Neuropsychologia, 1967, Vol. 5, pp. 135 to 140. Pergamon Press Ltd.

Printed in England

WORD FLUENCY AND BRAIN DAMAGE*

JOHN G. BORKOWSKI,~ ARTHUR L. BENTON and OTPRIED SPREEN~

Neurosensory Center and Departments of Neurology and Psychology
University of Iowa, Iowa City, Iowa, U.S.A.

(Received 4 November 1966)

Abstract--A group of sixty-six adult subjects was given the task of producing as many words
as possible beginning with specified letters of the alphabet. The number of words produced
during a period of 60 set correlated highly both with a frequency count derived from the
Thorndike-Lorge norms and with estimates derived from the dictionary of the number of
words in the English language beginning with each letter.
In a second experiment, eight letters representing three levels of difficulty as found in
normal subjects were given to thirty brain-damaged and thirty hospitalized control patients.
Results in terms of verbal productivity indicated that, for patients of high intelligence,
difficult letters (i.e. J and U) showed the greatest discrimination. On the other hand, for
patients of low intelligence, easy letters (i.e. F, S, P and T) were more effective in differen-
tiating the brain-damage and control groups.
The tindings also indicated that difficult letters may be particularly effective in distin-
guishing between patients with right and left hemisphere damage. An analysis of order of
presentation indicated that practice and fatigue effects were not related to verbal fluency
when as many as eight letters were administered. It is suggested that the addition of difficult
letters to standard word fluency tests may yield more precise discriminations between brain-
damaged and control patients when overall level of intellectual functioning is taken into
account.

1. INTRODUCTION

THE MEANINGFULNESS of a verbal unit, such as a word or a nonsense syllable, is often defined
by the number of associates produced in response to it in a given period of time (NOBLE [l];
SPREEN and SCHULZ [2]). ANDERSON [3], employing a written production method with
college students, has shown that the letters of the alphabet also differ quite reliably in the
number of associated responses which they elicit. Thus she was able to develop an associa-
tive hierarchy for single letters. The use of single letters, varying both in frequency of
associates and associative probabilities, as stimulus materials is only now beginning to show
potential for psycholinguistic research (TURNAGE and ANDERSON [4]).
Measures of verbal fluency and productivity have formed a part of many aphasia bat-
teries and have also been used to assess intellectual loss in patients with cerebral disease,
particularly for the purpose of defining the distinctive patterns of performance associated
with lesions in different loci. One such measure is the controlled association task which
requires the subject to produce as many words as possible beginning with a specified letter

* This investigation was supported by Research Grant NB-00616 and Program-Project Grant
NB-03354 from the National Institute of Neurological Diseases and Blindness. Neurosensory Center
Publication No. 118.
t Now at Oberlin College, Oberlin, Ohio, U.S.A.
: Now at the University of Victoria, Victoria, B.C., Canada.
135
136 JOHN G. BORKOWSKI, ARTHUR L. BENTONand OTFR~EDSPREEN

of the alphabet over a given period of time. This task, usually designated as “word fluency”,
has been employed in a number of recent investigations of brain-damaged patients (BECHTOLDT,
BENTON and FOGEL [5]; FOGEL [6]; MILNER [7]).
The present study was of both a normative and a clinical nature. One purpose was to
determine the relationship between the fluency of controlled associations to single letters and
the frequency of words beginning with those letters in the English language. A second
purpose was to investigate the extent to which verbal production instigated by specific letters
differentiated between brain-damaged and control patients. With respect to this latter
question, several alternative hypotheses might be suggested :
(1) It could be argued that over a 1 min association period, both difficult and easy letters
make significant demands on cognitive-linguistic abilities. Hence it would be predicted that
all letters will show equal discrimination between the diagnostic groups.
(2) Letters with few associates may make greater demands on verbal fluency; in con-
trast, high frequency or easy letters may produce a large number of automatized responses
that make minimal demands on associative processes. If this is so, it would be predicted that
the difficult letters will be more discriminative than the easier letters.
(3) A final possibility is that the differentiation between brain-damaged and control
patients may be related to an interaction between letter difficulty and level of intelligence.
Specifically, for groups of brain-damaged and control patients of relatively low intelligence,
easy letters may be more discriminative than difficult letters because even normal subjects
of modest intelligence can make only a few associations to the difficult letters. In contrast,
difficult letters may be more discriminative for groups of patients of relatively high intel-
ligence because these letters make significant demands on associative fluency and the pos-
sibility of automatized responses is minimized.
The present study examined each of these hypotheses.

2. EXPERIMENT 1
2.1. Subjects and procedure
The linguistic frequency for each letter of the alphabet was determined by assigning a score of 1 to
each AA word in the THORNDIKE and LORGE[8] count (T-L) and 0.5 to each A word. Table 1 shows the
distribution of letters based on this weighted T-L index. The letters Z and X are omitted from the table
and from further consideration since T-L scores for these letters were zero. It was felt that the associative
productivity to these letters would be extremely low.
The remaining twenty-four letters were divided into three sets. Each set had eight orders of presentation
to control for practice and/or fatigue effects and each contained an equal number of easy and difficult
letters defined on the basis of the weighted T-L frequency distribution (Table 1). A sample of sixty-six
maternity patients at the University Hospital, Iowa City, was divided into three groups of twenty-two,
each group receiving a different set of letters. The mean prorated verbal WAIS IQ (information and
arithmetic subtests) for the total sample was 93 and the mean age was 20 years; mean ages and IQs for
the three groups were not significantly different.
The patients received the following instructions: “I shall say a letter of the alphabet, then I want
you to give me as many words that begin with that letter as you can and as quickly as you can. For
instance, if I say, ‘B’, you might give me, ‘bag, battle, bed’. Do not use words which begin with a capital
letter like names of brands, people, or places such as ‘Boston or Bob’. Also, do not give numbers, or the
same word but with a different ending, for example, ‘eat, eating.’ Do you have any questions? Begin
when I say the letter. The first letter is --.” The patients were allowed 60 set to produce associations
to each letter.
2.2. Results and discussion
The mean number of words per letter is presented in Column 3 of Table 1. In terms of both associative
productions and written frequency (i.e. the T-L index), these letters can be conveniently separated into
three ranges of difficulty as shown by the divisions of Table 1. The stability of the word fluency hierarchy
is demonstrated by the high correlation (r=0.80) with the T- L index. Word productivity also correlated
 WORDFLUENCYAND BRAINDAMAGE 137

Table 1. Associations to letters in relation to frequency of occurrence

in the language and verbal productivity

T-L Frequency Mean number of

Difficulty level Letters (AA +A/2) associations

Q 8 5.18
J 12 4.83
Hard V 13 5.91
Y 14 5.73
K 15 4.32
U 17 4.83

I 34 7.91
0 38 7.36
N 40 8.23
Moderate E 49 6.95
c 50 9.05
L 58 11.18
R 59 11.75

H 66 10.00
D 70 10.14
M 14 11.18
W 83 10.45
A 85 10.22
Easy B 90 11.32
F 91 11.36
P 97 12.50
T 100 11.77
C 115 9.68
S 184 11.50

significantly (rz0.74) with the number of words per letter in Webster’s New Collegiate Dictionary. That
the former correlation is somewhat higher may be due to the fact that both the T-L index and word fluency
reflect associative probabilities while number of words per letter is not explicitly related to probability of
occurrence.
There is also a strong relationship (r=O.85) between the word fluency hierarchy derived from this
study and the letter-association data of ANDERSON[3], despite the differences in methods of production
(oral vs. written) and intellectual levels of the samples (maternity patients, IQ=93, vs. college students).
However, it may be noted that the oral productions obtained in this study with “average” IQ patients
resulted in a wider range of letter difficulty (4.32 to 12.50) than did the ANDER~~N[3] hierarchy for written
associations to lower case letters (8.2 to 11.6).

3. EXPERIMENT 2
3.1. Subjects andprocedure
Four pairs of letters (JU, NG, PT and FS) were selected from the word fluency hierarchy established
in Experiment 1 so as to represent easy, moderate, and difficult letters. (The FS pair was included as a
second easy pair because extensive normative data were available from a language assessment battery used
during the last 5 years at the Laboratory of Neuropsychology of the University of Iowa.) Eight orders
of presentation were used so that each letter occurred equally often in all positions.
The letters were presented to thirty brain-damaged and thirty hospitalized control patients. The
mean age, prorated verbal WAIS IQs, and educational levels for the brain-damaged and control groups
were 40.6, 93.2, 9.6 and 37.5, 94.9, 9.9. There were no significant differences between the groups with
respect to these characteristics. The brain-damaged group consisted of patients with established diagnoses
of disease involving the cerebral hemispheres and included nine patients with lesions confined to the right
hemisphere, ten patients with left hemisphere involvement, and eleven patients with evidence of bilateral
and/or diffuse disease. There were no differences between the ages and IQs of the diagnostic groups.
None of the patients with left hemisphere disease were aphasic at the time of testing. The most frequent
138 JOHN G. B~RKOWSKI, ARTHUR L. BENTON and OTFRIED SPREEN

Table 2. Mean associations, standard deviations, and contrasts between

brain-damaged and control groups as a function of letter difficulty

Brain damage Control

S.D. t, df=58

JU 7.13 5.02 11.40 5.13 2.74

NG 11.73 6.30 15.90 5.61 2.67

FS 16.00 8.07 21.17 6.73 2.65

FT 15.23 6.49 22.63 7.10 4.16

diagnosis (twelve cases) was convulsive disorder associated with demonstrable abnormality of one or
both hemispheres. This diagnosis was distributed proportionately across the three locus-of-lesion groups.
The control group consisted of patients from various medical services without history or present evidence
of cerebral disease.
The instructions and technique (60 set verbal productions) of Experiment 1 were employed.

3.2. Results and discussion

The overall means for each pair of letter, standard deviations, and t tests comparing
the brain-damaged and control groups are presented in Table 2. As would be expected, the
JU pair elicited the lowest number of associates and the FS and PT pairs the greatest for
both groups. Of major interest here are the contrasts between groups as a function of letter
difficulty. For all pairs of letters, the mean number of associations per pair is significantly
greater for the control than for the brain-damaged group. When the total groups are con-
sidered, examination of the number of brain-damaged patients below the 16 percentile of the
control distributions showed that the pairs differentiate equally well regardless of letter
difficulty (JU=13 Ss; NG=16 Ss; FS=15 Ss; PT=14 Ss).

Table 3. Mean number of associations for brain-damage and control patients

as a function of level of intelligence and letter difficulty (N= lo/group)

Difficult (JU) Easy (F’T+FS)

2

Means S.D. Means S.D.

C 15.90 4.46 24.60 5.99

HIQ
B-D 10.80 5.27 21.80 5.76

C 8.20 4.05 19.30 5.73

JJQ
B-D 3.90 2.21 9.20 2.50

Although these analyses suggest that easy and difficult letters show equal discriminative
power, such a conclusion must be tempered by the analyses of verbal fluency as a function of
the interaction of letter difficulty with level of intelligence. The mean productions for brain-
damaged and control patients with IQ > 100 (N= 10 per group) and IQ < 90 (N= 10 per
 WORD FLUENCYAND BRAIN DAMAGE 139

group) in relation to difficult (JU) and easy [(FS+PT)/2] pairs are presented in Table 3.
Since letter difficulty is a within-subject dimension and level of intelligence and type of
patient are between-subject dimensions, the data were compared by means of a LINDQUIST
[9] Type III analysis of variance. The triple order interaction was found to be significant,
r;( 1,316)-77.60, p < 0.001. The two-factor interactions involving letter difficulty and type
of patient were examined for high and low IQ levels separately by means of Type I analyses
of variance. With the low IQ group the interaction between type of patient and letter
difficulty was significant, F(1,38)=26.94, while the interaction for the high IQ group was not
significant, F(l,38)=1.88.
Contrasts between low IQ brain-damaged and control groups showed that both the
easy and difficult pairs discriminated significantly between the groups, t(18)=2.81 and
4.38. For high IQ groups, the hard letters (i.e. JU) differentiated the brain-damaged from
the controls, t(18)=2.22, but with the easy pairs [(FS+PT)/2] the two groups were not
significantly different, t(l8)= 1.03.
Six of ten low IQ brain-damaged patients were below the 95 percentile of the low IQ
controls on the (FS + PT)/2 combination, but only three patients were below this level with
the JU pair. In contrast, five of ten high IQ brain-damaged patients were below the 95 per-
centile score of the high IQ controls on JU, but only one of ten with the easy letters.
These analyses seem to indicate that for low IQ brain-damaged patients, the easy letters
of the alphabet provide greater discrimination on the word fluency test than do difficult
letters. On the other hand, when the patient is of a higher level of intellectual functioning,
difficult letters tend to be more discriminative. Of the three original hypotheses, the first two
are clearly rejected while the third hypothesis, which related brain-damaged and control
patient differences to letter difficulty and level of intellectual functioning, was generally
substantiated.
The mean associations to the JU pair for the patients with right hemisphere damage was
9.11, 8.36 for the bilateral-diffuse group, and 5.80 for left, non-aphasic patients. The com-
parison between the right and left lesion groups approached significance, t(17)= 1.63 ; no
other contrasts were statistically significant for these very small subgroups.
A final point of some interest is that neither brain-damaged nor control patients showed
practice or fatigue effects. Specifically, when mean productivity as a function of order of
presentation was analyzed, the maximum difference for control patients was 1.62 words.
Since even smaller differences were found with the brain-damaged group, the addition of
difficult letters (JU) to the standard word fluency test (FAS) should cause little concern with
respect to the possibility of practice or fatigue effects.

REFERENCES
1. NOBLE, C. E. An analysis of meaning. Psychor. Rev. 59, 421, 1952.
2. SPREEN, 0. and SCHULZ, R. W. Parameters of abstractness, meaningfulness, and pronounciability
for 329 nouns. J. verb. Learn. verb. Behav. 5,459, 1966.
3. ANDERSON, N. S. Word association to individual letters. J. verb. Learn. verb. Behav. 4, 541, 1965.
4. TURNAGE, T. W. and ANDERSON, N. S. Letter-frequency and associative probability as determinants
of learning and retention. J. verb. Learn. verb. Behav. 4,463, 1965.
5. BECHTOLDT, H. P., BENTON, A. L. and FOGEL, M. L. An application of factor analysis in nenro-
psychology. Psychol. Rec. 12, 147, 1962.
6. FOGEL, M. L. The Gerstmann syndrome and the parietal symptom-complex. Psychol. Rec. 12, 85,
1962.
7. MILNER, BRENDA. Some effects of frontal lobectomy in man. In The Frontal Granular Cortex and
Behavior, WARREN, J. M. and AKERT, K. (Editors), p. 313. McGraw-Hill, New York, 1964.
140 JOHN G. BORKOWSKI,ARTHURL. BENTONand OTFRIEDSPREEN

8. THORNDIKE,E. L. and LORGE, I. The Teacher’s Word Book of 30,000 Words. Columbia University
Press, New York, 1944.
9. LINDQUIST,E. F. Design of Experiments in Psychology and Education. Houghton Mifflin, Boston,
1953.

R&umXUn groupe de soixante-six sujets adultes fut soumis g une epreuve consistant B
produire autant de mots que possible commencant par certaines lettres de l’alphabet indiqu&s
par l’observateur. Le nombre de mots produits durant une p&iode de 60 set avait une haute
corrClation B la fois avec le compte de frequence d&rive de la liste de ThorndikeLorge et
avec des estimations, faites, d’aprlts le dictionnaire, du nombre de mots anglais commenCant
selon chacune des letteres donnkes.
Dens une seconde expbience huit lettres reprksentant trois niveaux de difficult& pour
les normaux, &aient donnCes ti trente sujets avec l&ion c&+brale et g trente sujets hospitalis&
de contrale. Les r&ultats en terme de productivitC verbale indiquaient que pour les sujets de
haut niveau intellectuel les lettres difficiles (c’est B dire J et U) se r&laient les plus discrimina-
tives. D’autre part, pour les sujets de bas niveau intellectuel les lettres les plus faciles (F, S,
P et T) Ctaient plus efficaces pour diffkrencier le groupe avec atteinte c&Cbrale et le groupe de
contrble.
Les constatations indiquaient aussi que les lettres difficiles peuvent Qtre sp&cialement
efficaces pour distinguer les sujets avec atteinte de l’h&misph&re droit de ceux avec atteinte de
l’h&misph&re gauche. Une analyse de l’ordre de presentation indiquait que les effets de
pratique et de fatigue n’etaient pas en relation aver la fluence verbale lorsqu’au moins huit
lettres &aient don&es. On suggbre que l’addition de lettres difficiles au test standard de
fluence verbale peut permettre des discriminations plus pr&cises entre les sujets avec l&ion
drebrale et les sujets de contrale lorsque le niveau g&&al de fonctionnement intellectuel est
retenu.

Zusammenfassung-Eine Gruppe von sechsundsechzig erwachsenen Versuchspersonen

erhielt die Aufgabe, so viele Worte wie miiglich zu finden, die mit einem bestimmten Buch-
staben des Alphabets beginnen. Die Zahl der Worte, die innerhalb von 60 Sek produziert
werden konnten, korrelierte hoch mit einem von den Lorge-Thomdike Normen abgeleiteten
Erscheinungsfrequenzwert und mit einem aus Wiirterbiichem abgeleiteten Schgtzwert der
Hgufigkeit des Auftretens von Worten mit jedem der einzelnen Buchstaben in der Englischen
Sprache.
In einem zweiten Experiment wurden acht Buchstaben, die drei verschiedene Schwierig-
keitsgrade bei den normalen Versuchspersonen reprlsentieren, bei dreissig Hirngeschldigten
und bei dreissig nicht-hirngeschgdigten Krankenhauspatienten angewandt. Die Ergebnisse
hinsichtlich der verbalen Produktivitat zeigten, dass bei Patienten mit iiberdurchschnittlicher
Intelligenz die schwierigen Buchstaben (d.h. J und U) die beste Gruppenunterscheidung
liefern. Einfache Buchstaben (d.h. F, S, P und T) dagegen ergaben eine bessere Trennung
von Hirngeschldigten und Kontrollpatienten mit niedrigerer Intelligenz.
Die Ergebnisse wiesen ferner darauf hin, dass schwierige Buchstaben besonders wirksam
in der Unterscheidung von Patienten mit Schldigungen in der rechten und linken Him-
hemisphtire sein kiinnen. Eine Analyse der Reihenfolge der Buchstaben zeigte, dass Ubungs-
und Ermiidungseffekte keinen Einfluss auf die verbale Produktivitlt haben, wenn bis zu acht
Buchstaben in einer Sitzung angeboten werden. Es wird darauf hingewiesen, dass durch die
zusltzliche Verwendung von Schwierigen Buchstaben bei den iiblichen Wortfliissigkeitstests
eine bessere Unterscheidung zwischen Himgeschgdigten und Kontrollpatienten erzielt
werden kann, wenn das allgemeine Intelligenzniveau dabei beriicksichtigt wird.