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1.  Estimating premorbid IQ in the prodromal phase of a neurodegenerative disease 
The Clinical neuropsychologist  2011;25(5):757-777.
Estimates of premorbid intellect are often used in neuropsychological assessment to make inferences about cognitive decline. To optimize the method of controlling for premorbid intellect in assessments of prodromal neurodegenerative disease, we examined performance on the American National Adult Reading Test (ANART; administered during Years 1 and 3) and the two-subtest version of the Wechsler Abbreviated Scale of Intelligence (WASI; administered in Years 2 and 4) in an ongoing prospective longitudinal study of 371 participants with prodromal Huntington disease and 51 participants with normal CAG repeats. Although both measures performed similarly, the ANART demonstrated slightly lower variability in performance over a two-year period and had slightly higher test-retest reliability than the WASI.
PMCID: PMC3159182  PMID: 21660882
premorbid IQ; intelligence; neuropsychological assessment; assessment; Huntington disease; prodromal neurodegenerative disease
2.  Test–retest stability on the WRAT-3 reading subtest in geriatric cognitive evaluations 
The primary goal of this study was to establish the stability of the Wide Range Achievement Test (WRAT-3) Reading score across two annual assessments of aging individuals. Participants were classified as controls (n = 200), mild cognitive impairment (MCI; n = 137), or possible or probable Alzheimer’s disease (AD; n = 41). Test–retest stability was acceptable to high for all diagnostic groups. The descriptive classification (e.g., “average”) remained consistent for only 74% of participants. Results indicated that WRAT-3 Reading scores are appropriate for use with older adults, though the use of categorical descriptors to describe premorbid ability based on these scores is not supported.
PMCID: PMC2728046  PMID: 18821160
Wide Range Achievement Test–Third Edition; Reading; Literacy; Test–retest; Geriatrics; Mild cognitive impairment; Alzheimer’s disease
The Clinical neuropsychologist  2008;22(6):1018-1034.
The WRAT-3 Reading subtest (WRS) may be inappropriate in diseases having disproportionate impact on populations with educational disadvantages (i.e., HIV/AIDS). To understand how low literate individuals would perform on an IQ test requiring minimal education, the General Ability Measure for Adults (GAMA) was studied. HIV+ participants completed WRS, GAMA, and neuropsychological tests. Participants with low WRS (<80 SS) but higher GAMA (≥80 SS) had significantly better overall neuropsychological functioning than those with <80 SS on both tests. The GAMA may be a useful test when disparities in educational quality render reading-based measures of IQ a poor surrogate of premorbid function.
PMCID: PMC2696226  PMID: 18609327
Ethnicity; HIV; Literacy; Neuropsychological testing; Premorbid IQ; Quality of education
4.  The Impact of Perinatal HIV Infection on Older School-Aged Children's and Adolescents’ Receptive Language and Word Recognition Skills 
AIDS patient care and STDs  2009;23(6):415.
Perinatally HIV-infected youths are reaching adolescence in large numbers. Little is known about their cognitive functioning. This study aims to describe and compare the receptive language ability, word recognition skills, and school functioning of older school-aged children and adolescents perinatally HIV infected (HIV-positive) and perinatally HIV-exposed but uninfected (seroreverters; HIV-negative). Participants included 340 youths (206 HIV-positive, 134 HIV-negative), 9–16 years old, and their caregivers. Youths completed the Peabody Picture Vocabulary Test, Third Edition (PPVT-III) and the Reading Subtest of the Wide Range Achievement Test, Third Edition (WRAT-3). Caregivers were interviewed regarding demographic characteristics and school placement of youths. Medical information was abstracted from medical charts. Both groups of youths scored poorly on the PPVT-III and WRAT-3 with about one third of youths scoring in less than the 10th percentile. The HIV-positive youths scored lower than the seroreverters (M = 83.8 versus 87.6, t = 2.21, p = 0.028) on the PPVT-III and on the WRAT-3 (M = 88.2 versus 93.8, t = 2.69, p = 0.008). Among the HIV-positive youths, neither CD4+ cell count, HIV RNA viral load or Centers for Disease Control and Prevention (CDC) classification were significantly associated with either PPVT-III or WRAT-3 scores. However, youths who were taking antiretroviral medication had lower WRAT-3 scores than youths not taking medication (M = 95.03 versus 86.89, t = 2.38, p = 0.018). HIV status remained significantly associated with PPVT-III and WRAT-3 standard scores after adjusting for demographic variables. Many youths had been retained in school and attended special education classes. Findings highlight poor language ability among youths infected with and affected by HIV, and the importance of educational interventions that address this emerging need.
PMCID: PMC2818481  PMID: 19415986
5.  Predicting premorbid memory functioning in older adults 
Applied neuropsychology  2010;17(4):278-282.
Assessing cognitive change during a single visit requires the comparison of estimated premorbid abilities and current neuropsychological functioning. Although premorbid intellect has been widely examined, estimating premorbid memory abilities has received less attention. The current study used demographic variables and an estimate of premorbid intellect to predict premorbid memory abilities in a sample of 95 community-dwelling, cognitively intact older adults. These prediction formulae were then applied to a sample of 74 individuals with amnestic Mild Cognitive Impairment to look for discrepancies between premorbid and current memory abilities. Despite minimal differences between premorbid and current memory abilities in the intact sample, large and statistically significant differences were observed in the impaired sample. Although validation in larger samples is needed, the current estimates of premorbid memory abilities may aid clinicians in determining change across time.
PMCID: PMC3050536  PMID: 21154041
Predicting cognition; learning and memory; assessment
6.  Brief Report: Language Ability and School Functioning of Youth Perinatally Infected with HIV 
The purpose of this paper is to describe the language ability and school functioning of early adolescents with perinatal HIV/AIDS.
Participants included 43 youths, 9–15 years, and their primary caregivers. Youths completed the Peabody Picture Vocabulary Test (PPVT) and the Reading Subtest of the Wide Range Achievement Test (WRAT3), and were interviewed regarding their future educational aspirations and parental supervision and involvement with homework. Caregivers were interviewed regarding the child’s school achievement, parental supervision and monitoring, and educational aspirations for their child.
Fifty-four percent of youths scored below average (<25th percentile) on the PPVT, and 29% scored <10th percentile; 40% scored below average (<25th percentile) on the WRAT3, and 24% scored <10th percentile. Scores were associated with parental monitoring and educational aspirations.
Youths performed poorly on tests of verbal and reading ability, although not dissimilar to other samples of inner-city youths. Future research should attempt to isolate the impact of HIV disease on intellectual and school functioning of HIV+ youths.
PMCID: PMC2712723  PMID: 19401248
perinatal HIV infection; verbal ability; reading ability
7.  The Impact of Perinatal HIV Infection on Older School-Aged Children's and Adolescents' Receptive Language and Word Recognition Skills 
AIDS Patient Care and STDs  2009;23(6):415-421.
Perinatally HIV-infected youths are reaching adolescence in large numbers. Little is known about their cognitive functioning. This study aims to describe and compare the receptive language ability, word recognition skills, and school functioning of older school-aged children and adolescents perinatally HIV infected (HIV-positive) and perinatally HIV-exposed but uninfected (seroreverters; HIV-negative). Participants included 340 youths (206 HIV-positive, 134 HIV-negative), 9–16 years old, and their caregivers. Youths completed the Peabody Picture Vocabulary Test, Third Edition (PPVT-III) and the Reading Subtest of the Wide Range Achievement Test, Third Edition (WRAT-3). Caregivers were interviewed regarding demographic characteristics and school placement of youths. Medical information was abstracted from medical charts. Both groups of youths scored poorly on the PPVT-III and WRAT-3 with about one third of youths scoring in less than the 10th percentile. The HIV-positive youths scored lower than the seroreverters (M = 83.8 versus 87.6, t = 2.21, p = 0.028) on the PPVT-III and on the WRAT-3 (M = 88.2 versus 93.8, t = 2.69, p = 0.008). Among the HIV-positive youths, neither CD4+ cell count, HIV RNA viral load or Centers for Disease Control and Prevention (CDC) classification were significantly associated with either PPVT-III or WRAT-3 scores. However, youths who were taking antiretroviral medication had lower WRAT-3 scores than youths not taking medication (M = 95.03 versus 86.89, t = 2.38, p = 0.018). HIV status remained significantly associated with PPVT-III and WRAT-3 standard scores after adjusting for demographic variables. Many youths had been retained in school and attended special education classes. Findings highlight poor language ability among youths infected with and affected by HIV, and the importance of educational interventions that address this emerging need.
PMCID: PMC2818481  PMID: 19415986
8.  A Shortened Instrument for Literacy Screening 
Journal of General Internal Medicine  2003;18(12):1036-1038.
The Rapid Estimate of Adult Literacy in Medicine (REALM-R), a new 8-item instrument designed to rapidly screen patients for potential health literacy problems, was administered to 157 patients. The REALM-R was correlated with Wide Range Achievement Test-Revised (WRAT-R) (.64) and demonstrated a Cronbach's α of 0.91. The REALM-R identified 26 of 30 persons scoring more than 1 standard deviation below the mean on the WRAT-R, corresponding to a sixth grade reading level. The REALM-R identified a substantial number of people who scored poorly on the WRAT-R, and depending on further studies of validity and reliability, may offer a practical approach to identify patients at risk for health literacy problems in a clinical setting.
PMCID: PMC1494969  PMID: 14687263
health literacy; screening; reading level
9.  Cognitive and Academic Outcomes after Pediatric Liver Transplantation: Functional Outcomes Group (FOG) Results 
This multi-center study examined prevalence of cognitive and academic delays in children following liver transplant (LT). 144 patients ages 5–7 and 2 years post-LT were recruited through the SPLIT consortium and administered the Wechsler Preschool and Primary Scale of Intelligence, 3rd Edition (WPPSI-III), the Bracken Basic Concept Scale, Revised (BBCS-R), and the Wide Range Achievement Test, 4th edition (WRAT-4). Parents and teachers completed the Behavior Rating Inventory of Executive Function (BRIEF). Participants performed significantly below test norms on intelligence quotient (IQ) and achievement measures (Mean WPPSI-III Full Scale IQ = 94.7± 13.5; WRAT-4 Reading = 92.7± 17.2; WRAT-4 Math = 93.1± 15.4; p<0001). 26% of patients (14% expected) had “mild to moderate” IQ delays (Full Scale IQ=71–85) and 4% (2% expected) had “serious” delays (Full Scale IQ ≤70; p<0.0001). Reading and/or math scores were weaker than IQ in 25%, suggesting learning disability, compared to 7% expected by CDC(1) statistics (p<0.0001). Executive deficits were noted on the BRIEF, especially by teacher report (Global Executive Composite = 58; p<0.001). Results suggest a higher prevalence of cognitive and academic delays and learning problems in pediatric LT recipients compared to the normal population.
PMCID: PMC3075835  PMID: 21272236
liver transplant; pediatric liver disease; psychological aspects of organ transplantation; cognition disorders; neuropsychological tests; learning disorders
10.  Neuropsychological Profiles in Individuals at Clinical High Risk for Psychosis: Relationship to Psychosis and Intelligence 
Schizophrenia research  2010;123(2-3):188-198.
Characterizing neuropsychological (NP) functioning of individuals at clinical high risk (CHR) for psychosis may be useful for prediction of psychosis and understanding functional outcome. The degree to which NP impairments are associated with general cognitive ability and/or later emergence of full psychosis in CHR samples requires study with well-matched controls.
We assessed NP functioning across eight cognitive domains in a sample of 73 CHR youth, 13 of whom developed psychotic-level symptoms after baseline assessment, and 34 healthy comparison (HC) subjects. Groups were matched on age, sex, ethnicity, handedness, subject and parent grade attainment, and median family income, and were comparable on WRAT-3 Reading, an estimate of premorbid IQ. Profile analysis was used to examine group differences and the role of IQ in profile shape.
The CHR sample demonstrated a significant difference in overall magnitude of NP impairment but only a small and nearly significant difference in profile shape, primarily due to a large impairment in olfactory identification. Individuals who subsequently developed psychotic-level symptoms demonstrated large impairments in verbal IQ, verbal memory and olfactory identification comparable in magnitude to first episode samples.
CHR status may be associated with moderate generalized cognitive impairments marked by some degree of selective impairment in olfaction and verbal memory. Impairments were greatest in those who later developed psychotic symptoms. Future study of olfaction in CHR samples may enhance early detection and specification of neurodevelopmental mechanisms of risk.
PMCID: PMC2964352  PMID: 20692125
Schizophrenia; Prodrome; Cognition; Ultra High Risk; Neurocognitive Functioning; IQ
11.  Estimating Premorbid Intelligence among Older Adults: The Utility of the AMNART 
Journal of Aging Research  2011;2011:428132.
This study examines the utility of the American version of the National Adult Reading Test (AMNART) as a measure of premorbid intelligence for older adults. In a sample of 130 older adults, aged 56 to 104, the AMNART was compared to other tests of premorbid intelligence. The results revealed that AMNART-estimated IQ was significantly higher than other premorbid estimates. Across specific educational groups (i.e., 0–12, 13–16, and 17 or more years of education), AMNART-estimated IQ was inflated relative to all other premorbid estimates. The AMNART also declined as cognitive impairment increased, and there was a significant interaction between aging-related diagnostic group and premorbid estimate. The AMNART may therefore overestimate premorbid ability relative to other premorbid measures, particularly among those with greater cognitive impairment and lower levels of education. These results suggest that the AMNART should be used cautiously among older adults and in conjunction with other estimates of premorbid ability.
PMCID: PMC3100635  PMID: 21629758
12.  Using Lexical Familiarity Judgments to Assess Verbally-Mediated Intelligence in Aphasia 
Neuropsychology  2008;22(6):687-696.
In this study, a task using forced-choice lexical familiarity judgments of irregular versus archaic words (a newly developed measure called the Lexical Orthographic Familiarity Test; LOFT) was compared to a standardized oral word-reading measure (the Wechsler Test of Adult Reading; WTAR) in a group of 35 aphasic adults and a comparison group of 125 community dwelling, non-brain damaged adults. When compared to non-brain damaged adults, aphasics had significantly lower scores on the WTAR but not the LOFT. Although both the WTAR and LOFT were significantly correlated with education in the non-brain damaged group, only the LOFT was correlated with education and also with the Barona full scale IQ index in the aphasic group. Lastly, WTAR performance showed a significantly greater relationship to the severity of language disorder in the aphasic group than did the LOFT. These results have both theoretical and clinical implications for the assessment of language disordered adults, as they indicate that patients with aphasia may retain aspects of verbally mediated intelligence, and that the LOFT may provide a better estimate of premorbid functioning in aphasia than other currently available measures.
PMCID: PMC2910429  PMID: 18999341
13.  Relationship of the Brief UCSD Performance-based Skills Assessment (UPSA-B) to multiple indicators of functioning in people with schizophrenia and bipolar disorder 
Bipolar disorders  2010;12(1):45-55.
This study assessed the relationship between multiple indicators of ‘real-world’ functioning and scores on a brief performance-based measure of functional capacity known as the Brief University of California San Diego (UCSD) Performance-based Skills Assessment (UPSA-B) in a sample of 205 patients with either serious bipolar disorder (n = 89) or schizophrenia (n = 116).
Participants were administered the UPSA-B and assessed on the following functional domains: (i) independent living status (e.g., residing independently as head of household, living in residential care facility); (ii) informant reports of functioning (e.g., work skills, daily living skills); (iii) educational attainment and estimated premorbid IQ as measured by years of education and Wide Range Achievement Test reading scores, respectively; and (iv) employment.
Better scores on the UPSA-B were associated with greater residential independence after controlling for age, diagnosis, and symptoms of psychopathology. Among both bipolar disorder and schizophrenia patients, higher UPSA-B scores were significantly related to better informant reports of functioning in daily living skills and work skills domains. Greater estimated premorbid IQ was associated with higher scores on the UPSA-B for both schizophrenia and bipolar disorder participants. Participants who were employed scored higher on the UPSA-B when controlling for age and diagnosis, but not when controlling for symptoms of psychopathology.
These data suggest the UPSA-B may be useful for assessing capacity for functioning in a number of domains in both people diagnosed with schizophrenia and bipolar disorder.
PMCID: PMC2846793  PMID: 20148866
employment; functional capacity; functional outcome; independence; severe; mental illness
14.  Estimating Premorbid Cognitive Abilities in Low-Educated Populations 
PLoS ONE  2013;8(3):e60084.
To develop an informant-based instrument that would provide a valid estimate of premorbid cognitive abilities in low-educated populations.
A questionnaire was drafted by focusing on the premorbid period with a 10-year time frame. The initial pool of items was submitted to classical test theory and a factorial analysis. The resulting instrument, named the Premorbid Cognitive Abilities Scale (PCAS), is composed of questions addressing educational attainment, major lifetime occupation, reading abilities, reading habits, writing abilities, calculation abilities, use of widely available technology, and the ability to search for specific information. The validation sample was composed of 132 older Brazilian adults from the following three demographically matched groups: normal cognitive aging (n = 72), mild cognitive impairment (n = 33), and mild dementia (n = 27). The scores of a reading test and a neuropsychological battery were adopted as construct criteria. Post-mortem inter-informant reliability was tested in a sub-study with two relatives from each deceased individual.
All items presented good discriminative power, with corrected item-total correlation varying from 0.35 to 0.74. The summed score of the instrument presented high correlation coefficients with global cognitive function (r = 0.73) and reading skills (r = 0.82). Cronbach's alpha was 0.90, showing optimal internal consistency without redundancy. The scores did not decrease across the progressive levels of cognitive impairment, suggesting that the goal of evaluating the premorbid state was achieved. The intraclass correlation coefficient was 0.96, indicating excellent inter-informant reliability.
The instrument developed in this study has shown good properties and can be used as a valid estimate of premorbid cognitive abilities in low-educated populations. The applicability of the PCAS, both as an estimate of premorbid intelligence and cognitive reserve, is discussed.
PMCID: PMC3605367  PMID: 23555894
15.  The Relation of Adiposity to Cognitive Control and Scholastic Achievement in Preadolescent Children 
Obesity (Silver Spring, Md.)  2012;20(12):2406-2411.
Adiposity may be negatively associated with cognitive function in children. However, the findings remain controversial, in part due to the multifaceted nature of cognition and perhaps the lack of accurate assessment of adiposity. The aim of this study was to clarify the relation of weight status to cognition in preadolescent children using a comprehensive assessment of cognitive control, academic achievement, and measures of adiposity. Preadolescent children between 7 and 9 years (n = 126) completed Go and NoGo tasks, as well as the Wide Range Achievement Test 3rd edition (WRAT3), which measures achievement in reading, spelling, and arithmetic. In addition to body mass index (BMI), fat mass was measured using dual X-ray absorptiometry (DXA). Data were analyzed with multiple regression analysis, controlling for confounding variables. Analyses revealed that BMI and fat mass measured via DXA were negatively associated with cognitive control, as children with higher BMI and fat mass exhibited poorer performance on the NoGo task requiring extensive amounts of inhibitory control. By contrast, no relation of weight status to performance was observed for the Go task requiring smaller amounts of cognitive control. Higher BMI and fat mass were also associated with lower academic achievement scores assessed on the WRAT3. These data suggest that adiposity is negatively and selectively associated with cognitive control in preadolescent children. Given that cognitive control has been implicated in academic achievement, the present study provides an empirical basis for the negative relationship between adiposity and scholastic performance.
PMCID: PMC3414677  PMID: 22546743
16.  Association of childhood trauma with cognitive function in healthy adults: a pilot study 
BMC Neurology  2010;10:61.
Animal and human studies suggest that stress experienced early in life has detrimental consequences on brain development, including brain regions involved in cognitive function. Cognitive changes are cardinal features of depression and posttraumatic stress disorder. Early-life trauma is a major risk factor for these disorders. Only few studies have measured the long-term consequences of childhood trauma on cognitive function in healthy adults.
In this pilot study, we investigated the relationship between childhood trauma exposure and cognitive function in 47 healthy adults, who were identified as part of a larger study from the general population in Wichita, KS. We used the Cambridge Neuropsychological Test Automated Battery (CANTAB) and the Wide-Range-Achievement-Test (WRAT-3) to examine cognitive function and individual achievement. Type and severity of childhood trauma was assessed by the Childhood Trauma Questionnaire (CTQ). Data were analyzed using multiple linear regression on CANTAB measures with primary predictors (CTQ scales) and potential confounders (age, sex, education, income).
Specific CTQ scales were significantly associated with measures of cognitive function. Emotional abuse was associated with impaired spatial working memory performance. Physical neglect correlated with impaired spatial working memory and pattern recognition memory. Sexual abuse and physical neglect were negatively associated with WRAT-3 scores. However, the association did not reach the significance level of p < 0.01.
Our results suggest that physical neglect and emotional abuse might be associated with memory deficits in adulthood, which in turn might pose a risk factor for the development of psychopathology.
PMCID: PMC2910667  PMID: 20630071
17.  Relationship of Medication Management Test-Revised (MMT-R) Performance to Neuropsychological Functioning and Antiretroviral Adherence in Adults with HIV 
AIDS and behavior  2012;16(8):2286-2296.
While performance-based tests of everyday functioning offer promise in facilitating diagnosis and classification of HIV-associated neurocognitive disorders (HAND), there remains a dearth of well-validated instruments. In the present study, clinical correlates of performance on one such measure (i.e., Medication Management Test—Revised; MMT-R) were examined in 448 HIV+ adults who were prescribed antiretroviral therapy. Significant bivariate relationships were found between MMT-R scores and demographics (e.g., education), hepatitis C co-infection, estimated premorbid IQ, neuropsychological functioning, and practical work abilities. MMT-R scores were not related to HIV disease severity, psychiatric factors, or self-reported adherence among participants with a broad range of current health status. However, lower MMT-R scores were strongly and uniquely associated with poorer adherence among participants with CD4 T-cell counts <200. In multivariate analyses, MMT-R scores were predicted by practical work abilities, estimated premorbid functioning, attention/working memory, learning, and education. Findings provide overall mixed support for the construct validity of the MMT-R and are discussed in the context of their clinical and research implications for evaluation of HAND.
PMCID: PMC3575112  PMID: 22722882
HIV; medication management; neuropsychological functioning; adherence; construct validity; instrumental activities of daily living
18.  Subclinical thyroid disorders and cognitive performance among adolescents in the United States 
BMC Pediatrics  2006;6:12.
Thyroid hormone plays a crucial role in the growth and function of the central nervous system. The purpose of the study was to examine the relationships between the status of subclinical thyroid conditions and cognition among adolescents in the United States.
Study sample included 1,327 adolescents 13 to 16 years old who participated in the Third National Health and Nutrition Examination Survey (NHANES III). Serum thyroxine (T4) and thyroid stimulating hormone (TSH) were measured and subclinical hypothyroidism, subclinical hyperthyroidism, and euthyroid groups were defined. Cognitive performance was assessed using the subscales of the Wide Range Achievement Test-Revised (WRAT-R) and the Wechsler Intelligence Scale for Children-Revised (WISC-R). The age-corrected scaled scores for arithmetic, reading, block design, and digit span were derived from the cognitive assessments.
Subclinical hypothyroidism was found in 1.7% and subclinical hyperthyroidism was found in 2.3% of the adolescents. Cognitive assessment scores on average tended to be lower in adolescents with subclinical hyperthyroidism and higher in those with subclinical hypothyroidism than the score for the euthyroid group. Adolescents with subclinical hypothyroidism had significantly better scores in block design and reading than the euthyroid subjects even after adjustment for a number of variables including sex, age, and family income level.
Subclinical hypothyroidism was associated with better performance in some areas of cognitive functions while subclinical hyperthyroidism could be a potential risk factor.
PMCID: PMC1459154  PMID: 16623938
19.  Normative Performance on an Executive Clock Drawing Task (CLOX) in a Community-Dwelling Sample of Older Adults 
The CLOX is a clock drawing test used to screen for cognitive impairment in older adults, but there is limited normative data for this measure. This study presents normative data for the CLOX derived from a diverse sample of 585 community-dwelling older adults with complete cognitive data at baseline and 4-year follow-up. Participants with evidence of baseline impairment or substantial 4-year decline on the Mini-Mental State Examination were excluded from the normative sample. Spontaneous clock drawing (CLOX1) and copy (CLOX2) performances were stratified by age group and reading ability from the Wide Range Achievement Test, 3rd edition (WRAT-3). Lowest mean CLOX scores were observed for the oldest age group (75+ years old) with the lowest WRAT-3 reading scores. For all groups, average scores were higher for CLOX2 than CLOX1. These normative data may be helpful to clinicians and researchers for interpreting CLOX performance in older adults with diverse levels of reading ability.
PMCID: PMC2957959  PMID: 20601672
Normative data; Clock drawing test; Reading ability; Older adults; Aging
20.  The Association among Literacy, Numeracy, HIV Knowledge and Health-Seeking Behavior: A Population-Based Survey of Women in Rural Mozambique 
PLoS ONE  2012;7(6):e39391.
Limited literacy skills are common in the United States (US) and are related to lower HIV knowledge and worse health behaviors and outcomes. The extent of these associations is unknown in countries like Mozambique, where no rigorously validated literacy and numeracy measures exist.
A validated measure of literacy and numeracy, the Wide Range Achievement Test, version 3 (WRAT-3) was translated into Portuguese, adapted for a Mozambican context, and administered to a cross-section of female heads-of-household during a provincially representative survey conducted from August 8 to September 25, 2010. Construct validity of each subscale was examined by testing associations with education, income, and possession of socioeconomic assets, stratified by Portuguese speaking ability. Multivariable regression models estimated the association among literacy/numeracy and HIV knowledge, self-reported HIV testing, and utilization of prenatal care.
Data from 3,557 women were analyzed; 1,110 (37.9%) reported speaking Portuguese. Respondents’ mean age was 31.2; 44.6% lacked formal education, and 34.3% reported no income. Illiteracy was common (50.4% of Portuguese speakers, 93.7% of non-Portuguese speakers) and the mean numeracy score (10.4) corresponded to US kindergarten-level skills. Literacy or numeracy was associated (p<0.01) with education, income, age, and other socioeconomic assets. Literacy and numeracy skills were associated with HIV knowledge in adjusted models, but not with HIV testing or receipt of clinic-based prenatal care.
The adapted literacy and numeracy subscales are valid for use with rural Mozambican women. Limited literacy and numeracy skills were common and associated with lower HIV knowledge. Further study is needed to determine the extent to which addressing literacy/numeracy will lead to improved health outcomes.
PMCID: PMC3382184  PMID: 22745747
21.  Low Numeracy Skills Are Associated With Higher BMI 
Obesity (Silver Spring, Md.)  2008;16(8):1966-1968.
Low numeracy skills and obesity are both common. Numeracy skills are used in healthy weight management to monitor caloric intake. The relationship between obesity and numeracy skills in adult primary care patients is unknown. A cross-sectional study enrolled adult, English-speaking primary care patients. BMI was assessed by self-report; numeracy and literacy skills were measured with the Wide Range Achievement Test, 3rd Edition (WRAT-3) and the Rapid Estimate of Adult Literacy in Medicine (REALM), respectively. The relationship between numeracy and BMI was described with Spearman's rank correlation and linear regression analyses. In 160 patients, the mean (s.d.) age was 46 (16) years, 66% were white, 70% were female, and 91% completed high school. The mean BMI was 30.5 (8.3) kg/m2. Less than 9th grade numeracy skills were found in 66% of the participants. Participants with numeracy skills <9th grade had a mean BMI of 31.8 (9.0) whereas those with numeracy skills ≥9th grade had a mean BMI of 27.9 (6.0), P = 0.008. Numeracy was negatively and significantly correlated with BMI (ρ = −0.26, P = 0.001). This correlation persisted after adjusting for age, sex, race, income, years of education, and literacy (β coefficient = −0.14; P = 0.010). Literacy skills were not associated with BMI. We found a significant association between low numeracy skills and higher BMI in adult primary care patients. A causal relationship cannot be determined. However, numeracy may have important clinical implications in the design and implementation of healthy weight management interventions and should be further evaluated to determine the magnitude of its effect.
PMCID: PMC2694664  PMID: 18535541
22.  Color-coding Improves Parental Understanding of Body Mass Index Charting 
Academic pediatrics  2009;9(5):330-338.
To assess parental understanding of body mass index (BMI) and BMI percentiles using standard versus color-coded charts and investigate how parental literacy and/or numeracy (quantitative skills) impacts that understanding.
A convenience sample of 163 parents of children aged 2–8 years at two academic pediatric centers completed a demographics questionnaire, the mathematics portion of the Wide Range Achievement Test (WRAT-3R), the Short Test of Functional Health Literacy in Adults (S-TOFHLA), and an “Understanding BMI” questionnaire, which included parallel BMI charting questions to compare understanding of standard versus color-coded BMI charting. Outcomes included parental-reported versus actual understanding of BMI, the odds (obtained by generalized estimating equations) of answering parallel questions correctly using standard versus color-coded charting, and odds of answering questions correctly based on numeracy and literacy.
Many parents (60%) reported knowing what BMI was, but only 30% could define it even roughly correctly. Parents using color-coded charts had greater odds of answering parallel BMI charting questions correctly than parents using standard charts (mean 88% vs. 65% correct; pooled AOR=4.32, 95% CI: 3.14–5.95; p<.01). Additionally, parents with lower numeracy (K-5 level) benefited more from color-coded charts (increased from 51% to 81% correct) than did higher numeracy parents (≥ high school level), who performed well using both charts (89% vs. 99% correct).
Parents consistently performed better using color-coded than standard BMI charts. Color-coding was particularly helpful for lower numeracy parents. Future studies should investigate whether these results translate into offices and whether understanding motivates parents toward important lifestyle change.
PMCID: PMC2746871  PMID: 19679524
Body Mass Index; Overweight; Obesity; Literacy; Numeracy
23.  Relationship of ethnicity, age, education, and reading level to speed and executive function among HIV+ and HIV- women: The WIHS Neurocognitive Substudy 
Use of neuropsychological tests to identify HIV-associated neurocognitive dysfunction must involve normative standards that are well-suited to the population of interest. Norms should be based on a population of HIV-uninfected individuals as closely matched to the HIV-infected group as possible, and must include examination of the potential effects of demographic factors on test performance. This is the first study to determine the normal range of scores on measures of psychomotor speed and executive function among a large group of ethnically and educationally diverse HIV-uninfected, high risk women, as well as their HIV-infected counterparts. Participants (n = 1653) were administered the Trailmaking Test Parts A and B (Trails A and Trails B), the Symbol Digit Modalities Test (SDMT), and the Wide Range Achievement Test-3 (WRAT-3). Among HIV-uninfected women, race/ethnicity accounted for almost 5% of the variance in cognitive test performance. The proportion of variance in cognitive test performance accounted for by age (13.8%), years of school (4.1%) and WRAT-3 score (11.5%) were each significant, but did not completely account for the effect of race (3%). HIV-infected women obtained lower scores than HIV-uninfected women on time to complete Trails A and B, SDMT total correct, and SDMT incidental recall score, but after adjustment for age, years of education, racial/ethnic classification, and reading level, only the difference on SDMT total correct remained significant. Results highlight the need to adjust for demographic variables when diagnosing cognitive impairment in HIV-infected women. Advantages of demographically adjusted regression equations developed using data from HIV-uninfected women are discussed.
PMCID: PMC3383771  PMID: 21950512
24.  Neuropsychological characteristics of Huntington's disease carriers: a double blind study. 
Journal of Medical Genetics  1995;32(8):600-604.
A cohort of 33 people at risk for Huntington's disease (HD), applying for genetic testing, were tested with a battery of neuropsychological tests covering attentional, visuospatial, learning, memory, and planning functions. A psychiatric rating scale, SCL-90R, was also applied, mainly as a control, since cognitive dysfunction could be ascribed to functional disorders as well as neurodegenerative processes. Self-rating did not indicate any psychiatric symptoms in carriers or non-carriers. However, significantly inferior cognitive functioning in the gene carriers was disclosed by the neuropsychological tests. Primarily, attentional, learning, and planning functions were affected. It is concluded that premorbid cognitive decline occurs in HD.
PMCID: PMC1051633  PMID: 7473650
This study investigated financial abilities of 154 patients with mild cognitive impairment (MCI) (116 Caucasian, 38 African American) using the Financial Capacity Instrument (FCI). In a series of linear regression models, we examined the effect of race on FCI performance and identified preliminary predictor variables that mediated observed racial differences on the FCI. Prior/premorbid abilities were identified. Predictor variables examined in the models included race and other demographic factors (age, education, gender), performance on global cognitive measures (MMSE, DRS-2 Total Score), history of cardiovascular disease (hypertension, diabetes, hypercholesterolemia), and a measure of educational achievement (WRAT-3 Arithmetic). African American patients with MCI performed below Caucasian patients with MCI on six of the seven FCI domains examined and on the FCI total score. WRAT-3 Arithmetic emerged as a partial mediator of group differences on the FCI, accounting for 54% of variance. In contrast, performance on global cognitive measures and history of cardiovascular disease only accounted for 14% and 2%, respectively, of the variance. Racial disparities in financial capacity appear to exist among patients with amnestic MCI. Basic academic math skills related to educational opportunity and quality of education account for a substantial proportion of the group difference in financial performance.
PMCID: PMC2992589  PMID: 20625268
Mild Cognitive Impairment; financial capacity; IADL; disability; ethnicity; African American

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