ANAM Assessment Library
ANAM4™ Tests and Modules
2-Choice Reaction Time
Cognitive Domain
Results of this test are used as a measure of processing speed and alternating attention with a motor speed component.
Test Description
This test measures choice reaction time by presenting the user with a "*" or "o" on the display. The user is instructed to respond as quickly as possible by pressing the designated button for each stimulus as soon as the stimulus appears. This test can be modified to present alternative symbols as stimuli.
Code Substitution - Learning
Cognitive Domain
Results of this test are used as an index of complex scanning, visual tracking, and attention.
Test Description
In this test the user must compare a displayed digit-symbol pair with a set of defined digit-symbol pairs, or the key. The user presses designated buttons to indicate whether the pair in question represents a correct or incorrect mapping relative to the key. In the Learning phase (simultaneous presentation mode), the defined pairs are presented on the screen along with the digit-symbol pair in question. In the Immediate Memory test (to immediately follow the learning phase) the comparison stimuli are presented individually without the key. In the Delayed Memory test (to follow later in the battery) the comparison stimuli are again presented individually without the key.
Past Studies
This test is designed to be a measure of visual scanning, information processing speed, and attention. It also measures associative learning to some degree since performance speed increases as the individual learns the pairings, thereby reducing the time needed for visual scanning. This test is modeled after several widely used neuropsychological tests assessing these domains (e.g., Wechsler Adult Intelligence Scale-III Digit Symbol & Symbol Digit Modality Test-Written). Notably, given the two button response choices, the ANAM version of this test removes a significant portion of the motor speed component present in similar neuropsychological measures. In general these types of tests are very sensitive to processing speed impairments seen across multiple disorders, most notably traumatic brain injury dementia, depression, multiple sclerosis, and Huntington's disease (Lezak, 2004).
In studies of construct validity, Code Substitution was found to load on a factor with other ANAM tests and traditional neuropsychological tests believed to measure processing speed and mental efficiency (e.g., Digit Symbol and Trails B) (Kabat et al 2001). In studies examining correlations between ANAM tests and traditional neuropsychological tests, Code Substitution consistently correlates highly with measures of information processing speed and attention including Digit Symbol and Symbol Search from the WAIS-III, verbal fluency, Trailmaking Test, etc. (Woodard et al 2004, Wilken et al, 2003). It was also one of the primary ANAM tests to remain in a stepwise regression to predict performance on traditional measures of processing speed in a general clinical sample. (Kabat et al 2001). Finally, this test was found to correlate with measures of memory in a sample of patients with Lupus (Roebuck-Spencer et al, 2006).
Code substitution has been used less frequently in clinical studies but based on growing evidence of its utility and strong correlations with neuropsychological tests, it is being used more frequently in newer ANAM test batteries. This test was retained in a stepwise logistic regression with two other ANAM tests to predict military subjects who were concussed within 10 days versus those without injury (Cernich, 2004). In a review by Lowe et al. (2007) decrements on the Code Substitution test were reported across various stressful environmental conditions, including high altitude, saturation deep diving, extreme water temperature, and accelerated decompression procedures. In a medication study of patients with schizophrenia treated with neuroleptics, this test was sensitive to the cognitive enhancing effects of an add-on medication compared to placebo (Poyurovsky et al, 2003).
Code Substitution - Delayed (Recognition)
Cognitive Domain
This test provides a measure of learning and delayed visual recognition memory.
Test Description
In this test the user is presented with a digit-symbol pair and must decide from memory if this pairing is correct based on the key presented during the Code Substitution — Learning test taken earlier in the test battery. The user presses designated buttons to indicate whether the pair in question represents a correct or incorrect match based on the earlier presented key.
Past Studies
This test measures the ability of the test-taker to recognize whether a presented pairing of a symbol and digit is correct based on an earlier presented learning trial. Given the delay period between the initial learning trial and this recall trial, the Delayed portion of the Code Substitution Test is intended to provide a measure of delayed memory within ANAM. Unlike some other traditional neuropsychological tests of memory, the Code Substitution test relies on accurate recognition memory rather than free recall where an individual has to independently generate stimuli pairings. Nonetheless, studies of ANAM construct validity and correlational studies with traditional neuropsychological tests have supported this as a test of memory retention. Kabat et al (2001) found that this test loaded on a factor with delayed recall of a verbal learning test. Kabat et al (2001) also demonstrated that this test correlated more strongly than other ANAM tests with traditional tests of learning and memory. In a confirmatory factor analysis, Short et al (2007) found moderate support that this test was measuring the construct of memory retention, but authors noted that results may be limited by a restricted range of memory problems in their sample. Correlational analyses of clinical samples has also demonstrated that Code Substitution Delayed is strongly correlated with measures of attention, processing speed, and short and delayed memory recall (Holliday et al 2003, Wilken et al 2003).
This test has also proven to be a good screening test for cognitive dysfunction and a good indicator of cognitive change following pharmaceutical interventions. For instance, Wilken et al (2003) found that this test along with two others provided the best model for predicting neuropsychological status in a group of patients with multiple sclerosis. In a study of the cognitive enhancing effects of medication, this test demonstrated significant improvements following administration of an add-on medication compared to placebo for patients with schizophrenia treated with neuroleptics (Poyurovsky et al, 2003).
Demographics Module
Description
The demographics module allows users to enter a wide variety of information including name, age, gender, ethnicity, medical diagnosis, medications, and additional comments that the researcher or clinician finds useful.
Effort Measure
The ANAM4 Effort Measure program is designed to give users of the ANAM4 test system a tool for evaluating the validity of scores from an ANAM4 battery by generating a Validity Indicator Report.
Analysis Description
The ANAM4 Effort Measure program uses data from four tests in ANAM4 to calculate an Effort Index and generate a Validity Indicator Report.
Go/No-Go
Cognitive Domain
This test assesses response inhibition.
Test Description
Impulsivity and difficulties with response inhibition have been observed following insult to the brain (Lezak 2004). The Go/No-Go test follows procedures for assessing response inhibition in a traditional Go/No-Go test procedure. This Go/No-Go task is modeled after other Go/No-Go tasks known to activate areas of the frontal lobes in neuroimaging studies of healthy individuals (Evan Nee et al 2007) and known to be sensitive to executive dysfunction in patients with frontal lesions and traumatic brain injury (e.g., Picton et al 2007; Wallesch et al 2001).
Logical Relations
Cognitive Domain
Results of this test are used as an index of reasoning and verbal syntax.
Test Description
This test assesses abstract reasoning and verbal syntax ability by asking the user to evaluate the truth of a statement (e.g., "& comes after #") describing the order of two symbols displayed on the display (e.g., "& #"). The user presses designated buttons to indicate whether the statement is true or false.
Manikin
Cognitive Domain
This test assesses three-dimensional spatial rotation ability, left-right orientation, problem solving, and attention.
Test Description
A man is displayed on the screen. The man is holding a ball in one hand and a cube in the other hand, and a ball or a cube is displayed at the bottom of the screen. The man is standing upright or upside down and either facing toward the user or facing away. The user is instructed to determine which of the man's hands is holding the object displayed at the bottom of the screen and to press one designated button to indicate the left hand and another designated button to indicate the right hand. In a variation of the test, there is no object displayed at the bottom of the screen, the man is only holding the ball, and the user is to indicate which hand is holding the ball.
Matching Grids
Cognitive Domain
Results of this test are used as an index of visuospatial processing.
Test Description
This test asks the user to determine if two grid patterns are identical except for a possible rotation. The two grid patterns are presented side by side on the display. The user presses designated buttons to indicate whether the grid patterns match or do not match. The patterns may be rotated relative to one another.
Matching to Sample
Cognitive Domain
Results of this test are used as an index of spatial processing and visuo-spatial working memory.
Test Description
During this test the user views a pattern produced by eight shaded cells in a 4x4 sample grid. The sample is then removed and two comparison patterns are displayed side by side. One grid is identical to the sample grid and the other grid differs by one shaded cell. The user is instructed to press a designated button to select the grid that matches the sample.
Past Studies
This test is different from other ANAM tests in that it relies more heavily on working memory or what some might call immediate memory, given the relatively short delay period of 5 seconds between stimulus presentation and response choices. This test measures visual recognition memory, which is different from a free recall memory test requiring an individual to independently generate an earlier presented stimulus. While this test relies heavily on visual-spatial processing and learning and memory skills, individuals might perform poorly for a number of reasons, including poor visual spatial discrimination/perception, poor attention, poor working memory abilities, impaired learning and memory, or slowed information processing speed. While this test might be specifically impaired in an individual with focal right hemisphere damage, impairment on this test can occur for a number of reasons including, but not limited to frontal or diffuse insult to the brain.
In a factor analytic study using healthy controls to examine the construct validity of ANAM, Bleiberg, et al (2000) found that the Matching to Sample test loaded on a factor with a test of verbal learning and memory (i.e., the HVLT). In a separate factor analytic study using a clinical sample, Kabat et al (2001) found that Matching to Sample loaded on a factor with other tests presumed to measure processing speed and cognitive efficiency. Results of this latter study suggested that Matching to Sample may be more closely related to measures of complex attention than memory/retention. In a study of patients with Lupus, the Matching to Sample test was consistently correlated with neuropsychological tests of attention and processing speed, such as Digit Span, Letter-Number Sequencing, Digit Symbol Coding, and the Trailmaking Test (Holliday, et al 2003). In a separate study of patients with Lupus, Roebuck-Spencer et al (2006) found that Matching to Sample correlated with 8 of 14 neuropsychological tests including tests of memory retention, information processing speed, and motor speed.
Matching to Sample has shown performance decrements across several clinical samples and has been shown to be sensitive to cognitive change in medication trials. For instance, this test has shown impairments in samples of patients with Alzheimer's disease (Kane et al, 2007) and in samples of patients with Lupus (Roebuck-Spencer et al., 2006). In a within-subjects design, this test was sensitive to change in cognition during migraine headache and showed improvement in cognition following administration of migraine medications (Farmer et al, 2003). This test also demonstrated improvements in cognition in a group of patients with Schizophrenia who received an add-on medication compared to a group of controls who received placebo. In a study predicting concussion status, Cernich et al (2004) found that this test along with two others was most predictive of group status. Finally, this test has frequently shown performance declines following a wide range environmental stressors, including saturation deep diving, water accelerated decompression, fatigue, and sleep deprivation (Lowe et al, 2007, Patel et al, 2007).
Interpretive information obtained from Lezak, 2004, p. 560; Lowe et al., 2007; Kane et al., 2007; Roebuck-Spencer et al., 2004; & Cernich et al., 2004.
Mathematical Processing
Cognitive Domain
Results of this test are used as an index of basic computational skills, concentration, and working memory.
Test Description
During this task, an arithmetic problem involving three single-digit numbers and two operators is displayed (e.g., "5 - 2 + 3 ="). The user presses buttons to indicate whether the answer to the problem is less than five or greater than five.
Memory Search
Cognitive Domain
Results of this test are used as an index of verbal working memory, immediate recognition, and attention. This test may also be used to index symbolic, non-verbal working memory by using symbols as test items instead of letters.
Test Description
A set of characters (the positive memory set) is displayed for memorization. Individual characters are then displayed and the user presses designated buttons to indicate if each character is or is not a member of the memorized set. The test assesses verbal working memory if letters are used and symbolic, non-verbal working memory if symbols are used.
Procedural Reaction Time
Cognitive Domain
This test measures the reaction time and processing efficiency associated with following a simple set of mapping rules.
Test Description
There are three possible blocks of trials for this test. In the Basic Block, the user is presented with a number constructed on the display using a large dot matrix (either a 2, 3, 4, or 5). The user is instructed to press one designated button for a "low" number (2 or 3) and another designated button for a "high" number (4 or 5). In the Coded Block, the user is presented with the same numbers and mapping rules, but the numbers are visually distorted by the presence of noise in the matrix and are more difficult to read. In the Time-Uncertainty Block, the user is presented with the same undistorted stimuli and mapping rules as in the Basic Block, but at longer, irregular interstimulus intervals.
Past Studies
As with other tests in the ANAM battery, slowed mental and motor processing speed can be indicative of brain dysfunction, as well as psychological distress (i.e., depression). The requirement to respond quickly based on a decision rule adds a relatively simple cognitive processing demand compared with the Simple Reaction Test. However, the cognitive demands for this test are presumably less than those of other slightly more complex ANAM tests. This test was not included in the primary factor analytic studies of ANAM construct validity. However, in a sample of patients with multiple sclerosis, this test showed significant correlations with traditional neuropsychological tests measuring problem solving, attention, and processing speed (Wilken et al 2003). In clinical samples, Bleiberg et al (1997) found that patients with mTBI performed worse on this test compared to controls, even with traditional neuropsychological tests were within the normal range. In a study of sleep deprivation, individuals in the sleep deprived group showed longer reaction times on this test (Acheson et al, 2007). Additionally, in a review of environmental toxic exposures, Lowe et al. (2007) reported that history of toluene exposure led to reduced performance on this test.
Interpretive information obtained from Lezak, 2004, p. 35; Cernich et al., 2007; Bleiberg et al., 1997; Bleiberg et al., 1998; & Lowe et al., 2007.
Pursuit Tracking
Cognitive Domain
Results of this test are used as an index of visuo-motor control.
Test Description
The user is instructed to move the mouse such that the mouse pointer tracks a moving box with a "+" inside. The pointer should remain inside the box and be kept as close to the "+" as possible. Options exist for the box to move horizontally, vertically, in a circle, along a square wave, or along a sine wave.
Running Memory Continuous Performance Test
Cognitive Domain
Results of this test are used as an index of attention, concentration, and working memory.
Test Description
In the running memory task, single characters are displayed on the display in rapid sequence. The user presses designated buttons to indicate if the displayed character matches or does not match the preceding character.
Simple Reaction Time
Cognitive Domain
Results of this test are used as an index of attention (i.e., reaction time & vigilance) and visuo-motor response timing.
Test Description
This test measures simple reaction time by presenting the user with a series of "*" symbols on the display. The user is instructed to respond as quickly as possible by pressing a button each time the stimulus appears.
Past Studies
Individuals might perform poorly on this test due to poor visual acuity, slowed information processing, poor attention, or slowed motor speed. Increased reaction time is a common symptom of neurological and psychiatric disease but can also occur as a result of transient changes in mental status, sleep deprivation, medication effects, and environmental stresses. Medical conditions known to lead to increased reaction times include multiple sclerosis, traumatic brain injuries, depression, and dementia (Lezak, 2004). Importantly slowed reaction time can be considered a sensitive indicator of cognitive dysfunction but is not specific to any one condition. Attentional impairments on this test may lead to slowed reaction time as well as an increased number of lapses (i.e., response omissions), suggesting inattentiveness, or anticipatory responses, suggesting impulsivity.
Given the high demand for visuomotor speed and the overall low cognitive demands of this test, it is not surprising that the Simple Reaction Time does not typically load with traditional neuropsychological measures in factor analytic studies examining the construct validity of ANAM. When it does load on specific factors, it has generally been considered to reflect motor or simple processing speed (Bleiberg et al 2000, Lowe et al, unpublished data). Likewise, the Simple Reaction Time test, when compared with other ANAM tests, typically shows fewer correlations with traditional neuropsychological tests. When present, correlations tend to be between Simple Reaction Time and neuropsychological tests that require some form of mental or motor speed (e.g., verbal fluency, Stroop word naming, Grooved Pegboard, Trails A, etc) (Woodard, et al 2004, Roebuck-Spencer et al 2006, Wilken et al 2003, Holliday et al 2003).
Despite relatively fewer direct relationships with neuropsychological tests, the Simple Reaction Time test has proven to be a sensitive indicator of cognitive dysfunction across clinical samples and a sensitive indicator of cognitive change. Specifically, Simple Reaction Time has been particularly helpful in discriminating concussed subjects from controls. In a study by Cernich et al. (2004), three ANAM tests, including Simple Reaction Time, were retained in a logistic regression model that showed good specificity in predicting concussed or control group status at up to 10 days post-injury. Simple Reaction Time was noted to be the strongest individual predictor of group status. In a study of adolescent athletes, Daniel at al. (1999) found reaction time differences of 20 - 110 milliseconds between concussed individuals and controls (even when the concussion occurred 1-3 years prior to testing). In a study of military cadets who experienced a concussion during a physical education boxing exercise, Warden et al. (2001) found significant declines on Simple Reaction Time and one other ANAM test at four days post-concussion compared to baseline. Such declines were not observed on other ANAM tests in the battery. Notably, in a follow-up study by Bleiberg et al (2004), deterioration on Simple Reaction Time was also seen in a control sample, suggesting that the stress and rigor of the academic and physical program may have led to these declines over time. In a large military normative study by Reeves et al (2006), there were significant but modest differences on the Simple Reaction Time test between individuals without prior brain injury and those with reported history of remote brain injury (average of five years) and loss of consciousness greater than one hour.
Deterioration on this test compared to control samples has also been seen across numerous other clinical samples and clinical conditions, such as systemic lupus erythmetosus (Roebuck-Spencer et al. 2004) and migraine headache (Kane et al 2007). This test has also been shown to be an important indicator of change in cognitive functioning in response to pharmaceutical trials. For instance, Farmer et al (2003) showed that this test was sensitive to decline during migraine headache and improvement in cognitive functioning after administration of medication. Finally, this test has proven sensitive to the cognitive effects of various environmental stressors including pre- versus post-dive, high stress military conditions, fatigue, and sleep deprivation (Lowe et al. 2007, Acheson et al 2007).
Interpretive information obtained from Lezak, 2004, p. 349-350; Roebuck-Spencer et al., 2004; Cernich et al., 2004; Daniel et al., 1999; Warden et al., 2001; Lowe et al., 2007; & Kane et al., 2007.
Spatial Processing: Successive
Cognitive Domain
Results of this test are used as an index of spatial processing ability and visuo-spatial working memory.
Test Description
This test asks the user to determine if two four-bar histograms are identical except for a rotation. First, the sample histogram is displayed upright on the display for memorization. The sample is then removed and the comparison histogram is displayed rotated 90 degrees clockwise or counter-clockwise. The user presses designated buttons to indicate if the comparison histogram is the same or different from the sample histogram, regardless of the orientation.
Standard Continuous Performance Task
Cognitive Domain
This test assesses sustained attention, concentration, and working memory.
Test Description
A target character is displayed for memorization. As individual characters are displayed in sequence, the user presses a designated button only if the target letter is displayed.
Stroop
Cognitive Domain
This test assesses processing speed, selective attention, interference, and executive functioning.
Test Description
There are three possible blocks of trials for this test. In the first block, the words RED, GREEN, and BLUE are presented individually in black type on the display. The user is instructed to read each word aloud and to press a corresponding key for each word (1 for RED, 2 for GREEN, 3 for BLUE). In the second block, a series of XXXX-s is presented on the display in one of three colors (XXXX, XXXX, XXXX). The user is instructed to say the color of the XXXX-s aloud and to press the corresponding key based on color. In the third block, a series of individual words (RED, GREEN, BLUE) are presented in a color that does not match the name of the color depicted by the word. The user is instructed to say the color of the word aloud rather than reading the actual word and to press the response key assigned to that color.
Switching
Cognitive Domain
This test assesses directed attention and executive function in addition to the abilities evaluated by the individual tests (i.e., visuo-spatial skills or mathematical computation).
Test Description
This test is a combination of the Manikin test and the Mathematical Processing test. One problem from each test appears on the display. The problems appear simultaneously side-by-side, and the user is directed by means of a red arrow at the bottom of the screen to respond to the problem on the left or on the right. Responses are entered using the keyboard as in the individual tests, with the left hand used for the Manikin and the right hand used for Mathematical Processing. In a variation of the test, only one type of problem is presented on each display and the user responds as appropriate for the given test.
Tapping (Left or Right)
Cognitive Domain
This test assesses simple motor skill and reaction time.
Test Description
The user is instructed to press the spacebar with the index finger of the left hand or the right hand as many times as possible in the time allotted for a single trial. The series of trials ends when the number of taps in the allotted time achieves the specified consistency criteria.
Tower Puzzle
Cognitive Domain
This test assesses visuo-spatial ability, motor control, rule adherence, spatial planning, and strategy development and execution.
Test Description
Three spindles (posts) and five disks, each disk a different size, are displayed on the screen. The user is instructed to move and arrange all the disks on the center spindle in size order from largest on the bottom to smallest on the top. Only one disk can be moved at a time and a larger disk can never be placed on top of a smaller disk. Disks are moved using either the mouse or the keyboard to select the spindles for disk moves.