Experimental and Clinical Psychopharmacology Copyright 2004 by the American Psychological Association

2004, Vol. 12, No. 3, 200 –207 1064-1297/04/$12.00 DOI: 10.1037/1064-1297.12.3.200

The Detection of Cognitive Impairment Among Substance-Abusing

Patients: The Accuracy of the Neuropsychological Assessment
Battery—Screening Module
Kerry Grohman and William Fals-Stewart
University at Buffalo, The State University of New York

In this investigation, the authors examined the classification accuracy of the Neuropsycho-
logical Assessment Battery—Screening Module (NAB–SM; R. A. Stern & T. White, 2003)
in detecting the presence of general cognitive impairment among substance-abusing patients.
The NAB–SM and the Neuropsychological Screening Battery (NSB; R. K. Heaton, L. L.
Thompson, L. M. Nelson, C. M. Filley, & G. M. Franklin, 1990), which has been shown to
discriminate reliably between cognitively impaired and unimpaired substance-abusing pa-
tients, were each administered to 84 detoxified substance-abusing patients entering residential
treatment. Using participants’ performance on the NSB as the criterion measure, the authors
found that 30 patients (36%) were cognitively impaired; using the NAB–SM, they classi-
fied 32 patients (38%) as cognitively impaired. Levels of agreement and diagnostic efficiency
between the 2 batteries were excellent, suggesting the NAB–SM can discriminate accurately
between cognitively impaired and unimpaired substance-abusing patients.

A large and growing body of empirical research has
revealed that chronic ingestion of alcohol and other psycho-
active substances is associated with measurable neuroana-
tomical changes that appear to give rise to discernable
cognitive impairments. Among different clinical popula-
tions of patients with long-term histories of substance de-
pendence, particularly chronic alcohol misuse, neuroimag-
ing techniques typically uncover general cortical shrinkage
(e.g., Pfefferbaum et al., 1993), enlarged ventricles (e.g.,
Wang et al., 1992), increased space between the gyri of the
cerebral cortex (Lilliquist & Bigler, 1992), and reduced
glucose utilization (Volkow et al., 1994).
Changes in neurobehavioral performance are also evident
on neuropsychological tests. For instance, aside from per-
manent neurological damage in the subset of alcohol-depen-
dent patients who develop Korsakoff’s syndrome or alco-
holic dementia, there is a general profile of cognitive im-
pairment observed among individuals with extended
histories of alcohol dependence. Typically, such individuals
have relatively preserved vocabulary and verbal learning
skills but have measurable deficits on tests of verbal prob-
lem solving, conceptual shifting, perceptual–spatial and ab-
stracting abilities, motor speed, information-processing
Kerry Grohman and William Fals-Stewart, Research Institute on
Addictions, University at Buffalo, The State University of New
York.
This investigation was supported, in part, by grants from the
National Institute on Drug Abuse (R01DA12189, R01DA14402,
R01DA14402-Supplement, R01DA01593, and R01DA016236)
and the National Institute on Alcohol Abuse and Alcoholism
(R21AA013690 and T32AA07583).
Correspondence concerning this article should be addressed to
Kerry Grohman, Research Institute on Addictions, 1021 Main
Street, Buffalo, NY 14203. E-mail: grohman@ria.buffalo.edu
speed, and memory (Errico, Parsons, & King, 1991; Grant,
1987). Although research on the cognitive functioning of
patients who primarily abuse illicit drugs is far less evolved
than the alcoholism literature, accumulating evidence indi-
cates that patients who abuse drugs also have measurable
cognitive impairment. For example, neuropsychological
studies have found cognitive decrements among detoxified
patients who have histories of abusing cocaine (O’Malley,
Adamse, Heaton, & Gawin, 1992), sedative-hypnotics
(Bergman, Borg, Engelbrecktson, & Vikander, 1989), and
solvents (Allison & Jerrom, 1984); polysubstance-abusing
patients also display neurocognitive deficits (Fals-Stewart &
Bates, 2003). Although estimates of the prevalence of mild
to moderate neuropsychological impairment vary depending
on the neuropsychological tests administered, performance
criteria against which the presence of impairment is deter-
mined, and the sample that is evaluated, findings from
several different investigations suggest that between one
third and three fourths of individuals who chronically abuse
alcohol or other drugs have measurable cognitive deficits
(e.g., Bates & Convit, 1999; Rourke & Loberg, 1996).
Researchers and clinicians have argued that the presence
of neurocognitive impairment among substance-abusing pa-
tients is likely to have a negative effect on treatment re-
sponse and outcome. If treatment is viewed as a form of
learning, impairments in cognitive abilities to receive, en-
code, and integrate information presented in therapy would
serve to hinder learning of new, more healthful behaviors
(e.g., Weinstein & Shaffer, 1993). Although research ex-
ploring the direct effect of cognitive status on long-term
posttreatment outcome for substance-abusing patients has
yielded weak and inconsistent findings (for a review, see
Knight & Longmore, 1994), the results of studies examining
the effects of cognitive functioning on proximal indicators
of treatment engagement and response have been somewhat

200
 COGNITIVE IMPAIRMENT
more robust. For example, compared with cognitively intact
substance-abusing patients in residential care, impaired pa-
tients are more likely to violate program rules, leave treat-
ment prematurely, and are rated as less participatory by
program staff during the course of treatment. In turn, as part
of a causal chain process, impaired patients’ comparatively
poorer treatment engagement and response are related to
poorer posttreatment outcomes than those for their unim-
paired counterparts (Fals-Stewart, 1993; Fals-Stewart &
Lucente, 1994; Grohman & Fals-Stewart, 2003). Thus,
many treatment providers and researchers have called for
more widespread use of neuropsychological testing in sub-
stance abuse treatment settings. The results of this type of
assessment could inform treatment planning, which might
be tailored in accordance with patients’ identified cognitive
strengths and weaknesses, with the hope of thereby improv-
ing treatment response and subsequent outcome (e.g., Bates,
Bowden, & Barry, 2003; Goldman, 1990; McCrady &
Smith, 1986).
However, certain limitations and drawbacks of available
neuropsychological test batteries have greatly limited their
use in substance abuse treatment programs. For example,
the strength of comprehensive batteries, such as the Hal-
stead–Reitan Battery (HSB; Reitan & Wolfson, 1985), is
that they provide extensive information about patients’ cog-
nitive strengths and deficits in multiple areas of functioning.
However, such batteries are prohibitively labor intensive
(i.e., administration and scoring of the HSB can take as long
as 10 hr) and are too costly (in terms of staff resources and
time) for the majority of substance abuse treatment pro-
grams to adopt and regularly administer.
Conversely, brief cognitive assessment batteries, by def-
inition, require less time and fewer program resources to
administer than do comprehensive batteries. However, this
important practical advantage is offset by these batteries’
often poor diagnostic accuracy with substance-abusing pa-
tients. For example, two well-known brief cognitive assess-
ments, the Mini-Mental State Exam (Folstein, Folstein, &
McHugh, 1975) and the Neurobehavioral Cognitive Status
Exam (NCSE; Northern California Neurobehavioral Group,
1988), have unacceptably high false-negative error rates and
may not increase the level of diagnostic accuracy achieved
through clinical examination alone (Fals-Stewart, 1997;
Nelson, Fogel, & Faust, 1986).
A potential solution to these problems is to use sensitive,
psychometrically sound intermediate-length batteries. For
example, the Neuropsychological Screening Battery (NSB;
Heaton, Thompson, Nelson, Filley, & Franklin, 1990) is of
reasonable length (i.e., the NSB can be administered in
roughly 45 min) and provides a total summary score that
can accurately identify the presence or absence of cognitive
impairment among substance-abusing patients (Fals-Stew-
art, 1996; O’Malley et al., 1992). However, the NSB is
limited in its capacity to measure accurately the cognitive
functioning of patients with very high or low levels of
functioning (i.e., it has a “low ceiling” and a “high floor”).
The battery also relies on a single version of each measure,
with no equivalent forms, which introduces significant prac-
tice effects when repeated testing is necessary. Finally, the
201
NSB was designed as a screening measure to identify gen-
eral cognitive impairment but not to identify impairment in
specific domains of functioning.
A newly published comprehensive neuropsychological
test battery, the Neuropsychological Assessment Battery
(NAB; Stern & White, 2003), has certain characteristics that
may make it an excellent battery for use in testing sub-
stance-abusing patients entering treatment. The NAB pro-
vides information about examinees’ performances in five
core domains of functioning: (a) attention, (b) language, (c)
memory, (d) spatial, and (e) executive. The NAB—Screen-
ing Module (NAB–SM), an intermediate-length cognitive
screening battery, can be administered to provide a rela-
tively brief assessment of each of these domains of func-
tioning; an index of overall cognitive functioning can also
be derived. The NAB–SM can be used either as a “stand-
alone” battery or, alternatively, the test performances in
different domains measured by the NAB–SM can guide
further evaluation (with use of tests from the full NAB) to
assess, in more depth, those areas shown to be impaired on
the NAB–SM.
The NAB has important and innovative features that
make it an attractive assessment battery, both in general and
for substance-abusing patients specifically, including (a)
screening for both impaired and normal performance; (b)
comprehensive coverage of cognitive domains; (c) avoid-
ance of floor and ceiling effects; (d) extensive normative
data; (e) demographically corrected norms based on age,
education level, and gender; and (f) availability of equiva-
lent or parallel forms, which reduces practice effects when
repeated assessments are needed to track changes in perfor-
mance. Because of its recent release, the characteristics of
the full NAB and the NAB–SM with substance-abusing
patients have yet to appear in the literature. Of course, it is
important to ascertain the functional characteristics of the
battery with substance-abusing patients before recommend-
ing its general use with this clinical population. An impor-
tant first step in this process would be to examine the
accuracy of the NAB–SM in identifying substance-abusing
patients with cognitive impairment.
The purpose of the present investigation was to examine
the classification accuracy of the NAB–SM in identifying
impaired and unimpaired substance-abusing patients enter-
ing treatment. More specifically, classification results of the
NAB–SM were compared with another neuropsychological
test battery, the NSB, which has well-established classifi-
cation accuracy in terms of identifying cognitively impaired
and unimpaired substance-abusing patients, to determine
the NAB–SM’s decision accuracy rates (e.g., sensitivity,
specificity, classification accuracy).
Method
Participants
Patients for this study were recruited from consecutive admis-
sions to one of three long-term residential inpatient substance
abuse treatment programs (i.e., 6-month planned duration). Each
of these programs, all of which provided individual and group
counseling, medical services, and vocational training, received
202 GROHMAN AND FALS-STEWART

most referrals from outpatient treatment programs or from agen- dence diagnosis on at least one other psychoactive substance.2
cies within the criminal justice system. To be eligible for admis- These patients were polydrug users, with most reporting that their
sion to these programs, individuals (a) had to meet Diagnostic and primary drug of abuse was a substance other than alcohol.
Statistical Manual of Mental Disorders (4th ed.; DSM–IV; Amer-
ican Psychiatric Association, 1994) criteria for a current substance Measures
use disorder; (b) could not meet current DSM–IV criteria for
schizophrenia, delusional (paranoid) disorder, or other psychotic Cognitive status. Composed of 14 primary tests (some of
disorder; and (c) could not be currently participating in a metha- which contain multiple parts and yield multiple scores), the
done maintenance program. NAB–SM assesses five broad domains of cognitive functioning:
For the current study, potential participants were excluded if (a) attention (tests include Orientation, Digits Forward, Digits
they (a) had a history of significant head trauma, (b) had a medical Backward, and Numbers and Letters [speed, errors, efficiency]);
disorder that would interfere with test performance (e.g., color- (b) language (tests include Auditory Comprehension of Colors,
deficient vision), or (c) were taking a prescribed medication that Shapes and Numbers; Naming); (c) memory (tests include Shape
might affect central nervous system functioning. Patients also had Learning [immediate recognition, delayed recognition, percentage
to remain enrolled in the program to which they were admitted for of retention]; Story Learning [immediate recall, delayed recall,
at least 2 weeks to be included in the investigation. Many inves- percentage of retention]); (d) spatial (tests include Visual Discrim-
tigators (e.g., Miller, 1985; Parsons & Farr, 1981) have recom- ination and Design Construction); and (e) executive (tests include
mended a 2-week drug-free period before neuropsychological test- Mazes, Word Generation, and Word Generation–Perseverations).
ing to reduce the likelihood that any residual effects of psychoac- Screening domain scores represent the sum of selected primary test
tive substances ingested directly prior to admission would standard scores (i.e., M ⫽ 100, SD ⫽ 15) for a given functional
adversely affect test performance.1 domain, summarizing the examinee’s performance on the test
Ninety-nine patients were asked to participate; 92 (93%) ini- within that given functional domain. The Total Screening Index
tially agreed to enter the study. Four of these patients (4%) left the (TSI) is based on the sum of the five screening domain scores; this
program after less than 2 weeks and were not tested. An addi- sum is also converted to a standard score and represents the
tional 4 patients (4%) who agreed to participate were excluded examinee’s overall performance on the NAB–SM. The standard
from the investigation because they had one or more conditions scores are based on the examinee’s demographic characteristics
that would have interfered with test performance (i.e., 2 patients (i.e., gender, age group, and education level for the demographi-
were found to have significant vision problems, 1 patient had cally corrected standardization sample).
color-deficient vision, and 1 patient was on a prescribed psycho- For the purpose of this investigation, the TSI was used to
active medication). Thus, the final sample consisted of 84 patients. classify patients as either impaired or unimpaired. Using the di-
The sociodemographic and background characteristics of the chotomous classification for the TSI described in the NAB scoring
sample are presented in Table 1. Although most patients met manual (Stern & White, 2003), we classified patients who received
DSM–IV criteria for alcohol dependence, all patients had a depen- a TSI standard score of 84 or less (i.e., more than 1 SD, or 15
points, below the mean of 100) as impaired.
For this study, the referent neuropsychological assessment bat-
tery was the NSB, which is a compilation and adaptation of a
Table 1 number of widely used neuropsychological tests. The NSB was
Sociodemographic and Background Characteristics of designed to provide a standardized assessment of a broad range of
Participants neurocognitive abilities, including psychomotor speed, sequencing
efficiency, visual attention, verbal and nonverbal learning, delayed
Characteristic n % M SD
Age 32.0 6.2
Years of education 12.9 1.7 1
It is also important to note that it was very unlikely that
Male 60 71 patients used alcohol or other psychoactive drugs during their
Racial/ethnic composition residential stays. Patients in these programs were routinely mon-
White 56 67 itored for substance use with random urine screening and breath
African American 24 29
Hispanic 2 2 tests. Patients also had limited (and monitored) contact with indi-
Other 2 2 viduals not in the programs. However, this was not true of nico-
Met DSM–IV diagnostic criteria for tine; most of the participants were smokers (n ⫽ 54, 64%). There
the following: is evidence to suggest that chronic smoking may be associated
Alcohol dependence 60 71 with impaired cognitive performance (e.g., Richards, Jarvis,
Cocaine dependence 49 58 Thompson, & Wadsworth, 2003). Moreover, nicotine withdrawal
Opiate dependence 25 30 may also be associated with impaired performance on neuropsy-
Cannabis dependence 7 8 chological tests (e.g., Pritchard & Robinson, 1998).
Dependence on another drug 18 21 Because these programs did not require residents to quit smok-
Percentage of days abstinent 32.3 29.9
Consecutive days abstinent before ing and none of the participants reported they were trying to quit,
testing 26.9 6.9 nicotine withdrawal did not likely influence performance. Analytic
Years of problematic substance use 11.5 4.8 comparisons of smokers versus nonsmokers on the NSB and the
NAART—Estimated IQ 102.6 11.1 NSB–SM revealed no significant differences (i.e., all ps ⬎ .25) on
BDI 9.0 4.1 the summary scores or the batteries’ subtests.
CAS 20.3 9.9 2
Each of these programs specialized in treating patients who
Note. N ⫽ 84. Percentage of days abstinent ⫽ percentage of days primarily abused drugs other than alcohol. Although alcohol abuse
of no alcohol or other drug use during the 90 days prior to program or dependence was not an exclusion criterion for admission to
entry; NAART ⫽ North American Adult Reading Test; BDI ⫽ these programs, individuals seeking treatment who had alcohol use
Beck Depression Inventory; CAS ⫽ Clinical Anxiety Scale. disorders only were referred to other agencies.
 COGNITIVE IMPAIRMENT
recall, visuoconstructional skills, expressive and receptive lan-
guage functions, and reading comprehension. The battery consists
of (a) the Symbol–Digit Modalities Test (Smith, 1973); (b) the
Trail Making Test, Parts A and B (Armitage, 1946); (c) time and
errors from the Numerical Attention Test (Rennicke, Keiser,
Rodin, Rim, & Lennox, 1974); (d) learning and memory scores
from the Wechsler Memory Scale (Wechsler, 1945); (e) copy,
learning, and memory scores from the Rey–Osterrieth Complex
Figure (Osterrieth, 1944); and (f) written fluency, oral fluency,
commands with auditory sequencing, visual naming, and sentence
repetition from an abbreviated version of the Multilingual Aphasia
Exam (Benton & Hamsher, 1976). Tests of aural comprehension
and reading comprehension are also included in the battery. A
standardization sample was used to establish two test score cutoff
points for the subtests and the summary score. The first cutoff
point was at the 1 standard deviation point (defining mild impair-
ment) and the second cutoff point was at the bottom fifth percentile
(defining severe impairment). The total summary score for the
NSB is computed by assigning 1 point for each mildly impaired
subtest score and 2 points for each severely impaired score. The
cumulative score across the subtests of 6 or greater is considered
in the impaired range. We established these cutoffs using the test
scores of 130 neurologically normal adults.
As noted earlier, the total summary score from the NSB has
been shown to discriminate reliably between substance-abusing
patients and demographically matched nonsubstance-abusing par-
ticipants. In this investigation, the classification of patients as
impaired or unimpaired, using the cutoff for the NSB total sum-
mary score, was used as the standard against which the NAB–SM
classification, using the TSI cutoff, was evaluated.
The North American Adult Reading Test (NAART; Blair &
Spreen, 1989) is a reading test of 61 irregularly spelled words (e.g.,
debris, psalm, caveat), printed in two columns on both sides of
an 8.5 ⫻ 11 in. (21.6 ⫻ 27.9 cm) card, which is given to the
examinee to read aloud. Each pronunciation error is counted as 1
point; the cumulative number of errors is entered into an equation
to provide a lower limit estimate of an examinees’ premorbid IQ
(Stebbins, Wilson, Gilley, Bernard, & Fox, 1990).
Substance use. To assess the frequency of alcohol and other
substance use, the Timeline Followback Interview (TLFB; Sobell
& Sobell, 1996) was administered to participants, with frequency
of substance use for the past year being the target time interval.
The TLFB has excellent psychometric properties for the evaluation
of alcohol and other drug use (e.g., Fals-Stewart, O’Farrell, Frei-
tas, McFarlin, & Rutigliano, 2000). Percentage of days abstinent
from drugs and alcohol during the 3 months prior to program
admission and number of consecutive days abstinent before the 1st
day of testing were derived from the TLFB.
Participants also were asked as part of their intake assessment to
the program when they began drinking alcohol regularly and when
they began using other drugs regularly. From these responses,
years of alcohol use and years of drug use were determined. All
participants were also interviewed with the substance use disorders
module of the Structured Clinical Interview for DSM–IV (SCID;
First, Spitzer, Gibbon, & Williams, 1995) to determine substances
for which they met current dependence criteria.
Affective functioning. As suggested by several researchers
(e.g., Errico, Nixon, Parsons, & Tassey, 1990; Heaton & Crowley;
1981), affective functioning, particularly anxiety and depression,
may influence neuropsychological test performance negatively and
should be assessed when conducting neuropsychological evalua-
tions. The Beck Depression Inventory (BDI; Beck & Beamesder-
fer, 1974) is a widely used 21-item self-report measure of depres-
sive symptoms with excellent reliability and validity. The Clinical
203
Anxiety Scale (CAS; Westhuis & Thyer, 1989) is a 25-item scale
used to measure general anxiety. The scale has a range of 0 to 100,
with higher scores indicating greater anxiety. The CAS has excel-
lent internal consistency and is able to discriminate reliably be-
tween control participants and patients diagnosed with anxiety
disorders.
Procedure
Within a week of admission to the treatment programs, patients
completed a psychosocial intake interview, which included a so-
ciodemographic questionnaire, and were administered the TLFB
and SCID by one of two trained research technicians. The neuro-
psychological tests, the BDI, and the CAS were administered
between 14 and 21 days after patients were admitted to the pro-
grams during 2 consecutive days.
For all participants, the test battery delivered on the 1st day of
testing (the NAB–SM or the NSB) was chosen randomly; the
battery not chosen was administered the following day. This pro-
cedure was used to reduce (a) the potential negative effects of
fatigue on subtest scores (which may have affected results if all
subtests were administered within the same day) and (b) any
influence administration order may have had on battery perfor-
mance. These examinations were conducted by one of two trained
master’s-level psychometricians.
The NAART was administered on the 2nd day of neuropsycho-
logical testing for all patients. Analysis of urine and breath samples
taken from patients on the 1st day of neuropsychological testing
revealed no recent alcohol or other drug use by any participants
(i.e., all results were negative). All participants denied any alcohol
or drug use during their time in the programs prior to testing.
Results
NSB and NAB–SM Test Results
Using the established cutoff of 6 or greater on the NSB
total summary score as an indication of general cognitive
impairment, we classified 30 (36%) of the 84 patients as-
sessed as impaired; for the TSI cutoff score of 84 or less, we
classified 32 (38%) of the 84 patients as impaired. It is
unlikely that the testing results were influenced by any acute
or residual psychoactive effects of ingested psychoactive
substances; the mean number of days of consecutive absti-
nence before the 1st day of neuropsychological testing
was 33.3 (SD ⫽ 19.9), with a range of 18.0 to 91.0 days of
abstinence.
The NSB subtest scores and total summary scores for im-
paired and unimpaired patients, classified using the NSB total
summary score, are located in Table 2. The impaired and
unimpaired patients were compared on sociodemographic and
background characteristics (i.e., all variables in Table 1). Im-
paired patients were significantly older (M ⫽ 34.9, SD ⫽ 7.3)
than were unimpaired patients (M ⫽ 30.5, SD ⫽ 4.9), F (1,
82) ⫽ 11.0, p ⬍ .01. Impaired patients also reported more
years of problematic substance use (M ⫽ 13.3, SD ⫽ 4.7) than
did unimpaired patients (M ⫽ 10.5, SD ⫽ 4.5), F (1, 82) ⫽ 7.1,
p ⬍ .01. No other differences were significant.
Analytic comparisons of NSB subtest and total summary
scores for the impaired and unimpaired patients are also
located in Table 2. Using age and years of problematic
substance use as covariates, we found that, compared with
204 GROHMAN AND FALS-STEWART

their unimpaired counterparts, impaired patients had signif- Table 3

icantly worse performances on tests of (a) visuomotor Mean Neuropsychological Assessment Battery Screening
speed, numeric sequencing, and visual scanning (i.e., Trail Module Screening Domain Standard Scores for Impaired
Making Test Part A); (b) visuomotor coordination and and Unimpaired Patients
visuospatial ability (i.e., Trail Making Test Part B); (c) Cognitive status
memory (i.e., Story Memory from the Wechsler Memory
Scale and Figure Memory from the Rey–Osterrieth Com- Impaired Unimpaired
(n ⫽ 32) (n ⫽ 52)
plex Figure test); (d) learning verbal information (i.e., Story
Learning from the Wechsler Memory Scale Story); (e) Screening domain M SD M SD
visuospatial construction (i.e., Figure Copy from the Rey– Attention 77.4 4.4 100.9 7.1**
Osterrieth Complex Figure test); (f) naming of visually Language 96.1 4.1 97.1 5.9
presented objects (i.e., Visual Naming); and (g) fluency of Memory 90.1 3.1 94.7 5.1**
Spatial 85.9 3.6 94.5 8.6**
writing (i.e., Written Fluency). Executive 87.6 4.7 93.1 8.3**
The NAB–SM domain scores for the impaired and un- Total Screening Index 80.1 4.3 94.2 8.9**
impaired patients, classified using the TSI, are located in
Note. The Total Screening Index is not an average of the domain
Table 3.3 Consistent with the results reported earlier using scores; it is calculated by summing the domain scores and con-
the NSB classifications, impaired patients were significantly verting that total to a standard score, based on demographically
older (M ⫽ 34.6, SD ⫽ 7.5) than were unimpaired patients adjusted norms. Comparisons were conducted using analysis of
(M ⫽ 30.8, SD ⫽ 5.1), F (1, 82) ⫽ 7.8, p ⬍ .01. Impaired covariance, with age and years of problematic substance use as
patients also reported more years of problematic substance control variables in the model.
** p ⬍ .01 (using a layered Bonferroni correction).
use (M ⫽ 13.7, SD ⫽ 4.6) than did unimpaired patients,
(M ⫽ 10.3, SD ⫽ 4.6), F (1, 82) ⫽ 10.6, p ⬍ .01. As with

the NSB, no other significant sociodemographic or back-

Table 2
ground differences were found. As shown in Table 3, with
Mean Neuropsychological Screening Battery Subtest
age and years of problematic substance use as control vari-
Scores of Cognitively Impaired and Unimpaired
ables, impaired patients had significantly lower scores in all
Substance-Abusing Patients
domains except attention.
Cognitive status
Impaired Unimpaired NAB–SM Classification Accuracy
(n ⫽ 30) (n ⫽ 54)
Measure M SD M SD The chance-corrected agreement between the classifica-
a tions of patients as either impaired or unimpaired by the
Symbol–Digit Modalities 48.9 8.9 63.6 11.8**
Trail Making Test NSB total summary score and NAB–SM TSI was good, ␬ ⫽
Part Ab 27.7 7.2 24.3 6.9* .75, p ⬍ .01. In addition to classification agreement between
Part Bb 83.2 16.1 62.6 20.2** a given test and a criterion measure, evaluation of classifi-
Numerical Attention Test cation accuracy of any method also involves examination of
Timeb 134.0 36.1 130.0 35.2 standard measures of sensitivity (proportion of true positive
Errorsb 3.6 2.9 3.9 2.6
Wechsler Memory Scale test results among individuals known to have the condition
Story Learninga 9.2 6.9 12.7 7.0* in question; in the present case, cognitive impairment),
Story Memorya 13.3 8.7 7.0 6.4** specificity (proportion of true negative test results among
Rey–Osterrieth Complex Figure individuals known not to have the target condition), the
Figure Copya 14.4 2.8 16.3 2.7**
Figure Learninga 12.9 4.0 14.6 2.8 predictive power of a positive test (the proportion of true
Figure Memoryb 6.9 4.0 4.9 4.1* positive test results to all positive test results), the predictive
Visual Naminga 17.0 1.8 17.8 2.0 power of a negative test (the proportion of true negative test
Aural Comprehensiona 11.4 0.4 11.9 0.6** results to all negative test results), and the overall classifi-
Reading Comprehensiona 11.6 0.8 11.7 0.7 cation accuracy of the measure, or “hit rate” (true positive
Written Fluencya 11.3 3.9 13.0 2.9*
Oral Fluencya 13.0 2.7 13.8 3.1 test results plus true negative test results divided by N).
Command With Auditory Typically, values of .80 or greater on these indices indicate
Sequencinga 23.0 0.5 23.2 0.5 good diagnostic accuracy (e.g., Blazer & Hays, 1998). With
Sentence Repetition 4.6 0.7 4.8 0.3 the NSB total summary score as the criterion measure, these
Speech Articulation Rating 8.0 0.0 8.0 0.0
Total summary score 7.6 1.8 2.4 1.7** indices for the TSI from the NAB–SM are presented in
Table 4. These results indicate very good diagnostic accu-
Note. Comparisons were conducted using analysis of covariance, racy across all of the indicators for the NAB–SM.
with age and years of problematic substance use as control vari-
ables in the model.
a
Lower scores on this test are associated with poorer perfor- 3
mance. b Higher scores on this test are associated with poorer The test scores of participants on the individual tests compris-
performance. ing each of the NAB–SM domains are available from William
* p ⬍ .05. ** p ⬍ .01 (with layered Bonferroni correction). Fals-Stewart upon request.
 COGNITIVE IMPAIRMENT
Table 4
Diagnostic Efficiency Statistics for Neuropsychological
Assessment Battery—Screening Module Classifications of
Patients’ Cognitive Status
Classification measure Proportion
Sensitivity 0.81
Specificity 0.92
Predictive power of a positive test 0.87
Predictive power of a negative test 0.88
Classification accuracy 0.88
Note. Sensitivity ⫽ proportion of positive test results among
participants with the index condition; Specificity ⫽ proportion of
negative test results among participants who do not have the index
condition; Predictive power of a positive test ⫽ proportion of true
positive test results to all positive test results; Predictive power of
a negative test ⫽ proportion of true negative test results to all
negative test results; Classification accuracy ⫽ true positive test
results plus true negative test results divided by N.
A limitation of these diagnostic efficiency statistics is that
they are influenced by decision biases that may be inherent
in the measure being evaluated. For example, a diagnostic
instrument that is biased toward providing positive results
(i.e., finding that the condition being evaluated is present)
would have artifactually increased sensitivity, with an ac-
companying decrease in specificity. Conversely, a test that
tends to provide negative results would have increased
specificity and decreased sensitivity. Thus, we also exam-
ined diagnostic accuracy using receiver operating charac-
teristics (Egan, 1975) analysis, which simultaneously takes
into account sensitivity and specificity and provides a single
index of diagnostic efficiency, A, that does not appear to be
influenced by decision biases (Swets, 1988). A can range
from 0.50 to 1.00. An A value of .50 indicates that classi-
fication accuracy is no better than chance; as classification
accuracy increases, A values approach 1.00. The A value for
classification accuracy of the TSI was 0.87 (SE ⫽ .04),
which was significantly different from chance agreement,
z ⫽ 19.41, p ⬍ .01.
Discussion
The purpose of the present investigation was to examine
the diagnostic efficiency of the NAB–SM with substance-
abusing patients. Compared with a battery with well-estab-
lished classification accuracy, results indicated that the
NAB–SM, using a preestablished cutoff on the TSI, has
excellent diagnostic efficiency in terms of accurately iden-
tifying cognitively impaired patients. Both batteries catego-
rized over a third of the patients as cognitively impaired;
this proportion of substance-abusing patients being identi-
fied as impaired is consistent with findings of previous
studies. Standard indicators of classification accuracy, in-
cluding sensitivity, specificity, and overall hit rate, were
excellent.
The NAB–SM may be an appropriate neuropsychological
assessment battery for those circumstances and settings in
which both the brevity of the assessment and classification
of functioning are critical. However, the NAB–SM not only
205
provides information about likely areas of impaired cogni-
tive performance (e.g., attention, language), but the test
report also provides specific recommendations for further
assessment with other modules from the full NAB (e.g.,
NAB—Attention Module, NAB—Language Module). This
allows for a comprehensive, yet focused, assessment of
functioning, with an emphasis on providing comprehensive
information about different areas of cognitive deficit. In
addition, in circumstances in which a full and comprehen-
sive assessment of cognitive strengths and deficits is desired
and staff resources and time are less of a concern, admin-
istration of the full NAB is an option. The NAB also has
parallel forms of various measures for repeated testing
during the treatment process, which is invaluable in sub-
stance abuse populations known to have a lengthy postab-
stinence period of neurocognitive recovery. In addition, the
NAB–SM has reduced ceiling and floor effects, which allow
examination and tracking of patients who range from very
impaired to relatively highly functioning (but not necessar-
ily at their baseline level of functioning). Thus, the NAB–
SM, which just recently became available for clinical use,
appears to hold great promise and usefulness as a screening
device for substance abuse treatment programs.
Although the investigation had several important
strengths, including the use of a well-established criterion
measure against which to assess the NAB–SM and assess-
ment of patients whose performance was not likely influ-
enced by recent substance use (due to being in a carefully
monitored residential treatment setting), certain limitations
should also be highlighted. The size of the sample was small
(although the sample size was relatively large in comparison
with similar neuropsychological investigations in this area)
and was recruited from only three residential substance
abuse treatment programs. Although the results are consis-
tent with previous studies, the sample was not large enough
to conduct a comprehensive comparison of impaired and
unimpaired patients on test performance or background
characteristics. Thus, these results should be viewed with
caution. Moreover, the findings may not generalize to sub-
stance-abusing patients in other types of treatment settings.
Thus, replication is necessary with a larger sample and in
multiple types of treatment programs to increase the gener-
alizability of the findings.
Also, this study examined the diagnostic accuracy of the
NAB–SM only. The full NAB battery contains a more
thorough examination of neurocognitive functioning, and
examination of the full battery in substance-abusing popu-
lations would provide more comprehensive evaluative in-
formation about patients’ specific cognitive strengths and
deficits. An evaluation of the full NAB with substance-
abusing patients would also yield important information
regarding how well patients in treatment would tolerate the
length of the full battery (which can take up to 4 hr to
administer). However, on the basis of examination of the
screening module alone, the NAB shows significant prom-
ise in overcoming assessment problems that have plagued
this programmatic line of research.
206 GROHMAN AND FALS-STEWART
References
Allison, W. M., & Jerrom, D. W. A. (1984). Glue sniffing: A pilot
study of the cognitive effects of long-term use. International
Journal of Addiction, 19, 453– 458.
American Psychiatric Association. (1994). Diagnostic and statis-
tical manual of mental disorders (4th ed.). Washington, DC:
Author.
Armitage, S. G. (1946). An analysis of certain psychological tests
used for evaluation of brain injury. Psychological Monographs,
60(Whole No. 277).
Bates, M. E., Bowden, S. C., & Barry, D. (2003). Neurocognitive
impairment associated with alcohol use disorders: Implications
for treatment. Experimental and Clinical Psychopharmacol-
ogy, 10, 193–212.
Bates, M. E., & Convit, A. (1999). Neuropsychology and neuro-
imaging of alcohol and drug abuse. In A. Calev (Ed.), Neuro-
psychological functions in psychiatric disorders (pp. 342–375).
Washington, DC: American Psychiatric Press.
Beck, A. T., & Beamesderfer, A. (1974). Assessment of depres-
sion: The Beck Depression Inventory. In P. Pichot (Ed.), Psy-
chological measurements in psychopharmacology (pp. 151–
169). Basel, Switzerland: Kargel.
Benton, A. L., & Hamsher, K. (1976). Multilingual Aphasia Ex-
amination. Iowa City, IA: Department of Neurology, University
Hospitals.
Bergman, H., Borg, S., Engelbrecktson, K., & Vikander, B.
(1989). Dependence on sedative hypnotics: Neuropsychological
impact, field dependence and clinical consequences in a 5-year
follow-up study. British Journal of Addiction, 84, 547–553.
Blair, J. R., & Spreen, O. (1989). Predicting premorbid IQ: A
revision of the National Adult Reading Test. Clinical Neuro-
psychologist, 3, 129 –136.
Blazer, D. G., & Hays, J. C. (1998). An introduction to clinical
research in psychiatry. New York: Oxford University Press.
Egan, J. P. (1975). Signal detection theory and ROC analysis. New
York: Academic Press.
Errico, A. L., Nixon, S. J., Parsons, O. A., & Tassey, J. (1990).
Screening for neuropsychological impairment in alcoholics.
Psychological Assessment, 2, 45–50.
Errico, A. L., Parsons, O. A., & King, A. C. (1991). Assessment of
verbosequential and visuospatial cognitive abilities in chronic
alcoholics. Psychological Assessment, 3, 693– 696.
Fals-Stewart, W. (1993). Neurocognitive defects and their impact
on substance abuse treatment. Addictions and Offender Coun-
seling, 13, 46 –57.
Fals-Stewart, W. (1996). Intermediate length screening of impair-
ment among psychoactive substance-abusing patients: A com-
parison of two batteries. Journal of Substance Abuse, 8, 1–17.
Fals-Stewart, W. (1997). Detection of neuropsychological impair-
ment among substance-abusing patients: Accuracy of the neu-
robehavioral cognitive status examination. Experimental and
Clinical Psychopharmacology, 5, 269 –276.
Fals-Stewart, W., & Bates, M. E. (2003). The neuropsychological
test performance of drug-abusing patients: An examination of
latent cognitive abilities and associated risk factors. Experimen-
tal and Clinical Psychopharmacology, 11, 34 – 45.
Fals-Stewart, W., & Lucente, S. (1994). Effect of neurocognitive
status and personality functioning on length of stay in residential
treatment: An integrative study. Psychology of Addictive Behav-
iors, 8, 179 –190.
Fals-Stewart, W., O’Farrell, T. J., Freitas, T. T., McFarlin, S. K.,
& Rutigliano, P. (2000). The Timeline Followback reports of
psychoactive substance use by drug-abusing patients: Psycho-
metric properties. Journal of Consulting and Clinical Psychol-
ogy, 68, 134 –144.
First, M., Spitzer, L., Gibbon, M., & Williams, J. (1995). Struc-
tural Clinical Interview for Axis I DSM–IV Disorders (SCID).
Washington, DC: American Psychiatric Association.
Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-
Mental State: A practical method for grading the cognitive state
of patients for the clinician. Journal of Psychiatric Research, 12,
189 –198.
Goldman, M. (1990). Experience-dependent neuropsychological
recovery and the treatment of chronic alcoholism. Neuropsy-
chology Review, 1, 75–101.
Grant, I. (1987). Alcohol and the brain: Neuropsychological cor-
relates. Journal of Consulting and Clinical Psychology, 55,
310 –324.
Grohman, K., & Fals-Stewart, W. (2003). Computer-assisted cog-
nitive rehabilitation with substance-abusing patients: Effects on
treatment response. The Journal of Cognitive Rehabilitation, 21,
10 –17.
Heaton, R. K., & Crowley, T. J. (1981). Effects of psychiatric
disorders and their somatic treatments on neuropsychological
test results. In S. B. Filskov & T. J. Bolls (Eds.), Handbook of
clinical neuropsychology (pp. 481–525). New York: Wiley.
Heaton, R. K., Thompson, L. L., Nelson, L. M., Filley, C. M., &
Franklin, G. M. (1990). Brief and intermediate length screening
of neuropsychological impairment in multiple sclerosis. In S. M.
Rao (Ed.), Multiple sclerosis: A neuropsychological perspective
(pp. 149 –160). New York: Oxford University Press.
Knight, R. G., & Longmore, B. E. (1994). Clinical neuropsychol-
ogy of alcoholism. Hillsdale, NJ: Erlbaum.
Lilliquist, M. W., & Bigler, E. D. (1992). Neurological and neu-
ropsychological consequences of drug abuse. In D. I. Templer,
L. C. Hartladge, & W. G. Cannon (Eds.), Preventable brain
damage: Brain vulnerability and brain health (pp. 161–192).
New York: Springer Publishing Company.
McCrady, B. S., & Smith, D. E. (1986). Implications of cognitive
impairment for the treatment of alcoholism. Alcoholism: Clini-
cal and Experimental Research, 10, 145–149.
Miller, L. (1985). Neuropsychological assessment of substance
abusers: Review and recommendations. Journal of Substance
Abuse Treatment, 2, 5–17.
Nelson, A., Fogel, B. S., & Faust, D. (1986). Bedside cognitive
screening instruments: A critical assessment. Journal of Ner-
vous and Mental Disease, 174, 73– 83.
Northern California Neurobehavioral Group. (1988). Manual for
the Neurobehavioral Cognitive Status Examination. Fairfax,
CA: Author.
O’Malley, S., Adamse, M., Heaton, R. K., & Gawin, F. H. (1992).
Neuropsychological impairment in chronic cocaine abusers.
American Journal of Drug and Alcohol Abuse, 18, 131–144.
Osterrieth, P. A. (1944). Le test de copie d’une figure complexe:
Contribution a l’etude de la perception et de la memoire. Ar-
chives de Psychologie, 30, 206 –356.
Parsons, O. A., & Farr, S. P. (1981). The neuropsychology of
alcohol and drug abuse. In S. B. Filskov & T. J. Boll (Eds.),
Handbook of clinical neuropsychology (pp. 320 –365). New
York: John Wiley.
Pfefferbaum, A., Sullivan, E., Rosenbaum, M., Shear, P., Matha-
lon, D., & Lim, K. (1993). Increase in brain cerebrospinal fluid
volume is greater in older than in younger alcoholic patients: A
replication study and CT/MRI comparison. Psychiatry Research
Neuroimaging, 50, 257–274.
 COGNITIVE IMPAIRMENT
Pritchard, W. S., & Robinson, J. H. (1998). Effects of nicotine on
human performance. In J. Snel & M. Lorist (Eds.), Nicotine,
caffeine, and social drinking: Behaviour and brain function (pp.
21– 81). Amsterdam: Harwood Academic.
Reitan, R. M., & Wolfson, D. (1985). The Halstead–Reitan Neu-
ropsychological Test Battery. Tucson, AZ: Neuropsychology
Press.
Rennicke, P. M., Keiser, T., Rodin, E., Rim, L., & Lennox, K.
(1974, December). Carbamazepine: Behavioral side effects in
temporal lobe epilepsy during short-term comparison with pla-
cebo. Paper presented at the annual meeting of the American
Epilepsy Society, New York.
Richards, M., Jarvis, M. J., Thompson, N., & Wadsworth, M. E. J.
(2003). Cigarette smoking and cognitive decline in midlife:
Evidence from a prospective birth cohort study. American Jour-
nal of Public Health, 93, 994 –998.
Rourke, S. B., & Loberg, T. (1996). The neurobehavioral corre-
lates of alcoholism. In I. Grant & K. M. Adams (Eds.), Neuro-
psychological assessment of neuropsychiatric disorders (pp.
423– 485). New York: Oxford University Press.
Sobell, L. C., & Sobell, M. B. (1996). Timeline Followback user’s
guide: A calendar method for assessing alcohol and drug use.
Toronto, Ontario, Canada: Addiction Research Foundation.
Smith, A. (1973). Digit–Symbol Modalities Test. Los Angeles:
Western Psychological Services.
Stebbins, G. T., Wilson, R. S., Gilley, D. W., Bernard, B. A., &
Fox, J. H. (1990). Use of the National Adult Reading Test to
estimate premorbid IQ in dementia. Clinical Neuropsycholo-
gist, 4, 64 – 68.
207
Stern, R. A., & White, T. (2003). Neuropsychological Assessment
Battery: Administration, scoring, and interpretation manual.
Lutz, FL: Psychological Assessment Resources.
Swets, J. A. (1988, June 3). Measuring the accuracy of diagnostic
systems. Science, 240, 1285–1293.
Volkow, N. D., Wang, G. J., Hitzemann, R., Fowler, J., Wolf, A.,
Overall, J., et al. (1994). Recovery of brain glucose metabolism
in detoxified alcoholics. American Journal of Psychiatry, 151,
178 –183.
Wang, G., Volkow, N., Hitzman, R., Oster, Z., Roque, C., &
Cestaro, V. (1992). Brain imaging of an alcoholic with MRI,
SPECT, and PET. American Journal of Physiologic Imaging, 7,
194 –198.
Wechsler, D. (1945). A standardized memory scale for clinical
use. Journal of Psychology, 19, 87–95.
Weinstein, C. S., & Shaffer, H. J. (1993). Neurocognitive aspects
of substance abuse treatment: A psychotherapist’s primer. Psy-
chotherapy: Theory, Research, Practice, Training, 30, 317–333.
Westhuis, D., & Thyer, B. A. (1989). Development and validation
of the Clinical Anxiety Scale: A rapid assessment instrument for
empirical practice. Education and Psychological Measure-
ment, 49, 153–163.
Received October 6, 2003
Revision received April 6, 2004
Accepted April 10, 2004 䡲