NeuroRehabilitation 55 (2024) 195–208 195

DOI:10.3233/NRE-240087
IOS Press

Normative data for verbal fluency and

naming tests in Spanish-speaking adults in
the United States
Laiene Olabarrieta-Landaa,b , Diego Riveraa,b , Bridget Xiac , Oswaldo Morenod , Daniela Ramos
Usugae , Gloria M. Morel Valdésf , Enrique Lopezg,h , Miriam J. Rodriguezi,j , Carmen I. Carriónk ,
Anthony H. Lequerical,m , Christin I. Dragon , Patricia Garcı́ao,p , Patricia M. Riveraq ,
Paul B. Perrinc,r and Juan Carlos Arango-Lasprillad,∗
a Department of Health Science, Public University of Navarre, Pamplona, Spain
b Institutode Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
c School of Data Science, University of Virginia, Charlottesville, VA, USA
d Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
e Biomedical Research Doctorate Program, University of the Basque Country (UPV/EHU), Leioa, Spain
f Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
g The Chicago School, Los Angeles, CA, USA
h Cedars-Sinai Medical Center, Los Angeles, CA, USA
i Clinical Psychology Program, Carlos Albizu University, Miami Campus, Miami, FL, USA
j Department of Health and Wellness Design, School of Public Health, Indiana University, Bloomington, NI, USA
k Department of Neurology, School of Medicine, Yale University, New Haven, CT, USA
l Center for Traumatic Brain Injury Research, Kessler Foundation, East Hanover, NJ, USA
m Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
n Private Practice, Miami, FL, USA
o Department of Neurology, School of Medicine, Indiana University, Indianapolis, IN, USA
p Department of Physical Medicine and Rehabilitation, School of Medicine, Indiana University, Indianapolis,

IN, USA
q Mental Health Department – Neuropsychology, Kaiser Permanente Northwest, Portland, OR, USA
r Department of Psychology, University of Virginia, Charlottesville, VA, USA

Received 2 April 2024

Accepted 3 July 2024

Abstract.
BACKGROUND: Linguistic deficits are common across neurological and neurodegenerative disorders. Currently there are
limited neuropsychological norms available for Spanish-speaking adults residing in the U.S.
OBJECTIVE: To generate norms for two verbal fluency tests and the Boston Naming Test (BNT) in a Spanish-speaking
population in the U.S., with adjustments for demographic and cultural variables.

∗ Address for correspondence: Juan Carlos Arango-Lasprilla,

PhD, Department of Psychology, Virginia Commonwealth Uni-

versity, Richmond, VA, USA. E-mail: [email protected].

ISSN 1053-8135/$35.00 © 2024 – IOS Press. All rights reserved.

196 L. Olabarrieta-Landa et al. / Normative data for verbal fluency and naming

METHODS: The sample consisted of 245 adults from the U.S. Participants completed phonological and semantic verbal
fluency tests and the BNT. A standardized four-step statistical procedure was used.
RESULTS: For the phoneme F, interactions between Spanish proficiency, age, and education arose. Better performance on
phonemes A, S, and M was related to education. Spanish proficiency, acculturation, and time in the U.S. were associated with
the phonemes S, A, P, M, and R. An age by education interaction was found for phonemes M and R. The FAS and PMR triads
were related to age, sex, time in U.S., and Spanish proficiency. For the semantic verbal fluency tests, an interaction between
education and Spanish proficiency arose. For the BNT, test scores were related to education, and significant interactions were
also found based on education’s interaction with Spanish proficiency and acculturation.
CONCLUSION: This study highlights the importance of accounting for sociodemographic and acculturative factors when
developing normative data for verbal fluency tests and the BNT for dominant Spanish-speaking adults in the U.S. These
sociodemographically-adjusted norms will help improve accuracy of diagnosis and interpretation of linguistic test perfor-
mance in Spanish speakers living in the U.S.

Keywords: Verbal fluency, Boston Naming Test, Hispanic, Bayesian inference, normative data

1. Introduction included in neuropsychological batteries due to

their simplicity, brevity, and ease of administration.
The United States is undergoing a rapid transfor- Among practitioners providing neuropsychological
mation in racial/ethnic diversity, with the Hispanic services in Spanish in the U.S., letter verbal fluency
population emerging as the largest racial/ethnic is the most frequently used language measure (24%;
minority group, comprising 63.7 million people Gasquoine et al., 2021).
(19.1% of the population; U.S. Census Bureau, 2023). However, clinicians face significant challenges
Additionally, Spanish is the most prevalent non- when interpreting the neuropsychological test results
English language spoken both at home and in the of their Hispanic patients, not only due to their
community, boasting approximately 41–42 million diverse backgrounds (e.g., national origin, English
speakers. A large percentage of Hispanics are also proficiency, acculturation level, and socioeconomic
bilingual in English and Spanish. According to the status), but also because of the limited availability
U.S. Census Bureau (2019; in Dietrich & Hernan- of normative data for this population. Gasquoine et
dez, 2022), 61.4% of Spanish speakers self-reported al. (2021) discovered that practitioners in the U.S.
speaking English as “very well”. often interpret Spanish language tests using norms
Hispanics exhibit increased susceptibility to generated in the continental U.S. However, the major-
numerous neurological disorders, including neu- ity of these available norms were established before
rodegenerative conditions such as mild cognitive 2010 and focused on semantic verbal fluency (pri-
impairment and Alzheimer’s disease (Vega et al., marily the animal´s category) for middle-aged and
2017; Alzheimer’s Association, 2021), as well as older individuals (>40 years old) residing along the
acquired brain injuries such as stroke (Gardener Mexico/U.S. border (California, New Mexico, and
et al., 2020). Contributing factors include a higher Texas; Ponton et al., 1996; Artiola I Fortuny, 1999;
prevalence of diabetes, depression, low income, La Rue et al., 1999; González et al., 2005; Mack et al.,
and low educational attainment (Vega et al., 2017; 2005; O’Bryant et al., 2017; Hall et al., 2017), Florida
Alzheimer’s Association, 2021), as well as dispari- (Acevedo et al., 2000; Roselli et al., 2009), and North-
ties in healthcare access and utilization (Saadi et al., ern Manhattan (Stricks et al., 1998). Existing norms
2017). also vary concerning Hispanic origin (some requiring
Accurate and reliable neuropsychological assess- inclusion criteria for people living in the U.S. having
ments are crucial for the diagnosis of rehabilitation arrive from Spanish-speaking countries, while others
planning of individuals with neurological disorders. accepted Hispanic ancestry as inclusion criteria) and
In large part, clinical neuropsychologists base their language of administration (exclusively Spanish or
diagnoses on the interpretation of neuropsycholog- both Spanish and English). Furthermore, Gasquoine
ical test results. Verbal fluency tests, being highly et al. (2021) noted that U.S neuropsychologists also
sensitive to brain damage and cognitive decline utilize norms from Latin American countries or Spain
associated with aging or neurodegenerative diseases (e.g., Olabarrieta-Landa et al., 2015) for interpret-
(Álvarez-Medina et al., 2023), they are commonly ing Spanish language tests (Casaletto et al., 2016;
 L. Olabarrieta-Landa et al. / Normative data for verbal fluency and naming 197

delCacho-Tena et al., 2023). The risk of misdiagno- allowing them to select the most suitable available
sis is increased in all of these scenarios where the norms that align with the sociocultural characteristics
clinician is relegated to utilizing norms based on pop- of their patients (Rivera Mindt et al., 2021).
ulations different from the patient being evaluated.
Given this neuropsychology landscape for His-
panic Americans, it has become evident that updated
and more granular normative data for Spanish speak- 2. Materials and methods
ers in the U.S. are essential. Based on this need, Rivera
Mindt et al. (2021) initiated. “The Neuropsycholog- 2.1. Participants
ical Norms for the U.S.-Mexico Border Region in
Spanish (NP-NUMBRS)” project, aiming to generate The initial sample consisted of 253 healthy indi-
norms for various neuropsychological tests, includ- viduals who were recruited from the U.S. (California,
ing phonological and semantic verbal fluency tests Connecticut, Florida, Indiana, New Jersey, Oregon,
(Marquine et al., 2021). Participants were adminis- Virginia, and Wisconsin). To participate in the study,
tered the letters PMR and the animals category in individuals met the following eligibility criteria: a)
Spanish. As with previous efforts, age and education be between 18–80 years of age, b) have been liv-
were primary predictors in the models to generate ing in the U.S. for at least 1 year (12 continuous
norms, while sex did not emerge as a significant months), c) self-identify Spanish as their “dominant
factor. language”, d) have at least 1 year of formal educa-
Despite significant progress in providing tools for tion, e) be able to read and write in Spanish, f) obtain
clinicians offering services to Spanish speakers in the a score of ≥ 23 on the Mini-Mental State Examination
U.S., plenty remains to be covered. Rivera Mindt (MMSE) (Folstein et al., 1975; Villaseñor-Cabrera et
et al. (2021) outlined the limitations of the NP- al., 2010), g) obtain a score of ≤ 10 on the Patient
NUMBRS project and proposed future directions for Health Questionnaire–9 (PHQ-9) (Kroenke et al.,
advancing the field. For instance, while the project 2001), and h) obtain a score of ≤ 10 on the Gen-
generated norms for native Spanish speakers from eralized Anxiety Disorder-7 (GAD-7) (Spitzer et al.,
the U.S. (California/Arizona)-Mexico border region 2006).
aged 19 to 60, caution was advised when apply- Individuals were ineligible if any of the follow-
ing these norms to Spanish-speaking populations ing exclusion criteria were present: a) history of a
from other unexamined regions (e.g., Northern U.S.). neurodevelopmental disorder, b) history of a learning
Additionally, considering that reference values are disorder, c) past or present neurological condition, d)
most precise in the year of their creation (Mitrushina past or present chronic medical condition that might
et al., 2005) and that the data for this project were affect cognition (e.g., metabolic syndrome, chronic
collected in two cohorts (1998–2000 and 2006–2009) heart failure, sleep apnea, complications associated
prior 2010, more recent norms are needed. Recogniz- with SARS-CoV-2), e) past or present use of psy-
ing that sociocultural variables can impact cognitive chotropic medications that might affect cognition, f)
performance, and that second and third generation past or present history of substance abuse or depen-
Hispanics living in the U.S. may retain their Spanish dence, or g) past or present history of a psychiatric
language, identity, and other aspects of their culture disorder.
and ancestry, future normative data for verbal fluency Eight participants were excluded from data analy-
tests should also incorporate relevant variables asso- sis due to incomplete sociodemographic information,
ciated with fluency performance in bilingual Hispanic resulting in a final sample of 245 participants.
samples, such as degree of bilingualism, accultur- The majority of the sample was comprised of
ation, and age of language acquisition (Bennett & women (60.8%, n = 149), the mean age was 41.1
Verney, 2019). (SD = 14.9), and the mean years of school completed
Consequently, the objective of this study was to was 15.1 (SD = 4.2). Sociodemographic characteris-
establish norms for phonological (/f/, /a/, /s/, /p/, /m/, tics are reported by Rivera et al. (2024).
and /r/ phonemes) and semantic (animals and fruits Each of the institutions obtained their own insti-
categories) verbal fluency tests in a sample of Spanish tutional review board protocol approval to cover the
speakers residing in various regions in the U.S. We ethical conduct of the study at their own site. All par-
posit that clinical neuropsychologists would benefit ticipants signed an informed consent form and were
from updated norms for these verbal fluency tests, offered $25 for their participation in the study.
198 L. Olabarrieta-Landa et al. / Normative data for verbal fluency and naming

2.2. Measures binations, where p refers to the number of covariates,

a candidate is obtained that may be potentially related
For the present study, phonological and semantic to the output (Li & Clyde, 2018).
verbal fluency tests were administered in Spanish. The full regression models included as predictors:
Participants were asked to provide as many words age, age2 , education (log- transformed), sex, the Bidi-
as possible within 60 seconds in each of the six mensional Acculturation Scale for Hispanics (BAS;
phonemes (/f/, /a/, /s/, /p/, /m/, and /r/) and two cate- Marin & Gamba, 1996), the Bilingual Dominance
gories (animals and fruits). Olabarrieta-Landa et al.’s Scale (BDS, Dunn & Fox, 2009), and all two-way
(2017) administration and scoring guidelines were interactions between these variables. Age was cen-
followed. For this study, the total score was used. tered (age in years – X̄Age in the sample) before
Participants also completed the standard (60-item) computing quadratic age to avoid multicollinear-
Spanish version of Boston Naming Test (BNT) that ity (Kutner et al., 2005). Once the variables were
differs slightly from the original BNT (Kaplan et al., selected, the model estimations were obtained using
1983). For example, item 14 is a carrot instead of a Poisson and Binomial regression models, respec-
mushroom, item 19 is a muffin instead of a pretzel, tively. The models can be expressed as follows:
item 28 is a crown instead of a wreath, item 40 is
(1) (p)
a pacifier instead of a knocker, item 48 is a needle μi = eβ0 · eβ1 Xi · . . . · eβp Xi ,
instead of a noose, item 51 is a keyhole instead of a
latch, and item 57 is a watering can instead of a trellis. to Poisson case, and
The BNT total score is the sum of correct spontaneous  
answers plus correct answers followed by a semantic   πj
logit πj = log ,
clue (Kaplan et al., 2005). The administration of the 1 − πj
BNT was conservative, and thus synonyms were not
considered correct responses. to binomial case. This means that a change of one
It should be noted that although a large portion of unit in any of the variables would suppose that the
the sample was bilingual, participants were required mean number of words is multiplied by eβp . Prior
to provide responses only in their dominant language distributions for each of the unknown parameters
of Spanish. Therefore, credit was not given for any (β0 , β1 , . . . βp ) followed a normal distribution cen-
correct English responses. tered at 0 and with large variance (i.e., σ 2 = 1.0 × 104
and τ = 1.0 × 10–3 ). This choice was made to reflect
2.3. Statistical analysis a non-informative or weakly informative prior. By
centering the distribution at 0, we express the belief
The detailed statistical analyses used to gener- that, a priori, the parameters are equally likely to be
ate the normative data for this test are described in positive or negative, without strong prior knowledge
Rivera et al. (2024). In summary, since the verbal favoring any particular direction. The large variance
fluency total score consisted of the number correct ensures that the prior distribution is diffuse, allow-
words produced in 60 seconds [Yi (i = 1, . . . , n)], ing the data to play a dominant role in the posterior
Poisson distribution was assumed [Yi ∼ Po (μi )]. inference. This approach is particularly useful in sce-
However, BNT total score was considered as 60 tri- narios where there is little prior information available
als or attempts, where each trial can be classified as or when we want to minimize the influence of the
success
 or failure, assuming
 a binomial distribution prior on the posterior results (see Bayarri et al., 2012;
Yi ∼ Bin mj , πj , where m is the total number of Garcia-Costa et al., 2022). The large variance indi-
trials (m = 60) and π is the probability of success on cates that we are open to a wide range of possible
each trial. values for the parameters, reflecting our initial uncer-
A Bayesian approach was adopted to determine tainty.
which variables should be included as predictors, The Bayesian inference procedure was performed
wherein the available prior information was com- using Markov Chain Monte Carlo methods through
bined with the information from the data. This the software JAGS (Just Another Gibbs Sampler) and
combination is summarized in a posterior probability its R interface rjags (Plummer, 2022). For the conver-
distribution for each unknown quantity in the model. gence of three chains for each parameter, a burning
In the variable selection procedure, the unknown period was used. A total of 3000 samples of each
quantity is the true model and, for each of the 2p com- posterior distribution were left.
 L. Olabarrieta-Landa et al. / Normative data for verbal fluency and naming 199

3. Results found, such that women with higher Spanish profi-

ciency produced a greater number of words whereas
3.1. Variable selection men did not.
Regarding the /p/ phoneme, an age by educa-
Twenty-nine possible candidate covariates were tion interaction was found, such that people with
examined. Table 1 shows the posterior inclusion greater years of education and older age achieved
probability (PIP) values of all covariates in each neu- higher scores compared to older people with fewer
ropsychological score. From the PIPs, an elbow plot years of education (Fig. 1G). Furthermore, a sex by
(x-axis=each covariate, y-axis=PIP values) was made BDS interaction was found, such that women with
and the substantial change in PIPs was studied to higher Spanish proficiency produced a greater num-
select variables for the regression model for each ber of words, while men maintained their level of
neuropsychological score (Table 1). performance regardless of their Spanish or English
proficiency. Finally, a BAS by time in the U.S. interac-
3.2. Phonological verbal fluency tion was found, such that people with higher Hispanic
acculturation performed better on this phoneme
Table 2 presents the mean, median, mode, and cred- regardless of the time spent in the U.S. However, peo-
ibility interval (95%) of the posterior distributions ple with lower Hispanic acculturation perform worse
for the for the parameters in each model. The final if they had spent more time in the U.S.
model for /f/ showed that age by BDS interaction For the /m/ phoneme, scores increased according
arose, such that people over 50 years old who had to the natural logarithmic transformation of educa-
higher English competence generated more words tion. A sex by BDS interaction was found, such
than those with higher Spanish proficiency. However, that men generated a greater number of words with
people younger than 50 years old with higher Span- higher English competence compared to women, but
ish proficiency produced more words than those with with higher Spanish competence, women produced a
higher English competence (Fig. 1A). Also, an edu- greater number of words (Fig. 1H). Finally, a BAS
cation by BDS interaction was found, such that after by time in the U.S. interaction was found, such that
ten years of education, people with higher Spanish people with higher Spanish acculturation and more
proficiency produced a greater number of words than time living in the U.S. performed worse compared to
those with higher English proficiency. However, peo- those living in the U.S. for less time. However, when
ple with fewer than ten years of education but higher people had lower Hispanic acculturation, they per-
English proficiency produced more words than those formed equally well regardless of the time living in
with higher Spanish proficiency (Fig. 1B). the U.S.
Education was related to the /a/ phoneme, such that Finally, for the /r/ phoneme, an age by education
scores increased according to education’s natural log- interaction arose, such that people with greater years
arithmic transformation (Fig. 1C). Moreover, a sex by of education and older age performed much better
BDS interaction was found, such that women with than those with fewer years of education (Fig. 1I).
higher Spanish competence produced a greater num- Lastly, a sex by BDS interaction was found, such
ber of words whereas men did not (Fig. 1D). Finally, that women produced a greater number of words
a sex by time in the U.S. interaction was found, such with greater Spanish proficiency, while men produced
that women with a greater number of years living in fewer words.
the U.S. generated fewer words, whereas men gener-
ated a greater number (Fig. 1E). 3.3. Summatory scores for FAS and PMR triads
The /s/ phoneme was also associated with edu-
cation, such that scores increased according to Summatory score for FAS triad showed an educa-
education’s natural logarithmic transformation. Fur- tion by BDS interaction, such that after 10 years of
thermore, a BAS by time in the U.S. interaction was education, people with higher Spanish competence
found, such that people who spent a greater number of produced a greater number of words than those with
months in the U.S. and had lower Hispanic accultur- higher English competence. However, people with
ation performed better on this phoneme. However, fewer than 10 years of education but higher English
people with fewer months living in the U.S. but competence produced a greater number of words than
higher Hispanic acculturation achieved higher scores those with higher Spanish competence. Also, a sex
(Fig. 1F). Moreover, a sex by BDS interaction was by time in the U.S. interaction was found, such that
 200
Table 1
Posterior inclusion probabilities (PIP) to variable selection by each test score
Covariable Phoneme F Phoneme A Phoneme S Phoneme M Phoneme R Animals Fruits BNT FAS PMR
Intercept 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000

L. Olabarrieta-Landa et al. / Normative data for verbal fluency and naming

Age 0.266 0.123 0.224 0.181 0.234 0.037 0.075 0.053 0.155 0.549
Age2 0.061 0.052 0.064 0.089 0.088 0.022 0.029 0.030 0.213 0.226
log(education) 0.536 0.801 0.940 0.838 0.884 0.948 0.755 0.109 0.71 0.742
Sex (Woman) 0.101 0.112 0.053 0.131 0.069 0.040 0.191 0.102 0.419 0.076
Time in U.S. 0.255 0.219 0.263 0.199 0.234 0.321 0.126 0.044 0.227 0.204
BAS-Hispanic 0.100 0.086 0.099 0.235 0.201 0.066 0.040 0.056 0.336 0.436
BDS 0.487 0.064 0.064 0.229 0.058 0.274 0.395 0.174 0.291 0.074
Age*Age2 0.076 0.055 0.059 0.052 0.091 0.023 0.032 0.042 0.133 0.299
Age*log(education) 0.365 0.164 0.454 0.316 0.557 0.043 0.071 0.043 0.266 0.882
Age*Sex (Woman) 0.149 0.064 0.071 0.122 0.173 0.024 0.029 0.023 0.832 0.145
Age*Time in U.S. 0.075 0.114 0.127 0.125 0.154 0.050 0.073 0.029 0.109 0.137
Age*BAS-Hispanic 0.180 0.115 0.255 0.149 0.159 0.034 0.066 0.050 0.132 0.148
Age*BDS 0.456 0.085 0.051 0.062 0.072 0.025 0.043 0.102 0.156 0.078
Age2 *log(education) 0.066 0.057 0.076 0.143 0.075 0.022 0.031 0.044 0.289 0.346
Age2 *Sex (Woman) 0.170 0.265 0.467 0.237 0.320 0.036 0.025 0.055 0.974 0.993
Age2 *Time in U.S. 0.086 0.125 0.069 0.099 0.061 0.022 0.028 0.022 0.244 0.272
Age2 *BAS-Hispanic 0.057 0.051 0.071 0.062 0.076 0.022 0.030 0.034 0.274 0.278
Age2 *BDS 0.046 0.048 0.060 0.054 0.072 0.023 0.098 0.035 0.108 0.207
log(education)*Sex (Woman) 0.088 0.121 0.051 0.163 0.067 0.046 0.271 0.113 0.202 0.074
log(education)*Time in U.S. 0.203 0.216 0.266 0.183 0.402 0.313 0.108 0.042 0.234 0.41
log(education)*BAS-Hispanic 0.161 0.081 0.100 0.220 0.188 0.070 0.052 0.595 0.336 0.396
log(education)*BDS 0.613 0.061 0.070 0.228 0.057 0.688 0.460 0.800 0.551 0.075
Sex (Woman)*Time in U.S. 0.268 0.884 0.045 0.232 0.124 0.077 0.063 0.381 0.983 0.104
Sex (Woman)*BAS-Hispanic 0.095 0.121 0.058 0.096 0.075 0.036 0.125 0.111 0.401 0.081
Sex (Woman)*BDS 0.062 0.947 0.738 0.458 0.976 0.022 0.039 0.037 0.294 0.999
Time in U.S.*BAS-Hispanic 0.316 0.061 0.524 0.507 0.397 0.235 0.137 0.074 0.207 0.516
Time in U.S.*BDS 0.110 0.051 0.048 0.075 0.099 0.036 0.052 0.085 0.117 0.098
BAS-Hispanic*BDS 0.130 0.079 0.068 0.241 0.076 0.078 0.182 0.086 0.181 0.073
Note* BAS = Bidimensional Acculturation Scale for Hispanics; BDS = Bilingual Dominance Scale.
 L. Olabarrieta-Landa et al. / Normative data for verbal fluency and naming 201

Table 2
Mean, median, mode, and credibility interval (95%) for the posterior distributions of the parameters in the phonologic verbal fluency models
Test score Parameters Mean Median Mode HDI Low HDI High
Phoneme F Intercept 1.9896 1.9986 2.0079 1.5243 2.4650
Age 0.0073 0.0074 0.0077 0.0032 0.0115
log(education) 0.1104 0.1067 0.0951 –0.0552 0.2864
BDS –0.0389 –0.0392 –0.0381 –0.0659 –0.0072
Age*BDS –0.0004 –0.0004 –0.0004 –0.0007 –0.0002
log(education)*BDS 0.0169 0.0169 0.0165 0.0060 0.0273
Phoneme A Intercept 1.3913 1.3855 1.3563 1.0448 1.7677
log(education) 0.3660 0.3679 0.3733 0.2270 0.4803
Sex 0.1202 0.1197 0.1105 –0.0431 0.2795
Time in U.S. 0.0002 0.0002 0.0002 –0.0002 0.0006
BDS –0.0003 –0.0004 –0.0008 –0.0055 0.0050
Sex*Time in U.S. –0.0008 –0.0008 –0.0008 –0.0013 –0.0003
Sex*BDS 0.0105 0.0106 0.0110 0.0042 0.0172
Phoneme S Intercept 1.5130 1.5149 1.5371 0.7843 2.1927
log(education) 0.2645 0.2638 0.2604 0.1455 0.3880
Sex (Woman) –0.0304 –0.0291 –0.0247 –0.1481 0.0806
Time in U.S. 0.0007 0.0007 0.0007 –0.0010 0.0025
BAS-Hispanic 0.0726 0.0739 0.0816 –0.1049 0.2495
BDS 0.0050 0.0050 0.0044 –0.0005 0.0112
Time in U.S.* BAS-Hispanic –0.0003 –0.0003 –0.0003 –0.0008 0.0002
Sex*BDS 0.0060 0.0059 0.0057 –0.0006 0.0126
Phoneme P Intercept 1.8927 1.9073 1.9708 1.2915 2.5336
Age –0.0120 –0.0120 –0.0119 –0.0312 0.0063
log(education) 0.3010 0.3004 0.3072 0.1901 0.4222
Sex –0.0074 –0.0065 –0.0042 –0.1131 0.1022
Time in U.S. –0.0002 –0.0001 0.0000 –0.0017 0.0014
BAS-Hispanic –0.0010 –0.0017 –0.0047 –0.1626 0.1455
BDS –0.0004 –0.0005 –0.0013 –0.0065 0.0051
Age* log(education) 0.0064 0.0064 0.0065 –0.0006 0.0135
Sex*BDS 0.0071 0.0072 0.0073 0.0003 0.0134
Time in U.S.* BAS-Hispanic –0.0002 –0.0002 –0.0002 –0.0006 0.0003
Phoneme M Intercept 1.5301 1.5614 1.5997 0.8639 2.0908
log(education) 0.3677 0.3694 0.3791 0.2506 0.4803
Sex 0.0231 0.0235 0.0278 –0.0977 0.1320
Time in U.S. 0.0004 0.0004 0.0004 –0.0011 0.0021
BAS-Hispanic –0.0128 –0.0170 –0.0272 –0.1600 0.1553
BDS 0.0072 0.0073 0.0075 0.0009 0.0127
Time in U.S.* BAS-Hispanic –0.0003 –0.0002 –0.0002 –0.0007 0.0002
Sex*BDS 0.0047 0.0047 0.0049 –0.0019 0.0116
Phoneme R Intercept 1.5296 1.5337 1.5674 1.1931 1.8878
Age –0.0173 –0.0169 –0.0137 –0.0378 0.0044
log(education) 0.3358 0.3358 0.3325 0.2147 0.4664
Sex –0.0770 –0.0780 –0.0805 –0.1823 0.0289
BDS 0.0008 0.0009 0.0008 –0.0047 0.0057
Age*log(education) 0.0073 0.0072 0.0072 –0.0004 0.0155
Sex*BDS 0.0123 0.0122 0.0122 0.0057 0.0185
Note: *Interaction; BAS = Bidimensional Acculturation Scale for Hispanics; BDS = Bilingual Dominance Scale; HDI = Highest Density
Intervals.

women with a greater number of years living in the erated a greater number of words with higher English
U.S. generated fewer words, whereas men a greater competence compared to women, but with higher
number. Finally, an age by sex interaction arose, such Spanish competence, women produced a greater
that while men’s performance maintained stable with number of words. Moreover, an age by education
increasing age, women’s performance improved with interaction was found, such that people with greater
increasing age until they reached age 65 after which years of education and older age achieved higher
a decline in performance was observed. scores compared to older people with fewer years of
On the other hand, summatory score for PMR triad education. Finally, as with FAS triad, an age by sex
showed a sex by BDS interaction, such that men gen- interaction arose, such that while men’s performance
202 L. Olabarrieta-Landa et al. / Normative data for verbal fluency and naming

Fig. 1. Predicted mean count as a function of demographic variable included in the phonologic verbal fluency models. Note:
BAS = Bidimensional Acculturation Scale for Hispanics; BDS = Bilingual Dominance Scale.

maintained stable with increasing age, women’s per- and greater Spanish proficiency produced a greater
formance improved with increasing age until they number of animals than those with greater English
reached age 65 after which a decline in performance proficiency. However, in fruits category, the differ-
was observed (see Table 3). ences between Spanish and English proficiency were
maintained regardless of educational attainment, and
3.4. Semantic verbal fluency people with greater Spanish proficiency always pro-
duced a greater number of fruits (Fig. 2A, B). See
For Animal and Fruit categories, an education Table 4 for mean, median, mode, and credibility inter-
by BDS interaction was found, such that after 5 val (95%) for the posterior distributions for the of the
years of education, people with higher education parameters for each model.
 L. Olabarrieta-Landa et al. / Normative data for verbal fluency and naming 203

Table 3
Mean, median, mode, and credibility interval (95%) for the posterior distributions of the parameters in total sum of words for phonemes
models
Test score Parameters Mean Median Mode HDI Low HDI High
Total sum of Intercept 2.8676 2.8680 2.8538 2.5675 3.1510
/f/a/s Age 0.0009 0.0009 0.0007 –0.0015 0.0038
Age2 0.0001 0.0001 0.0001 0.0000 0.0002
log(education) 0.2153 0.2141 0.2137 0.1080 0.3242
Sex (Woman) 0.2006 0.2002 0.1942 0.1175 0.2835
Time in U.S. –5.47 × 10−6 –6.76 × 10−6 –7.36 × 10−6 –0.0002 0.0002
BDS –0.0148 –0.0149 –0.0168 –0.0318 0.0029
Sex (Woman)*Time in U.S. –0.0008 –0.0008 –0.0007 –0.0011 –0.0005
Age*Sex (Woman) 0.0063 0.0063 0.0060 0.0028 0.0096
Age2 *Sex (Woman) –0.0003 –0.0003 –0.0004 –0.0005 –0.0002
log(education)*BDS 0.0072 0.0072 0.0071 0.0004 0.0132
Total sum of Intercept 2.6808 2.6823 2.6994 2.4784 2.8567
/p/m/r Age –0.0209 –0.0208 –0.0200 –0.0326 –0.0093
Age2 0.0002 0.0002 0.0002 0.0001 0.0003
log(education) 0.3246 0.3243 0.3182 0.2577 0.3952
Sex (Woman) –0.0238 –0.0242 –0.0284 –0.0813 0.0412
BDS 0.0026 0.0026 0.0025 –0.0002 0.0058
Age*Sex (Woman) 0.0015 0.0016 0.0017 –0.0018 0.0047
Age2 *Sex (Woman) –0.0004 –0.0004 –0.0005 –0.0006 –0.0003
Sex (Woman)*BDS 0.0071 0.0070 0.0070 0.0033 0.0113
Age*log(education) 0.0081 0.0080 0.0075 0.0034 0.0123
Note: *Interaction; BDS = Bilingual Dominance Scale; HDI = Highest Density Intervals.

3.5. Boston Naming Test (BNT) Bear in mind that demographic variables were
multiplied by 3000 samples of parameters. 2) The
Education was related to the BNT total score, such probability based on the Poisson/Binomial Cumula-
that scores increased according to the natural loga- tive Distribution Function was estimated for each of
rithmic transformation of education. In addition, an the 3000 sample parameters, 3) a mean probability
interaction between education by BAS and education was calculated, and 4) this probability was multiplied
by BDS were found, such that people with higher His- by 100 to interpret it as a percentile.
panic acculturation and greater Spanish proficiency
obtained higher scores than those with lower His- 3.7. User-friendly normative data
panic acculturation and greater English proficiency.
Moreover, performance increased with greater years To facilitate the understanding of the procedure to
of education (Table 4 and Fig. 2C, D). obtain the percentile associated with a given score
on this test, an example will be given. Suppose you
3.6. Normative procedure need to find the probability for a woman, who is
50 years old and has 15 years of education. She
An expanded explanation of the procedure can be obtained a BDS score of 10 and a score of 8 on the /f/
found in Rivera et al. (2024). Briefly, norms (e.g., phoneme.
a percentile score) for the verbal fluency and BNT Since the method explained above is complex
scores were established using a four-step procedure: and can be prone to human error due to the number
1) The expected test score (μ̂i ) was computed based of required computations, we have created an
on the parameters  estimates
 from the established online calculator based on https://www.rstudio.com/
regression model β̂p , using: products/shiny/. This will facilitate probability
(1) (p) calculation as clinicians should only include patient
μ̂i = eβ̂0 · eβ̂1 Xi · . . . · eβ̂p Xi information requested in the calculator (i.e., gross
and score for the specific test, age, education, and so on).
 This tool is available for all users at https://neurop
(1) (p)
exp β̂0 + β̂1 Xj + β̂p Xj sychologylearning.com/datos-normativos-archivos-
π̂j =  . descargables/. Using the calculator and introducing
(1) (p)
1 + exp β̂0 + β̂1 Xj + β̂p Xj the information requested, this woman would obtain
204 L. Olabarrieta-Landa et al. / Normative data for verbal fluency and naming

Fig. 2. Predicted mean score as a function of demographic variable included in the semantic verbal fluency and BNT models. Note:
BAS = Bidimensional Acculturation Scale for Hispanics; z-BDS = Bilingual Dominance Scale – rescaling to z distribution.

a mean probability score of .245, that is, at the 24.5th However, these effects were often qualified by inter-
percentile. actions with time spent in the U.S., Hispanic cultural
identity, and Spanish proficiency.
In the current study, while sex did not emerge as
4. Discussion a meaningful independent predictor of verbal flu-
ency or BNT test scores, sex interacted with Spanish
The purpose of the study was to develop norma- proficiency, such that Spanish proficiency was more
tive data for the phonological and semantic verbal strongly associated with higher scores on many of
fluency tests as well as the BNT among Spanish- the phonological verbal fluency measures in women
speaking adults residing in the U.S. It was the first compared to men. Thus, sex was included in the
known study to control for the effect of both sociode- models to establish norms based on the interaction
mographic and Hispanic acculturation variables on between sex and other key predictors such as Spanish
test performance where appropriate. Across different proficiency. The impact of sex on language measures
phonemes, semantic categories, and the BNT, age, has been variable and inconclusive; in many previ-
education, and sex exhibited several main effects. ous studies, sex did not significantly impact verbal
 L. Olabarrieta-Landa et al. / Normative data for verbal fluency and naming 205

Table 4
Mean, median, mode, and credibility interval (95%) for the posterior distributions of the parameters in the semantic verbal fluency and
Boston Naming Test models
Test score Parameters Mean Median Mode HDI Low HDI High
Animals Intercept 2.1931 2.2003 2.2199 1.7833 2.6111
log(education) 0.2267 0.225 0.219 0.0799 0.3782
BDS –0.0132 –0.0134 –0.0133 –0.0368 0.0105
log(education)*BDS 0.0089 0.0089 0.0087 5.00 × 10−4 0.018
Fruits Intercept 1.8868 1.8857 1.8779 1.45 2.3161
log(education) 0.2438 0.244 0.239 0.0723 0.3921
BDS 0.0098 0.0096 0.0082 –0.0157 0.0342
log(education)*BDS 3.00 × 10−4 4.00 × 10−4 0.0012 –0.0091 0.009
BNT Intercept 0.2112 0.2989 0.3079 –2.0554 1.8876
log(education) 0.1599 0.1226 0.1026 –0.4931 0.9815
BAS-Hispanic –0.0792 –0.106 –0.0805 –0.6112 0.5394
z-BDS –0.319 –0.3171 –0.3315 –0.6547 0.0281
log(education)*BAS-Hispanic 0.0879 0.0994 0.103 –0.1491 0.2818
log(education)*z-BDS 0.2464 0.2451 0.2412 0.1143 0.369
Note: *Interaction; BAS = Bidimensional Acculturation Scale for Hispanics; BDS = Bilingual Dominance Scale; HDI = Highest Density
Intervals; z-BDS = Bilingual Dominance Scale – rescaling to z distribution; BNT = Boston Naming Test.

fluency test scores (Marquine et al., 2021; Menon et age was more strongly associated with increased
al., 2012; Peña-Casanova et al., 2009a). The findings verbal fluency among people with higher education
from the current study suggest that this might have levels across phonemes /p/ and /r/. Also, the effect
been because other key acculturative moderators of of age on phoneme /p/ performance was positive for
the effect of sex were not considered. men but negative for women. Thus, age was included
The effects of education on test performance found in the models to establish norms based on the inter-
in the current study were generally in line with pre- action between age and other key predictors such as
vious studies; higher scores on many of the verbal education and gender.
fluency measures and the BNT were observed for Interestingly, some interactions were found
those with higher educational attainment. Addition- between time in the U.S. and other variables such
ally, several significant interactions were found based as Hispanic acculturation. For example, the effect
on education’s interaction with other key predic- of time in the U.S. on phoneme /s/ performance
tors such as Spanish proficiency. Prior literature has was negative for individuals with a higher Hispanic
similarly found that individuals with higher educa- acculturation level but positive for those with lower
tion levels have better performance on verbal fluency Hispanic acculturation levels. As a result, while time
tasks (Lubrini et al., 2022; Strauss et al., 2006) and in the U.S. is an important covariate in neuropsycho-
the BNT (Neils et al., 1995; Zec et al., 2007), and logical testing for these Spanish speakers, it must be
that language proficiency impacts phonological and qualified on different verbal fluency tasks by other
semantic fluency test performance (Friesen et al., important demographic and acculturative variables.
2015; Kastenbaum et al., 2019). One interesting find-
ing in the current study was the interaction effect 4.1. Clinical implications
between education and Spanish language proficiency
for the /f/ phoneme, animals, fruits, and the BNT, This study has important implications for neu-
such that higher education had a stronger effect on ropsychology practice and research. The norms
performance among individuals with higher Spanish provided may help clinicians and researchers improve
proficiency. Thus, the current study not only gen- accurate identification of neurocognitive impair-
erated education-adjusted norms but did so in the ments relating to phonological and semantic verbal
context of participants’ Spanish language proficiency. fluency and word naming among Spanish-speaking
While previous studies have found lower ver- adults in the U.S., facilitating appropriate treatment
bal fluency scores with older age (Boone et al., selection. The findings have also demonstrated the
2007; Peña-Casanova et al., 2009b), the current study importance of generating normative data on language
demonstrated the differential effect of age on verbal measures for dominant Spanish speakers in the U.S.,
fluency test scores as a function of education. Older since social, cultural, and linguistic differences have
206 L. Olabarrieta-Landa et al. / Normative data for verbal fluency and naming

been shown in the current study and past research sociocultural factors may influence test scores on
(e.g. Mungas et al., 2005) to impact neuropsycholog- language measures and established norms that were
ical test performance. In order to utilize these norms, adjusted based on the interaction effects of tradi-
the BDS and BAS must be administered to capture tional demographic variables (age, gender, education)
acculturation and bilingual dominance, two factors and immigration variables (Spanish proficiency,
that are important when working with the diverse pop- level of acculturation, time in the U.S.). Overall,
ulation of dominant Spanish speakers in the U.S. It is the use of group-specific, sociodemographically-
also important to note that the use of phonemes differs adjusted norms is supported to improve the clinical
somewhat from letter fluency because the instructions utility of language measures in neuropsychological
here were designed to elicit words that begin with a assessments for Spanish-speaking immigrant popu-
sound rather than a letter. This is a small but impor- lations in the U.S.
tant distinction that may be useful for individuals with
low education or literacy (Olabarrieta-Landa et al.,
2017). The effects of sociocultural variables on tra- Acknowledgments
ditional demographic variables should be examined
in future norming efforts for immigrant populations. We extend our sincere gratitude to the institu-
tions and participants whose contributions made
4.2. Limitations and future directions this research possible. We sincerely thank Frances
Chiliquinga, M.A., Zara Belo, and Erika Mendez,
The current study had several limitations that Yanci Almonte Vargas, B.S. for their assistance in
present opportunities for future research. First, the participant recruitment and community engagement.
mean years of education in the current sample was Their contributions were vital to the study’s success.
more than 12 years, which may limit the generaliz-
ability of the norms for individuals with lower levels
of education. Additionally, this study only included Declaration of interest
neurologically healthy adults, highlighting the gap for
future research to establish normative data with pedi- The authors have no conflicts of interest to declare.
atric populations or adults with neurological and/or
psychiatric illnesses. Second, while this study exam-
ined the effects of language proficiency on phonemic
Funding
fluency test scores, the BDS is a subjective measure
of language dominance that relies on individuals’
This research was supported in part by grants
memory and perception of their own linguistic profi-
awarded to Carmen I. Carrión, Psy.D. from the
ciency and language use. Since self-ratings are prone
National Institutes of Health (P30 AG066508) and
to bias, future research may consider using objec-
CTSA (grant number UL1 TR001863) from the
tive measures to assess bilingualism (Gollan et al.,
National Center for Advancing Translational Science
2024). Finally, the current norms may only be used
(NCATS), a component of the National Institutes of
when the individual is fluent in Spanish and resides
Health (NIH). Its contents are solely the responsibil-
in the U.S., whereas the application of these norms
ity of the authors and do not necessarily represent the
to Spanish-speaking individuals outside of the U.S.
official view of NIH. This research was also funded
would increase the risk of misdiagnosis.
in part by a grant awarded to Miriam J Rodrı́guez to
the National Institutes of Health/National Institute on
Aging (grant number L60 AG069322).
5. Conclusion

The present study addressed the urgent need to

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