COWAT Metanorms Across Age, Education, and Gender LOONSTRA, TARLOW, & SELLERSCOWAT METANORMS

Ann S. Loonstra, Alison R. Tarlow, and Alfred H. SellersCenter for Psychological Studies, Nova Southeastern University, Fort Lauderdale, Florida, USA

Norms for the Controlled Oral Word Association Test (COWAT; Benton & Hamsher, 1976)have been published as summary statistics from many relatively small samples. The purpose ofthis study was to combine statistics from these samples to produce metanorms broken down byage, gender, and level of education. Means and standard deviations of letters F, A, and S (FAS)totals from normative samples and samples of normal controls were gathered from a wide vari-ety of research studies and then stringently selected based on factors such as adequacy of thesample and presence of the appropriate statistics. The resulting aggregate statistics for FAS to-tals suggest differences may exist in verbal fluency task performance, depending on a person’sage, gender, and level of education.

Key words: verbal fluency, norms, COWAT, FAS

The Controlled Oral Word Association Test(COWAT; Benton & Hamsher, 1976) has been usedsince its inception as an aid in determiningneurocognitive ability. It has been used to detect verbalcommunication deficits after brain lesions, to monitordelays in language development in children, and to as-sess an individual’s ability to communicate in daily life(Spreen & Strauss, 1991). Although normative data forthe letters F, A, and S (FAS) version of the COWATcurrently exist in published form, these data have beenaccumulated a little at a time, piece by piece across nu-merous studies. As a result, no large sample of compre-hensive norms exists for this test across age, education,gender, and IQ.

Word fluency testing as a measure of neurocognitivefunctioning is often used to compare neurologically im-paired participants with normal controls. A fundamen-tal difficulty encountered in this type of research is theprocurement of an adequate sample size. Small sampleshave a propensity for distortion or bias due to sampledemographics. Because patterns have been found to beinconsistent among groups (Margolin, Pate, Friedrich,& Elia, 1990), it is crucial that normative data be ex-tracted and compiled carefully. This preliminary studyis a beginning toward such an end. We combined infor-

mation from diverse studies containing samples of nor-mal performance of total words produced from the let-ters F, A, and S of the COWAT.

Method

Selection of Studies

A literature search was conducted to locate pub-lished studies containing normative samples of perfor-mances on the COWAT. These studies were eithernormative studies or studies in which a control group ofnormal participants was used. Collection methods in-cluded the close examination of any study using a wordfluency test. Studies were included only if participantswere required to orally generate words in accordancewith Benton’s administration criteria (Spreen &Strauss, 1991), beginning with the letters F, A, and S ina 60-sec time span (see appendix for detailed rules con-firming standard procedure). The total number ofwords produced in response to all three letters were thereported scores. Only samples that contained normalparticipants and for which both means and standard de-viations were reported were used. The means and stan-dard deviations of the various test performances in thesamples were then combined to produce aggregatesummary statistics. Studies in which the COWAT wasadministered in a language other than English were ex-cluded. Studies containing word fluency measures uti-

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Applied Neuropsychology Copyright 2001 by2001, Vol. 8, No. 3, 161–166 Lawrence Erlbaum Associates, Inc.

Requests for reprints should be sent to Ann S. Loonstra, Centerfor Psychological Studies, Nova Southeastern University, 3301 Col-lege Avenue, Fort Lauderdale, FL 33314, USA. E-mail:loona@nova.edu

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lizing more than three letters or letters other than FASwere also excluded, as were tests using categories in-stead of initial consonants.

Procedures for Combining SampleStatistics

To calculate the total number of members (N) in allsamples of the test score, the numbers in each validsample (ns) were summed. To calculate the aggregatemeans of the test scores, each test mean of each validsample was multiplied by the number (n) of the sample,resulting in the sum of that sample’s scores. The sumwas then simply divided by the total number of the sam-ple (N) to give the aggregate mean.

To calculate the aggregate standard deviation, eachsample standard deviation was first squared, then mul-tiplied by the degrees of freedom of that sample, yield-ing a sum of squared deviations (SS) for that sample.These were then summed across samples. This resultrepresents the SS within the samples. The SS betweenthe samples was calculated by adding the weightedsquared differences between sample means and overallcomposite mean. The SS between the samples wasadded to the SS within the samples to produce the totalSS across all samples. This value was then divided bythe total degrees of freedom (N – 1) yielding the aggre-gate variance. The square root of this is the aggregatestandard deviation.

Results

We identified 32 studies comprising a total of 92separate samples that met our basic criteria for inclu-sion in this study. In several of these studies the criteriaof normality were quite vague or based only on self-re-port. Demographic data are also incomplete in a num-ber of cases. Only 17 of the studies providedinformation about the educational level of their sam-ples, and just 10 studies provided information regard-ing IQ. Of these 10 studies, only 1 (Boone, 1999)stratified FAS data by IQ groupings (average, high av-erage, and superior). Hence, it was not possible to strat-ify the metanorms on IQ. However, all but six samplesprovided gender information, and age was provided forall samples. Thus, we were able to stratify themetanorms on age (< 40 years, 40–59 years, 60–79years, and > 80 years), level of education, and gender,although cross-classification was not possible. Thelarge proportion of the metanorms for the overall, gen-

der, and 40- to 60-year category was derived from datapublished by Cerhan et al. (1998).

Table 1 shows the studies, their sample statistics,and the aggregate of these, for the overall FAS acrossboth age and gender. Contributing samples andmetanorms broken down by gender are shown in Ta-ble 2; Table 3 shows these statistics broken down byage groups. Table 4 provides the sample and aggre-gate statistics for the FAS totals by level of education,and Table 5 summarizes the aggregate statistics forthe total FAS across all groupings. The increasedsample sizes thus resulted in more stable score norms.The significance of increased stability provided bycompiling aggregate statistics is that there is an in-creased level of confidence that similar results will be

LOONSTRA, TARLOW, & SELLERS

Table 1. Sample and Aggregate Statistics for Overall Mean andStandard Deviation of FAS Totals

Study Year M SD N

Axelrod et al. 1992 38.63 11.08 80Bolla et al. 1990 44.50 11.72 199Boone 1999 40.15 10.86 151Boone et al. 1990 41.28 10.60 61Boone et al. 1995 40.45 11.12 110Cerhan et al. 1998 33.90 12.55 13,775Clark et al. 1997 41.40 10.30 92Coen et al. 1996 29.50 8.91 16Crossley et al. 1997 25.00 11.60 628Dalrymple et al. 1994 41.00 2.80 8Demakis 1999 37.80 11.10 21Eslinger et al. 1984 38.62 11.04 19Friedman et al. 1995 44.29 12.50 24Geffen et al. 1993 30.00 8.50 10Goethe et al. 1989 44.17 7.58 18Gordon et al. 1986 42.27 11.10 250Hoff et al. 1996 43.70 10.00 54Joyce et al. 1996 46.95 2.72 16Klimczak et al. 1997 40.15 11.43 14Kozora et al. 1995 43.65 12.23 174Lafleche et al. 1995 51.90 10.99 11Norris et al. 1995 38.43 9.32 94Nyberg et al. 1997 42.10 9.77 39Parkin et al. 1991 49.15 9.64 40Parkin et al. 1994 36.90 10.70 22Parkin et al. 1999 49.45 12.35 60Poreh et al. 1995 51.80 7.90 19Shogeirat et al. 1990 38.00 7.50 31Simkins et al. 1994 43.58 9.63 19Tombaugh et al. 1999 37.50 13.10 1,300Yeudall et al. 1986 45.80 5.83 225Zec et al. 1999 36.60 13.10 45Aggregate 34.78 12.83 17,625

obtained when the test is administered toneurocognitively intact individuals.

Discussion

The aggregate statistics for FAS totals per age groupsuggest that there may be a progressive age-related de-cline in performance on oral measures of word fluency.This is in contrast to numerous studies that reported noeffect of age (Axelrod & Henry, 1992; Bolla, Lindgren,Bonaccorsy, & Bleecker, 1990; Boone, 1999; Boone,Miller, Lesser, Hill, & D’Elia, 1990; Parkin & Java,1999). The difference could in part be due to the possi-ble influence of verbal IQ on overall FAS performance(Boone, 1999) and the fact that a number of individualsamples that did not show an age effect may have used apopulation with a higher overall verbal intelligence(e.g., Bolla et al., 1990; Boone et al., 1990). Earlierstudies using participants of low ability, due to poor ed-ucation, low intelligence, or both, showed substantiallylower scores (Spreen & Strauss, 1991). The absence ofFAS normative data for individuals with lower than av-erage IQ and education in many of the more recent nor-mative studies is an issue raised by Mitrushina, Boone,and D’Elia (1999), who suggested that the use of thosedata alone could turn out to be problematic in clinicalpractice.

The aggregate statistics for FAS totals according togender indicate that women may slightly outperformmen on this verbal fluency task. This is consistent withresults garnered by Bolla et al. (1990). Other studies didnot find a significant gender difference (Tombaugh,Kozak, & Rees, 1999; Yeudall, Fromm, Reddon, &

Stefanyk, 1986). Lezak (1995) reported in her review ofFAS test characteristics that no difference in perfor-mance exists between men and women. Yeudall et al.(1986)noted the inherentdifficulty inmaking inferencesabout gender differences in a data set derived from di-verse biological and environmental sources. Tombaughet al. (1999) found less than 1% of the variance to be ac-counted for by gender in administration of the FAS to asample of 1,300 cognitively intact individuals.

The aggregate statistics for FAS totals by level ofeducation show an increase in verbal fluency perfor-mance between those who continued beyond highschool and those with an education of 12 years or less.This confirms the suggestion of previous studies thatFAS scores tend to increase with increasing education(Tombaugh et al., 1999).

Although it appears that age, education, and genderplay a role in verbal fluency performance on theCOWAT, it is as yet unclear how many of these differ-ences should be attributed to these factors and howmany should be attributed to verbal intelligence. Therole of verbal intelligence as a predictor of verbal flu-ency is an area that merits further research and analysis.

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Table 2. Sample and Aggregate Statistics for FAS Totals on Males and Females

Males Females

Study Year M SD N M SD N

Bolla et al. 1990 42.15 11.70 80 46.08 11.51 119Cerhan et al. 1998 32.70 12.68 6,098 34.86 12.37 7,677Crossley et al. 1997 23.20 12.10 258 26.20 11.00 370Goethe et al. 1989 44.17 7.58 18 — — —Gordon et al. 1986 40.76 11.46 90 43.12 10.84 160Hoff et al. 1996 43.70 10.00 54 — — —Klimczak et al. 1997 45.00 11.69 7 35.29 9.57 7Poreh et al. 1995 51.80 7.90 19 — — —Tombaugh et al. 1999 37.00 13.00 559 37.80 13.10 741Yeudall et al. 1986 45.08 5.90 127 44.43 5.73 98Aggregate 33.28 12.96 7,310 35.14 12.59 9,172

Note: Dashes indicate data were not reported.

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Table 3. Sample and Aggregate Statistics for FAS Totals by Age Group

Age FAS Total

Study Year N Range Group M SD

Demakis et al. 1999 21 15–38 < 40 37.80 11.10Goethe et al. 1989 18 18–29 < 40 44.17 7.58Joyce et al. 1996 20 30–39 < 40 46.95 2.72Klimczak et al. 1997 7 17–22 < 40 45.00 11.69Klimczak et al. 1997 7 17–22 < 40 35.29 9.57Norris et al. 1995 40 18–28 < 40 40.50 7.80Parkin et al. 1999 20 20–32 < 40 49.45 14.55Poreh et al. 1995 19 18–25 < 40 51.80 7.90Tombaugh et al. 1999 19 16–19 < 40 39.30 12.00Tombaugh et al. 1999 106 20–29 < 40 41.20 9.20Tombaugh et al. 1999 132 30–39 < 40 43.10 11.40Yeudall et al. 1986 62 15–20 < 40 41.83 6.72Yeudall et al. 1986 73 21–25 < 40 44.92 6.53Yeudall et al. 1986 48 26–30 < 40 44.58 5.69Yeudall et al. 1986 42 31–39 < 40 49.72 5.87Aggregate 634 15–39 < 40 43.51 9.44Axelrod et al. 1992 20 50–59 40–59 41.10 9.90Boone et al. 1990 25 50–59 40–59 43.56 6.51Cerhan et al. 1998 1,519 45–49 40–59 35.39 12.26Cerhan et al. 1998 3,780 50–54 40–59 34.01 12.46Cerhan et al. 1998 3,552 55–59 40–59 33.17 12.37Kozora et al. 1995 41 50–59 40–59 41.23 12.10Tombaugh et al. 1999 121 40–49 40–59 43.50 12.20Tombaugh et al. 1999 144 50–59 40–59 42.10 11.10Aggregate 9,202 40–59 40–59 34.24 12.48Axelrod et al. 1992 20 60–69 60–79 39.60 10.70Axelrod et al. 1992 20 70–79 60–79 36.00 9.30Boone et al. 1990 21 60–69 60–79 42.33 14.21Boone et al. 1990 15 70–79 60–79 36.00 8.93Cerhan et al. 1998 1,710 65–69 60–79 31.70 12.80Cerhan et al. 1998 3,219 60–64 60–79 32.37 12.34Crossley et al. 1997 139 65–74 60–79 24.00 12.00Dalrymple et al. 1994 8 60–70 60–79 41.00 2.80Geffen et al. 1993 10 60–79 60–79 30.00 8.50Kozora et al. 1995 43 60–69 60–79 41.23 12.10Kozora et al. 1995 47 70–79 60–79 45.76 14.26Parkin et al. 1994 22 60–79 60–79 36.90 10.70Parkin et al. 1999 20 63–72 60–79 51.25 10.94Aggregate 5,294 60–79 60–79 32.31 12.70Axelrod et al. 1992 20 80–89 > 80 37.80 14.00Crossley et al. 1997 146 85+ > 80 24.00 10.80Kozora et al. 1995 43 80–89 > 80 46.49 10.46Tombaugh et al. 1999 200 80–89 > 80 28.90 11.70Tombaugh et al. 1999 24 90–95 > 80 28.20 11.00Aggregate 433 80–95 > 80 29.37 13.05

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Table 4. Sample and Aggregate Statistics for FAS Totals by Level of Education

Years of Education FAS Totals

Study Year N Range Group M SD

Crossley et al. 1997 140 0–6 0–12 16.20 6.90Crossley et al. 1997 170 7–9 0–12 23.70 9.90Tombaugh et al. 1999 163 0–8 0–12 24.90 10.70Geffen et al. 1993 10 7–12 0–12 30.00 8.50Dalrymple et al. 1994 8 8–12 0–12 41.00 2.80Tombaugh et al. 1999 664 9–12 0–12 36.70 12.20Crossley et al. 1997 202 10–12 0–12 27.00 10.20Aggregate 1,357 0–12 0–12 30.07 13.09Crossley et al. 1997 115 13+ > 12 34.20 12.60Tombaugh et al. 1999 392 13–16 > 12 42.60 11.60Tombaugh et al. 1999 81 17–21 > 12 43.90 12.30Aggregate 588 13–21 > 12 41.14 12.37

Table 5. Summary of Aggregate Statistics for FAS Totals

Category N M SD

GenderMales 7,310 33.28 12.96Females 9,172 35.14 12.59

Age< 40 634 43.51 9.4440–59 9,202 34.24 12.4860–79 5,294 32.31 12.7080–95 433 29.37 13.05

Education0–12 1,357 30.07 13.09> 12 588 41.14 12.37

Overall 17,625 34.78 12.83

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Original submission May 3, 2000Accepted January 19, 2001

AppendixCOWAT Administration

Administer the test as follows:

Use a stopwatch and have the patient comfortablyseated before giving the following instructions: “I willsay a letter of the alphabet. Then I want you to give meas many words that begin with that letter as quickly asyou can. For instance, if I say ‘B,’ you might give me‘bad,’ ‘battle,’ ‘bed.’ I do not want you to use wordsthat are proper names such as ‘Boston,’ ‘Bob,’ or‘Brylcreem.’ Also do not use the same word again witha different ending such as ‘eat’ and ‘eating.’ Any ques-tions?” (Pause.) “Begin when I say the letter. The firstletter is ‘F.’ Go ahead.” (Begin timing immediately.)Allow one minute for each letter (F, A, and S). Say“Fine” or “Good” after each one-minute performance.If patients discontinue before the end of the minute, en-courage them to try to think of more words. If there is asilence of 15 seconds, repeat the basic instructions, andthe letter. For scoring purposes, write down the actualwords in the order in which they are produced. Admin-ister all three letters: F, A, and S. The test administra-tion takes about five minutes. The score is the sum ofall admissible words for the three letters. Inadmissiblewords produced under these instructions are notcounted as correct. (Spreen & Strauss, 1991, p. 222)

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