J. Neurolinguistics, Volume 7, Number 4, pp. 379-424, 1992 0911~6tM4/92 $5.00+.

00
Printed in Great Britain 0 1993 Pergamon Press Ltd

Linguistic Assessment of Chinese-speaking

Aphasics: Development of a Cantonese
Aphasia Battery

Edwin M-L. Yiu

University of Queendund

ABSTRACT

The characteristics of Chinese being a logographic and tonal language has often made it
attractive For research. In particular, the right hemisphere has been postulated to be more
important in Chinese hecause of its superiority in prosody and visuo-spatial processing. Literature
on Chinese-speaking aphasia is usually single case studies and without a standardised assessment
protocol, comparison across studies would be diftIcult.
This study reports the development of a Chinese aphasia test battery with quantitative criteria.
It aims at providing clinicians and researchers with guided comprehensive survey of language
skills in Chinese (Cantonese).
Language performance of 51 Chinese (Cantonese)- speaking aphasic subjects were reported.
All of the subjects had aphasias following leg hemisphere damage. The classical aphasia patterns
of IndoEuropean language speakers were readily demonstramd in these Chinese-speaking subjects.

INTRODUCTION

It has been suggested that Chinese, being a tonal and isolating language, may have
a neuroanatomicalnetwork for language function different from an inflecting language
such as English, or an agglutinating language like Japanese. The right hemisphere, in
particular, has been postulated to be of more importance in Chinese because of its
superiority in prosody and visuo-spatial recognitions (April and Tse 1977; April and
Han 1980; Ross and Mesulam 1979).
Studies have begun to appear in the literature which aim at addressing such issues
(e.g. Gao and Benson 1990; Packard 1986). However, as Gao and Benson (1990)
pointed out the lack of a validated, standardized aphasia test battery in Chinese
380 Journal of Neurolinguistics, Volume 7, Number 4 (1992)

has made the classification of aphasia relatively difficult, which in turn creates diffi-
culty in cross-studies comparison.
In the study of speech and language disturbances in aphasia, the linguistic test is an
essential tool. It is useful not only in providing information on how different language
abilities are impaired, but also serves to categorize aphasic subjects into relatively
small groups with similar language impairment.
Different classification systems have been developed to describe aphasia. Studies in
Chinese speaking aphasia have also adopted approaches developed in the Western
world. For examples, the Wernicke-Lichtheim (or Bostanian) model is being em-
ployed in the studies by Gao and Benson (1990) and Wong and Cai (1986); While
Studies by Hung et al. (1985), Li et al. (1986), and Zhu et al. (1986) followed that
of the modality approach (Weisenburg and McBride 1935).
The studies reported so far suggested that the performance of Chinese-speaking
aphasics was not dissimilar from that of the English. A classification scheme based
on those already proposed and used extensively in the field of aphasiology might well
apply to the Chinese population.
Different nomenclature systems have been proposed and used in classifying aphasia.
Unfortunately, “there is no classification yet which has gained universal acceptance:
(Kertesz 1979, 13)“. Brookshire (1983) also contended that “no standard terminology
and no standard way to assign descriptive labels to aphasic subjects exist today, and
none is likely to appear in the near future. However, there are descriptive labels and
labelling systems which have been used sufficiently often that they will have meaning
to large segments of an article’s readership”. (Brookshire 1983, 345).
In clinical research, we must have an objective, operationally defined measuring
instrument which enables replication of the experiment. In order to exclude the risk
of judgement being contaminated by information on the dependent variable, a system
with a strict quantitative criteria is preferred to that with room for clinical judgement
for research purposes (Reinvag 1985). Therefore, in order to classify the subjects in
this study into their appropriate categories, an aphasia test with quantitative criteria
is necessary.
Currently, there are no standardized aphasia tests readily available for Cantonese.
Hence, we chose to adapt from current valid aphasia tests developed for English
speakers. Over the last 20 years, the Bostanian approach (Goodglass and Kaplan
1972, 1983) has been used extensively in classifying and describing aphasia. More
recently, the cognitive neuropsychology approach has begun to emerge which influences
aphasia assessment and therapy (Lesser 1987; Byng et al. 1990). Among the many
tests considered, the Western Aphasia Battery (WAB)’ and Boston Diagnostic
Aphasia Examination (BDAE) have been chosen as the basis for the construction of
a Cantonese aphasia test. They were chosen because they are well researched, vali-
dated and standardized diagnostic instruments designed to assess the severity and type
 Linguistic Assessmentof Chinese-speaking Aphasics 381

of aphasia using score profiles. Kertesz also introduces the concept of aphasia
quotient, which is a quantitative criterion (Kertesz 1979; 1982). Indeed, WAB was
originally intended as a modification of the BDAE (Kertesz and Poole 1974). Review
of the current literature demonstrates that the Boston psycholinguistic approach of
aphasia classification is one of the most commonly employed model in English-
speaking population.
The inherent problem with the WAB classification scheme is that it has only a
predetermined set of syndromes and any mixed aphasias that occur more often in
clinical practice would not fit into the classification system (Spreen and Risser 1981).
Furthermore, the syndrome approach makes the assumption that two aphasics having
the same syndrome would have similar underlying language processing deficits which
in reality, is not often the case (Byng et al. 1990). With these cautions, the WAB still
serves to satisfy the aims of this study: Firstly, to provide the clinicians with a guided
comprehensive survey of language skills in Chinese (specifically, Cantonese, which
is the dialect used in Hong Kong, Macau, Guangdzou, and among the Chinese com-
munities in Australia, the U.K. and the west coast of the U.S.A. Secondly, to
condense the huge amount of clinical and psycholinguistic information to several
pattern of language deficits which allow generalization.

The primary aim of this study was to provide normative data on Cantonese aphasia
as there has yet to be any published data available. Secondly, as mentioned above, the
aim was also to provide the clinicians with a useful language test which could classify
aphasic subjects into relatively similar patterns.
Rationales used in developing the test battery and the areas of language parameters
that the battery covers are discussed below.

TESTING MATERIAL

The format of the verbal language part of the Cantonese aphasia test follows that
of the WAB. It consists of a number of sections measuring spontaneous speech
(fluency and information content), comprehension, repetition and naming abilities.
The concept of the aphasia quotient (AQ), was also adopted from the WAB. It gives
a measure of overall aphasia severity. Tests of reading comprehension, writing, praxis,
drawing and visual attention are also included. Many of the items were adapted from
the WAB and some from the BDAE. The rationales, main features of the test and
statistical treatment are discussed in the following sections.
382 Journal of Neurulinguistics,Volume 7, Number 4 (1992)

Spontaneous Speech

Of all the linguistic behaviour observed in aphasia, conversation is undoubtedly the

richest source of symptomatological information. The procedure adopted by WAB and
BDAE in eliciting extended speech is to begin with simple conversation by asking
daily conversational questions. Conversational language has the disadvantage of not
permitting the examiner to identify with certainty what it was that the patient attempted
to say. As a consequence, paraphasias may not be readily and precisely identified. To
overcome this, a picture description task is used as a supplementary task which
provides some constraints on vocabulary and permits the identification of word finding
difficulty and facilitates the identification of verbal transformation. The patients des-
criptive strategy such as organization of description is also facilitated. The Cantonese
Aphasia Battery also employed these two procedures. A picture depicting “home
scene” (see Appendix) was used to replace the original WAB “picnic picture”. Each
patient’s performance was scored according to a set of quantitative criteria on two
parameters of spontaneous speech: fluency and information content.

Fluency

Albert et al. (198 1) suggested that the first level of analysis of the conversational
samples involves a decision as to whether the speech is fluent or nonfluent. The
fluency rating of the present test followed that of the WAB. It incorporated phrase
length, variety of grammatical constructions, jargon, word finding difficulty as well
as circumlocution. Discrete categories allowed quantification and thus minimizing
subjectivity. Kertesz (1979) suggested eleven categories of rating. Similar categories
were employed in the present test (see Appendix).
The categories were arrived at after examining those suggested by Kertesz (1979)
and Huang (unpublished aphasia test being developed at the Department of Medicine,
University of Hong Kong, Huang and Lau 1985) and discussion among three native
Cantonese-speaking speech pathologists after watching a variety of aphasic perfor-
mances. The categories do not form a smooth continuum. The first live nonfluent
categories are distinguished from the fluent categories readily except the barely fluent
(5) and mildly nonfluent (4). It should be emphasized that one drawback of such a
categorization scheme is that the scores are just in ordinal scale. That is, these scores
are not on a smooth continuum. Say, a score of 8 is not twice as good as a score of
4. The categories are detailed in the Appendix.

Information content

This scale scores the amount of information actually communicated in response to

everyday, conversational questions and to the description of a picture. The scale of
the present test follows that of Kertesz (1979) and is detailed in Appendix.

Auditory Verbal Comprehension

The literature in clinical aphasiology indicates that the ability to comprehend

language is always deficient. Such deficiencies are impairment in assigning meaning
to an incoming auditory message or to understanding words as they related to objects,
persons, ideas and experiences. For many patients, this impairment is confounded by
deficiencies in auditory memory. Patients performance on test can also be complicated
by difficulties of verbal expression and apraxia.
Several levels of auditory comprehension are being assessed following the sugges-
tions by Albert er al. (1981):

1. The ability to understand personally relevant material;

2. The ability to grasp and make simple inference on hearing material unrelated to
the immediate situation;
3. The comprehension of vocabulary items of different categories;
4. The amount of information that can be comprehended in a single message;
5. The ability to grasp relational syntactic constructions.

These areas are covered in three subtests: yes/no question, auditory recognition and
subtest on sequential commands. The test content and detail in test administration are
given in the Appendix.

Repetition

An aphasic’s ability to repeat depends not only on the length and phonological
complexity of the target utterances, but also on their semantic category, grammatical
and lexical composition or whether they are real or nonsense words.
The repetition task begins with simple nouns and a single syllable word. Phono-
logical complexity is introduced by using multisyllabic words. Sentences of increasing
length and grammatical and phonological complexity are further introduced.
The items also include numbers. The shift from repeating nouns to repeating numbers
proved to be particularly difficult for conduction aphasics than other categories of
English speaking aphasics (Albert ef al. 1981). The literal paraphasia found in noun
repetition usually gives way to perfect production of one word numbers. With multi-
word numbers, the conduction aphasic is likely to produce verbal paraphasias.
An item of isolated grammatical structure “or, and, but” is also included. The
repetition of isolated grammatical structure proved to be particularly difficult for
English speaking conduction aphasics.
384 Journal of Neurohguistks, Volume 7, Number 4 (1992)

There are 12 test items in this section. The items were selected with careful control
of word (syllable) length. Two points are scored for each correct repetition of syllable.
When repetition is impaired above other language functions, the diagnosis of conduc-
tion aphasia is considered. Selective preservation of repetition is indicative of trans-
cortical aphasia. The term ‘transcortical’ or ‘conduction’ are used as traditional
descriptive labels for complex clinical phenomenon, rather than to imply established
anatomical or physiological mechanisms.

Naming ability disturbance generally serves as a non-specific index of the degree

of severity of aphasia. There are four subtests under this section: object naming, word
fluency, sentence completion and responsive naming.
The ability to name object on visual confrontation is perhaps the best single index
of the overall severity of aphasia (Albert et al. 1981). The word fluency ability in
giving lists of words within an assigned category (e.g. animals) is useful as an index
of improvement in aphasic patients. The sentence completion subsection assesses the
capacity to complete an incomplete sentence. Aphasic subjects usually perform better
in naming tasks with a trigger phase. Naming in response to a defining question
involves true word retrieval in response to the arousal of its concept.

Reading

Reading is a complex achievement involving the parallel operation of several

perceptual-linguistic processes. Premorbid reading and educational achievement will
influence the results of testing. Moreover, Chinese is an ideographic language and the
psycholinguistic processes involved in reading and writing Chinese have been proved
to be different from that of alphabetical language such as English (Huang 1984). The
reading comprehension task in the Cantonese Aphasia Battery is by no means com-
prehensive and the content is restricted to requiring only a moderate level of
intelligence and limited attention span. It was decided to adapt and modify some of
the reading test items from the WAB for the current study.

writing

This section consists of six subtests which assess the basic writing mechanics.
Subjects automatized writing of name and address are assessed. Difficulty increases
from that required in copying words and sentences to dictation of words and sentences.
The reading and writing sections only sample some aspects of the written language
of Cantonese. As there is evidence that the writing system of monosyllabic language
 Liapistk Amssment of Chinesespeaking Apbmks 385

(Huang 1984), more research is necessary before a more comprehensive reading or

writing test can be developed (in progress). Illiteracy is not uncommon in the Cantonese
aged population as education opportunity in the past was rare. Therefore, not all
aphasic patients can be assessed on their reading and writing abilities.

Supplementary Neuropsychobgical Tests

Praxis test, visual spatial drawing (from WAB) and visual neglect test (Albert 1973)
are selected because of their relevancy to brain damaged subjects. The details are
described in the Appendix.
A complete test form, a scoring sheet and instructions on the administration of the
test are included in Appendix.
Classification of aphasia type relies on the verbal language subtest scores. The
maximum score for each subtest follows that of the WAB:

Fluency 10
Information content 10
Auditory comprehension 10
Repetition 10
Naming 10

Classification is arrived at by comparing the fluency, auditory comprehension,

repetition and naming scores against the specified criteria (see Table 1). The sum of
the subtest scores (fluency, information content, auditory comprehension, repetition
and naming) multiplied by two gives a severity indication-total aphasia quotient
(AQ).

TABLE 1
Criteria for classllication according to Kertesz (1982) on the WAB

Fluency Compreh. Repetition Naming

Global 04 o-3.9 04.9 O-6

Broca’s 04 4-10 o-7.9 O-8
Isolation (Mixed Trans) 04 o-3.9 5-10 O-6
Transcortical motor 04 4-10 8-10 O-8
Wemicke’s 5-10 o-6.9 o-7.9 O-9
Transcortical sensory 5-10 o-6.9 B-10 o-9
Conduction 5-10 7-10 o-6.9 o-9
Anemic 5-10 7-10 7-10 o-9
386 Journal of Neudiitics, Volume 7, Number 4 (1992)

SUBJECTS

All aphasic subjects referred to the Speech Therapy Clinics of the Medical and
Health Department (now Hospital Services Department), Hong Kong over a period
of 20 months were administered the Cantonese Aphasia Battery. There were 54 left
hemisphere damaged aphasic subjects. In addition there were 16 normal, 4 brain
damaged non-aphasic dysarthrics subjects and 4 demented subjects tested as con-
trols. Therefore, a total of 78 subjects were tested. All of them were administered
the verbal language tests. Thirty-five of them also had the Reading Test and 28 of
them had the Writing Test. Fourteen of them were also administered the Supple-
mentary Neuro-psychological Tests. The sample reported here is admittedly selective.
The system of referral in Hong Kong has produced a selective group, with patients
who are considered to be possible candidates for speech rehabilitation.

PROCEDURE

The experimenter (a speech pathologist) and one other speech pathologist carried
out this experiment. The experimenter administered the aphasia battery and came up
with a diagnosis according to the quantitative criteria specified by Kertesz (1982, see
Table 1). The second speech pathologist interviewed the subject on a separate occasion
and classified the subject into one of the aphasia categories using the descriptive
criteria suggested by Goodglass and Kaplan (1983, see Table 2). The categories in the
classification scheme are identical to those of WAB with the addition of a “mixed
nonfluent aphasia” category. The reason why Goodglass and Kaplan included this
category was that they consider some nonfluent aphasics whose language outputs
resemble that of Broca’s aphasia have auditory comprehension too impaired to be
classified as Broca’s aphasics.

RESULTS

Three subjects who were classified as Broca’s aphasia by the test received dif-
ferent diagnoses from the speech pathologists. The clinicians’ diagnoses, in all three
cases, were atypical Broca’s aphasia (or mixed nonfluent aphasia), on the grounds
that they had severe nonfluent jargon speech with comprehension severely impaired
(comprehension AQ scores were just slightly more than 4). Only those subjects
whose aphasia categories were agreed by both examiners were included in the final
analysis. Therefore, these three subjects were excluded from the analysis.
 C-Mea of different typesof aphaaIa
(Excerpt from Goodglass and Kaplan, 1983 pp. ?2-100).

GIobaI aphasia: “All aspects of language are severely impaired,”

Bmca’s aphasia: “Awkward a&&&ion, rest&t4 vocabuhq, restrictionof grammar to the simpie&,
most over&rned forms, a& relative preservation of attd&o~ ~~~~i~n* *’
Mixed Transcortical aphasia: (Severe hnp&fXl output and camprehension with relatively intact repetition.)
Transcortical motor aphasia: “Repetition is particularly intact iu a setting of otherwise liiited speech.”
Wemicke’s aphasia: ’ %npiti anditory comprehensionand fluently articulatedbut paqhasic speech. ”
TV sensory aphasia: “Remarkable pupation of repetition in the context of severe We~c~s
aphasia*”
Conduction aphasia: s‘Repetitionis ~s~o~~o~~ly severely impaire4 in relation to the level of fluency
in sponmeous speech and to the near normal level of auditory comprehension.“’
Anemia aphasia: ‘ ‘FVomham of word finding difficulty in the context of fluent, grammatically
we~fo~~ speech.”
‘Mixednonfluent aphasia: ’‘Sparse output of Broca’s@&a, but. L. audimry comprehensionis too impaired.*’ 9
t
8

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388 Journal of Neurulinguistics,Volume 7, Number 4 (1992)

Sample Characteristics

The sex ratio (Fig. 1) was heavily weighted (27.5:72.5) in favour of males. They
were all right-handed. Seventy percent of the subjects had right hemiplegia (Table 3).
With regard to etiology, more than half of the sample had ischaemic infarcts (Fig. 2).
The distribution of aphasia type is shown in Fig. 3. Anemic aphasia is the most
common type, followed by Broca’s and Wemicke’s aphasias. When the incidence of
the present study is compared to that of Kertesz’s studies (Kertesz 1979; Kertesz and
Poole 1974, see Table 4), comparable distribution of Anemic, Broca’s Conduction and
Wemicke’s aphasias are noted in the present and Kertesz’s studies. (Kertesz 1979;
Kertesz and Poole 1974). On the other hand, global aphasia constituted a larger
proportion in Kertesz’s sample ( 17.3 and 14.2 76) while the present study had a smaller
size (9.8 %a).Interestingly, the study by Gao and Benson (1990) showed that the global
aphasics constituted the biggest group while the anemic aphasics being the smallest
group. Such discrepancy may be explained by the fact that the severe aphasics were
often not referred for speech rehabilitation in Hong Kong and hence they were not
sampled. Moreover, the subjects sampled by Gao and Benson (1990) were having a
relatively recent onset, which explained the low incidence of anemic aphasia, which
is often the residual signs of long standing aphasia, in their study.
Sex distribution

male
(72.5%)

No. of Ss=51
Figure 1.
Etiology

;y;; (un:e;ked)
- (17.6%)

hremorrbage
irchasmia (13.7%)
(56.9%)
cad injury

No. of Sn=Sl

Figure 2.
 Linguistk Assessmentof Chineee-epeaUngAphasics 389

Aphasia Typo

Anomie

IXWI tr(ln8COrtlC(II
Global 2%
10%

Figure 3.

TABLE 3
Number of Subjectswith Hemipkgia Under Each Category of Aphasia

Nil Hemiplegia

Anomia 3 12
Broca’s 1 8
Conduction 5
Global 5
Trans motor 6
Trans sensory 2
Mixed Tram 1
Wemicke’s 6 2

15 (19.4%) 36 (70.6%)

The mean age, years of education and time post-onset (months) are presented in
Table 5. None of these three subject variables differed among the aphasic group and
control groups (Age factor: F = 2.79, df = 3.66, p > 0.05; Education level: F =
0.71, df = 3,66, p > 0.5; Post-onset month: F= 2.34, df = 3,66, p > 0.5). The
aphasic groups were not significantly different from one another on these three
variables (Age factor: F = 2.10, df = 7,43, p > 0.06; education level: F = 0.27,
df = 7,43, p > 0.9; Post-onset month: F = 0.92, df = 7,43, p > 0.5).
390 Journal of Neurolinguistics,Volume 7, Number 4 (1992)

TABLE 4
Comparison of Distribution of Aphasia Type Across Three Studies

Present study Kertesz (1979) Gao and Benson ( 1990)

Aphasia Type Percent Percent Percent

(N=51) (1974) (1979) (N = 54 excluding
subcortical aphasias)
Anomia 29.4 26.6 31.3 1.85
Broca 17.6 16 18.4 9.26
Conduction 9.8 10 8.5 7.41
Global 9.8 17.3 14.2 29.63
Mixed transcortical 2.0 3.3 2.1 9.26
Transcortical motor 11.8 2.7 5.0 11.11
Transcortical sensory 3.9 5.3 9.2 11.11
Wemicke 15.7 18.7 11.3 16.67
Supplementary motor - - - 3.70
TOTAL 100% 100% 100% 100%

TABLE 5
Means of Age, Years of Education and Months Post Onset

4s Education Month post onset

Cases Mean SD Mean SD Mean SD

Aphasic 51 54.58 14.39 6.54 5.95 9.23 15.42

normal 16 50.81 13.44 6.81 6.29 0.0 0.0
dysarthric 4 39.25 19.27 10.00 7.65 11.00 4.76
demented 4 68.00 11.43 3.75 4.92 17.00 28.71

The Aphasic Profiles

The mean scores and standard deviations of subtest scores by aphasia types are
summarized in Table 6. The aphasic types are described below starting from the most
to the least severe categories.
 TOti FIuency Gove Aud. ~rnpr~h. Repetition Naming
w0 (1Q (101 (10) (10) (101
N Mean SD Meau SD Mean SD Mean SD Mean SD Mean SD

At1 aphasics 51 59.63 26.51 5.60 2.82 6.09 2.92 6.74 2.64 6‘31 3*68 4-66 3.31
Asia 15 85.83 7.12 7.93 l-43 8.66 1.11 9.10 0.83 9.54 0.74 7.67 I,27
Brwa’s 9 44.88 19.18 2.55 1.23 4.88 2.08 6.33 1.91 4.08 2.90 2.43 2.26
Co~u~?ion 5 67.66 18.31 7.60 1.51 7.20 2.16 8.58 I.17 4.14 2,16 5.48 3.03
01&d 5 11.24 6.25 LOO 1.22 1.00 1.00 1.68 1.21 1.76 2.01 0.18 0.24
Mixed Trans 1 55.80 0.0 4.00 0.0 6.00 0,O 3.70 0.0 9.80 0.0 4.40 0.0
Truns Sensory 2 58.30 19.37 6.50 2.12 6.00 4.24 4.55 0.35 8.95 0.35 3.40 3.67
Tmns Motor 6 69.31 13.40 4.16 0.40 7.00 219 7.60 1.59 9.60 0,26 6.63 2.83
We&eke’s 8 45.88 18.31 7.37 0.74 4.50 2.26 5.08 I.22 3.41 3+42 2,72 2.73

Normai 16 98.59 1.09 10.00 0.0 10.00 0.0 9.93 0.05 10.00 0.0 9.36 0.49
Dyswhrics 4 96.57 1.66 9.25 0.5a 10.00 0.0 9.90 0.14 9.90 0.20 9.12 0.37
Demented 4 91.12 2.73 9.25 0.50 8.50 1.0 9.42 0.62 9.95 0.10 8.45 0.45

Y
392 Journal of Neurolingu&ti~, Vdume 7, Number 4 (1992)

Global aphasia is the most severe group (mean total AQ = 11.24). These patients
were severely affected in all language functions with mean subtest scores below 1.76.
Broca’s aphasia is the second most severe group (mean total AQ = 44.89). Infor-
mation content (4.88), fluency (2.55), repetition (4.08) and naming (2.43) were
severely impaired with relatively better auditory comprehension (mean auditory
comprehension score = 6.33). Wemicke’s aphasia, with a mean severity (mean total
AQ = 45.88) comparable to that of Broca’s aphasia, was characterized by fluent
output (7.37) with low information (4.50), auditory comprehension (5.08), repetition
(3.41) and naming (2.72) scores. Mixed transcortical (total AQ = 55.8) and trans-
cortical sensory aphasias (mean total AQ = 58.3) had good repetition (score > 8.9).
Since the numbers of subjects in each of these categories are small (N = 1 and 2
respectively), there was no attempt to generalize these data to group trends. Con-
duction aphasia (mean total AQ = 62.32) was characterized by relatively fluent (7.60)
and informative speech (7.20) with preserved auditory comprehension (8.58) but
impaired repetition (4.14) and naming (5.48) abilities. Anemic aphasia was the least
severe form (mean total AQ = 85.8) and the most common (N = 15, 29.4%) form.
Fluency (7.93) was slightly impaired by the naming (7.67) difficulty. Other subtest
scores were greater than 8 66.
When compared with the normal subjects, even the least severe (highest total AQ)
aphasic group, that is, the anemic aphasics, had a mean total aphasia quotient signi-
ficantly lower than the normal subjects (t = 6.86 df = 14.62 p < 0.0001). In order to
determine whether the performance of the aphasic subjects in each group were
different from the others, a one-way analysis of variance was carried out followed by
a post-hoc Scheffe test. The global aphasic group was significantly more severe than
most other groups. Broca’s and Wemicke’s aphasics were significantly more severe
than the least severe group-anemic aphasics (see Table 7).

TABLE 7
Statistical Result of One-way Analysis of Total AQ and Aphasia Groups

Sum of Mean F
Source D.F. squares squares Ratio Prob.

Between Groups 7 26377.3332 3768.1905 18.4653 0.0000

Within Groups 43 8774.9633 204.0689
Total 50 35152.2965
Multiple Range Test (Scheffee Test):
(*) Denotes pairs of groups significantly different at the .050 level

Continued
 Liqguistic Asmmment of Cbimq Aphasics 393

TABLE 7-continued

Mean Group Global Broca Wemicke

11.2400 Global
44.8889 Broca *
45.8875 Wemicke *
55.8000 Mixed trans
58.3000 Trans sensory
67.6600 Conduction *
69.3167 Trans motor *
85.8333 Anomia * * *

Table 8 compares the mean total AQ of subject groups of the present study with
those of Kertesz’s (1979). The aphasic subjects as a group of the present study tended
to have a higher total AQ (59.63) than that of Kertesz’s study (48.2).

TABLE 8
Compnrison of Mean Total AQ of Two Studies

Present study Kertesz (1979)

N Mean SD N Mean SD

Global 5 11.24 6.25 26 10.5 9.2

Bmca’s 9 44.88 19.18 24 31.7 16.6
Wemicke’s 8 45.88 18.31 28 39.0 12.8
Mixed tram 1 55.80 0.0 5 34.3 11.9
Trans sensory 2 58.30 19.37 8 59.6 5.5
Conduction 5 67.66 18.31 15 60.5 12.7
Trans motor 6 69.31 13.40 4 54.4 8.4
Anomia 15 85.83 7.12 40 83.3 7.8
All aphasics 51 59.63 26.51 150 48.2 28.2
Normal 16 98.59 1.09 21 98.4 1.0
Dysarthric 4 %.57 1.66
Demented 4 91.12 2.73

Performance profile for each aphasic group (except with mixed transcortical and
transcortical sensory aphasias, which only had 1 and 2 subjects respectively) were
illustrated graphically using the means and standard deviations of subtests scores
394 Journal of NeurolingnMb, Volume 7, Number 4 (1992)

(Figs 4-9). These illustrate the outstanding features and the variation of the subtests
scores of each aphasic group. The mean performance of the aphasic categories are
further grouped into fluent and nonfluent types to facilitate comparisons within each
type across all subtests (Fig 10). Auditory comprehension and repetition serve to
further differentiate among the groups. That is, auditory comprehension separates the
anomia and conduction from the transcortical sensory and Wemicke’s aphasias in the
fluent group and Broca’s and transcortical motor from the mixed transcortical and
global aphasias in the nonfluent group; while the repetition scale distinguishes anomia
and transcortical sensory from Wemicke’s and conduction aphasias in the fluent group
and transcortical motor and mixed transcortical from Broca’s and global aphasias in
the nonfluent group. Thus, in aphasia classification using the Boston model, the first
thing to do would be to classify the subjects using the fluent/nonfluent dichotomy.
After that, scores of repetition and auditory comprehension tasks helped to categorise
the subjects into the appropriate aphasia types.

hicln and rtandard deviation

Broca’6 apha6ia
-

2
(:=-- _

/- ‘\
.-._
0
Fluency Auditory comprehension Nunina
Information Repetition

Figure 4.

Mean and rtandatd deviation

I_jl ;;

E - - -Mean -6d
*_ -Mean ‘1 ._.e.-
- - -Mean +6d
0’
Fluency Auditory comprehension NUbIs
Information Repetition

Figure 5.
 MOM and sun{ dud deviation

iljl ,7&&y l
4 - ’ -MOM -6d
2- -Mean
- - -MOM +td
o-
FlUWlC]r Auditory compr&nrion N&B
Information Repetition

Figure 6.

Mean and rtmdud deviation

0lobal6pllrsia
10
-. -Mean -rd
6- -mm
z --.Msan+rd
: 6-

9 4-
--\
% *L-- *
----__4c _c-- 4
.

0
Flaency Auditory contprohenatt N-N
Infomution Repetition

Figure 7.

Mean and rtandud deviation

t

I’j: &T-&+zEj::

2-
‘\.
O-
PllNIlCy Auditory comproh.nrioIl N-S
Information Repetition
Figure 8.
3% Journal of Neurollugulatlcs, Volume 7, Number 4 (1992)

Mean and standard deviation

-. -Mean -sd
-Mean
- - -Mean +sd

Fluency Auditory comprehension Nalaiag

Information Repetition

Figure 9.

-. -Anemia Mean of subjects

-Conduction Fluent aphasia
10 - - -Trans sensory
..-..Werniche _._.w.-.--‘-‘W\
8 /\
‘N.
t0 . ’ \
\
,
Y
%
3
2 \
.
0
Pluellcy Auditory compmhenrion Ramla6
Information Repetition

-. -Broca’s Nonfluent aphasia

- -Global ..*P’.
- - -Mixed trans *.** / \’ 3 I
- .*...Trans motor *.** 0 \“.
*_.......*e* / \ -*.* Trans motor
: \ -.
.-. \
. . .* cc .( Q’ \ I
.* &# .e
c 5 *#’ .fl -. / ’ ‘\ ‘\ ’ Mixed trans
./ ..H ‘\
0 ‘\
/’ ‘\

Pluoacy Auditory comprohonrion Nata@

Information Repetition

Figure 10.
 Lit@stie Aesessmeatof Cbl~~ Aphasics 397

Difficulty Level of Subtests

The difficulty level of each subtest was not comparable (chi square = 56.23, df = 4,
p c 0.00001). A profile of performance (mean and standard deviation of subscores)
of all the aphasic subjects as a group (Fig. 11) demonstrated that the auditory com-
prehension subtest was comparatively easier than the subtest which required spon-
taneous speech (naming, fluency and information content scores) while naming subtest
was in general more difficult than any other subtests @ < 0.05).

Mean and standard deviation

All aphasia

Ij _______;----- Q
.
8

P 4- ._‘\
E ‘N
_.-*-.-
c-Mcan -rd +N.~
2- -Mean *-..
- - -Mean +sd
0
Pluoncy Auditory compmhenaion Nunin
Information Repetition
Figure 11.

Criteria for Diagnosis as Aphasic

The sum of the subtest scores (information, fluency, comprehension, repetition and
naming) multiplied by 2 gives an aphasia quotient (AQ). This gives an indication of
the severity of language impairment.
Kertesz (1979) suggested an AQ of 93.8 as a cutoff point for normal and aphasic
subjects. This cutoff point was the mean AQ of the diffised brain damaged group who
demonstrated no aphasia clinically (IV= 21). However, Kertesz also reported a group
of recovered aphasic subjects whose word finding difficulty or the occasionally uttered
paraphasia would justify them as aphasic clinically but their performance on the WAB
was in the normal range as defined by the suggested cutoff point. Indeed, a false
negative rate of 30% was reported if the 93.8 AQ was used as the labelling criterion.
The present study suggested a cutoff point to be %.40, which is 2 standard deviations
below the mean of the normal healthy control (it should be noted that using similar
criterion, i.e. 2 standard deviations in Kertesz’s study yielded the same value--96.4).
An examination of the normal subjects performance on the subteats would indicate that
the test was relatively easy for normal subjects. Therefore, using 2 standard deviations
below the mean is justified. Indeed, in clinical setting, the use of the cutoff point
398 Joumal of Neuro~cs, Volume 7, Number 4 (1992)

per se is not sufficient to label whether a brain damaged patient is aphasic. Clinical
observation is also essential in the process of differential diagnosis.
Table 9 gives the descriptive statistics of normal subjects performance on the
various subtests. Such statistics are useful which form the basis of normative data to
be used for aphasia test.

Correlation of Subtests

Pearson product-moment coefftcients of correlation were computed for each AQ

subscores (Table 10). Naming AQ score has a high significant correlation (> 0.78)
with all the other AQ scores.
Table 11 shows the correlations between individual subtests and AQ subscores

TABLE 9
Means, Standard Deviations, Range for Normal Performance on the Cantonese
Aphasia Test

N Mean SD Median Range

Yes/No 15 60 0 60 60
Word 14 59.3 1.4 60 55-60
Command 15 80 0 80 80
Repetition 15 100 0 100 100
Naming object 14 59.6 0.9 60 57-60
Animal fluency 55 17.9 4.7 18 1l-28
Sentence complete 14 9.8 0.36 10 8-10
Responsive speech 14 10 0 10 10

TABLE 10
Correlation Matrix for the AQ Subscores on the Cantonese Aphasia Test

Spon. Speech Comprehension Repetition Naming

AQ AQ AQ AQ
Spon Speech AQ 1.0000
Comprehension AQ 0.7374** 1.0000
Repetition AQ 0.6148** 0.5792** 1.OOOo
Naming AQ 0.8083** 0.7868** 0.7900** 1.0000

No. of cases: 51; l-tailed Signif: *-0.01; **-0.001.

 Lhguistk Amemmeat of Cbinec#-spcakiug Aphasks 399

with aphasia severity (total AQ). They are ranked in order and separated into a high
correlation and moderate correlation. It can be seen that all the AQ subscores are
highly reflective of the overall severity. If we examine the individual subtests, it can
be seen that “fluency” and “yes/no question” subtest scores correlated less well with
the overall severity (below 0.7) than the others.

TABLE 11
Correlation of Subtest and Subscores with Total Severity (Total AQ)

High correlation (more than 0.8) Moderate correlation (less than 0.8)

Naming (AQ) 0.9331** Command 0.7%7**

Object 0.9236** Word 0.7598**
Information 0.9191** Word fluency 0.7532**
Spontaneous Speech (AQ) 0.8955** Fluency 0.6839**
Responsive Speech 0.8697** Yes/No 0.6759**
Sentence completion 0.8439**
Aud Comprehension (AQ) 0.8251**
Repetition (AQ) 0.8148**
Repetition 0.8148**

No. of cases: 51. l-tailed Signif: *-0.01; **-0.001.

Interjudge and Intrqiudge Reliabilities

Kertesz (1979) contended that the scoring system of the WAB allows little variation
except in the subtests which require subjective judgement scoring, such as fluency of
spontaneous speech and to a lesser extent in the repetition subtest where paraphasias
may not be easily distinguishable from dysarthric speech. Due to constraints on
clinical resources, the number of subjects that can be re-scored by different inves-
tigators in the interjudge reliability measurement was limited. Six subjects were scored
simultaneously by two speech pathologists who were familiar with the test. For the
intrajudge reliability measurement, seven subjects were audiotaped during the
administration of the Cantonese Aphasia Battery. The examiner then restored the test
on a second occasion. In both inter- and intrajudge reliability measurements, all
correlation coefficients, except the fluency scale, were statistically signifkant above
0.9 (Tables 12 and 13). The statistical nonsignificant correlation coefficients of the
fluency scale, which were still above 0.8, may have been due to small sample size.
Despite this, the high reliabilities of the other scales reliably support the test to be used
for the purpose of the present study, that is, to classify and quantify the language
performance of aphasic subjects.
400 Journal of Neurolinguistia, Volume 7, Number 4 (1992)

TABLE 12
Interjudge Reliability Measures of Subtests

Correlation

Information 0.9616*
Fluency 0.8765
Spon Speech 0.9504*
Aud Compreh 0.9946**
Repetition 0.9999**
Naming 0.9999**
Total AQ 0.9853**

No. of cases: 6.
l-tailed Signif: * -0.01; ** -0.001.

TABLE 13
Intrajudge Reliability Measures of Subtests

Correlation

Information 0.9625**
Fluency 0.8272
Spon Speech 0.9421**
Aud Compreh 0.9726**
Repetition 0.9984**
Naming 0.9656**
Total AQ 0.9785**

No. of cases: 7.
l-tailed Signif: **-0.001.

Test-retest Reliability

Generally, in the test-retest reliability measurement, the retest interval should not
exceed 6 months (Anastasi 1976). Furthermore the test-retest reliability measurement
proves to be particularly difficult with aphasic patients because of the effect of
recovery on the performance. To take the recovery factor into consideration, chronic
patients (at least 12 months post-onset) were chosen as it is generally agreed that there
is minimal recovery when the time post-onset exceeds 6 months (Samo 1981). Seven
chronic patients were scored by the investigators on two separate occasions with an
interval of at least 3 months in between. Correlations were significantly high across
all subtests (Table 14).
 TABLE 14
Test-ntest ReliabilityMeosares of suw

Correlation

Informatiorl 0.9900**
Fluent y 0.9956**
Spon Speech 0.9963**
Aud Compreh 0.9854**
Repetition 0.9512**
Naming 0.9747**
Total AQ 0.9949**

No. of cases: 7.
l-tailed Signif: ** -0.001.

Reading and Writing

Not all subjects who had been administered the verbal language part of the aphasia
test were assessed on reading and writing because many of them were illiterate or had
very little education. Table 15 shows the mean scores and number of subjects across
all aphasic categories except global aphasics, who were not included in this analysis
because almost all of them failed to complete the reading and writing subtests and the
resulting low scores would have neutralized the pooled data of other aphasic groups.

TABLE 15
Means and Standard Deviationsof Reading and Writing Scores

Reading Subscore Writing Subscore

(out of 76) (out of 40)
Cases Mean SD Cases Mean SD

Aphasic as a group 35 49.22 19.64 28 26.57 12.41

Anomia 11 65.18 12.82 36.75 4.20
Broca 7 33.85 14.26 23.33 9.26
Conduction 4 60.25 12.28 38.08 2.64
Mixed Tram 1 38.00 0.0 1.00 0.0
Tram motor 4 37.75 23.37 18.50 16.01
Tram sensory 2 30.00 21.21 5.00 0.0
Wemicke 6 46.50 16.37 23.20 5.11
402 Journal of Neurolingu&tks, Volume 7, Number 4 (1992)

A Z-score profile of reading and writing scores (Fig. 12) shows clearly that conduction
and anemic aphasics were the least impaired groups while transcortical sensory was
the most dyslexic and dysgraphic (besides global aphasia).

Reading 2 score
1.2
I
o.a- -_.__-a-- “._.= y-r -- .rr _ .. _Anomia
0.4 - -Broca’r
o- - - -Conduction
-0.4 - - -Mixed tram
-0.8 - - - - - - Tram motor
-1.2- ------ Tram sensory
-1.6- - - - Wernicke
-2.0 - I
-2.4’ I
Reading Z ~com writizq z IGor*

Figure 12.

Correlation analysis (Table 16) revealed that the reading score correlated best with
the writing score followed by the auditory comprehension AQ subscore. While the
writing score correlated best with auditory comprehension.

TABLE 16
Correlations of Reading and Writing Scores With Verbal Language Subtest
SCOreS

Correlations: Reading Writing

Total AQ 0.6563** 0.5763**

Reading - 0.7621**
Writing 0.7621** -
Spon Speech 0.7070** 0.6205**
Aud compreh 0.7136** 0.8190**
Repetition 0.1397 0.0246
Naming 0.7126** 0.6386**

No. of cases: 28.

l-tailed Signif: ** -0.001.

In conclusion, these results suggested that reading and writing were impaired in all
aphasic groups but the degree of severity varied from group to group.

Apraxia, Drawing and Neglect

The number of subjects that had been administered the neuropsychological tests was
 Lhgbtk-ofCbinese_speakingApbasics 403

small (IV= 14) and over generalization of these data should be avoided. Nevertheless,
these preliminary data have revealed that none of the aphasic subjects had any signs
of neglect (Table 17). Praxis and drawing (visuospatial) functions were impaired in
some of the aphasic groups and apraxia was found to be correlated with severity
(correlations of total AQ with apraxia: 0.7189, p < 0.01; drawing: 0.2341, nonsigni-
ficant; neglect: 0.1772, nonsignificant).

TABLE 17
Neuropsychologkal (Apraxia, Drawing and Neglect) Tests Scores

Apraxia Drawing Neglect

(out of 45) (out of 30) (out of 40)
N Mean SD Mean SD Mean SD

All Aphasics 14 33.14 10.76 18.14 8.94 39.57 0.64

AnOlXh 3 45.00 0.0 21.33 8.62 39.66 0.57

BlVtX 2 32.50 14.84 21.00 2.82 40.00 0.0
Conduction 1 45.00 0.0 30.00 0.0 40.00 0.0
Global 3 19.00 1.73 17.66 10.59 39.33 1.15
Mixed Tram 1 25.00 0.0 7.00 0.0 39.00 0.0
Tram motor 1 36.0 0.0 10.08 0.0 39.08 0.0
Tram sensory 1 38.00 0.0 4.00 0.0 40.00 0.0
Wemicke 2 31.50 3.53 22.00 7.07 39.50 0.70

Lesion -II

Early studies with a CT scan or isotope localiition in aphasia, support the locali-
zation& view of the Wemicke-Lichtheim model (Naeser and Hayward 1978; Kertesz
1979, 1983). More recently, there were reports of aphasia with lesions outside the
classical language zones, such as basal ganglia and thalamus (Alexander et al. 1987;
Damasio et al. 1982; Naeser et al. 1982). Although it was not the intent of this study
to examine the relationship between types of aphasia and lesion sites, there are some
findings worth discussing.
A total of 30 aphasic subjects with information on lesion sites were reported. Table
18 shows the number of subjects under each aphasia type and lesion site distribution.
The information was gathered through inspection of CT scan films and/or reports.
There was no particular pattern demonstrated as it can be seen that an anterior lesion
(frontal or fronto-parietal) could produce either a fluent or nonfluent type of aphasia.
404 JournaI of Ne~~~linguhtics,Volume 7, Number 4 (1992)

Furthermore, many subjects, both fluent and nonfluent aphasics, had subcortical
lesions. The high proportion of subjects with subcortical lesions suggested that clas-
sical aphasic symptoms can be caused by composite lesions, i.e. coexisting cortical
and subcortical lesions. It is obvious that lesion sites are not independent of each other.
The distribution of the blood supply of the brain determines the likelihood of a
particular combination of lesions in vascular cases. It should be emphasized that
the important role of the subcortical structures play in language should not be
underestimated.

DI!XXJSSION

This report has given a detailed explanation and the rationales in developing a
Cantonese aphasia test battery. The test has been standard&d on 54 aphasic subjects
and 24 controls. The results are described and the test has been demonstrated to be
a valid assessment tool in classifying Chinese-speaking aphasic patients into appro-
priate categories using the Wernicke-Lichtheim model as in Indo-European patients
(see also Gao and Benson 1990).
The criteria for classification of aphasics follow that of the WAB. The criteria for
differentiating aphasics from controls is described and validated. High test-retest
reliability, and intrajudge and interjudge reliability is shown.
The sample, though restricted to subjects who were referred for speech rehabili-
tation only, provided a somewhat representative view of aphasia after stroke in
Chinese (Cantonese) speakers.
To examine the postulation by some investigators about the right hemisphere
superiority in Chinese, it can be seen that, with the present data, such postulation is
not supported. All the aphasic subjects in the present study had left hemisphere
damage. However, the role played by the right hemisphere in Chinese, particularly
in the area of reading and writing, should not be underestimated as some data has
begun to emerge and suggested that in some aspect of reading, the right hemisphere
may play a more significant role in the Chinese language (in progress). Nevertheless,
more data is necessary to help further clarify this issue.
It is hoped that with the development of this Cantonese aphasia battery, future
aphasia studies in Chinese aphasia, especially Cantonese, can make use of the test in
describing and classifying aphasic subjects.Moreover, practising clinicians can have
access to a linguistic tool which enable them to assess their aphasic patients.
 cortical subcortieal
f ffp t t/p p p/o ffplo lllahmus Bati ganglia Unspecified N

AlHXBiZi 1 2 I. 3 7
Conduction 2 1 3
Wemicke’s 1 1 1 1 2 6
Trans sensory 1 1
17
Bruca’s 1 2 I s
Trms mmw 1 1 I 3
Mixed trans 1 1
Global 1 1 2 4
13

Keys: f-front& t-temporal; p--pa&d; o--mcipit&.

406 Journal of Neurolinguistics,Volume 7, Number 4 (1992)

NOTE

1. Consent from Kertesz obtained (Personal communication, 1987).

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1973 “A Simple Test of Visual Neglect,” Neurology 23. 658-64.
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1976 Psychological Testing, New York: Macmillan.
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1980 ‘Crossed Aphasia in a Right-handed Bilingual Chinese Man: A Second
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Brookshire, R. H.
1983 “Subjects Description and Generality of Results in Experiments with
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Byng, S., J. Kay, A. Edmundson and C. Scott
1990 “Clinical Forum Aphasia Tests Reconsidered,” Aphasiology 4. 67-91.
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 Liqtubtk Asecssavat of Cw A@aaks 407

Huang, C. Y.
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in Linguistic, Psychology and the Chinese Language, S. R. Kao and R.
Hoosain (eds), Hong Kong: University of Hong Kong.
Huang, C. Y. and W. K. Lau
1985 “Semantic Locked in Dysphasia: Relatively Preserved Reading and Writing
in a Case of Global Dysphasia,” Journal of Neurolinguistics 1. 191-208.
Hung, C. C., Y, K. Tu, S. H. Chen and R. C. Chen
1985 “A Study on Handedness and Cerebral Speech Dominance in Right-
handed Chinese,” Journal of Neurolinguistics 1. 143-64.
Kertesz, A.
1979 Aphusia and Associated Disorders: Taxonomy,Lacakation and Recovery,
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1982 Western Aphasia Battery, New York: Gnme and Stratton.
1983 Localization in Neuropsychology, New York: Academic Press.
Kertesz, A. and E. Poole
1974 “The Aphasia Quotient: The Taxonomic Approach to Measurement of
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Lesser, R.
1987 “Cognitive Neuropsychological Influences on Aphasia Therapy,”
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Li, X., C. Q. Hu, Y. L. Zhu, Z. W. Song and Y. Li
1986 “Language Disorders in Patients with Cerebral Vascular Accidents,” in
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1982 “Aphasia with Predominantly Subcortical Lesion Sites: Description of Three
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1978 “Lesion Localization in Aphasia with Cranial Computed tomography and
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408 JoumdofNeadqWu, Volume 7, Number 4 (1992)

Ross, E. D. and M-M. Mesulam

1979 “Dominant Language Functions of the Right Hemisphere,” Archives of
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1981 Acquired Aphasia, New York: Academic Press.
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1986 “Agraphia in Chinese Aphasic Patients,” in Linguistic, Psychology and
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University of Hong Kong.

APPENDIX

CanW Aphasia Battery

Summary Score

Spontaneous speech information 0 3 5 7 10

fluency 0 3 5 7 10
sub AQ (total) =

Auditory comprehension Y/N question 0 15 30 45 60

word 0 15 30 45 60
commands 0 20 40 60 80
sub AQ (totalI20) =

Repetition 0 25 50 75 100
sub AQ (total/lO) =

Continued
 Lingdtic Assessment of Chinesc9pecrMne Apimsks 409

Naming objects 0 15 30 45 60
word fluency 0 5 10 15 20
sen completion 0 3 5 7 10
responsive sp 0 3 5 7 10
sub AQ (totalll0) =
Total AQ = total sub AQ x 2 =

Reading sentence 0 10 20 30 40
command 0 10 20
wordlobj 0 3 6
word/pit 0 3 6
piclword 0 3 6
spoken/word 0 1 2 3 4

Writing name, address 0 5

picture 0 8 17 25 34
dictation I 0 5
dictation II 0 5 10
l-20 0 5 10
simple word 1 2 3 4 5
copying 0 5

I spontaneous
sp?ch
Fluency scale

0 = No response or meaningless utterances.

1 = Recurrent utterances used with some meanings.
2 = Single or bisyllable words used with effort or hesitation.
3 = Fluent, recurrent stereotypical jargon.
4 = Single words, occasionally short telegraphic utterances.
5 = Often telegraphic but mostly with fluent utterance, paraphasia may be obvious,
occasionally complete sentences.
6 = More complete propositional sentences, paraphasia still evident.
7 = Fluent but phonemic jargon, difficult to understand, may be logorrheic.
8 = Circumlocution, fluent speech, marked word finding difficulty, often complete
but inappropriate sentences with semantic paraphasia.
9 = Fluent complete sentences, occasionally phonemic paraphasia, hesitation or
word finding difficulty.
10 = Fluent, complete and clear sentences.

(Translated from the Cantonese version.)

410 Journal of Neurohguistics, Volume 7, Number 4 (1992)

Information content

0 =
No information/response.
1 =
Incomplete response only, no content.
2 =
Can answer any one question.
3 =
Can answer any two questions.
4 =
Can answer any three questions.
5 =
Can answer any three questions plus some response to the description of picture.
6 =
Can answer any four questions plus some response to the description of picture.
7 =
Can answer any four questions and mention at least six nouns or verbs in the
picture.
8 = Can answer any five questions but incomplete picture description.
9 = Can answer six questions and almost complete picture description: with at least
ten things/or circumlocution.
10 = Can answer six questions and complete picture description.
(Translated from the Cantonese version.)

II Auditory Verbal Comprehension

Yes/no question

Patients are asked to reply or nod “yes” or “no” only to questions. Patients with
apraxia may have difficulties but there is no easy way to overcome this as a yes/no
task requires the least motor activity. It is observed that patients usually respond better
to questions or commands which relate to his immediate life situation, as opposed to
questions concerned with more remote factual situation (Albert et al. 1981). Three
types of questions are included in this subsection: Questions of personal relevance;
Questions related to immediate situation; And questions about common facts.
Consideration has been given in incorporating linguistic forms such as “larger than”,
“before” etc.

Auditory word recognition

The patient is asked to point to an item, spoken by the examiner, from a choice of
six or more in the same category. Most of the items are those used in the original WAB
(Kertesz 1982). There are six objects, six line drawings of objects, six simple stroke
words varying from one to four strokes (these six words were chosen on the basis that
they are among the most basic and simple words which would be recognised easily
by all literate persons (National Institute for Compilation and Translation 1967).
Moreover, they also occur as radicles which are basic components of a character upon
which more complex characters are built), six numbers, six geometric forms, six
colors, six items of furniture in the room, six body parts of the patient, five items of
finger recognition and seven items of right/left discrimination.
This subsection tests the patient’s ability in understanding the meaning of words
spoken out of context. It requires the patient to point to the ~rop~a~ object, picture
or body parts by listening to the auditory word. Differences are often found among
various semantic categories: letters, colours, actions, objects etc (Goodglass et al.
1966). For example, it is common to find the Wemicke’s aphasics fail badly with
items relating to objects and perform better with those involving letters and numbers.
Generally, the ability to point to various body parts on verbal request is usu~ly more
severely impaired than object identification.

Sequential commands

This task has been variously called auditory retention span or auditory sequencing.
It is powerful in detecting slight degrees of comp~he~on deficit. Most aphasics are
markedly restricted in the ability to point in succession to two or more of a group of
objects. This subsection is designed to test the number of informational elements with
which a patient can deal in a single message. They also probe for the ability to decode
various syntactic constructions, including the use of prepositions of time and space
relation as well as prepositions determining the case of an object noun. The items of
sequential commands are similar to those of the original WAB (Kertesz 1982). The
initial commands are simple and short such as “open your eyes” and “raise your
hand”. Then there are sequential pointing tasks. Commands involve manipulation of
one object to touch another, incorporating grammatical structures (such as “on top
Of’, “the other side”, “turn over”, and “beneath”), and increasing the length of the

sentence and the number of compnents. Comprehension of these relational words in

English has heen shown by Goodglass et al. (1970) to be particularly difficult for
aphasics. Credit is given for partial response if the underlined portion of the sentence,
representing action or object is appropriately performed.

III Repetition
There are twelve items with length varying from one to nine syllables (four
morphemes).

Twenty common objects, most of them the same as those used in the original WAB
(Kertesz 1982), are presented visually. About 20 set are allowed for each item. Cues
412 Journal of Neurolinguistics,Volume 7, Number 4 (1992)

can be provided if the patients require them. The phonemic cue in Cantonese is not
practical. Therefore, a unique cueing system is designed. The cues are either a first
syllable, sound or semantic cues. The objects, according to Kertesz (1982), were
selected for their availability and handy size but the shape, the category of the objects
and difficulty level were introduced deliberately.

Word fluency

In this subsection, the patient is asked to name as many animals as possible. This
task is particularly vulnerable to frontal lobe diseases as well as to extensive lesions
elsewhere in the brain. A dissociation is sometimes observed, especially in the case
of certain frontal lesions, between naming, which is normal or nearly so, and word
fluency, which is particularly deficient.

Sentence completion

Three common expressions and two popular proverbs which serve to “trigger”
answers were used. They were:

1. Spring, summer, autumn and (winter).

2. We write with a - @en).
3. Wash face and brush (teeth).
4. A drunken man’s desire is not the (wine).
5. River water will not mix with (well water).

Responsive naming

This task presupposes an adequate level of auditory comprehension. A deficit in

comprehension may result in a lower rating in responsive speech than in picture
confrontation naming. Items used in this task elicit one- or two-syllable names.

V Reading

Reading comprehension of sentences

This part consists of seven multiple choice items. The possible answers include
several wrong responses, which are associatively related to words in the stimulus
material. The sentences length ranges from five words to a small paragraph of three
sentences and 35 words.
 Liagaba - of cw Aphwka 413

The items used were translated from those of the original WAB. Scoring is pro-
vided for reading aloud and for doing what the command requests, separately.
Such scoring system is designed for the occasional patient who can read without
comprehending.
The remaining subtests assess the patients reading skill at word level. In the “written
word-object matching “, “written word-picture matching’* and “picture-written word
matching’* tasks, the word-concept association ability are tested. “Spoken word-
written word” is a phonetic association task which examines auditory-graphic
association without necessary comprehension or verbalization by the patient. Some of
the wrong choice are ideographically or phonetically similar to the correct word, while
others are of same semantic category.

VI writhlg

Name and addreap

To assess the mechanics of writing, automat&d writing is tested. The most

automatised possible writing performance the patient can do is to write his name and
then the address, which are highly overlearned skill.

COPY&

A further test of writing mechanics is to ask the patient to copy a sentence.

Numbersand basic simple stroke chprocters

The patient is also tested for his ability to write some simple prime words-words
which are so overlearned that they are probably written essentially by rote, with
minimal reliance on the mapping of phonological units onto the character.

Dictation I and Dictation II

These two subsections tested patient’s ability to write a sentence and common object
names.
414 Journal of Neurolinguistics,Volume 7, Number 4 (1992)

VII Supplementary Neuropsychological Test

Test for apraxia

Three areas are being assessed:

(1) Upper limb apraxia such as making a fist, saluting, waving goodbye, scratching
head, and clapping hand.
(2) Buccofacial apraxia such as sticking out tongue, whistling, blowing air, sniffing
or closing eyes.
(3) Instrumental apraxia which involves the use of a comb, a toothbrush, a
hammer, a key and a spoon.
The sequence of testing follows that suggested by Goodglass and Kaplan (1983).
First, the command is given and if the patient does not understand, it is repeated.
Approximate performance on verbal stimulation is accepted but partial score is given.
If the patient does not perform, the next step is to ask the patient to imitate the
examiner. If this is not performed either, finally, the instrument or object will be given
to the patient for actual use.

viiual spatial drawing test

The drawing test of the WAB is used here. The patient is asked to draw a circle,
a square, a tree, a person, a cube, a clock, a house and to bisect a line. Scoring is
given according to the set criteria specified in the original WAB.

Visual negkt test

Albert’s (1973) test on visual inattention is employed. The patient is asked to cross
out 40 lines drawn in a predetermined pattern on a sheet of paper. Patients with visual
neglect may ignore lines on one side of the paper. Each line is scored one point.
 CANTONESE APHASIA TEST

DATE OF TESTING:

NAME : AGE/SEX :

LANGUIGE/DIALECT:

HINDEDNESS:

EDUCATION: OCCUPATION:

HEMIPLEGJA: HEMIANOPIA:

DATE OF ONSET: POST ONSET (H):

MEDICAL HISTORY / CT SCAN RESULT:

NEL 7J4-K
416 Journal of Neurol~ics, Volume 7, Number 4 (1992)

Scoring of Spontaneous speech i=l%Fis’ffmw

Information fis

0
1
2
3
4
5
6
7
8
9
10

0
1
2
3
4
5
6
7
8
9
10

Observations:

0 adynamia El jargon

r3 automatic/stnrcoLyped sentences only 0 literal paraphasias

C! circumlocution n semantic paraphrnsias

CI difficulty in initiating speech u telegraphic

0 groping/searching gevLure 3 word finding difficulty

II. Auditory verbal Comprehension sm.&

A. yes/no questionss$@p: cBBmzc*)

1. eJewm!k___tt~~7
2. 4~&ollt~___(m*)7
3. 4%~~&___t*')?
4. y~~~*rmm%%)?
5.
6. r
,&&wi&ljc~&
7. 4&*m83/kA(*)?
8. 4s;*mclEp~ tm%)?
9. WG%m!w*.h (i%) 7
10 REwmHmcBnwm (r;)y)?
11 BW'Tf4WlW~~~~~?
12 rnW%WiBW tsga)?
13 RwvJiUAmB$m (4%)?
14 i%mm*&#kLMm tw!H#?) ?
15 afE*mQ#~~*((8)7
16 =H#w**YiEJ,~i# (f%r) 7
17 S,**f!JaSm.4%%rm%drcm*) ?
18 t-R$f+rtlEfFFVR%!~f@$IspI,
7
19 !F!wwl*tkrtPb3~ C&) 7
20 4M!?ozI41Rln43vPi*~~~ (US@?) 7 / 60

B-auditory word recognition: ~$f~--%j..JmmJ~~~~---~~

me=

fin tlllB*
_____--______----^________~__-~~~~~~~-~~~~~~~~__~~--~~~__
r&ET 5
ZLph! \
iF@ 3% '-- 61
S&E ;$ 500
f=ie F LJ 1867
;: 32
!w?Mtk tz z -$! 5000
_____________________~~~~~~~_~~~~~~~~~~~~~~~~~~~~~~~~~~_~
_-_-______---_______-_-~~--~_~~~~~~~~~~~~~~~~~~--~~~~~~_-
aiz ?P#efS mH?mi
4t Z" :: &USm
Kc aa UA .E!
m/** Lea aei#B -zz
YT 3?R
: .*X&Z -FEZ z!! zim
___________________.______~~~_~~~~~~~~_~~~~~~~~~~~~~~~~~~~
/60
418 Journal of Neurolinguistics, Volume 7, Number 4 (1992)

80

III.Repetition ms

GEww.+. literal paraphasia Z$&$~kF$%#D---fj

syllable unit
l.Jx 2 1

2.# 2 1

3*#H 4 1

4-m+-x 6 1

5-Y-L=% 6 1

6./-\+-_+-- 10 1
 Lilqp&k~ofc~AphMka 419

IV.Nnming
A.object naming: $~@J?Z~J. p nrnphasis 1w~.~~~-~j

Ezls #.a!~f~~
__-_--_-__-______________-_______~-~~-~-~~-~-~-----~-~--_-~-~--~-~
%F
gy
=a
n
SwF Ti!
#ust
EuiB
!!k,
Baa
F!
&iE
3
EM
aa*?@
z
EL! /s/

;z
t
X /ts/
Ass 9c
~-~-~--~-~--~-^-~~-~-~~-~-~~-~-~~~~~~~~~~~~~~~--------------------
160

/20

C.sentence completion: &&cf, m4,,paraphssias -_M.

ftt%#:
1. ?&SH...........( .q 1

......... 110

D.responsive speech: wd&~59. par-aphasia --jj

110
420 JonrdofNeudh@da, Volume 7, Number 4 (1992)

READING
A. Sentence comprehension
 Liqubtk Asscssmcnt of w Aphasics 421

B. Reading commands
w w!

1. elpe** 1 1
2. Hw=~* 1 1
3. ~_lzsHiE 1 1
4. ~!&lImMii.w-?i= 2 2
5. #wF-%!w. PHBTkePY 2 2
6. oti&ti*. Inllh=jr@HEF#cEJ* 3 3
/20
C.Written word-object (words presented individually)

fl #fi, SHE tlz rk?e !t!miwt /6

D. Written word-picture (words presented individually)

x A!!@? 4+ !w#Vtti *fi .&%E /6

E. Picture - written word (pictures presented individually)

FF $a;lp &Mwtt A!# fE #iz /6

F. Spoken word - written word

a#+
IMP7 WPT 2kPY f%F PYrn
/4
422 Journalof Neurolim, Volume7, Number 4 (1992)

WRITING

43FF-~
paragraphic )a**

/5

B. kKt %3ze-~
"wkws@" /5

C. mt Point to the object. if necessary

/10
4.s**~

110

-6 a
/5

/5
 ~hguistk Assearmce of Chinescsperkins Ap8dc.s 423

DRdWING *B

1.
2.
3.
4.
5.
6.

7.
8.
424 Journal of Neurolim, Volume 7, Number 4 (1992)

. -
L ..