Boston Diagnostic Aphasia Examination (BDAE)

Evidence Reviewed as of before: 25-10-2012
Author(s): Sabrina Figueiredo, BSc; Vanessa Barfod, BA
Contributor: Katherine Salter
Editor(s): Lisa Zeltzer, MSc OT; Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc
Expert Reviewer: Dr. Lorraine Obler

Purpose

The BDAE is designed to diagnose aphasia and related disorders. This test evaluates various perceptual modalities (auditory, visual, and gestural), processing functions (comprehension, analysis, problem-solving) and response modalities (writing, articulation, and manipulation). The BDAE can be used by neurologists, psychologists, speech language pathologists and occupational therapists (Goodglass & Kaplan, 1972).

In-Depth Review

Purpose of the measure

The BDAE is designed to diagnose aphasia and related disorders. This test evaluates various perceptual modalities (auditory, visual, and gestural), processing functions (comprehension, analysis, problem-solving) and response modalities (writing, articulation, and manipulation). The BDAE can be used by neurologists, psychologists, speech language pathologists and occupational therapists (Goodglass & Kaplan, 1972).

Available versions

The BDAE was developed in 1972 by Goodglass and Kaplan. A second edition was published in 1983 by the same authors. The most recent edition was published in 2001 by Goodglass, Kaplan, and Barresi and contains both a shortened and extended version of the BDAE.

Features of the measure

Items and scoring:
Items and scoring on the BDAE is as follows (Goodglass & Kaplan, 1972):

1. Fluency: In this section the client should be encouraged to engage in a free narrative and an open-ended conversation. The following features are then assessed:

Melodic line: The examiner should observe the intonational pattern in the entire sentence.

Phrase length: The examiner should observe the length of uninterrupted runs of words.

Articulatory agility: The examiner should observe how the client articulates phonemic sequences.

Grammatical form: The examiner should observe the variety of grammatical construction.

Paraphasia in running speech: The examiner should observe substitutions or insertions of semantically erroneous words in running conversation.

Word-finding: The examiner should observe the client’s capacity to evoke needed concept names and informational content in the sentences.

All features are scored on a 7-point scale where 1 is the maximum abnormality and 7 the minimum abnormality.

2. Auditory Comprehension
Word discrimination: Consists of a multiple choice task and samples six categories of words: objects, geometric forms, letters, actions, numbers and colors. Five words are written on cards and the client is asked to identify among them the word requested by the examiner. Clients are given 2 points for correctly identifying the word within 5 seconds, 1 point for correct identification taking longer than 5 seconds, half a point for localizing the right category. The maximum score is 72. The examiner should record in writing all incorrect choices by the client.

Body-part identification: Includes 24 items, the first 18 are related to body part names, and the remaining 8 with right-left comprehension. The client is asked to identify on his own body the body part named by the examiner. One point is given for correctly identifying the body within 5 seconds. When more time is required on identifying the body parts only a half point is scored. For right-left comprehension, the examiner requires the client to identify the right forearm, for example. One point is given for correctly identifying the side within 5 seconds. When more time is required on identifying the side of the body only one point is scored.

Commands: The client is requested to carry out commands. The score in this subscale ranges from 0 to 15.

Complex ideational material: In this section the examiner asks general questions such as “will a stone sink in water?” and the client is required to understand and express agreement or disagreement. Each item consists of two questions, one having yes and the other no as response options. One point is scored for each item with both questions correctly answered. Score ranges from 0 to 10.

3. Naming
Responsive naming: The examiner asks the client a question containing a key word associated with the expected answer. Then the client should answer the question using the following words: nouns (watch, scissors, match, drugstore); colors (green, black), verbs (shave, wash, write) and a number (twelve). Three points are given when the response is provided within 3 seconds, 2 points within 3 to 10 seconds, 1 point within 10 to 30 seconds, and 0 if the client provides an improper answer. Maximum score is 30.

Visual Confrontation: The client should name the images presented by the examiner. The visual stimulus items are from cards 2 and 3 and represent objects, geometric forms, letters, actions, numbers, colors and body parts. Three points are given when the response is given within 3 seconds, 2 points within 3 to 10 seconds, 1 point within 10 to 30 seconds, and 0 if the client is unable to provide the correct answer. Maximum score is 105.

Animal naming: The first word “dog” is provided by the examiner to stimulate the client. Then the client should provide all animals name that he/she knows within 60 seconds. The score consists of counting the number of different animals named by the client.

Body part naming: The examiner points to 10 body parts to be named on him/her. Three points are given when the response is given within 3 seconds, 2 points within 3 to 10 seconds, 1 point within 10 to 30 seconds, and 0 if the client if the client provides the wrong answer. Maximum score is 30.

4. Oral Reading
Word reading: The examiner indicates a word from card 5 that should be read by the client. Three points are given when the word is read within 3 seconds, 2 points within 3 to 10 seconds, 1 point within 10 to 30 seconds, and 0 if the client provides the wrong answer. Maximum score is 30.

Oral sentence: Ten sentences should be read from cards 6 and 7. The sentences are scored as pass (score of 1) or fail (score of 0).

5. Repetition
Words: A wide sampling of word types is presented, including a grammatical function word, objects, colors, a letter, numbers, an abstract verb of three syllables and a tongue twister. An item is scored correct if all phonemes are in correct order and recognizable. One point is allowed per item for a total of 10.

High and low probability sentences: The sentences should be repeated by the client, alternating between a high- and a low-probability item. One point is given for each sentence correctly repeated and high- and low- probability sections are scored separately from 0 to 8.

6. Automatic speech
Automatized sequences: Four sequences are tested: days of the week, months of the year, number from one to twenty-one and the alphabet. Two points maximum are given for complete recitation of any series and 1 point is given for unaided runs of 4 consecutive words when reciting days, 5 consecutive words when reciting months, 8 consecutive words when reciting numbers and 7 consecutive words when reciting the alphabet.

Reciting: Several nursery rhymes are suggested to elicit completion responses. A score of 0 is given if the client is unable to recite, 1 for impaired recitation and 2 for good recitation.

7. Reading Comprehension
Symbol discrimination: Cards 8 and 9 contain 10 items each. The examiner shows the word or letter centered above the five multiple-choice responses and asks the client to select the equivalent. One point is given to each correct item.

Word recognition: Using cards 10 and 11 the client is requested to identify the one word, out of 5, which matches the word said previously by the examiner. This task is repeated another 7 times and a score of 1 point is given to each correct answer.

Oral spelling: The client should recognize 8 words spelled by the examiner. One point is given for each correct recognition.

Word-picture matching: Ten words are selected from card 5 to be identified on cards 2 and 3. One point is given for each correct recognition.

Sentences and paragraphs: The examiner reads 10 sentences from cards 12 to 16. The client is requested to complete the ending of a sentence with a four multiple choice options. One point is given for each correct sentence.

8. Writing
Mechanics: The client is requested to write his/her name and address with the stronger hand. In case he/she is not able to do so, then the examiner can write the sentence and the client should then transcribe it. Score ranges from 0 to 3 according to performance level.

Serial writing: The client should write the alphabet and numbers from 1 to 21. The score is the total number of different, correct letters and numbers, combined for a maximum score of 47.

Primer-level dictation: The client should write the letters, numbers and primer words that are dictated by the examiner. A score is given by adding the number of correct words.

Spelling to dictation: The client should write the words dictated by the examiner. Score is based on the amount of correct words written by the client.

Written confrontation naming: The patient should write the name of the figure that is shown from cards 2 and 3 by the examiner. The examiner should show 10 figures. One point is given for each correctly spelled response.

Sentences to dictation: The client should write the three sentences dictated by the examiner. Scores for each sentence range from 0 to 4.

Narrative writing: Card 1 has a picture of a cookie theft which is shown to the client who must then write as much as he/she can about what he/she sees in the picture. The client should be encouraged to keep writing for 2 minutes. Scores for this section range from 0 (no relevant writing) to 4 (full description in grammatical sentences).

16 stimulus cards are enclosed with the BDAE. These cards include a range of images, words and sentence that are shown to the client during the assessment.

Detailed administration guidelines are in the test manual that should be purchased.

Time:
The BDAE takes 90 to 120 minutes to administer. The extended format of the BDAE may take up to 2 1/2 hours (Sbordone, Saul & Purisch, 2007). The shortened version takes 30 to 45 minutes (Goodglass & Kaplan, 2001).

Subscales:

The BDAE is comprised of 8 subscales:

  • Fluency
  • Auditory comprehension
  • Naming
  • Oral reading
  • Repetition
  • Automatic speech
  • Reading comprehension
  • Writing

Equipment:
The BDAE requires specialized equipment that should be purchased in specialized stores or online.

Training:
The test costs approximately US$450.00 and includes the full test battery, manual and instructional video.

Alternative forms of the BDAE

Shortened version: described as “a brief, no frills assessment.”

Extended version: includes an assessment of praxis in addition to the standard assessment.

Client suitability

Can be used with:

  • Adults with stroke
  • Adults with communication and language impairments

Should not be used with:

  • Not reported

In what languages is the measure available?

English, Spanish, Portuguese, French, Hindi, Finnish, and Greek (Radanovic & Scaff, 2002; Rosselli, Ardila, Florez & Castro, 1990; Tsapkini, Vlahou & Potagas, 2009/2010).

Summary

What does the tool measure? The BDAE is designed to diagnose aphasia and related disorders.
What types of clients can the tool be used for? The BDAE can be used with, but is not limited to clients with stroke.
Is this a screening or assessment tool? Assessment
Time to administer
  • 90 to 120 minutes (BDAE)
  • 30 to 45 minutes (shortened version)
  • up to 2 1/2 hours (extended version)
Versions Shortened and extended versions
Other Languages English, Spanish, Portuguese, French, Hindi, Finnish, and Greek
Measurement Properties
Reliability
  • No studies have examined the internal consistency of the BDAE in clients with stroke.
  • No studies have examined the reliability of the BDAE in clients with stroke.
Validity


No studies have examined the content validity of the BDAE in clients with stroke.

Criterion
Concurrent Validity: No studies have examined the concurrent validity of the BDAE in clients with stroke.

Predictive Validity: No studies have examined the predictive validity of the BDAE in clients with stroke.

Construct
Convergent/Divergent Validity: 4 studies have examined the convergent validity of the BDAE and reported poor to adequate correlations between the repetition and the commands subscales of the BDAE and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS); poor correlations between the BDAE and the Visuospatial Index of the RBANS and adequate correlations between the BDAE and the Language Index of the RBANS; adequate to excellent correlations with modified versions of the Stroke Impact Scale (Communication, Participation, Physical and Stroke Recovery domains) and Activity Card Sort (total, instrumental and low demand leisure scores); and excellent correlations with the Bilingual Aphasia Test (BAT) comparable automated sequences, listening comprehension and reading subtests.

Known Groups: 1 study has examined known groups validity of the BDAE-SF (Greek version) using Wilcoxon W and reported differentiation between healthy adults and patients with aphasia following stroke.

Floor/Ceiling Effects No studies have examined ceiling effects of the BDAE in clients with stroke.
Sensitivity/Specificity No studies have explored the sensitivity/specificity of the BDAE.
Does the tool detect change in patients? No studies have examined the responsiveness of the BDAE in clients with stroke.
Acceptability The BDAE administration is lengthy and some clients can become irritated with the more simplistic items.
Feasibility The BDAE is widely used as an assessment of aphasia. Age and education-adjusted norms are available (Borod, Goodglass & Kaplan, 1980).
How to obtain the tool?

The BDAE can be obtained from one of the following websites at costs from US$435 to US$496:

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the Boston Diagnostic Aphasia Examination (BDAE) in individuals with stroke. We identified 5 studies.

Floor/Ceiling Effects

No studies have examined the ceiling effects of the BDAE in clients with stroke.

Reliability

No studies have examined the reliability of the BDAE in clients with stroke.

Validity

Content

No studies have examined the content validity of the BDAE in clients with stroke.

Criterion

Concurrent.
No studies have examined the concurrent validity of the BDAE in clients with stroke.

Predictive.
No studies have examined the predictive validity of the BDAE in clients with stroke.

Construct

Convergent/Discriminant.
Larson, Kirschner, Bode, Heinemann and Goodman (2005) analyzed the construct validity of the BDAE by comparing it to the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) (Randolph, 1998) in 88 clients with stroke. Correlations between the Repetition subscale of the BDAE and the Attention, Language, Immediate Memory, and Delayed Memory Indexes of the RBANS were adequate (r = 0.45; 0.42; 0.40; 0.38, respectively), while correlations between the Repetition subscale of the BDAE and the Visuospatial Index of the RBANS were poor (r = 0.25). Correlations between the Commands subscale of the BDAE and the Language and Immediate Memory Indexes of the RBANS were adequate (r = 0.38; 0.37, respectively) while between the Commands subscale of the BDAE and the Delayed Memory, Attention and Visuospatial Indexes of the RBANS correlations were poor (r = 0.30; 0.24; 0.14, respectively).

Wilde, (2006) examined the construct validity of the BDAE by comparing it to the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) (Randolph, 1998) in 22 clients with stroke. The BDAE showed an adequate correlation with the Language Index of the RBANS (r = 0.40) and a poor correlation with the Visuospastial Index of the RBANS (r = 0.19).

Tucker et al. (2012) developed modified versions of the Stroke Impact Scale (SIS), Medical Outcomes Study Short Form-36 (SF-36), Activity Card Sort (ACS) and the Reintegration to Normal Living Scale to improve the use of the measures with patients with aphasia. The authors examined the relationship between patients’ performance on these modified measures and the severity of aphasia as measured using the BDAE-3 Short Form, in a sample of 29 community-dwelling people with subacute or chronic stroke and aphasia. The BDAE Expressive component demonstrated excellent correlations with the SIS Communication, Participation and Stroke Recovery domains (r=0.72, 0.66, 0.60 respectively), and adequate correlations with the SIS Physical domain (r=0.46) and the ACS total, Instrumental and Low Demand Leisure scores (r=0.55, 0.53, 0.57 respectively). The BDAE Auditory Comprehension component demonstrated adequate correlations with the SIS Communication, Participation and Stroke Recovery domains (r=0.57, 0.50, 0.45 respectively) and the ACS total, Instrumental and Low Demand Leisure scores (r=0.51, 0.48, 0.47 respectively). The BDAE Language Competency Index (LCI) demonstrated excellent correlations with the SIS Communication and Participation domains (r=0.67, 0.61 respectively) and adequate correlations with the SIS Stroke Recovery domain (r=0.56) and the ACS total, Instrumental and Low Demand Leisure scores (r=0.55, 0.53, 0.55 respectively). Correlations with other SIS domains, ACS scores and the SF-36 and Reintegration to Normal Living Scale were not significant.

Peristeri and Tsapkini (2011) examined correlations between similar subtests of the BDAE-3 Short Form (Greek version) and the Bilingual Aphasia Test (BAT) (Greek version) in 9 patients with agrammatic aphasia, including 7 with chronic stroke. Correlations between tests of automated sequences, listening comprehension (BDAE complex ideational material subtest) and reading were excellent (r=0.75; 0.75; 0.88, respectively). Correlations between tests of fluency, commands, verbal auditory discrimination, word repetition, sentence repetition and naming were not significant.

Known groups.
Tsapkini, Vlahou and Potagas (2009/2010) examined the discriminative (known group) validity of the BDAE-SF (Greek version) by comparing the performance of healthy community-dwelling adults and patients with aphasia secondary to stroke, using Wilcoxon’s rank sum test (W). Participants were matched according to education, age and gender. Significant differences between healthy adults and individuals with aphasia were seen in subgroups of middle-aged individuals (40-59 years) of middle education and higher education on subtests of auditory comprehension (W=32, p=0.005; W=20, p=0.015 respectively), oral expression (W=32, p=0.005; W=20, p=0.015 respectively) and reading (W=24, p=0.003; W=10, p=0.035 respectively), and in a subgroup of older individuals (60 years+) with low education on subtests of auditory comprehension (W=56.5, p=0.009) and oral expression (W=51, p=0.005).

Responsiveness

No studies have examined the responsiveness of the BDAE in clients with stroke.

References

  • Borod, J.C., Goodglass, H., & Kaplan, E. (1980). Normative data on the Boston Diagnostic Aphasia Examination, Parietal Lobe Battery, and the Boston Naming Test. Journal of Clinical Neuropsychology, 3, 209-215.
  • Enderby, P.M., Wood, V.A., Wade, D.T., & Hewer, L.R. (1987). The Frenchay Aphasia Screening Test: A short, simple test for aphasia appropriate for nonspecialists. International Journal of Rehabilitation Medicine, 8, 166-170.
  • Goodglass, H. & Kaplan, E. (1972). The assessment of aphasia and related disorders. Philadelphia, Boston: Lea & Febiger.
  • Larson, E.B., Kirschner, K., Bode, R., Heinemann, A., & Goodman, R. (2003). Construct and predictive validity of the repeatable battery for the assessment of neuropsychological status in the evaluation of stroke patients. Journal of clinical and experimental neuropsychology, 27, 16-32.
  • Peristeri, E., & Tsapkini, K. (2011). A comparison of the BAT and BDAE-SF batteries in determining the linguistic ability in Greek-speaking patients with Broca’s aphasia. Clinical Linguistics & Phonetics, 25 (6-7): 464-479.
  • Radanovic, M. & Scaff, M. (2003). Speech and language disturbances due to subcortical lesions. Brain and language, 84, 337-352.
  • Randolph, C. (1998). The Repeatable Battery for the Assessment of Neuropsychological Status. San Antonio, TX: The Psychological Corporation.
  • Rosselli, M., Ardila, A., Florez, A., & Castro, C. (1990). Normative data on the Boston Diagnostic Aphasia Examination in a Spanish-speaking population. Journal of Clinical and Experimental Neuropsychology, 12, 313-322.
  • Sbordone, R.J., Saul, R.E., & Purisch, A.D. Neuropsychology for Psychologists, Health Care Professionals, and Attorneys. Boca Raton, FL: Taylor and Francis Group. Tucker, F.M., Edwards, D.F., Mathews, L.K., Baum, C.M., & Connor, L.T. (2012). Modifying Health Outcome Measures for People With Aphasia. American Journal of Occupational Therapy, 66, 42-50.
  • Tsapkini, K., Vlahou, C.H., & Potagas, C. (2009/2010). Adaptation and validation of standardized aphasia tests in different languages- Lessons from the Boston Diagnostic Aphasia Examination – Short Form in Greek. Behavioural Neurology, 22, 111-119.
  • Tucker, F.M., Edwards, D.F., Mathews, L.K., Baum, C.M., & Connor, L.T. (2012). Modifying Health Outcome Measures for People With Aphasia. American Journal of Occupational Therapy, 66, 42-50.
  • Wilde, M.C. (2006). The validity of the repeatable battery of neuropsychological
    status in acute stroke. The clinical neuropsychologist, 20, 702-715.

See The Measure

How to obtain the BDAE:

The BDAE can be obtained in the following websites and costs from US$ 435 to US$ 496.

Other language impairment outcome measures in stroke:

  • Frenchay Aphasia Screening Test (FAST) – Enderby, Wood, Wade, and Hewer, 1987.
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