The Three-Minute Assessment:

Clinical Profiles Associated with

Verbal Fluency

Jacqueline Hinckley, Ph.D., BC-ANCDS

Contact:
Dr.JJHinckley@gmail.com
www.SLandP.com
 Disclosure Statement
I have no relevant financial or nonfinancial
relationship(s) within the products or services
described, reviewed, evaluated or compared
in this presentation.
 Handout
A handout with summary and selected
references is posted online (ASHA Handouts).
I will be posting a protocol sheet and additional
information about this topic on my blog at
www.SLandP.com
Please email me to request a copy of these
slides.
Dr.JJHinckley@gmail.com
In 3-5 minutes, it is
possible to get clues
about language and
executive functions by
assessing performance
on verbal fluency.
 Most key sources are available at:

http://www.asha.org/members/ebp/compendiu
m/reviews/
Benton, A. L. & Hamsher, K. (1976). Multilingual aphasia examination. (2nd ed). Iowa City, IA: AJA Associates.

Henry, J. D. & Beatty, W. W. (2006). Verbal fluency deficits in Multiple Sclerosis. Neuropsychologia, 44, 1166-1174.

Henry, J. D. & Crawford, J. R. (2004a). A meta-analytic review of verbal fluency performance following focal cortical
lesions. Neuropsychology, 18, 284-295.

Henry, J. D. & Crawford, J. R. (2004b). A meta-analytic review of verbal fluency performance in patients with traumatic
brain injury. Neuropsychology, 18, 621-628.

Henry, J. D. & Crawford, J. R. (2004c). Verbal fluency deficits in Parkinson's disease: A meta-analysis. Journal of the
International Neuropsychological Society, 10, 608-622.

Henry, J. D., Crawford, J. R. & Phillips, H. R. (2004). Verbal fluency performance in dementia of the Alzheimer's type: A
meta-analysis. Neuropsychologia, 42, 1212-1222.

Laws, K. R., Adlington, R. L., Gale, T. M., Moreno-Martinez, F. J. & Sartori, G. (2007). A meta-analytic review of category
naming in Alzheimer's disease. Neuropsychologia, 45, 2674-2682.

Loonstra, A. S., Tarlow, A. R. & Sellers, A. H. (2001). COWAT metanorms across age, education, and gender. Applied
Neuropsychology
When we use any practice that has accumulated
evidence, we increase the likelihood that what
we are doing clinically will produce the
desired results.
 What is verbal fluency?
• The search and retrieval of words that fit a
particular criteria within a time limit.
– Semantic (aka category) fluency = generating
words that fit into a semantic category
– Phonemic (aka letter) fluency = generating words
that begin with a particular letter
• The phrase Controlled Oral Word Association
Test was coined to differentiate verbal fluency
from language fluency in aphasia.
 A semantic fluency task
“I’d like you to think about and name as many
animals as you can in about a minute while I
count them. They could be any kind of
animal, for example, they could be from the
farm, the jungle, the ocean, or house pets.
For instance, you could start with ‘dog’.” (BDAE
task instructions)
STOP
 A phonemic fluency task
• F-A-S
• Standard administrations include three letters
and at least one constraint
• Example:
– “I’d like you to say as many words as you can that
begin with a particular letter. They cannot be proper
nouns, though, so they cannot be names of people or
places, for example. Also, you may not use words that
have different endings, like “fish” and “fishing”. I’d like
you to say words that begin with ‘F’.”
STOP
 A phonemic fluency task
• F-A-S
• Example:
– “I’d like you to say as many words as you can that
begin with a particular letter. They cannot be
proper nouns, though, so they cannot be names
of people or places, for example. I’d like you to say
words that begin with ‘A’.”
 A phonemic fluency task
• F-A-S
• Example:
– “I’d like you to say as many words as you can that
begin with a particular letter. They cannot be
proper nouns, though, so they cannot be names
of people or places, for example. I’d like you to say
words that begin with ‘S’.”
A cognitive task analysis of semantic
and phonemic fluency
Semantic
Search Strategies
Fluency Generate search
strategy
Executive Deploy search
Functions strategy
Switch to new
strategy

penguin cow
Linguistic
dog monkey
Functions whale Features
Associations

Semantic Store

Chertkow & Bub, 1990

Poor
Performance Search Strategies
Generate search
strategy
Deploy search
Difficulty with strategy
search strategies Switch to new
strategy

And/or
penguin cow
Decreased
dog monkey
semantic store whale Features
Associations

Semantic Store

Chertkow & Bub, 1990

Phonemic
Fluency Search Strategies
Generate search
strategy
Executive Deploy search
Switching Remembering
Functions strategy and adhering
to constraint
Switch to new
strategy

fork fly
Linguistic
Clustering
Functions
fry fact
four
France

Semantic Store

Troyer et al, 1997

 Search Strategies

Executive
Functions
Executive
Functions Linguistic
Functions
Linguistic
Functions

Semantic Store

Chertkow & Bub, 1990

 Verbal fluency compared to automatic speech:
Left hemisphere more active in verbal fluency

Birn et al, 2010

• Category Fluency (red):
– Occipital (visual) cortex
– Left middle frontal gyrus
Birn et al, 2010
• Letter fluency (blue):
– Left precentral gyrus
– Left inferior frontal gyrus
– Bilateral superior
parietal cortex
Subcortical structures such as the basal ganglia are also
involved in verbal fluency, especially phonemic fluency
(Thames et al, 2012)
 Different neurological conditions are
associated with different
performances on verbal fluency tasks.

1. Scoring
2. Clinical Profiles
 Quantitative Scoring: Is the
performance different from normal?
 Quantitative Scoring
Semantic Fluency: Animal Naming
• Number of non-repeated correct animal
names produced in sixty seconds
• Alternate forms include other categories with
published norms, such as
– Tools
– Supermarket items
– Fruits
Tombaugh
et al, 1999
 Quantitative Scoring
Phonemic Fluency: F-A-S
• Total number of all appropriate non-repeated
words produced across three minutes (all
three letters)
– Exclude repetitions
– Exclude proper nouns
– Exclude related words that differ by suffix
• Alternate forms: C-F-L, P-R-W
• Aka Controlled Oral Word Association Test
(COWAT)
Loonstra et al, 2001 © J. J. Hinckley, 2012
Qualitative Scoring: How is the
performance different?
 Qualitative Analysis
Semantic Fluency
• Subcategories
– Switching from one subcategory to another
• Lack of switching suggests executive function
impairment
– Exploring/exploiting exemplars within one
subcategory
• Difficulty generating items within subcategories may be
more indicative of semantic generation impairment
 Qualitative Analysis
Semantic Fluency
• Repetitions
– May signal difficulty with memory
• Out-of-category items
– May suggest difficulty to maintain set or maintain
task instructions
 Qualitative Analysis
Phonemic Fluency
• Clustering: Generating items that are homonyms
or share spelling
– E.g., words that start with a blend (“fl”)
– E.g., “fat”, “far”
• Switching: Switching from one of these cluster
strategies to another
• Repetitions
– May signal difficulty with memory
• Rule violations, including inappropriate items
– May suggest disinhibition, memory impairment
Clinical Profiles
 Aphasia
• Both semantic and phonemic verbal fluency are
reduced compared to normal controls
• Individuals with posterior lesions and fluent-type
aphasias (e.g., Wernicke’s) are more likely to have
semantic fluency worse than phonemic fluency
• Individuals with anterior lesions and nonfluent-
type aphasia (e.g., Broca’s) are more likely to
have phonemic fluency worse than semantic
fluency
Verbal fluency performance: aphasia with
temporal lobe involvement
(Baldo et al, 2010)
Baldo et al, 2010
Verbal fluency performance: aphasia
with frontal lobe involvement
(Baldo et al, 2010)
Baldo et al, 2010
Traumatic Brain Injury
(Henry & Crawford, 2004)
 Traumatic Brain Injury
(Henry & Crawford, 2004)

• Phonemic fluency performance is more

sensitive to brain injury than Wisconsin Card
Sort Task
• Qualitative error analysis reveals rule
violations, repetition of items, inappropriate
items characteristic of phonemic fluency
performance in TBI
 Dementia
(Henry, Crawford & Phillips, 2006)

Both phonemic and

semantic fluency scores
are positively correlated
with dementia severity
ratings
 Dementia
Is verbal fluency performance reflective of other
naming performance, like picture naming?

NO

Both semantic and phonemic fluency

are more impaired than
picture naming (Boston Naming Test)
 Why would verbal fluency
performance be worse than picture
naming?
Picture Naming
Search Strategies
Generate search
strategy
Deploy search
Difficulty with strategy
search strategies Switch to new
strategy

And/or
penguin cow
Decreased
dog monkey
semantic store whale Features
Associations

Semantic Store

Chertkow & Bub, 1990

 Dementia
(Henry, Crawford & Phillips, 2006)

Semantic fluency is generally more impaired

than phonemic fluency
 Multiple Sclerosis
(Henry & Beatty, 2006)

1. Both phonemic and semantic fluency are

equally impaired in MS.

2. Both phonemic and semantic fluency are

more impaired than other measures of
naming (e.g., Boston Naming Test or other
measures of executive function (e.g.,
Wisconsin Card Sort).
 Parkinson’s Disease
(Henry & Crawford, 2004)

• Non-demented PD do fairly well on both

semantic and phonemic fluency
• Demented PD do equally poorly on semantic
and phonemic fluency
• Compare to DAT: Semantic fluency worse than
phonemic fluency
Applicability to culturally and
linguistically diverse groups
Arabic norms (Khalil, 2010)
 General Conclusions
• Verbal fluency is a quick, evidence-based
assessment tool that provides clinical
information about executive and linguistic
functions.
• An equivalent degree of impairment in both
phonemic and semantic fluency implicates
executive function impairments.
• Differences between semantic and phonemic
fluency suggest focal impairments.
Dr.JJHinckley@gmail.com