NORMATIVE DATA AND SCREENING POWER

OF A SHORTENED VERSION OF THE TOKEN TESr

E. De Renzi and P. Faglioni

(Neurological Department, University of Modena)

The aim of this paper is to provide detailed instructions and normative

data for an abbreviated form of the Token Test that has been shown to
have a high discriminative power in distinguishing between normals and
aphasics. When the original version of the Token Test was published (De
Renzi and Vignola, 1962), emphasis was placed on the sensitivity achieved
by a comprehension test in which the redundancy of commands is reduced.
Little attention was given to the criteria for differentiating a normal from
an aphasic performance. This circumstance encouraged a rather loose use
of the test, some authors considerably reducing the number of items, othf:rs
changing the scoring system, still others the shape and colors of the tokens.
Although the changes the test has undergone have not detracted from its
popularity as an effective tool to diagnose aphasia and may have even enlarged
the scope of its application, they have left the scientific community without
a conventional form of the test, to which everybody may refer when
discussing results obtained in different groups of patients.
Since we too have devised a version of the Token Test that differs from
the original one in some aspects and have extensively used it with normal
and brain-damaged patients (De Renzi and Faglioni, 1975), we think that
it may be useful to provide normative data in order to encourage its
employment as a clinical device. The main differences from the original
version are as follows: (1) The number of items has been limited to 36,
reducing the commands of part I to IV from 10 to 4 and the commands
of part V from 21 to 13. On the other hand, a new section has been
introduced at the beginning of the test, containing 7 items of minimal
difficulty, in that they require the comprehension of one word only (e.g.,
"Touch the circle"). The purpose was to broaden the assessment capacity
of the test with respect to aphasics with severe comprehension deficit,

' Th1s work was supported by a grant from the Consiglio Nazionale delle Ricerche.

Cortex (1978} 14, 41-49.

42 E. De Renzi and P. Faglioni

whose performance would be, otherwise, equalized at zero level. (2) The
material of the test has been changed slightly: squares instead of rectangles
have been used, in consideration of the greater frequency of occurrence of
the former compared to the latter word, and black tokens have been
substituted for blue tokens in view of the suggestion (Scotti and Spinnler,
1970) that some normal as well as brain-damaged patients may find it
difficult to discriminate blue from green. Since there are green tokens in
the test, it was thought desiderable to avoid the confounding effect of
color misperception.

MATERIAL AND METHODS

Subjects
Only right-handed Ss were tested. The control group consisted of 215 subjects,
for the most part patients admitted to the wards for disease involving the spinal
cord, peripheral nerves, muscles or eventually diagnosed free from nervous system
pathology. A minority consisted of relatives or inpatients, of nurses or of acquaint­
ances of the investigators. The aphasic group was made up of 200 patients with
injury to the left hemisphere, examined in the course of several years in the aphasia
units of the Milan and Modena University departments and who proved to be
impaired on one or more subsections of a standard aphasia battery. No special
attempt was made to select them according to predetermined criteria and by and
large they may be considered representative of the aphasia population in the
setting of a neurological department. Cerebrovascular accidents were the main
etiology, followed by neoplasm, trauma and cerebral atrophy. The time elapsed
since onset of aphasia ranged from 1 day to 12 years.

Token Test
The test consists of 20 plastic tokens 3 mm in thickness. Ten are circles and
ten squares. Five circles and squares are large, i.e. are 30 mm on each side or in
diameter, respectively, and five circles and squares are small, i.e. are 20 mm on
each side or in diameter, respectively. In each series of 5 circles or squares, the
following colors are represented: black, white, red, yellow and green. When all
20 tokens are used, their arrangement on the table is that indicated in Figure 1.
The patient is seated in front of the token array and is told, "As you see,
there are 20 tokens here. Some of them are squares (the E quickly puts his finger
on the two series of squares), while others are circles (he does the same). Some
are large, others are small (he so indicates). There are red ones, black, green, yellow
and white ones (each time he points to the tokens of the color named). Now, I'm
going to tell you to touch one of these tokens: 'Touch a circle."' If the subject
asks, "Which one?", theE answer "Whichever one you want: just touch a circle."
In giving the commands the words should be uttered distinctly and without
any special prosodic emphasis, with the exception of the "no" in item 34, which
is accentuated and followed by a brief pause, before saying "the white squares."
 Shortened version of the token test 43

00000
[][][][][ ]
88888
Fig. 1 - Token Test: Arrangement of tokens.

Part 1. All 20 tokens displayed as in Figure 1:

1. Touch a circle
2. Touch a square
3. Touch a yellow token
4. Touch a red one
5. Touch a black one
6. Touch a green one
7. Touch a white one

Part 2. The small tokens are removed:

8. Touch the yellow square
9. Touch the black circle
10. Touch the green circle
11. Touch the white square

Part 3. The small tokens are replaced:

12. Touch the small white circle
13. Touch the large yellow square
14. Touch the large green square
15. Touch the small black circle
44 E. De Renzi and P. Faglioni

Part 4. The small tokens are removed:

16. Touch the red circle and the green square
17. Touch the yellow square and the black square
18. Touch the white square and the green circle
19. Touch the white circle and the red circle

Part 5. The small tokens are replaced:

20. Touch the large ·white circle and the small green square
21. Touch the small black circle and the large yellow square
22. Touch the large green square and the large red square
23. Touch the large white square and the small green circle

Part 6. The small tokens are removed:

24. Put the red circle on the green square
25. Touch the black circle with the red square
26. Touch the black circle and the red square
27. Touch the black circle or the red square
28. Put the green square away from the yellow square
29. If there is a blue circle, touch the red square
30. Put the green square next to the red circle
31. Touch· the squares slowly and the circles quickly
32. Put the red circle between the yellow square and the green square
33. Touch all the circles, except the green one
34. Touch the red circle - no - the white square
35. Instead of the white square, touch the yellow circle
36. In addition to touching the yellow circle, touch the black circle

If following each command of parts 1-5 the patient fails to initiate a response
after 5 sec. or if he responds incorrectly, the examiner returns the tokens to their
original order, when necessary, and says "Let's try that again" and the command
is repeated. One point is credited for a correct performance on the first presentation
and .5 point if the performance is correct only on the second presentation. The
items of the sixth part are not repeated, because experience has shown that
patients usually do not benefit from a second presentation and often become
frustrated, not knowing where the error is. Corrections made spontaneously are
accepted. If the patient complains that he has forgotten part of the command, he
is told that he should do as much as he remembers.
If no correct response occurs in five successive items of the first five parts,
the test is discontinued. However, Part 6 is given in its entirety, whenever the
performance of the patient on the earlier parts makes him eligible to take it.

RESULTS

Table I shows the distribution of the normal subjects' scores. The first
step was to assess the influence of age and educational level on performance
by computing the regression coefficients of the test scores on these two
 Shortened version of the token test 45

TABLE I
Distribution of Normal Subjects' Scores

N" of subjects
T. T. scores (raw scores) (adjusted scores)

.36 21 14
.35 .35 .34
.34 43 .3.3
.3.3 3.3 56
.32 29 .36
.31 21 22
.30 18 7
29 5 2
28 2 6
27 3 2
26 2
25 1
24
2.3
22 1 1
21 1

For the sake of convenience, the scores with half point have been rounded to the upper figure.

factors. In keeping with Orgass and Poeck's ( 1966) findings, the effect
of age was negligible, the regression coefficient being - .03. The effect of
years of schooling was more substantial: the regression coefficient was .30
(p < .001 with 213 d.f.). To partial out its influence on the performance,
the normal subjects' scores were corrected according to the following
formula: observed score + 2.36-.30 X years of schooling. This procedure
was also effective in normalizing the score distribution. The mean of the
adjusted scores was 32.86 and the S.D. 2.14.
The cutting score distinguishing a normal from a pathological perform­
ance was determined by computing the 90% tolerance interval around
the mean (Lieberman and Miller, 1963 ): the score of 29 corresponded to
the lower tolerance limit, below which 5% of the normal population is
expected to fall. In our sample 11 subjects had an adjusted score inferior
to 29, which corresponds exactly to 5%. An expeditious way to transform
observed scores into adjusted scores is to add 1 point for subjects with 3-6
years of schooling, and to substract 1 point for subjects with 10-12 years
of schooling, 2 points for subjects with 13-16 years of schooling and 3 points
for subjects with 17 years of schooling.
The scores of aphasic patients were extremely dispersed, ranging from
a minimum of 0 to a maximum of 33 points. They were corrected for
years of schooling by the same formula used for normals. The adjusted
46 E. De Renzi and P. Faglioni

scores had a mean of 17.05 and a S.D. of 7 .81. Fourteen patients (7%)
attained or exceeded the cutting score of 29.
The sensitivity of the Token Test in detecting impairment of oral
comprehension may be better appreciated by comparing this percentage of
wrong classification with that obtained administering to the same patients
a 10 phrase comprehension test, which is used in our Aphasia Standard
Examination. It is made up of the following commands: ( 1) Open the book,
(2) Blow your nose, (3) Raise your left hand, (4) Give me the ashtray,
(5) Put the pencil in your pocket, (6) Knock on the table, (7) Fold the
sheet in four, (8) Touch your forehead, (9) Turn over the wastebasket,
(10) Look at the mirror. Each item could be repeated a second time; the
patient received 1 point if the item was correctly executed immediately
and .5 point if it was correctly executed only on the second presentation.
On the basis of the performance of 50 normal subjects, the cutting score
leaving below no more than 5% of normal controls, had been set at 8.5
points. The data of the phrase comprehension test were available for 106
out of 200 aphasics. Forty-two (40%) scored above the cutting point,
while the corresponding number for the Token Test was 8 (7.5% ).
It has been maintained (Orgass and Poeck, 1966; Cohen, Kelter, Engel,
List and Strohner, 1976) that the Token Test does not discriminate between
fluent and non-fluent aphasics, although subsequently Poeck, Hartje,
Kerschensteiner and Orgass (197 3) provided evidence that sensory aphasics
are more impaired that motor and amnesic aphasics. In our sample, 108
patients were diagnosed as fluent and 71 as non fluent on the basis of
their speech output in free conversation, open ended questions and tell-a­
story test. (The remaining patients belonged to conduction aphasia (7) and
to other less represented categories, such as pure anomia, word deafness,
.tgraphia, alexia and alexia plus agraphia). The means and S.D.s of the two
groups were: fluent = 16.38 and 7 .86; non fluent = 17.02 and 8.04. This
difference falls far short of the significance level (t = .53). One must keep
in mind, however, that the heading of non-fluent aphasia encompasses two
categories of patients, Broca's and global aphasics, to whom corresponds,

TABLE II

Levels of Comprehension Deficit in Aphasics According to the Token Test Scores

Score Impairment N" of patients in

each group

36-29 Nil 14 (7%)

28-25 Mild 20 (10%)
24-17 Moderate 76(38%)
16-9 Severe 58 (29%)
8-0 Very severe 32 (16%)
 Shortened version of the token test 47

respectively, a lesion restricted to the pars opercularis of the third frontal

convolution and adjacent region, or a lesion encroaching upon the entire
language area. Since the distinction between these two forms rests, at the
clinical level, on the degree of the comprehension impairment, which is mild
to moderate in Broca's aphasics and severe in global aphasics, we suggest
to use the Token Test mean (17) of our aphasic sample as an objective
measure for distinguishing between Broca's and global aphasics. Thus, non­
fluent aphasics scoring 17 or more would be considered Broca's, those
scoring less than 17 global. On the same grounds, Table II proposes a
classification of the comprehension deficit, which hinges on the mean plus
or minus one standard deviation and defines four levels of impairment. Its
value is, obviously, only practical, and it simply aims at providing objective
criteria for making clinical evaluations. The number of patients of our sample
falling in each category is also given.

CONCLUSIONS

The Token Test used in this study is very similar to the version employed
by Spellacy and Spreen ( 1969 ), which is the same of that included in the
Neurosensory Center Comprehensive Examination for Aphasia (Spreen and
Benton, 1969). The main differences are that 13 instead of 16 items of part
six have been selected and that .5 point is credited if the patient performs
correctly on the second presentation. Spellacy and Spreen, on the basis of
the data obtained from 3 7 non-aphasic brain-damaged patients and 6 7 aphasic
patients, determined empirically a critical score of 32, which discriminated
at best aphasics from non aphasic brain-damaged patients and found a hit
rate of 79% for the aphasic and of 86% for the non aphasic patients. Our
method for determining the cutting score entirely relied on the control
subjects' performance, and, since their number (215) was sufficiently large
and the moderate influence of years of schooling was taken into account,
we are reasonably confident that the sample is representative of the normal
population. Although it is possible that slight changes in the position of
the cutting score as well as in the bearing of educational level on the perform­
ance would occur in non-Italian samples, it seems unlikely that they would
affect the screening power of the test. With a cutting score that correctly
identifies 95% of normals, the hit rate for aphasics is 93%, a percentage
remarkably higher that ( 60%) found with a sentence comprehension test.
Also Poeck et al. ( 197 3) have reported the Token Test to be clearly
superior to a test of identification of right and wrong sentences.
No comparison has been made in this study between the performance
of aphasics and of left brain-damaged non-aphasic patients, which are the
48 E. De Renzi and P. Faglioni

group more relevant for assessing the screening power of the test. However,
we re-analyzed the protocols of 50 left brain-damaged non aphasic patients,
whose performance had been previously reported (De Renzi and Faglioni,
1975), and corrected the scores for years of schooling: 42 (84%) of them
scored 29 or higher and were, therefore, correctly identified as non-aphasic.
Most of those who scored below the cutting point did so only marginally
and the lowest score was 21. It is, of course, open to question whether
the Token Test misclassifies these patients or reflects more faithfully than
other measures their comprehension level.
The advantage of using the short version is remarkable in terms of time
saving and of the patient's fatiguability: the present test does not take more
than 10-15 minutes in comparison to the 20-30 minutes necessary for
administering the conventional test. On the other hand, a further abbreviation
of the test, as proposed by Spellacy and Spreen (1969), who reduced it to
16 items, does not appear to be justified, in view of the decreased power
that shorter forms have shown with respect to both the aphasic-non-aphasic
dimension (van Harskamp and van Dongen, 1977) and the improvement
occurring in children of increasing age (Lass, De Paolo, Simcoe and Samuel,
1975). We would suggest, therefore, the use of the 36-item-version as the
standard test for diagnostic purpose, while any researcher remains obviously
free to employ longer or shorter forms whenever he thinks that they
would better meet the requirements of his investigation.

SuMMARY

A 36-item-version of the Token Test is described and normative data obtained

from its administration to 215 normal subjects are given. Years of schooling (but
not age) were found to significantly affect the performance. The scores were
corrected for this factor and the lower limit of the 90% tolerance interval around
the mean of the adjusted scores was determined: it was found to correspond to
29 and left below it exactly 5% of the normal sample.
The test was given to 200 aphasic patients. Fourteen (7%) were found to
have an adjusted score of 29 or more, namely would have been classified as non­
aphasic. This is a percentage remarkably smaller than that (40%) obtained with
a 10 sentence comprehension test, which supports previous studies pointing to
the sensitivity of the Token Test to the presence of oral language disorders. On
the basis of the aphasic patients' performance, cutting scores allowing evaluation
of the severity of the comprehension deficit are provided. The 36-item-version of
the test appears to be an useful and convenient device to diagnose aphasic impairment
of language comprehension.
Acknowledgments. The help provided by the Centro di Calcolo dell'Univer­
sita di Modena is gratefully acknowledged.
 Shortened version of the token test 49

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Dr. Ennio De Renzi, M.D., and P. Faglioni, M.D., Clinica Neurologica, via del Pozzo 71, Modena 41100, Italy.