Keywords
executive functions, brain lesions, neuropsychological assessment, confounding effects
executive functions, brain lesions, neuropsychological assessment, confounding effects
Executive functions are the cognitive capacities that control lower-level functions and are essential to future-oriented thought and behaviour. They are affected by head injuries24 or arise because of a focal frontal lesion, either cortical5,24,25 or subcortical13. In particular, the term executive functions refers to cognitive, emotional and behavioural aspects of conduct involved in achieving a specific purpose. Executive functions include processes that are complex, mixed together and in constant interaction. They facilitate the optimum adaptation of the individual to the environment1,16,23,24. Lezak16 suggested the division of competencies into four specific components: volition, planning, goal-oriented behaviour and effective performance. Several psychometric instruments are available for evaluating executive functions during neuropsychological examinations. However, most of them are generally highly structured (the task and the stimuli set the goal and the processes required to achieve that goal)15,16. Moreover, none of the tools currently in use for evaluating the performance in the domain of executive functions is able to assess how the patients are able to formulate a goal and to plan how to pursue it, which are prerequisites for a return to work as well as for social life.
The Tinkertoy was created originally as a toy for kids made of various wooden and plastic pieces (wooden dowels, knobs, wheels, connectors, caps, points), to be assembled freely in order to make constructions. Based on this toy, Lezak created a test for the neuropsychological assessment of executive functions, which gives subjects the opportunity to use their own initiative and does not force them to choose from a series of predetermined alternatives. In fact, one of the most relevant characteristics of frontal lobe syndrome is an environment-dependent behaviour, which makes it difficult to cope with the requirements of everyday life. In this respect, Lezak’s Tinkertoy test (TTT) stands out, because it was specifically conceived to examine the ability to generate the most achievable goal, to organize, to plan and act, and to respond in a flexible way in a given context15. At the outset, studies of the TTT showed that it could be considered a useful predictor of employability3,15. Particularly, some researchers found the TTT complexity score correlated more positively with the employability of traumatic brain-damaged patients, than other tests for executive functions, such as trail making test -B, maze tracking, and several WAIS-R subtests9,10. Ownsworth and Shum20 showed that the difference in TTT scores between employed and unemployed patients after strokes was highly significant (p < 0.005 in a group of 27 subjects.) According to the authors, the TTT seems to describe productivity outcomes better than other tests of executive functioning (i.e. the FAS test and the five -point test), independent of the presence of hemiplegia and the elapsed time since the stroke. Furthermore, the TTT has been shown to be useful both for differentiating between types of dementia and for evaluating the severity of dementia12,17. In addition, subjects generally find the TTT interesting or amusing, so that it is easy to carry out this test, even in the cases of patients who are not very cooperative. Despite the fact that the TTT is commonly used in a clinical context, the only normative data refers to a very small sample of non-Italians16. Given both the potential relevance of this instrument for neuropsychological practice, and the lack of any validation so far, the present study aimed at setting TTT normative values in Italian adults, in order to determine firstly inferential cut-off points and their tolerance limits, and then equivalent scores, applying a statistical technique developed for neuropsychological tests7,8,22.
Two hundred and fifty six neurologically unimpaired Italian subjects (mean age: 44.6; sd 20.85, range: 15–86 years) enrolled in this study on a voluntary basis, with verbal consent. The Research Ethics Committee of the University of Milano-Bicocca approved this (permit number: RM-2016-40) as a minimal risk study, whereby a signed consent document was not required. The subjects were nearly equally distributed according to sex (126 women and 130 men) and age class (range: 15 to 86 years). The level of education (from primary school to university) was recorded in years. Nobody showed a history or evidence of psychiatric disorders or dementia. The demographic distribution of the sample is shown in Table 1.
Test items, administration procedure and scoring criteria in this study followed the ones described by Lezak in the fourth edition of the Neuropsychological Assessment Handbook16. The test items were selected from the classic version of the Tinkertoy set. Namely, 50 items were used: 24 wooden dowels (4 red, 4 green, 4 orange, 6 blue, 6 yellow), 10 wooden knobs, 4 wooden wheels, 4 wooden caps, 4 wooden connectors, and 4 plastic yellow connectors (Figure 1).
Each subject was individually presented with the aforementioned 50 pieces in different colours and forms, placed at random on a clean surface, and were told to build up whatever construction they wanted with a 5-minute minimum time limit, but no maximum time limit. On completion, the subjects were asked to say what the construction represented. Assessment took into account 7 performance variables: 1. Made construction(s) - whether the subject made any combination of pieces; 2. Number of pieces - total number of pieces used; 3. Name - whether and when the subject gave a name appropriate to the construction’s appearance; 4. Mobility (wheels working) and moving parts; 5. Three-dimensionality - whether the subject’s construction had three dimensions; 6. Free-standing - whether the subject’s construction stayed standing; 7. Errors - pieces forced together (misfit), connections not properly made (incomplete fit), and dropped and not picked up pieces (see Table 2). At the end a complexity score was given, determined by the sum of the points earned in each of the performance variables, with a maximum of 12 points (for two examples, see Figure 2).
The choice of the equivalent scores procedure was prompted by the need to obtain norms that could be directly compared to the already available norms of a wide set of other neuropsychological tests. In the first place, the influence of age, education and gender, the latter dichotomised, was evaluated through a linear multiple regression model, with least square estimation method. Several monotonic transformations of independent variables were analysed and the most effective in reducing the residual variance was adopted. The effect of each variable was studied partialling out the effect held in common with the other variables, after discarding age, as non significant as a covariate. In this way, it was possible to estimate the effects of confounding factors on the raw scores and, based on these estimates, adjusted scores were computed, adding or subtracting the contribution of the significant confounding effect. After ranking adjusted scores, Wilks’ nonparametric procedure was applied to set tolerance limits26,27 for pathological TTT result 0 (the lower 5% of all population). The maximum equivalent score, 4, was set with the analogous procedure for the upper 5% of population, whereas equivalent scores 1,2,3 were determined based on the ranking. Spss 21 package for the Social Science led to linear model estimation and to the ranking, Wilks’ tolerance intervals by mean of the R package ‘tolerance’27.
Normality criteria are generally appraised by comparing one subject’s performance to that of all the other subjects. This implies homogeneity across the subjects in the comparison, and hence imposes the requirement that all possible factors influencing performance have been taken into account and removed from the raw scores. From a statistical point of view, this aim can be accomplished using stratification, which nonetheless, in some cases, raises problems concerning the sample size in each stratum. Alternatively, the effect of confounding factors can be removed from raw scores in a multiple regression model4,8,22. In order to set correction grids for the raw values of participants’ complexity scores, a linear model for the simultaneous effect of sex, age and educational level in years was fitted. Apart from sex, coded as a dummy variable, all dependent and independent variables were centred, where centring each variable on its mean corrected for any overlap with the effect of other terms of the model. The multiple regression proved significant (F2;242) = 9.08; p <0.001, adjusted Rsquare = 0.45). With regard to regression coefficients, sex and education proved significant (p = 0.002 and p = 0.008 respectively), whereas age did not, due to multicollinearity with education (rp = 0.422; p < .001) and it was therefore discarded. On average, females obtained lower scores than males (8.71 versus 9.40, sd 1.743 and 1.645 respectively). Education played a positive but modest role, an increase in the score from one education class to the adjacent one accounting approximately half a point (Table 3).
Education in years | Mean score | Standard deviation |
---|---|---|
≤5 | 8.64 | 1.580 |
6–8 | 8.78 | 1.607 |
9–13 | 9.22 | 1.771 |
14–16 | 9.03 | 1.630 |
≥17 | 9.50 | 1.877 |
Let yf,, ym indicate the score of a female and a male respectively and x the number of years of education. Then, the estimated impact of confounding variables on the TTT Complexity Centred raw scores can be expres e (males coded as 0, females as 1) and centred years of education.
The estimation of the linear regression for the raw scores gives:
Accordingly, adjustment was performed subtracting the estimated contribution of the confounding variables from each raw score, distinctly for females, with x = 1, and for males, with x = 0 in (2). In order to produce the adjustment to be applied to patients raw scores evaluated in rehabilitation practice, Table 4 shows the correction grid with the points to be added to raw Complexity Scores in order to calculate adjusted scores. Once the adjusted distribution had been computed, the identification of a cut-off point that assessed normality or impairment was a crucial step19. The appropriate criteria were represented by the interval underlying the lowest 5% tail of the adjusted scores in the cumulative distribution.
However, misclassification of performance may arise and needs to be taken into account. In using the widely accepted value of the lower 5% of the normal population (regarded as a reasonable criterion for classifying subjects that are probably not normal) there is an inherent risk of incorrect categorization. The estimation of inferential tolerance limits enable one to obtain the thresholds above (or below) which there is at least (or at most) a desired percentage of the population, and the estimation of these limits keeps errors in performance assessment under control7,18. With the thirteenth observation, corresponding to the value of 6.25, representing the fifth percentile of the cumulative distribution function, the tenth and the sixteenth observation were identified as the outer and the inner limits, yielding the values of 5.86 and 6.44 respectively. Values equal to, or lower than, the outer tolerance limit indicate a pathological performance, with a controlled error risk. In order to compare the performance in this test to those in other tests, the standardization issue needs to be faced. The commonly used z-scores raise various difficulties, such as an alteration of the statistical dispersion of adjusted scores and problems with floor and ceiling values7. Distribution-free techniques are required here, since the best standpoint seems to be that of regarding adjusted scores as raw estimates of performance and hence converting them into an ordinal scale with just a few ordinal values, by means of the cumulative function of adjusted scores. A 5-point scale from (0 to 4), termed equivalent scores, is widely used, where 0 indicates the score that lies below the outer non-parametric tolerance limit of adjusted scores, Equivalent scores 1, 2 and 3 are intermediate between 0 and 4, id est they are obtained in the cumulative adjusted scores distribution. The equivalent score 4 indicates a performance equal to or superior to the median, thus no longer distinguishing between scores found in the upper half of the distribution. Equivalent scores 1, 2 and 3 are intermediate between 0 and 4 on a quasi-interval scale. An equivalent score equal to 0 is considered below the normal range, with a controlled error risk. This contracted scale of equivalent scores is then measured on a quasi-interval scale8 and may be viewed as a standardisation of adjusted scores. Table 5 shows the equivalent score limits, the density (i.e. the number of subjects within each equivalent score), and the cumulative frequency of subjects from 0 to 4 equivalent scores.
The TTT has proved to be a highly sensitive instrument for the assessment of organization, planning abilities and response flexibility in a less structured context, compared with other neuropsychological tests generally used to evaluate executive functions16. Previously, the TTT could not be administered during psychometric neuropsychological examinations, owing to the absence of normative values, apt to compare the performance of frontal brain-damaged patients with the mean performance of unimpaired subjects with similar demographic features. The present study has filled this gap, establishing TTT normative data for a wide, healthy population sample, representative of the Italian population (n=256). Statistical analyses were adopted according to the methodology that is most widely used in Italy for the computation of normative values2,6–8,14,21,22. Our findings showed how TTT performance was affected by sex and education. In particular, males performed better than females and the higher the education the higher the TTT scores. Both effects have already been found in other tests for executive functions, such as the Wisconsin card sorting and Weigl tests14 and show an effect of culture and learning in structuring high-level functions. The relationship with education was also found by Apollonio and collaborators with the FAB2. Adjusted scores and inferential cut-off scores were calculated. Moreover, adjusted scores were transformed into equivalent scores, since the availability of equivalent scores makes it possible to evaluate whether a patient presents a homogeneous cognitive profile, or if he/she presents selective deficits in one or more cognitive areas. Therefore, it is now possible to compare the performance of brain-damaged patients directly with the TTT and other neuropsychological tests, using normative data with equivalent scores.
F1000Research: Dataset 1. Raw data for ‘Normative data for Lezak’s Tinkertoy test in healthy Italian adults’, Crippa et al. 2016., 10.5256/f1000research.8409.d11868428
Written informed consent was obtained from each patient in the normative study and from a pathological patient whose construction is depicted.
LC provided expertise in the clinical practice and the administration of the test. RD designed the study and supervised data collection. FC performed the statistical analysis. FC and RD prepared the first draft of the manuscript, LC contributed to the preparation of the manuscript. All authors were involved in the revision of the draft manuscript and have agreed to the final content.
Views | Downloads | |
---|---|---|
F1000Research | - | - |
PubMed Central
Data from PMC are received and updated monthly.
|
- | - |
Competing Interests: No competing interests were disclosed.
Competing Interests: No competing interests were disclosed.
Alongside their report, reviewers assign a status to the article:
Invited Reviewers | ||
---|---|---|
1 | 2 | |
Version 1 22 Apr 16 |
read | read |
Click here to access the data.
Spreadsheet data files may not format correctly if your computer is using different default delimiters (symbols used to separate values into separate cells) - a spreadsheet created in one region is sometimes misinterpreted by computers in other regions. You can change the regional settings on your computer so that the spreadsheet can be interpreted correctly.
Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list:
Sign up for content alerts and receive a weekly or monthly email with all newly published articles
Already registered? Sign in
The email address should be the one you originally registered with F1000.
You registered with F1000 via Google, so we cannot reset your password.
To sign in, please click here.
If you still need help with your Google account password, please click here.
You registered with F1000 via Facebook, so we cannot reset your password.
To sign in, please click here.
If you still need help with your Facebook account password, please click here.
If your email address is registered with us, we will email you instructions to reset your password.
If you think you should have received this email but it has not arrived, please check your spam filters and/or contact for further assistance.
Comments on this article Comments (0)