Amsterdam-Nijmegen Everyday Language Test (ANELT)

Evidence Reviewed as of before: 23-04-2009
Author(s): Sabrina Figueiredo, BSc
Editor(s): Lisa Zeltzer, MSc OT; Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

The ANELT is designed to assess the level of verbal communicative abilities of individuals with aphasia. A second goal of the ANELT is to estimate a client’s change on verbal communicative abilities over time (Blomert et al., 1994).

In-Depth Review

Purpose of the measure

The ANELT is designed to assess the level of verbal communicative abilities of individuals with aphasia. A second goal of the ANELT is to estimate a client’s change on verbal communicative abilities over time (Blomert et al., 1994).

Available versions

The ANELT was published in 1994 by Blomert, Kean, Kosters, and Schokker. There are two available versions (ANELT I and ANELT II). Both versions have the same number of items, and the same difficulty level. The main difference is how the items are worded. Typically, the ANELT II is used as a re-evaluation of a client when the second assessment is performed within a short period of time. Therefore, it may prevent possible learning and memory effects.

Features of the measure

Items:
The ANELT I and II consist of 10 items each that characterize familiar everyday life situations. Before starting the test, the examiner should allow the client to practice by asking two items from the measure. During the practice trial, the examiner should provide instructions and correct the client if he or she does not appear to understand the instructions (Blomert et al., 1994).

The examiner should record the administration of the ANELT on audiotape for later scoring. The examiner presents each item verbally to the patient and must avoid conversing with the client during the administration of the test. Instead, the examiner should act as an interested listener, while the client answers the items as a monologue (Blomert et al., 1994).

The items-scenarios all have a strongly conventional script-like character. They engage the interest of the client, minimize stress in the testing situation, and encourage optimal performance. The ANELT I test items are as follows (Blomert et al., 1994):

  1. You are now at the dry cleaner’s. You have come to pick this up and you get it back like this [present shirt with scorch mark]. What do you say?
  2. The kids on the street are playing football in your yard. You have asked them before not to do that. You go outside and speak to the boys. What do you say?
  3. You are in a store and want to buy a television. I am the salesperson here. ‘Can I help you?’
  4. You go to the shoemaker with this shoe. [Present shoe] There is a lot wrong with this shoe, but for some reason you want him to repair only one thing. You may choose one. What do you say?
  5. You have an appointment with the doctor. Something else has come up. You call up and what do you say?
  6. You are in the drug store and this [present glove] is lying on the floor. What do you say?
  7. You see your neighbor walking by. You want to ask him/her to come to visit some time. What do you say?
  8. Your neighbor’s dog barks all day long. You are really tired of it. You want to talk to him about it. What do you say?
  9. You have just moved in next door to me. You would like to meet me. You ring my doorbell and say…
  10. You are at the florist. You want to have a bouquet of flowers delivered to a friend. I am the salesperson. What do you say?

Scoring:
Each item is scored from 0 to 5 on two different scales: One scale is used to score understandability and is also known as ANELT A. This scale assesses whether the content of the message given by the client is interpretable. The other scale, ANELT B, rates intelligibility. This scale is independent of content and assesses whether the words provided by the client are able to be perceived or clearly recognized (Blomert et al., 1994).

A score of 0 is given when the patient, due to severe aphasia, is incapable of taking instructions and/or producing an answer. A score of 5 indicates the client’s speech is unimpaired. The total score for each scale is obtained by summing all items. The total score on each scale (ANELT A & B) ranges from 0 to 50. Scores lower than 36, on each scale, are indicative of a moderate or severe verbal communicative deficit. Non-verbal responses should only be scored when they are provided by the client to reinforce or clarify a verbal response (Blomert et al., 1994).

Time:
The ANELT takes 15 to 25 minutes to administer (Blomert et al., 1994).

Subscales:
The ANELT is comprised of 2 subscales:
Understandability (ANELT A) and
Intelligibility (ANELT B).

Equipment:
The ANELT requires specific equipment, according to the items being used such as a stained shirt, a damaged shoe, and a pair of gloves.

Training:
Not reported.

Alternative forms of the ANELT

None

Client suitability

Can be used with:

  • Clients with stroke.
  • Clients with communicative deficits.

Should not be used in:

  • The ANELT should not be used with clients that are not able to communicate.

In what languages is the measure available?

Dutch, Swedish, German and English (Blomert et al., 1994; Doesborgh, 2004; Laska, 2007).

Summary

What does the tool measure? The ANELT was designed to assess verbal communicative abilities of patients with aphasia and to estimate change over time.
What types of clients can the tool be used for? The ANELT can be used with, but is not limited to clients with stroke.
Is this a screening or assessment tool? Assessment
Time to administer The ANELT takes 15 to 25 minutes to administer.
Versions ANELT I and ANELT II.
Other Languages Dutch, Swedish, German and English.
Measurement Properties
Reliability
  • One study examined the internal consistency of the ANELT and reported a Cronbach’s alpha >0.90, which could be indicative of redundancy.
  • One study examined the test-retest reliability of the ANELT and reported reliability across repeated measures using factor analysis.
  • One study examined the inter-rater reliability of the ANELT and reported excellent agreement between both scales and between naïve and expert raters using Krippenndorf analysis and Pearson correlations.
Validity

Content
One study examined the content validity of the ANELT and reported the item generation process for the ANELT.

Criterion
Concurrent Validity:
Two studies examined the concurrent validity and reported an excellent correlation between the ANELT and the Aachener Aphasia Test (AAT) using Pearson correlation. Moreover, the semantic component of the AAT explained 33% of variance of the ANELT.

Predictive Validity:
Three studies examined the predictive validity of the ANELT and reported that the ANELT measured shortly after stroke predicted recovery at 6 and 18 months post-stroke. However, it does not predict life situation of the significant other.

Construct
Convergent Validity:
Two studies examined the convergent validity of the ANELT and reported excellent correlations between the ANELT and the Coefficient in Norsk Grunntest for Afasi and adequate correlations between the ANELT and the Scandinavian Stroke Supervision Scale using Pearson correlation.

Longitudinal:
One study examined the longitudinal validity of the ANELT and reported, in the group receiving semantic treatment, adequate change score correlations between the ANELT and semantic measures and poor correlations between the ANELT and phonological measures. In the group receiving phonological intervention, change score correlations were adequate between the ANELT, the phonological measures and the Semantic Association Test, and poor between the ANELT and the Synonym Judgment subscale from the Psycholinguistic Assessment of Language Processing Aphasia.

Known Groups:
One study using ANOVA examined known groups validity of the ANELT and reported that the ANELT is able to discriminate between healthy individuals and those with communicative impairments.

Floor/Ceiling Effects One study reported that ceiling effects may be present when administering the ANELT to clients with mild communication deficits.
Sensitivity/Specificity One study examined the sensitivity/specificity of the ANELT and reported that an ANELT cut-off of 3.5 yields a sensitivity of 79% and a specificity of 83%.
Does the tool detect change in patients? Three studies examined the responsiveness of the ANELT and reported significant changes on the ANELT measured at 3, 6 or 18 months post-stroke. Significant changes were more pronounced in the first 3 months and in clients with fluent aphasia. Furthermore, a positive change of 8 points was identified as the minimal clinically significant change.
Acceptability Within 11 days of stroke onset, ANELT administration achieves a 90% completion rate (Laska et al., 2001)
Feasibility The administration of the ANELT is quick and simple, but requires some standardized equipment.
How to obtain the tool?

The ANELT I can be obtained on the website:

http://www.hogrefe.nl/site/?/test/show/52/

The complete pack consists of the manual, 20 forms, instruction card and CD-ROM. It costs 150.00 Euros, excluding taxes and postage.

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the Amsterdam Nijmegen Everyday Language Test (ANELT) in individuals with stroke. We identified 6 studies.

Floor/Ceiling Effects

Laska, Hellblom, Murray, Kahan and Von Arbin (2001) reported that ceiling effects may be present when administering the ANELT to clients with mild communication deficits.

Reliability

Internal Consistency:
Blomert, Kean, Kosters, and Schokker (1994) verified the internal consistency of the ANELT I & II in 35 clients with stroke. Each version showed a Cronbach’s alpha > 0.90. This result suggests the possibility of some redundant items on the ANELT.

Test-retest:
Blomert et al. (1994) examined the test-retest reliability of the ANELT I scales (A & B) in 30 clients with stroke. Participants were re-assessed within a 3 month interval. Stability over test-retest was measured using factor analysis. Comparisons for all items showed no significant differences, suggesting there was no change across two-repeated measures. These results suggest both ANELT I scales (A & B) are stable and reliable over time.

Inter-rater:
Blomert et al. (1994) evaluated the inter-rater reliability of the ANELT in 14 clients with stroke. Participant’s answers were rated by 6 evaluators, who were blinded to each other’s scores. Inter-rater reliability on individual items was calculated using Krippendorff analysis. Inter-rater reliability was excellent for the understandability scale (0.92) and adequate for the intelligibility scale (0.70). Additionally, in the same study, the authors analyzed the correlation between naïve and expert raters. In the first analysis when naïve evaluators rated a video performance and expert evaluators rated an audio performance, correlations between naïve and expert raters were excellent for the understandability (r = 0.83) and the intelligibility (r = 0.63) scales. When both naïve and expert evaluators rated audio performance, correlations for the understandability and the intelligibility scales were also excellent but with higher values (r = 0.99 and 0.97, respectively).

Validity

Content
Blomert et al. (1994) began content validation with a large number of items that they administered to 60 healthy individuals. Twenty items were then selected based on a high response rate. After completion of the test, the 60 participants were questioned about the nature of the remaining items. All items were considered highly imaginable and recognizable, independent of biographical background, and representative of daily situations.

Criterion
Concurrent:
Blomert el al. (1994) analyzed, in 254 clients with stroke, the concurrent validity of the ANELT by comparing it with the Aachener Aphasia Test (AAT) (Huber, Poeck, Weninger & Willmes, 1983) as the gold standard. The AAT is a 10 minute semi-structured interview used to elicit information on the communicative level of the patient and also to diagnose aphasia syndromes. Correlations between the ANELT and the AAT were excellent (r = 0.81).

Doesborgh, van de Sandt-Koenderman, Dipple, van Harskamp, Koudstaal and Visch-Brink (2002) assessed the concurrent validity of the ANELT by comparing it to semantic (word-meaning) and phonological (word-sounding) measures in 29 clients with stroke and aphasia. Regression analysis indicated that semantic measures, when compared to phonological measures, were better related with ANELT scores. The semantic component of the Aachener Aphasia Test (AAT) (Huber et al., 1983) explained 33% of variance of the ANELT scores.

Predictive:
Laska et al. (2001) assessed the ability of ANELT scores, measured shortly after stroke, to predict functional recovery at 18 months post-stroke in 119 clients. Linear regression analysis indicated that the ANELT scores were a significant predictor of functional recovery. Furthermore, less severe aphasia at baseline was related to higher degrees of functional recovery.

Franzen-Dahlin, Laska, Larson, Wredling, Billing, and Murray (2007) examined, in 148 clients with stroke (71 with depression and 77 with aphasia), whether age, gender, need of assistance, personality change, state of aggression, ANELT scores, Barthel Index scores (Mahoney & Barthel 1965), severity of depression, cohabitant/single and previous stroke were able to predict life situation of the significant other measured at 3 to 6 months post-stroke. Linear regression analysis indicated that ANELT scores were not a significant predictor of life situation of the significant other, which was best predicted by the need of assistance, personality change and living with the patient.

Laska, Bartfai, Hellblom, Murray and Kahan (2007) assessed the ability of the ANELT and the Coefficient in Norsk Grunntest for Afasi (Coeff) (Reinvang, 1985) to predict recovery at 6 months post-stroke. The Coefficient in Norsk Grunntest for Afasi is a measure of the severity of impairments on fluency, comprehension, naming and repetition in addition to writing and reading (Reinvang, 1985). Predictive validity was calculated by use of c-statistics to calculate the area under the Receiver Operating Characteristic (ROC) curve. A Coeff ≥ 49 (AUC = 0.82) and an ANELT ≥ 3.5 (AUC = 0.80) were both excellent on predicting recovery 6 months post-stroke. These results suggest that the percentage of patients correctly classified according to their recovery level at 6 months post-stroke is slightly lower when using the ANELT over the Coefficient in Norsk Grunntest for Afasi. Using an ANELT cut-off of 3.5 yields a sensitivity of 79% and a specificity of 83% to predicting recovery 6 months post-stroke.

Construct
Convergent/Discriminant:
Blomert et al. (1994) assessed the construct validity of the ANELT subscales – understandability and intelligibility – in 254 clients with stroke and aphasia. Correlations between the understandability and intelligibility subscales were excellent (r = 0.70). However the strength of the association between the ANELT subscales varied according to the type of aphasia: excellent in clients with Wernicke’s aphasia (r = 0.66), adequate in clients with Global and Rest aphasia (r = 0.35; r = 0.33, respectively), and poor in clients with Anomic and Broca’s aphasia (r = 0.28; r = 0.27, respectively). These results suggest that within a large sample, with large variance, both scales are reflective of verbal communicative impairments. However, within certain types of aphasia, the ANELT is able to measure two sub-constructs: understandability and intelligibility. In other words, these two scales are not completely independent; but each contributes uniquely to the overall validity of the construct of verbal communication.

Laska et al. (2007) examined the convergent validity of the ANELT by comparing it to Coefficient in Norsk Grunntest for Afasi (Reinvang, 1985) and the Scandinavian Stroke Supervision Scale, a measure of neurological impairment (Röden-Jüllig, Britton, Gustavsson, & Fugl-Meyer, 1994) at baseline and 6 months later. The number of participants ranged from 72 to 118. Correlations between the ANELT and the Coefficient in Norsk Grunntest for Afasi were excellent both at baseline and 6 months later. (r = 0.71; r =0.87, respectively). Adequate correlations were found between the ANELT and the Scandinavian Stroke Supervision Scale (r = 0.33; r = 0.53). This result suggests that aphasia’s severity level is directed associated with neurological impairments.

Longitudinal:
Doesborgh et al. (2004) analyzed the longitudinal validity of the ANELT in 29 clients with stroke and aphasia by comparing change scores on the ANELT with change scores in semantic and phonological measures within each group. Semantic measures, which reflects word-meaning, were composed of the Semantic Association Test (SAT) (Visch-Brink, Denes, & Stronks, 1996) and the Synonym Judgment subscale from the Psycholinguistic Assessment of Language Processing Aphasia (PALPA) (Kay, Lesser, & Coltheart, 1992). Phonological measures, which are concerned about word-sounding, were represented by the Repetition Non-words and Lexical Decisions subscales from the PALPA. In the SAT the client is required to make a semantic association with the target (word or picture) by grouping the relevant information from a multiple choice set (words or pictures) while the PALPA assesses orthography, phonology, word and picture semantics, morphology and syntax and therefore is a complete assessment of language impairment. Participants were randomized into two groups: either semantic or phonological intervention. The group receiving semantic treatment demonstrated adequate change score correlations between the ANELT and both semantic measures (r = 0.58; 0.34, respectively), and poor correlations between the ANELT and both phonological measures (r = 0.04; 0.24, respectively). In the group receiving phonological intervention, change score correlations were adequate between the ANELT, the phonological measures and the Semantic Association Test (0.58, 0.50, 0.40, respectively) and poor between the ANELT and the Synonym Judgment subscale from the PALPA (r = 0.16).

Known groups:
Blomert et al. (1994) verified the ability of the ANELT to discriminate between healthy individuals (n = 60) and individuals who had experienced stroke and aphasia (n = 252). Known group validity, as calculated using ANOVA, suggested that scores of healthy subjects were significantly higher than the scores of the participants with verbal communicative impairments, thus supporting the known groups validity of the ANELT.

Responsiveness

Laska et al. (2001) evaluated the responsiveness of the ANELT in 119 clients with stroke and aphasia. Participants were assessed at four points in time: baseline, 3, 6, and 18 months post-stroke. Clients with fluent aphasia had greater ANELT score changes than clients with non-fluent aphasia (p<0.0001). Additionally, ANELT score changes were more significant in the 3 first months of recovery (p<0.0001) as would be expected based on what is known about post-stroke recovery.

Doesborgh et al. (2004) assessed the responsiveness of the ANELT in 55 clients with stroke. Participants were assessed at two points in time: at admission to a rehabilitation program and after 40 hours of treatment. In this study, the percentage of patients who showed a clinically significant improvement (> 8 points) was 39% after semantic treatment (focusing on word-meaning) compared with 35% after phonological treatment (focusing on word-sounding).
Note: A clinically significant improvement > 8 points was determined by Blomert, Koster, and Kean in 1995. However the original publication is in Dutch. (Blomert L, Koster Ch, Kean ML. Amsterdam-Nijmegen Test voorAlledaagse Taalvaardigheid. Lisse, Netherlands: Swets & Zeitlinger).

Laska et al. (2007) examined the responsiveness of the ANELT in 148 clients with stroke and aphasia. Participants were evaluated at baseline and at 6 months post-stroke. Changes on ANELT scores were significant for all participants (p<0.0001) from baseline to 6 months suggesting that the ANELT is responsive to clinical improvement.

References

  • Blomert, L., Kean, M.L., Koster, C., & Schokker, J. (1994). Amsterdam-Nijmegen Everyday Language Test: construction, reliability and validity. Aphasiology, 8, 381-407.
  • Franzen-Dahlin, A., Laska, A.C., Larson, J., Wredling, R., Billing, E., & Murray, V. (2008). Predictors of life situation among significant others of depressed or aphasic stroke patients. Journal of Clinical Nursing, 17, 1574-1580.
  • Frattali, C., Thompson, C.K., Holland, A.L., Wohl, C., & Ferketic, M.M. (1995). The American Speech-Language-Hearing Association Functional Assessment of Communication Skills for Older Adults (ASHA FACS). Rockville MD: ASHA.
  • Doesborgh, S.J.C., van de Sandt-Koenderman, W.M.E., Dipple, D.W.J., van Harskamp, F., Koudstaal, P.J., & Visch-Brink, E.G. (2002). The impact of linguistic deficits on verbal communication. Aphasiology, 16, 413-423.
  • Doesborgh, S.J.C., van de Sandt-Koenderman, M.W.E., Dippel, D.W.J., van Harskamp, F., Koudstaa, P.J., & Visch-Brink, E.G. (2004). Effects of semantic treatment on verbal communication and linguistic processing in aphasia after stroke. A randomized controlled trial. Stroke, 35, 141-146.
  • Huber, W., Poeck, K., Weninger, D., & Willmes, K. (1983). Der Aachener Aphasietest Gottingen: Hogrefe.
  • Kay, J., Lesser, R., & Coltheart, M. (1992). Psycholinguistic Assessment of Language Processing in Aphasia. Hove, UK: Lawrence Erlbaum Associates Ltd.
  • Mahoney, F. I., Barthel, D. W. (1965). Functional evaluation: The Barthel Index. Md State Med J, 14, 61-5.
  • Laska, A.C., Hellblom, A., Murray, V., Kahan, T., & Von Arbin, M. (2001). Aphasia in acute stroke and relation to outcome. J Intern Med, 249, 413-422.
  • Laska, A.C., Bartfai, A., Hellblom, A., Murray, V., & Kahan, T. (2007). Clinical and prognostic properties of standardized and functional aphasia assessments. J Rehabil Med, 39, 387-392.
  • Reinvang, I. (1985). Aphasia and brain organisation. New York: Plenum Press.
  • Röden-Jüllig, Ã…., Britton, M., Gustavsson, C., Fugl-Meyer, A. (1994). Validation of four scales for acute stage of stroke. J Intern Med, 236, 125-136.
  • Visch-Brink, E.G., Denes, G., & Stronks, D. (1996). Visual and verbal semantic processing in aphasia. Brain Lang, 55, 130-132.

See The Measure

How to obtain the ANELT:

The ANELT I can be obtained on the website: http://www.hogrefe.nl/site/?/test/show/52/

The complete pack consists of the manual, 20 forms, instruction card and CD-ROM. It costs 150.00 Euros, excluding taxes and postage.

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