal
polysensory cortex in guidance of limb movements. Brain
Research. 169. 183-188.
Diller, L., Ben-Yishay, Y., Gerstman, L., Goodkin, R.,
Gordon, W., & Weinberg, J. (1974). Studies on cognition
and rehabilitation in hemiplegia; Rehabilitation
Monograph No. 50. New York: N.Y.U. Medical Center.
Dustman, R. & Beck, E. (1980). Memory-for-Designs Test: A
comparison of performance of young and old adults.
Journal of Clinical Psychology. 36. 770-774.
Eidelberg, E., & Schwartz, A. J. (1971). Experimental
analysis of the extinction phenomenon in monkeys. Brain.
94, 91-108.
Ill
Ettlinger, G. , Warrington, E., & Zangwill, 0. L. (1957). A
further study of visual spatial agnosia. Brain. 80. 335-
361.
Flandrin, J. M., & Jeannerod, M. (1981). Effects of
unilateral superior colliculus ablation on oculomotor and
vestibulo-occular responses in the cat. Experimental
Brain Research. 42, 73-80.
Fleet, W. S., & Heilman, K. M. (1986). The fatigue effect
in hemispatial neglect. Neurology. 36 (Supplement 1),
25JK8.
Fox, J. (1983). Unilateral neglect: Evaluation and
treatment. Physical and Occupational Therapy in
Geriatrics. 2, 5-15.
Friedland, R. & Weinstein, E. (1977). Hemi-inattention and
hemisphere specialization: Introduction and historical
review. Advances in Neurology. 18. 1-31.
Fullerton, K., McSherry, D., & Stout, R. (1986). Albert's
test: a neglected test of perceptual neglect. Lancet.
8478. 430-432.
Gainotti, G. (1968). Les manifestations de negligence et
d'inattention pour l'hemispace. Cortex. 4., 64-91.
Gainotti, G., Caltagirone, C., & Miceli, G. (1977). Poor
performances of right brain damaged patients on Raven's
Coloured Matrices. Neuropsvcholoaia. 15, 675-680.
Gainotti, G., Caltagirone, C., & Miceli, G. (1979). The
meaning of poor performance obtained on Raven's Coloured
112
Matrices by right brain damaged patients. Italian
Journal of Psychology. 6, 135-145.
Gainotti, G., D'Erme, P., Villa, G., & Caltagirone, C.
(1986). Focal brain lesions and intelligence: A study
with a new version of Raven's colored matrices. Journal
of Clinical and Experimental Neuropsychology. 8, 37-50.
Gainotti, G., Messerli, P., & Tissot, R. (1972).
Qualitative analysis of unilateral spatial neglect in
relation to laterality of cerebral lesions. Journal of
Nneurology. Neurosurgery, and Ppsvchiatrv. 35. 545-550.
Gainotti, G., & Tiacci, C. (1971). The relationships
between disorders of visual perception and unilateral
spatial neglect. Neuropsvchologia. 9, 451-458.
Gauthier, L. , DeHaut, F., & Joanette, Y. (1989). The Bells
Test: A quantitative and qualitative test for visual
neglect. International Journal of Clinical
Neuropsychology. 10. 49-54.
Graham, F. & Kendall, B. (1960). Memory-for-designs test:
revised general manual. Perceptual and Motor Skills. 11.
147-188.
Grundvig, J. L., Ajax, E. T., & Needham, W. E. (1973).
Screening organic brain impairment with the Memory-for-
designs Test: Validation of comparison of different
scoring systems and exposure times. Journal of Clinical
Psychology. 29, 350-354.
113
Grundvig, J. L., Needham, W. E., & Ajax, E. T. (1970).
Comparison of different scoring and administration
procedures for the Memory-for-Designs Test. Journal of
Clinical Psychology. 26., 353-357.
Halligan, P., & Marshall, J. (1989). Perceptual cueing and
perceptuo-motor compatibility in visuo-spatial neglect:
A single case study. Cognitive Neuropsychology. 6,
423-435.
Halligan, P., & Marshall, J. (1989). Is neglect only
lateral? A quadrant analysis of line cancellation.
Journal of Clinical and Experimental Neuropsychology. 11.
793-798.
Halsband, U., Gruhn, S., & Ettlinger, G. (1985).
Unilateral spatial neglect and defective performance in
one half of space. International Journal of
Neuroscience. 28. 173-195.
Heilman, K. M., Pandya, D. N., & Geschwind, N. (1970).
Trimodal inattention following parietal lobe ablations.
Transactions of American Neurology Association. 95.
259-261.
Heilman, K. M., Schwartz, H. D., & Watson, R. T. (1978).
Hypoarousal in patients with neglect syndrome and
emotional indifference. Neurology. 28., 229-232.
Heilman, K. M., & Valenstein, E. (1972a). Auditory neglect
in man. Archives of Neurology. 26, 29-35.
114
Heilman, K. M., & Valenstein, E. (1972b). Frontal lobe
neglect in man. Neurology. 22, 660-664.
Heilman, K. M., & Valenstein, E. (1979). Mechanisms
underlying hemispatial neglect. Annals of Neurology. 5,
166-170.
Heilman, K. M., Valenstein, E., & Watson, R. T. (1985).
The neglect syndrome. In J. Fredericks (Ed.), Handbook of
clinical neurology: Clinical neuropsychology, (pp.
153-183). New York: Elsevier Science Publications.
Heilman, K. M., & Van Den Abell, T. (1979). Right
hemispheric dominance for mediating cerebral activation.
Neuropsychologic. 17, 315-321.
Heilman, K. M., & Van Den Abell, T. (1980). Right
hemisphere dominance for attention: The mechanism
underlying hemispheric asymmetries of inattention
(neglect). Neurology. 30. 327-330.
Heilman, K. M., & Watson, R. T. (1977a). Mechanisms
underlying the unilateral neglect syndrome. In E. A.
Weinstein and R. P. Friedlands (Eds.), Hemi-inattention
and hemisphere specialization (pp. 93-105). New York:
Raven Press.
Heilman, K. M., & Watson, R. T. (1977b). The neglect
syndrome, A unilateral defect of the orienting response.
In S. Harnad, R. Doty, L. Goldstein, J. Jaynes, and G.
Krauthamer (Eds.), Lateralization in the nervous system,
(pp. 285-302). New York: Academic Press.
115
Heilman, K. M., & Watson, R. T. (1978). Changes in the
symptoms of neglect induced by changing task strategy.
Archives of Neurology. 35, 47-49.
Hier, D., Mondlock, J., & Caplan, L. (1983). Recovery of
behavioral abnormalities after right hemisphere stroke.
Neurology. 33. 345-350.
Holmes, G. (1919). Disturbances of visual space
perception. British Medical Journal. 2, 230-233.
Howard, A. R., & Shoemaker, D. J. (1954). An evaluation of
the Memory-for-Designs Test. Journal of Consulting
Psychology. 18. 266.
Ishiai, S., Sugishita, M., Odajima, N., Yaginuma, M., Gono,
S., & Kamaya, T. (1990). Improvement of unilateral
spatial neglect with numbering. Neurology. 40. 1395-
1398.
Jensen, A. R. (1982). The chronometry of intelligence. In
R.J. Sternberg (Ed.), Advances in the psychology of human
intelligence (pp. 255-310). Hillsdale: Erlbaum.
Joanette, Y., Brouchon, M., Gauthier, L. & Samson, M.
(1986). Pointing with left vs. right hand in left visual
field neglect. Neuropsvchologia. 24. 391-396.
Johnston, C., & Diller, L. (1986). Exploratory eye
movements and visual hemi-neglect. Journal of clinical
and Experimental Neuropsychology. 8, 93-101.
116
Kendall, B. S. (1966). Orientation errors in the Memory-
for-Designs Test. Perceptual and Motor Skills. 22. 335-
345.
Kennard, M., & Ectors, L. (1938). Forced circling in
monkeys following lesions of the frontal lobes. Journal
of Neurophysiology. 1, 45-54.
Kertesz, A., & Dobrowolski, S. (1981). Right-hemisphere
deficits, lesion size and location. Journal of Clinical
Neuropsychology. 3, 283-299.
Kinsbourne, M. (1977). Hemi-neglect and hemisphere
rivalry. In E. A. Weinstein & R. P. Friedland (Eds.),
Advances in neurology, vol. 18. New York: Raven Press.
Kirshner, H. (1986). Behavioral neurology: A practical
approach. New York: Churchill Livingstone.
Ladavas, E., Del Pesce, M., & Provinciali, L. (1989).
Unilateral attention deficits and hemispheric asymmetries
in the control of visual attention. Neuropsvchologia.
27., 353-366.
Laplane, D., & Degos, J. D. (1983). Motor neglect.
Journal of Neurology. Neurosurgery, and Psychiatry. 46.
152-158.
Levine, D. N., Warach, J. D., Benowitz, L., & Calvanio, R.
(1986). Left spatial neglect: Effects of lesion size
and premorbid brain atrophy on severity and recovery
following right cerebral infarction. Neurology. 36. 362-
3 66.
117
Lezak, M. (1983). Neuropsychological assessment (2nd
Edition). New York: Oxford University Press.
Locher, P., & Bigelow, D. (1983). Visual exploratory
activity of hemiplegic patients viewing the motor-free
visual perception test. Perceptual and Motor Skills. 57,
91-100.
Mark, V. w . , Kooistra, C. A., & Heilman, K. M. (1988).
Hemispatial neglect affected by non-neglected stimuli.
Neurology. 38. 1207-1211.
Massironi, Antonucci, G., Pizzamiglio, L., Vitale, M., &
Zoccolotti, P. (1988). The Wundt-Jastrow illusion in
the study of spatial hemi-inattention. Neuropsvchologia.
26. 161-166.
McFie, J., Piercy, M., & Zangwill, 0. L. (1950). Visual
spatial agnosia associated with lesions of the right
hemisphere. Brain. 73. 167-190.
McFie, J., & Zangwill, 0. (1960). Visual-constructive
disabilities associated with lesions of the left cerebral
hemisphere. Brain. 83. 243-260.
Meerwaldt, J. D. (1983). Spatial disorientation in right
hemisphere infarction: a study of the speed of recovery.
Journal of Neurology. Neurosurgery, and Psychiatry. 46.
426-429.
Mesulam, M. (1981) . A cortical network for directed
attention and unilateral neglect. Annals of Neurology.
10, 309-325.
118
Ogden, J. (1987) . The neglected left hemisphere and its
contribution to visuospatial neglect. In M. Jeannerod
(Ed.)* Neurophvsioloqical and neuropsychological aspects
of spatial neglect. New York: Elsevier Science
Publishers, 215-233.
Oppenheimer, H. (1883). Uber sensibilitatsstorung bei
einseitigen erkrankungen des grobhirns. Neurologisches
Zentralblatt. 23., 529-533.
Oxbury, J. M., Campbell, D. C., & Oxbury, S. M. (1974).
Unilateral spatial neglect and impairments of spatial
analysis and visual perception. Brain. 97, 551-564.
Paterson, A., & Zangwill, 0. L. (1944). Disorders of
visual space perception associated with lesions of the
right cerebral hemisphere. Brain. 67, 331-358.
Piercy, M., & Smith, V. 0. G. (1962). Right hemisphere
dominance for certain non-verbal intellectual skills.
Brain. 85, 775-790.
Posner, M. I., Cohen, Y., & Rafal, R. D. (1982). Neural
systems control of spatial orienting. Philosophical
Transcripts of the Roval Society. 298. 60-70.
Rapcsak, S. Z., Verfaellie, M., Fleet, W. S., & Heilman, K.
M. (1989). Archives of Neurology. 46. 178-182.
Raven, J. C. (1962). Coloured progressive matrices, sets
A,AB,B. London: H. K. Lewis (originally published in
1947, revised order in 1956).
Raven, J. C. (1965). Guide to using the coloured progressive
119
matrices. London: H. K. Lewis. New York:
Psychological Corporation.
Reuter-Lorenz, P. A., & Posner, M. (1990). Components of
neglect from right hemisphere damage: An analysis of
line bisection. Neuropsvcholoaia. 28, 327-333.
Riddoch, M. J., & Humphreys, G. (1983). The effect of
cueing on unilateral neglect. Neuropsvcholoaia. 21,
589-599.
Robertson, I. (1989). Anomalies in the laterality of
omissions in unilateral left visual neglect:
Implications for an attentional theory of neglect.
Neuropsvcholoaia. 27. 157-165.
Samuels, I., Butters, N., & Goodglass, H. (1971). Visual
memory deficits following cortical and limbic lesions:
effects of field of presentation. Physiology and
Behavior. 6, 447-452.
Schenkenberg, T., Bradford, D., & Ajax, E. (1980). Line
bisection and unilateral visual neglect in patients with
neurologic impairment. Neurology. 30. 509-517.
Spearman, C. (1946). Theory of a general factor. British
Journal of Psychology. 36. 117-131.
Spiers, P. A., Schomer, D. L., Blume, H. W., Kleefield, J.,
O'Reilly, o., Weintraub, S., Osborne-Shaefer, P., &
Mesulam, M. (1990). Visual neglect during intracarotid
amobarbital testing. Neurology. 40, 1600-1606.
120
Sprague, J. M., Chambers, W. W., & Stellar, E. (1961).
Attentive, affective, and adaptive behavior in the cat.
Science. 133. 165-173.
Stein, S., & Volpe, B. T. (1983). Classical "parietal"
neglect syndrome after subcortical right frontal lobe
infarction. Neurology. 33., 797-799.
Taylor, F.R. (1961). A revised scoring system for the
Graham-Kendall Memory-for-Designs Test. Unpublished
masters thesis, University of Utah.
Valenstein, E., & Heilman, K. M. (1981). Unilateral
hypokinesia and motor extinction. Neurology, 31, 445-
448.
Valenstein, E., Van Den Abell, T., Watson, R. T., Heilman,
K. M. (1982) . Nonsensory neglect from parietotemporal
lesions in monkeys. Neurology. 32. 1198-1201.
Vallar, G., & Perani, D. (1986). The anatomy of unilateral
neglect after right-hemisphere stroke lesions: A
clinical/CT-Scan correlation study in man.
Neuropsvchologia. 24, 609-622.
Van Deusen, J. (1983). Normative data for ninety-three
elderly persons on the Schenkenberg line bisection test.
Physical and Occupational Therapy in Geriatrics. 3, 49-
53.
Vilkki, J. (1989). Hemi-inattention in visual search for
parallel lines after focal cerebral lesions. Journal of
Clinical and Experimental Neuropsychology. 11. 319-331.
121
Wade, D., Wood, V. , & Hewer, R. L. (1988). Recovery of
cognitive function soon after stroke: A study of visual
neglect, attention span, and verbal recall. Journal of
Neurology. Nneurosurqerv, and Psychiatry. 51, 10-13.
Watson, R. T., & Heilman, K. M. (1979). Thalamic neglect.
Neurology. 29, 690-694.
Watson, R. T., Heilman, K. M., Cauthen, J. C., & King, F.
(1973). Neglect after cingulectomy. Neurology. 23.
1003-1007.
Watson, R. T., Heilman, K. M., Miller, B. D., & King, F.
(1974). Neglect after mesencephalic reticular formation
lesions. Neurology. 24. 294-298.
Watson, R. T., Miller, B. D., & Heilman, K. M. (1978).
Nonsensory neglect. Annals of Neurology. 3, 505-508.
Watson, R. T., Valenstein, E., & Heilman, K. M. (1981).
Thalamic neglect: Possible role of the medial thalamus
and nucleus reticularis in behavior. Archives of
Neurology. 38. 501-506.
Webster, J., Scott, R., Nunn, B., McNeer, M. F., & Varnell,
N. (1984). A brief neuropsychological screening
procedure hat assesses left and right hemispheric
function. Journal of Clinical Psychology. 40. 237-240.
Weinberg, J., Diller, L., Gordon, W., Gerstman, L. J.,
ieberman, A., Lakin, P., Hodges, G., & Ezrachi, 0.
(1977). Visual scanning training effect on reading-
122
related tasks in acquired right brain damage. Archives
of Physical Medicine and Rehabilitation. 58, 479-486.
Weinstein, E., & Friedland, R. (1977). Behavioral
disorders associated with hemi-attention. In E.
Weinstein & R. Friedland (Eds.), Hemi-attention and
hemispheric specialization: Advances in neurology (pp.
51-62). New York: Raven Press.
Welch, K., & Stuteville, P. (1958). Experimental
production of unilateral neglect in monkeys. Brain. 81.
341-347.
Wilson, B., Cockburn, J., & Halligan, P. (1987).
Development of a behavioral test of visuospatial neglect.
Archives of Physical Medicine and Rehabilitation. 68,
98-102.
Winer, B. J. (1971). Statistical principles in experimental
design. (2nd Edition). New York: McGraw-Hill.