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Aphasiology
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Letting the CAT out of the bag:

A review of the Comprehensive
Aphasia Test. Commentary on
Howard, Swinburn, and Porter,
“Putting the CAT out: What the
Comprehensive Aphasia Test has to
offer”
a a
Carolyn Bruce & Anne Edmundson
a
University College London , UK
Published online: 24 Nov 2009.

To cite this article: Carolyn Bruce & Anne Edmundson (2010) Letting the CAT out of the bag:
A review of the Comprehensive Aphasia Test. Commentary on Howard, Swinburn, and Porter,
“Putting the CAT out: What the Comprehensive Aphasia Test has to offer”, Aphasiology, 24:1,
79-93, DOI: 10.1080/02687030802453335

To link to this article: http://dx.doi.org/10.1080/02687030802453335

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 APHASIOLOGY, 2010, 24 (1), 79–93

FORUM COMMENTARY 2

Letting the CAT out of the bag: A review of the

Comprehensive Aphasia Test. Commentary on Howard,
Swinburn, and Porter, ‘‘Putting the CAT out: What the
Comprehensive Aphasia Test has to offer’’
Carolyn Bruce and Anne Edmundson
Downloaded by [University of Kent] at 17:00 28 November 2014

University College London, UK

Background: For many years, aphasia batteries have been widely used to assess language
difficulties associated with aphasia. Although many clinicians use aphasia batteries in
their clinical evaluation, a gradual shift away from these tests has occurred in the last 10
years. Concerns about whether established aphasia batteries fulfil the purposes of
assessment have resulted in the development and use of other measures to investigate
the effects of brain injury on language function and communication. Recently, a new
aphasia battery was published. The Comprehensive Aphasia Test (CAT; Swinburn,
Porter, & Howard, 2005) is a standardised test designed to comprehensively assess
processes concerned with the recognition, comprehension, and production of spoken
and written language. In addition, it attempts to evaluate how any language-processing
difficulties identified by the test impact on the individual’s everyday life and record the
person’s own perspective of his or her aphasia.
Aims: This paper attempts to provide a critical review of the most widely used aphasia
batteries in the UK. It also aims to evaluate the CAT, a relatively new aphasia battery.
Main Contributions: The paper begins with a brief history of aphasia assessment
followed by a discussion of the purposes of assessment. Then, some of the aphasia test
batteries commonly used in both clinical and research settings in the UK are reviewed.
Finally the CAT, the newest aphasia battery for a number of years, is critiqued.
Questions are asked about the adequacy of aphasia batteries in general and the CAT in
particular to achieve the goals of assessment.
Conclusion: The CAT is a valid and reliable test of language-processing abilities in
adults with aphasia. The test identifies the nature of the person with aphasia’s
impairments and his or her intact processes. It also provides some insight into how the
person feels about his or her aphasia. The information gained may be used to identify
further areas for assessment or provide the basis for devising a therapy programme.
Given the time constraints experienced in clinical and research settings and the useful
information on language skills provided by the CAT, this assessment tool should be of
interest to clinicians and researchers.
Keywords: Aphasia; Assessment battery; The CAT.

Address correspondence to: Carolyn Bruce, Department of Human Communication Science,

University College London, Chandler House, 2 Wakefield Street, London WC1N 1PF, UK. E-mail:
c.bruce@ucl.ac.uk

# 2010 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
http://www.psypress.com/aphasiology DOI: 10.1080/02687030802453335
 80 BRUCE AND EDMUNDSON

There are many tests that can be used to assess people with aphasia. These range
from functional measures of communication to tests of linguistic ability, and from
single tests to comprehensive language batteries. Given the wide variety of aphasia
tests currently available, we might question whether a new test is required.
Furthermore, in light of the ongoing debate over the adequacy of aphasia test
batteries for planning therapy and monitoring change (Byng, Kay, Edmundson, &
Scott, 1990; Nickels, 2005) we might question more specifically whether a new
aphasia test battery is needed. The answers to these questions largely depend on how
well existing tests meet research and clinical needs. Thus, before we can evaluate the
CAT we first need to consider some of the important variables that influence aphasia
assessment practices, in particular what is measured and how.
The decision to use a particular assessment depends on the user’s theoretical
perspective, their experience, the aims of the assessment process, the characteristics
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of the person with aphasia, the environment, and the time and resources available
(Kerr, 1993). The changing perception of aphasia over the last few decades has
meant that different clinicians and researchers may consider aphasia from different
theoretical frameworks. The medical model, cognitive neuropsychological model,
disability model, and social model are just some of the frameworks that might guide
a potential tester’s choice of assessments. Each of these approaches has resulted in
the development of assessments and methods of analysis that focus on specific
aspects of communication. For example, the medical model gave rise to tests of
language and cognitive skills, which aimed to diagnose and classify people with
aphasia into syndromes; the social model, which emphasised the importance of the
communicative environment, produced quality of life scales and social participation
indices, such as the Stroke and Aphasia Quality of Life Scale-39 (SAQOL-39; Hilari,
Byng, Lamping, & Smith, 2003) and the ASHA Quality of Communication Life
Scale (Paul et al., 2004).
The International Classification of Functioning, Disability and Health (ICF;
WHO, 2001) has also been used as a framework for defining aphasia (Cruice,
Worrall, Hickson, & Murison, 2003; Davidson, Worrall, & Hickson, 2003; Howe,
Worrall, & Hickson, 2004; Threats & Worrall, 2004). The ICF is not an assessment
tool, but the framework can help guide the selection of assessment methods. The
framework encourages a broad view of aphasia as it describes ‘‘conditions in terms
of body function and structure, performance of activities, participation in relevant
life situations, and the influence on functioning of environmental and personal
factors’’ (Simmons-Mackie, Threats, & Kagan, 2005, p. 12). No single assessment
can hope to measure such a complex and multidimensional process; rather a variety
of assessments and protocols are needed to evaluate the different domains. Ideally
the assessments should be selected to target the key factors that prevent the person
from participating in the areas of life most important to them. For some people this
may mean assessing impairments of body structures and functions, but for others it
may mean identifying participation restrictions. Even for individuals with aphasia
who have prioritised a specific area on which to focus in therapy, a comprehensive
assessment of their language impairment may be useful. Therapy tasks often make
use of multiple modalities. For example, naming therapy may involve matching a
written name to a picture or encouraging an individual to gesture or write the name
of an item they are unable to retrieve in conversation. In order to minimise failure, it
is important to evaluate these other skills prior to attempted rehabilitation.
 CAT FORUM: COMMENTARY 2 81

PURPOSES OF ASSESSMENT
The decision to use a particular assessment is influenced by both the clinician’s
theoretical perspective and his or her aims for the assessment process. Different
opinions about the purpose of assessment explain at least some of the controversy
that surrounds what constitutes a good assessment measure. Assessment of an
individual after brain injury may be carried out for a number of reasons. These
include detecting possible signs of aphasia, making a diagnosis, classifying the type
of aphasia, which can lead to inferences concerning cerebral localisation, clarifying
the nature of the language impairment, establishing the severity level, determining a
prognosis, setting goals for treatment, ascertaining a baseline, selecting possible
therapy approaches, and monitoring change following treatment. The information
required to fulfil these various goals is different and it is as unrealistic to think that a
wide-ranging aphasia battery will achieve them all, as it is to think that a single
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assessment will be able to adequately examine all components of the ICF framework.
The assessments selected need to fit the purpose in hand. For example, clinicians
working in an acute hospital setting may use a screening test such as the Frenchay
Aphasia Screening Test (FAST; Enderby, Wood, Wade, & Langton Hewer, 1987) to
identify the presence of aphasia and some of its specific characteristics, which they
may then evaluate further with more targeted testing. In contrast, people involved in
research may select an assessment such as the Western Aphasia Battery (WAB;
Kertesz, 1982) because it assigns the individual with aphasia to a ‘‘traditional’’
syndrome category, such as Broca’s or Wernicke’s aphasia. By classifying research
participants into specific categories the researcher is able to draw conclusions about
group characteristics. Then again, in the USA a clinician who is seeking third-party
payer coverage of treatment may choose to use The Porch Index of Communicative
Ability (PICA; Porch, 1981) as it provides predictive information about the course
and extent of recovery based on initial test scores.

REVIEW OF ESTABLISHED APHASIA BATTERIES

In the past decade several surveys have collected information about assessment
practices in the English-speaking world (Hesketh & Hopcutt, 1997; Katz et al., 2000;
Petheram, 1998). These surveys revealed that a wide variety of assessments were used
in clinics and that different clinicians assessed different aspects of performance and
used different tests to do this. Despite the growing interest in working within a
functional framework, the majority of respondents in these surveys administered
tests that focused on the language impairment of the person with aphasia. Moreover,
aphasia batteries that were primarily designed to provide a classical aphasia type and
to localise damage rather than plan treatment were widely used by these aphasia
therapists. This seems surprising on two counts: first, recent advances in brain-
imaging technology have significantly decreased the importance of language data for
localisation, and second, cognitive neuropsychology has revealed the importance of
investigating underlying language processes when planning rehabilitation. In a
multinational survey of five English-speaking healthcare systems by Katz and
colleagues (2000), the Boston Diagnostic Aphasia Examination (BDAE; Goodglass
& Kaplan, 1972, revised 1983), the Western Aphasia Battery (WAB; Kertesz, 1982),
and the Boston Naming Test (BNT; Kaplan, Goodglass, & Weintraub, 1983) were
reported to be administered most frequently.
 82 BRUCE AND EDMUNDSON

The above results largely concur with the findings reported by an earlier survey of
the availability and use of aphasia assessments in the UK (Petheram, 1998). While a
variety of tests were listed by the clinicians, the BDAE (Goodglass & Kaplan, 1983),
the Psycholinguistic Assessments of Language Processing in Aphasia (PALPA; Kay,
Lesser, & Coltheart 1992), the Minnesota Test for the Differential Diagnosis of
Aphasia (MTDDA; Schuell, 1965), and the WAB (Kertesz, 1982) appeared to be the
most frequently available. Another important finding was that availability did not
equate with use: more than 80% of the speech and language therapists reported that
they used informal tests instead of or as well as formal tests. As the assessments in
Petheram’s study appear to be in widespread use at the moment, they will be looked
at in more detail in the following section. However, it should be noted that other
comprehensive aphasia tests are used in the United States and Canada, including the
Porch Index of Communicative Ability (PICA; Porch, 1981) and the Aphasia
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Diagnostic Profiles (ADP; Helm-Estabrooks, 1992). The Aachen Aphasia Test

(AAT; Huber, Poeck, Weniger, & Willmes, 1983) is the most popular assessment in
Europe, and an English version of the AAT has recently been developed (Miller,
Willmes, & De Bleser, 2000).
Although all the most popular assessments referred to in Petheram’s study (1998)
are comprehensive aphasia tests that target language and/or cognitive skills, they
come from different theoretical standpoints and were designed to meet different aims
(see Appendix). Three of the tests, the MTTDA, BDAE, and WAB, are aphasia
batteries. They are designed so that all of the subtests that comprise the core
components are administered regardless of how the person with aphasia presents. On
occasion, for example when time is short, clinicians may administer only portions of
these batteries, but they are designed to be administered in their entirety. Another
option might be to use shortened versions of the more comprehensive aphasia
batteries. For instance, shorter versions of the MTTDA (Powell, Bailey, & Clark,
1980) and the BDAE-3 (Goodglass, Kaplan, & Barresi, 2001) are available. The
PALPA is not an aphasia battery in the strict sense of the word. Rather than
administering PALPA in its entirety, subtests are selected based on the tester’s
hypothesis of the nature of the individual’s impairment. PALPA, which originated in
the UK, provides only limited psychometric data for a small number of subtests. The
three aphasia batteries were standardised in the North America. The sensitivity of
these tests when used with other populations is questionable. However, over the
years other countries, for example Brazil, have adapted versions of these tests and
normative studies for their populations have been published (Radanovic & Mansur,
2002). As the CAT is an aphasia battery, this discussion will focus on comparing the
three established standardised aphasia batteries mentioned above with the CAT in
order to determine whether the CAT offers any advantages.
The comprehensive aphasia batteries offer a standardised measure that attempts
to provide a broad-ranging comprehensive profile of the person with aphasia’s
abilities, and to detect and measure their impairment. Most standardised aphasia
batteries are based on a modality approach. They measure performance in four main
language areas: expression, auditory comprehension, reading, and writing. The tests
are divided into subsections, which examine each modality using a range of tasks; for
example, conversation through automatic speech to repetition and reading aloud.
The subtests within each section usually increase in difficulty, with mostly pass–fail
scoring, although sometimes with acknowledgement of delays in responding. Within
a relatively short time period a summary profile of an individual’s performance
 CAT FORUM: COMMENTARY 2 83

across the subtests can be obtained and this can be compared with the performance
of his or her brain-damaged or non-brain-damaged peers. Even though normative
data are available for tests such as the WAB and the BDAE, some authors have
questioned how representative they are of typical people with aphasia, as these data
were obtained from individuals treated at single institutions (Biddle, Watson,
Hooper, Lohr, & Sutton, 2002).
Standardised tests are chosen by clinicians because they believe that they provide
valid, reliable, and sensitive measurements. However, evidence indicates that not all
aphasia tests possess these characteristics to a suitable level. A recent review of
speech and language assessments found that although the WAB met the standard of
evidence set by the authors for both reliability and validity (greater than 0.80 if
measured using a correlation coefficient), the BDAE-2 did not (Biddle et al., 2002).
The level of sensitivity of aphasia batteries has also been questioned (Byng et al.,
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1990; Howard & Hatfield, 1987).

Determining the type and severity of aphasia is not the only aim of assessment.
For many clinicians the main purpose of assessment is to set appropriate goals for
therapy and to measure treatment effectiveness. There has been a great deal of
debate about the adequacy of standardised aphasia batteries, including the
MTDDA, BDAE, and WAB, to fulfil these roles. Byng et al. (1990) argue that
aphasia batteries that are primarily designed to classify a person with aphasia into a
syndrome say very little about the underlying nature of the language impairment,
and consequently contribute little to rehabilitation. A major reason for this is that
the subtests in the aphasia batteries do not control for the variables known to affect
aphasic performance, such as frequency, imageability, animacy, word length, and
spelling regularity. Another reason is that the BDAE and the WAB, which are based
on the Wernicke-Lichtheim model, do not provide a theoretical framework within
which to interpret the results of the subtests. In contrast, Goodglass (1990) maintains
that as the aphasia batteries also provide an overview of language skills, they assist
the clinician in deciding where to focus treatment. Several researchers have suggested
that most aphasia batteries are unsuitable for measuring the effectiveness of therapy
or language recovery, as the subtests include too few items to identify small changes
(David, 1990; Kay, Byng, Edmundson, & Scott, 1990). A final reason for
administering an assessment may be to predict the future functioning of an
individual with aphasia. This information may assist the clinician in devising an
appropriate intervention programme and contribute to the planning of the person’s
overall care pathway. The BDAE, MTDDA, and WAB do not provide evidence of
predictive validity.
Another criticism of current aphasia batteries is that potentially important aspects
of language and communication are not adequately assessed (Simmons-Mackie,
2001). All the assessments mentioned above consider the abilities of a person with
aphasia in structured language tasks providing a measure of language impairment
rather than in communicative activities of daily living, for example, conversation.
Concerns have been expressed that what is measured in these tests is largely
unimportant for life fulfilment or competent functioning in everyday activities
(Sarno, 1972). Although some of these objections may be valid, the information
obtained from aphasia batteries is not irrelevant. Most studies that have examined
the relationship between language impairment and activity limitations and
participation restrictions (Bakheit, Carrington, Griffiths, & Searle, 2005; Irwin,
Wertz, & Avent, 2002; Ross & Wertz, 1999) have found a significant correlation
 84 BRUCE AND EDMUNDSON

between scores on standardised aphasia batteries and standardised tests of functional

communication—e.g., The Communicative Effectiveness Index (CETI; Lomas et al..,
1989) and Communicative Abilities in Daily Living (CADL; Holland, 1980). The
language and cognitive skills examined in language impairment batteries clearly
support a range of functional behaviours, and the integrity of these skills provides
useful information about how well a person with aphasia will manage independently
in the community. Identification of the individual’s retained abilities is essential for
determining the nature of the problem, the severity of the difficulty, the resources
that can be used in therapy, and the potential for recovery.
Despite the frequent use of aphasia batteries in clinical practice, the concerns
raised above have caused some authors to question their value. According to Nickels
(2005) broad-ranging comprehensive batteries do not provide sufficient benefits to
justify their use in the assessment process. She asserts that the time taken to perform
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the tests would be better used in observation of the individual and administration of
selective assessments, such as subtests of the PALPA. This collection of tests, which
is inspired by a psycholinguistic model of language processing, satisfies many of the
criteria for aphasia tests sought by Byng and her colleagues (1990). The PALPA
allows the tester to examine in detail a potential trouble source within a model of
language processing. However, in order to use the PALPA effectively the ‘‘clinician
must know enough about models of language processing to decide which subtests to
administer and then how to interpret the results’’ (Swinburn et al., 2005, p. 3).
Nickels (2005) concedes that established aphasia batteries may be useful to less-
experienced clinicians and students whose observation and hypothesis-testing skills
are not fully developed. Although the authors of this paper would join with Byng,
Howard, Nickels, and others in promoting the hypothesis-driven approach as an
effective means of understanding the nature of the language impairment, a test that
provides an overview of an individual’s performance can be useful even to skilled
clinicians. This might be particularly so for therapists who, because of health service
restructuring, find that they are less accustomed to providing services for adults with
aphasia (MacKenzie et al., 1993). Our experience of working in a busy community
clinic suggests that it is possible to overlook or underestimate a skill that may impact
on a person’s communicative ability and or response to therapy. In the initial
interview, individuals with aphasia may not identify the full range of problems they
have experienced since their strokes. This may be because they are not aware of the
difficulty, have developed some strategies to overcome the problem in key situations,
avoid difficult tasks, and/or want to project a more positive image of themselves.
Some language deficits are not so immediately obvious and may be less easy to
evaluate informally. For example, it has been suggested that it is more difficult to
examine auditory comprehension reliably than to observe speech (Lesser, 1989). It is
the case that aphasia test batteries are often quite lengthy and as a result take time to
administer. However, it could be argued that as much if not more time might be
taken up collecting a piecemeal description of the individual. Swinburn et al. (2005)
state that one of the weaknesses of the PALPA is that it ‘‘does not provide a
summary profile of impairment and abilities within a short time period’’ (p. 3).
Whether the time collecting the data is well spent will depend on whether the aphasia
batteries are sensitive and reliable and provide the sought-for information. Current
aphasia batteries do not appear to fulfil adequately some of the key aims of
assessment: they do not provide a clear description of the underlying nature of the
language disorder, which can be used to set appropriate goals for therapy, nor do
 CAT FORUM: COMMENTARY 2 85

they provide a means to evaluate treatment. The question now is whether the CAT
does any better.

THE COMPREHENSIVE APHASIA TEST

The CAT is designed to investigate both the impaired and intact abilities of adults
with aphasia across a wide range of language functions. It also examines the effect of
the impairment on the individual’s life. A further use of the battery is as a predictor
of aphasia recovery 1 year post onset. According to the authors (Swinburn et al.,
2005, p. 8), the CAT should be useful in:

1) diagnosis of impairment and impairment-based treatment planning; 2) motivating

and guiding further assessment; 3) assessing the overall severity of the language
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disorder; 4) predicting and following changes in severity of aphasia over time; 5)

targeting intervention towards goals that are meaningful and relevant; 6) involving the
client in the process of setting goals for intervention.

Like the PALPA, the CAT is based on information-processing models of normal

language, in particular single word processing. It provides a series of subtests that
assist in identification of the locus of deficit in terms of the model. The authors state
that their decision to include a subtest and or manipulate particular parameters
depended on whether there was evidence in the literature that they affected aphasic
performance. For example, imageability, frequency, length, and spelling-to-sound
regularity are controlled for in the ‘‘Reading aloud’’ section. Other criteria that
influenced selection of tasks included the length of time taken to administer a test
and whether the language ability was commonly the focus of speech and language
therapy treatment.

Structure of the CAT

The CAT consists of three components, a cognitive screen, a language battery, and a
disability questionnaire. The cognitive screen assesses an individual’s ability across a
range of tasks such as memory, arithmetic, gesture/object use, and word fluency, any
of which might affect his or her functional ability and rehabilitation. Sensory and
cognitive deficits are often associated with acquired neurological damage, so even a
quick screen of some of these skills is useful. The first subtest of the CAT, a line
segmentation task, is of particular importance to the ongoing administration of the
battery. This task screens for a visual field defect which, if present, could influence
the person’s test performance.
The main part of the CAT is the language battery, which is divided into five broad
sections: language comprehension, repetition, spoken language production, reading
aloud, and writing. Each section comprises of a number of subtests. Most subtests
have a practice item so that the tester can be sure that the individual understands the
task before continuing with the test. The language comprehension section consists of
tests of spoken word to picture matching, written word to picture matching, spoken
sentence and picture matching, written sentence and picture matching, and spoken
paragraph comprehension. The investigation of expressive language begins with a
series of tests that investigate the repetition of words, complex words, nonwords,
digit strings, and sentences. This is followed by the spoken language production
 86 BRUCE AND EDMUNDSON

section, which comprises tests of naming objects, naming verbs, and a spoken picture
description. The reading aloud section is made up of tests of word reading, complex
word reading, function word reading, and nonword reading. The writing section
consists of tests of copying, written picture naming, writing to dictation, and written
picture description. In most of the language battery subtests the items are scored on
a 3-point scale: correct response 5 2; correct response following repetition or delay
of 5 seconds, or self-correction 5 1; and incorrect 5 0. The scores of the subtests of
the CAT can be transformed into T-scores, allowing performance to be compared
across the different subtests. The means and standard deviations of the T-scores are
provided in the manual.
The final component of the CAT uses a series of questions to investigate changes
in the person’s daily living skills and his or her sense of self. The disability
questionnaire is divided into four parts. It obtains information about the client’s
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perspective on (1) disability, (2) intrusion, (3) self-image and (4) emotional
consequences. Responses are scored using a 5-point scale for most items; the higher
the score, the greater the perceived disability. The authors advise that this
component should be used with care and it can be omitted if it is felt that the
person with aphasia is not ready or able to address these issues. Also, the
questionnaire may not be appropriate for individuals with limited comprehension
and/or cognitive deficits, who may have difficulty understanding some of the items
or expressing their responses.

Psychometric standardisation, validity, reliability and normative data

The CAT manual provides the user with a clear account of how and why each test
was constructed. It also contains detailed administration and scoring instructions,
with suggestions for further testing that could be completed to establish which of the
processes and representations of the various components of single word are intact
and which are impaired. Examples of patient data help the user to score the tests and
interpret the results. Relevant literature that explores a problem area in more detail
is recommended. The manual also provides normative data along with data on
reliability and validity. The CAT was standardised in the UK on 27 controls (mean
age 5 61.3) and 266 individuals with aphasia. A total of 56 people with aphasia were
tested 1, 3, 6, and 12 months post onset. The remaining 57 individuals were tested
only once, most of them more than 6 months post onset. Generally high inter-rater
reliability was found, although agreement was lower for the subtest ‘‘Gesture/object
use’’. High test–retest reliability was demonstrated for the combined modality scores
on the CAT, but was lower for some individual subtests, particularly those with few
items.
The predictive validity of the CAT was measured using discriminant analysis.
This analysis successfully classified 93.1% of the participants into aphasic and non-
aphasic groups. Concurrent validity was established by correlating the scores of a set
of people with aphasia who were tested using the CAT, the Frenchay Aphasia
Screening Test (FAST; Enderby et al., 1987) and the Mini-Mental State
Examination (MMSE; Folstein, Folstein, & McHugh, 1975). All the correlations
were significant. These results were supported by strong positive correlations that
were observed between scores on subtests of the CAT and scores on other tests that
investigated the same functions.
 CAT FORUM: COMMENTARY 2 87

Information in the manual also suggests that the results of the CAT can be used to
predict the aphasic person’s potential for recovery in different modalities. Graphs
show the recovery patterns over the first year post stroke for three groups, those with
least severe, modest, and most severe aphasia. The degree of accuracy is greater for
initial assessments administered 3 or more months post onset. These findings are
based on a study of 55 people with aphasia who were tested on the CAT as soon as
they were neurologically stable and then at 3 months, 6 months, and 12 months post-
stroke. In general, the score on a modality at 1 month post-onset was a significant
predictor of performance in the same modality at 12 months. This was even stronger
for scores obtained at 3 months post-onset, when most of the overall improvement
had occurred. Although the best overall predictor was performance in the same
language modality, memory scores contributed significantly to predicting the
outcome in many of the language modality scores at 1 month post onset. However,
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only naming was significantly predicted by memory performance at 3 months. The

effects of therapy on the patterns of recovery are difficult to determine, as the
participants received considerably different amounts of treatment.

WHAT THE CAT PROVIDES AND WHAT IT DOES NOT

Overall, the CAT provides much useful data about the language functions tested.
The language comprehension section provides information about the individual’s
ability to retrieve meaning from single words and sentences in the spoken and written
form, as well as comprehension of spoken paragraphs. Reading comprehension at a
paragraph level is deliberately omitted by the authors because of time factors, the
fact that parameters that affect performance at this level are not well understood,
and their claim that paragraph reading is not used widely within treatment.
Although some restrictions may be necessary, the omission of written paragraphs is a
limitation if one is interested in an individual’s ability to retrieve meaning from
extended text. Users who seek this level of information are directed to other
assessments of reading.
The spoken output tasks of the expressive language component of the test provide
information about repetition skills, single word naming, and connected speech. One
limitation of the spoken language production section is that, despite the present state
of knowledge about verb processing and its importance in sentence formulation, this
aspect of language is not well assessed. Although problems with the spoken and/or
written production of verbs have been well documented for adults with acquired
aphasia (Dean & Black, 2005; Marshall, 2002; Marshall, Pring, & Chiat, 1998), verb
processing is given only a cursory examination. It is difficult to see how any
conclusions about verb deficits can be drawn from such a small set of items.
Furthermore, the imbalance between the number of objects and verbs makes it
difficult to know whether retrieval of these forms is equally damaged; there are 24
objects compared with 5 verbs in the confrontation naming subtests. In view of the
small numbers of verbs, it is particularly unfortunate that several pictures show
situations that are already outdated, e.g., winding a watch, licking a stamp, and
typing on a typewriter. Another weakness in this section relates to the spoken picture
description. The sample of connected speech is obtained from describing a picture of
a man sleeping in an armchair, while a cat sitting on a shelf above his head knocks
over a pile of books. Although the composite picture shows a recognisable internal
scene, the format seems to have restricted the narrative accounts produced by some
 88 BRUCE AND EDMUNDSON

people in our clinic. The quality and quantity of speech was greater if they were
asked to describe a picture story sequence (Hughson, 2004; O’Leary, 2006; Richards,
2007; see also BDAE-3; Goodglass et al., 2001).
The reading aloud section provides information that helps to define an
individual’s reading difficulty. Using only the small number of carefully controlled
items provided in the tasks, it is possible to identify the locus of deficit within an
information-processing model. This section provides a valuable starting point for
more in-depth investigations of reading and or may be used by the clinician to select
goals for therapy.
The introduction of the disability questionnaire shows an attempt to look beyond
the impairment to the impact on real-life communication. It provides information on
what the individual actually does and how they view their own life. The
questionnaire is divided into four sections. The first examines how the person views
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daily communication situations, the second investigates the significance of these

difficulties on his or her life, and the third looks at how his or her sense of self has
been affected. The final section screens for the emotional consequences of living with
aphasia. Although the questionnaire is a positive step, it is unfortunate that the items
in the CAT often appear to have been worded to measure the ‘‘dissatisfied’’ range of
the spectrum. Many of the questions asking about the emotional consequences of
stroke are negative in tone; for example, ‘‘Does your communication make you feel
helpless?’’ Although the last question is more positive, ‘‘Are there things you enjoy at
the moment?’’ it is only one question out of eight. Filter questions are used to limit
the bias caused by the implicit assumptions made by some of the questions. For
example, the user establishes the frequency with which the person feels an
emotion before ascertaining the intensity of that emotion. Despite attempts to
minimise the negative tone of certain questions, in our experience this section feels
unbalanced. Fortunately, it is an optional component of the test and may be
omitted.
The CAT has been designed to predict and follow changes in the severity of
aphasia over time. The possibility that the CAT may be able to predict the amount of
recovery a person with aphasia can expect could be extremely useful for clinicians
who need to answer the frequently asked questions about whether or not the person
with aphasia will get better and if so how much better. Clearly, information about
the likely course of recovery would be useful in the management of the person with
aphasia and in assisting families to make plans. However, while the graphs provide
an estimate of potential recovery for different levels of initial severity, the manual
emphasises that ‘‘the prediction is not particularly accurate for individual subjects’’
(p. 134). A further reservation about the predictive validity of the CAT relates to the
difficulties in determining the contribution therapy has made to recovery in the
group of participants reported in the CAT manual.
The test identifies the nature of the person with aphasia’s impairments and his/her
intact processes. It also provides some insight into how the person feels about his or
her aphasia. The CAT does not assign an individual with aphasia to a syndrome
category. Other aphasia batteries, such as the BDAE or the WAB, exist for this
purpose. Most clinicians, unless they are conducting research, will not be concerned
by this omission, particularly as the value of syndrome categories has been
questioned by some researchers. It has been pointed out that people with aphasia do
not form homogeneous groups and that there often are important differences
between people within the same syndrome (Howard & Hatfield, 1987).
 CAT FORUM: COMMENTARY 2 89

USING THE CAT

No specific training is required to use the CAT. However, as with all complex tasks,
practice ensures that the material and the data collected are handled more effectively
and efficiently. The test is comparatively easy to administer once the user has
familiarised him/herself both with the materials and the specific scoring system for each
of the subtests. The scoring book provides verbatim instructions for each subtest and
states when the test should be discontinued. However, writing the instructions in larger
print in the scoring book, or even better on the test materials, would have made the
administration process even easier. As it stands, the attention of the user is sometimes
diverted from interacting with the person being assessed to finding and reading the
instructions and timing responses. The authors suggest that between 90 and 120
minutes are required for the administration of the CAT. They state that the test can be
completed in one sitting, but that it may be preferable to spread it out over two sessions.
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They recommend that the cognitive and language sections are completed together. In
our experience, no one has been able to complete the CAT in one session and most
people have had to carry over some of the language subtests into a second session. As
some of the subtests use the same materials but require different responses, e.g., spoken
and written picture description, two sessions seem to be desirable. Moreover, the
written and spoken sentence comprehension task uses the same pictures but the
sentences used in the two versions are different. The design might prevent people from
learning the correct response, but in our experience it has led to confusion for some
individuals who are influenced by their previous responses.
The CAT consists of a manual, a cognitive and language test book, a disability
questionnaire test book, and a pack of 10 scoring books all contained in a bright-yellow
shoulder bag, which offers easy portability. On the whole the pictures are well drawn
and easy to recognise, although we have some reservations about the composite picture.
The test book is laminated and as this protects the pages this should extend the life of
the material. However, the test book in our clinic is already looking tired. This is largely
because test stimuli are printed on both sides of the page, which makes it difficult to
ensure that only the pertinent page is on display. The test does not stand unsupported,
so it is not easy to flip over the pages of the book during administration. A layout where
only one set of stimuli was printed per page rather than back-to-back would have been
preferable. This would allow the tester to keep the book flat on the table and his or her
hands free to write the responses.

CONCLUSION
To conclude, the CAT will be particularly useful for people with moderate to severe
aphasia, although people with more severe aphasia may find the disability
questionnaire difficult to complete. The CAT is likely to be too easy for people
with mild aphasia. Despite the shortcomings outlined above, the CAT is a valuable
development in aphasia testing. It combines the breadth of investigation that exists
in other aphasia batteries with the controlled stimuli and tasks found in the PALPA
(Kay et al., 1992). The CAT is useful in diagnosing the individual’s impairment,
assessing the overall severity of the language disorder, and predicting and following
changes in the severity of aphasia over time. It is the only aphasia battery to
incorporate a measure of functional independence. Although this component is not
entirely successful, it does provide some insight into the personal consequences of
 90 BRUCE AND EDMUNDSON

aphasia. Furthermore, it encourages clinicians to consider this area as an integral

part of aphasia.
As with any assessment, the CAT by itself does not provide all the information
needed to understand a person with aphasia’s deficits and retained abilities, and to
plan treatment. The findings need to be supplemented with other tests, observations,
and information from the person with aphasia. In fact, the authors of the CAT
suggest that it may be useful in assisting the clinician in formulating his or her
hypothesis and in selecting appropriate subtests of the PALPA to administer.
Important clinical decisions follow from the assessment process. These clinical
decisions affect an individual’s access to services and the type of intervention that is
offered. Thus, clinicians need to be sure that their time is well spent in carrying out
an assessment and that they have selected a measure that is maximally informative.
Selecting an assessment is extremely complex, and to date there is no consensus
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about what domains need to be assessed and which measures are best at recording
the vast array of information that could be collected. Ideally, the assessment that is
selected should have relevance for clinicians, patients, and their communicative
partners, and be psychometrically controlled. Despite the criticisms in the literature
about aphasia batteries they can, if well constructed like the CAT, fulfil a number of
important functions. The CAT is a useful resource for both research and clinical
practice and will be a welcome addition to any test library.

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APPENDIX
Comprehensive language batteries in use in clinical practice
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Name of the test Theoretical Approx. time

and its authors viewpoint Structure Purpose of the test to administer

The Minnesota Stimulation 46 subtests designed Comprehensive 2–6 hours

Test for hypothesis. to assess (i) auditory assessment of the
Differential Based on the disturbances, (ii) visual patient’s strengths
Diagnosis of premise that and reading and weaknesses in all
Aphasia (1965) aphasia is unitary disturbances, (iii) language modalities as
(MTDDA) in nature, with speech and language a guide to planning
H. Schuell the core deficit in disturbances, (iv) treatment. Additional
all aphasic visuomotor and aims include differential
individuals being writing disturbances, diagnosis from other
an impairment of (v) disturbances of conditions and
auditory verbal numerical relations prediction of recovery.
short term and arithmetic
memory. processes.

Boston Localisation 40-plus subtests A comprehensive 1–4 hours

Diagnostic theory. divided into the measure of aphasia
Aphasia following sections: that aims to provide:
Examination conversational ‘‘1) diagnosis of
(BDAE) 3rd expository speech, presence and type of
edition (2001) auditory comprehension, aphasic syndrome,
H. Goodglass, oral expression, reading leading to inferences
E. Kaplan, & and writing, and praxis. concerning cerebral
B. Barresi The third edition localization and
contains several new underlying linguistic
subtests that target processes that may have
assessment of narrative been damaged and the
speech, category-specific strategies used to
word comprehension, compensate for them;
syntax comprehension, 2) measurement of
and specific reading performance over a wide
disorders. The test has range of tasks, for both
standard, short, and initial determination and
extended formats. detection of change over
time; 3) comprehensive
assessment of the assets
and liabilities of the
patient in all areas as a
guide to therapy’’ (p. 1).
 CAT FORUM: COMMENTARY 2 93

APPENDIX
(Continued )

Name of the test Theoretical Approx. time

and its authors viewpoint Structure Purpose of the test to administer

Western Aphasia Localisation 31 subtests. The A comprehensive 1 hour +

Battery (WAB) theory. subtest scores for assessment that
(1982) A. spontaneous speech, identifies the
Kertesz comprehension, individual’s
repetition, and naming aphasia syndrome
are combined to yield and their severity.
Aphasia Quotient
(AQ); subtest scores
for reading and writing,
praxis, and construction
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are combined to yield

cortical quotient (CQ);
subtest scores for
auditory comprehension,
oral expression, reading,
and writing performance
may be combined to
yield lexical quotient
(LQ).

Psycholinguistic Structured 60 subtests that assess An extensive Varies

Assessment of around (i) auditory processing, assessment that depending
Language psycholinguistic (ii) reading, (iii) spelling, provides information on the test(s)
Processing in model of (iv) picture and word about the integrity of selected
Aphasia language semantics, and (v) the language-processing
(PALPA) (1992) processing. sentence comprehension. system. The knowledge
J. Kay, Individual subtests are provides a firm
R. Lesser, & selected depending on grounding on which a
M. Coltheart the specific questions. treatment programme
can be based.

The Structured 34 subtests, including a The assessment 90–120

Comprehensive around models cognitive screen, a provides a profile of minutes
Aphasia Test of language language battery, and a performance across all
(CAT) (2005) processing from disability questionnaire. modalities of language
K. Swinburn, cognitive The language battery is production and
G. Porter, & neuropsychology. designed to assess (i) comprehension, as well
D. Howard language comprehension, as identifying associated
(ii) repetition, (iii) cognitive deficits. It also
spoken language reveals the psychological
production, (iv) reading and social impact of
aloud, and (v) writing. impairment from the
perspective of the person
with aphasia. It predicts
and follows changes in
severity over time.