NIH toolbox cognition tests following traumatic brain injury: Frequency of low scores.
Open accessAbstract
PURPOSE/OBJECTIVE: To apply multivariate base rate analyses to the National Institutes of Health Toolbox Cognition Battery (NIHTB-CB) to facilitate the identification of cognitive impairment in individuals with traumatic brain injury (TBI). Research Method/Design: In a multisite cross-sectional design, 158 participants who sustained a complicated mild or moderate TBI (n = 74) or severe TBI (n = 84) at least 1 year earlier were administered the NIHTB-CB. The NIHTB-CB is comprised of 2 crystallized cognition tests (reflecting premorbid ability) and 5 fluid cognition tests, measuring processing speed, memory, and executive functioning. Base rates for obtaining 0 to 5 low fluid cognition scores were calculated across a range of cutoffs for defining a low test score (≤25th to 5th percentiles). Base rates of low scores in the TBI sample were compared to the NIHTB-CB normative sample using diagnostic accuracy statistics. RESULTS: The proportion of the TBI sample obtaining low scores decreased as the cutoff for defining a low score decreased. Individuals with lower premorbid cognitive ability, as measured by NIHTB-CB Crystallized Composite score, tended to produce more low scores on the NIHTB-CB fluid cognition tests, even when using fully demographically adjusted scores. Certain patterns of low scores were associated with TBI (defined as likelihood ratio >2.0), whereas others were nonspecific, occurring almost as often in participants without TBI. CONCLUSIONS/IMPLICATIONS: Premorbid ability stratified base rate tables provided in this article can guide researchers and clinicians in the interpretation of NIHTB-CB performance in adults with TBI. (PsycINFO Database Record
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Written from the paper’s full text.
TL;DR
In a multisite cross-sectional sample of 158 adults with complicated mild/moderate or severe TBI assessed at least one year post-injury, low scores on the five NIH Toolbox Cognition Battery fluid tests were common and strongly related to estimated premorbid crystallized ability. The paper provides base-rate tables and ability-stratified algorithms to improve interpretation and screening for persistent cognitive impairment, with some low-score patterns showing likelihood ratios >2.0 for TBI.
Key findings
- Low scores decreased as the cutoff became more conservative, and lower premorbid cognitive ability was associated with more low fluid scores even when using demographically adjusted norms. At the ≤16th percentile, 63.9% of the TBI sample had at least one age-adjusted low score; among those with low crystallized ability (<90), 88.4% had at least one low fluid age-adjusted score versus 44.4% of those with high crystallized ability (110+).
- Premorbid-ability stratification produced large base-rate differences: three or more age-adjusted scores ≤16th percentile occurred in 65.1% of participants with low crystallized ability versus 16.7% with high crystallized ability; with fully demographically adjusted norms, the rates were 54.8% versus 24.3%.
- Diagnostic accuracy varied by pattern: 15% of the normative sample had three or more fluid scores ≤25th percentile, compared with 38% of complicated mild/moderate TBI and 58% of severe TBI. At ≤16th percentile, one or more low scores occurred in 59% of complicated mild/moderate TBI and 75% of severe TBI, but the normative base rate was 46% (LR+ = 1.3 and 1.6); three or more scores ≤16th percentile yielded LR+ = 2.8 for complicated mild/moderate TBI and 4.5 for severe TBI.
- Table 6 algorithms held the normative false-positive rate near 15%: for high average crystallized ability (T=58+), two or more scores ≤25th percentile occurred in 13.4% of the normative sample, 45.4% of complicated mild/moderate TBI, and 53.3% of severe TBI; for average ability (T=50–57), two or more scores ≤16th percentile occurred in 14.0%, 38.1%, and 44.4%, respectively.
Methods
- Multisite cross-sectional design: 158 participants with medically documented complicated mild/moderate TBI (n=74) or severe TBI (n=84) at least one year post-injury, recruited from three rehabilitation centers; the NIHTB-CB normative sample was N=843 for age-adjusted analyses and N=793 for demographically adjusted analyses.
- The NIHTB-CB included two crystallized tests (Picture Vocabulary, Oral Reading Recognition) and five fluid tests (List Sorting Working Memory, Picture Sequence Memory, Pattern Comparison Processing Speed, Flanker Inhibitory Control and Attention, Dimensional Change Card Sort); age-adjusted scale scores had M=100, SD=15, and demographically adjusted T scores had M=50, SD=10.
- Base rates for obtaining 0 to 5 low fluid cognition scores were calculated at cutoffs of ≤25th, 16th, 9th, and 5th percentiles, compared with the normative sample using diagnostic accuracy statistics (sensitivity, specificity, LR+, LR−), and stratified by estimated premorbid ability using the Crystallized Cognition Composite.
Limitations
- The paper states that all participants were assessed at a single time point, so longitudinal research is needed to examine diagnostic accuracy during neurologic recovery; it also did not include the mildest TBI cases, such as those discharged from an Emergency Department without inpatient rehabilitation, and lacked a control group with traumatic injuries to regions other than the head.
- The paper notes that stratifying on demographics and estimated premorbid cognitive ability should have only partly accounted for pre-injury dissimilarities between uninjured controls and people with TBI.
- The text also makes evident that the algorithms use obtained Crystallized Composite scores as a proxy for pre-injury ability; the paper notes these obtained scores might be lower than pre-injury scores, especially after severe TBI, which likely underestimates the true rate of cognitive impairment for people near an ability-classification border.
Model-written summary. Check it against the paper before relying on it.
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Cites
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Claims the paper makes
3 of 13 cited sources checked · 1 supported · 0 flagged · accuracy not yet measured
- Premisecitation
For individuals with acquired brain injury, the Crystallized Cognition Composite Score can serve as an estimate of pre-injury general cognitive ability.
“For individuals with acquired brain injury, the Crystallized Cognition Composite Score can serve as an estimate of pre-injury general cognitive ability.”
Quote in the paperNot a substantial claim1 of 2 sources checked- cites Gershon et al., 2014 source
The Introduction (Subdomain Definition; page unavailable) says reading and vocabulary tests can provide proxy estimates of overall intellectual ability in healthy individuals. It does not say that the Crystallized Cognition Composite Score estimates pre-injury ability in people with acquired brain injury; the same section notes that brain injuries can impair language performance. (LLM, conf=0.85)
Experimental — accuracy not yet measured - cites Tulsky et al., under review
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Findingown data
For individuals with low crystallized ability (<90), 88.4% had at least one low fluid age-adjusted test score.
“For individuals with low crystallized ability (< 90), 88.4% had at least one low fluid age-adjusted test score.”
Quote in the paperSubstantial claim - Findingown data
Rates of low age-adjusted scores (≤16th percentile) on the fluid tests were significantly correlated with the NIHTB-CB Crystallized composite (r=-.45, p<.001).
“Specifically, rates of low age-adjusted scores (i.e., ≤16th percentile) on the fluid tests were significantly correlated with the NIHTB-CB Crystallized composite (r=-.45, p<.001), Picture Vocabulary Test (r=-.46, p<.001), and Oral Reading Recognition Test (r=-.37, p<.001).”
Quote in the paperSubstantial claim - Findingown data
15% of the normative sample obtained three or more Fluid cognition test scores ≤25th percentile.
“For example, 15% of the normative sample obtained three or more Fluid cognition test scores ≤25th percentile, compared to 38% of those with complicated mild or moderate TBIs (column 3) and 58% of those with severe TBIs (column 4).”
Quote in the paperSubstantial claim - Findingown data
BR differences between individuals with low vs. high premorbid ability tend to become more extreme as the low score cutoff becomes more conservative and/or the number of low scores increases.
“BR differences between individuals with low vs. high premorbid ability tend to become more extreme as the low score cutoff becomes more conservative and/or the number of low scores increases.”
Quote in the paperSubstantial claim
- Findingown data
The proportion of the TBI sample obtaining low scores decreased as the cutoff for defining a low score decreased.
“The proportion of the TBI sample obtaining low scores decreased as the cutoff for defining a low score decreased.”
Quote in the paperNot a substantial claim - Findingown data
Rates of low age-adjusted scores (≤16th percentile) on the fluid tests were significantly correlated with the NIHTB-CB Oral Reading Recognition Test (r=-.37, p<.001).
“Specifically, rates of low age-adjusted scores (i.e., ≤16th percentile) on the fluid tests were significantly correlated with the NIHTB-CB Crystallized composite (r=-.45, p<.001), Picture Vocabulary Test (r=-.46, p<.001), and Oral Reading Recognition Test (r=-.37, p<.001).”
Quote in the paperNot a substantial claim - Findingreasoning
For a single score at or below the 16th percentile, the LR+ for complicated mild/moderate TBI versus the normative sample is 1.3.
“individuals with a single score at or below the 16th percentile are only 1.3 times more likely to be identified as being in the mild-complicated/moderate TBI group than being in the normative sample”
Quote in the paperSubstantial claim - Findingown data
Using a cut-off score of ≤16th percentile, having three or more low scores is uncommon in the normative sample for those with average cognitive ability (BRs 5-13%).
“Using a cut-off score of ≤16th percentile (Table 3), having three or more low scores is uncommon in the normative sample for those with average cognitive ability (BRs 5-13%).”
Quote in the paperSubstantial claim - Findingown data
Using fully demographically-adjusted norms, obtaining three or more scores at or below the 16th percentile occurred in 24.3% of participants with high crystallized ability.
“For example, obtaining three or more scores at or below the 16th percentile occurred in 54.8% of participants with low crystallized ability and 24.3% of participants with high crystallized ability, compared to 65.1% and 16.7% based on age-adjusted norms.”
Quote in the paperNot a substantial claim - Findingown data
For three fluid cognition test scores at or below the 16th percentile, the LR+ for complicated mild/moderate TBI versus the normative sample is 2.8.
“having three Fluid cognition test scores at or below the 16th percentile (Table 3) is 2.8 times more likely in the mild-complicated/moderate TBI group compared to the normative sample”
Quote in the paperSubstantial claim - Findingown data
Certain patterns of low scores were associated with TBI (defined as Likelihood Ratio>2.0).
“Certain patterns of low scores were associated with TBI (defined as Likelihood Ratio>2.0), whereas others were non-specific, occurring almost as often in participants without TBI.”
Quote in the paperSubstantial claim - Findingown data
When considering the five fluid tests, 63.9% of the TBI sample had at least one age-adjusted score at or below the 16th percentile.
“When considering the five fluid tests, 63.9% of the TBI sample had at least one age-adjusted score at or below the 16th percentile.”
Quote in the paperSubstantial claim - Findingown data
Other patterns of low scores were non-specific, occurring almost as often in participants without TBI.
“Certain patterns of low scores were associated with TBI (defined as Likelihood Ratio>2.0), whereas others were non-specific, occurring almost as often in participants without TBI.”
Quote in the paperSubstantial claim - Findingown data
For three fluid cognition test scores at or below the 16th percentile, the LR+ for severe TBI versus the normative sample is 4.5.
“and 4.5 times more likely in the severe TBI group compared to the normative sample”
Quote in the paperSubstantial claim - Findingown data
Using fully demographically-adjusted norms, obtaining three or more scores at or below the 16th percentile occurred in 54.8% of participants with low crystallized ability.
“For example, obtaining three or more scores at or below the 16th percentile occurred in 54.8% of participants with low crystallized ability and 24.3% of participants with high crystallized ability, compared to 65.1% and 16.7% based on age-adjusted norms.”
Quote in the paperSubstantial claim - Findingown data
Individuals with low crystallized ability were twice as likely to have at least one low score (≤16th percentile) as individuals with high crystallized ability.
“That is, individuals with low crystallized ability were twice as likely to have at least one low score (≤16th percentile).”
Quote in the paperSubstantial claim - Findingown data
The present study identified psychometric algorithms, stratified by estimated intellectual ability, that can be used to identify cognitive impairment in people with TBIs.
“Second, the present study identified psychometric algorithms, stratified by estimated intellectual ability that can be used to identify cognitive impairment in people with TBIs (see Table 6).”
Quote in the paperSubstantial claim- The authors state this as an assumption: The Crystallized composite score can serve as a proxy for pre-injury Crystallized abilities.
- Findingown data
Performance on the NIHTB-CB in TBI is strongly related to estimated premorbid ability.
“First, we illustrated that performance on the NIHTB-CB in TBI is strongly related to estimated premorbid ability.”
Quote in the paperSubstantial claim - Findingown data
58% of those with severe TBIs obtained three or more Fluid cognition test scores ≤25th percentile.
“For example, 15% of the normative sample obtained three or more Fluid cognition test scores ≤25th percentile, compared to 38% of those with complicated mild or moderate TBIs (column 3) and 58% of those with severe TBIs (column 4).”
Quote in the paperSubstantial claim - Findingown data
It was less common (BR=44.4%) for individuals with high crystallized ability (110+) to have an age-adjusted score at or below the 16th percentile.
“In contrast, it was less common (BR=44.4%) for individuals with high crystallized ability (110+) to have an age-adjusted score at or below the 16th percentile.”
Quote in the paperSubstantial claim - Findingreasoning
For a single score at or below the 16th percentile, the LR+ for severe TBI versus the normative sample is 1.6.
“and 1.6 times more likely to be identified as being in the severe TBI group than being in the normative sample.”
Quote in the paperSubstantial claim - Findingown data
Differences between participants in each strata of crystallized ability were also present when using fully demographically-adjusted instead of age-adjusted norms.
“Differences between participants in each strata of crystallized ability were also present when using fully demographically-adjusted instead of age-adjusted norms.”
Quote in the paperSubstantial claim - Findingown data
38% of those with complicated mild or moderate TBIs obtained three or more Fluid cognition test scores ≤25th percentile.
“For example, 15% of the normative sample obtained three or more Fluid cognition test scores ≤25th percentile, compared to 38% of those with complicated mild or moderate TBIs (column 3) and 58% of those with severe TBIs (column 4).”
Quote in the paperSubstantial claim - Findingown data
Having four or more low scores is uncommon for those in the normative sample with below average cognitive ability (Crystallized Composite<T=43; BR=11%).
“Having four or more low scores is uncommon for those in the normative sample with below average cognitive ability (Crystallized Composite<T=43; BR=11%).”
Quote in the paperSubstantial claim - Findingown data
The ability-stratified criteria for cognitive impairment hold the false positive rate (normative base rate) constant.
“Notice that these ability-stratified criteria for cognitive impairment hold the false positive rate (i.e., the normative base rate) constant.”
Quote in the paperSubstantial claim- The authors state this as an assumption: The Crystallized composite score can serve as a proxy for pre-injury Crystallized abilities.
- Findingown data
Rates of low demographically-adjusted scores on the fluid tests were significantly correlated with the NIHTB-CB Picture Vocabulary Test (r=-.35, p<.001).
“This relationship was also observed for demographically-adjusted scores: Crystallized composite (r=-.30, p<.001), Picture Vocabulary Test (r=-.35, p<.001), and Oral Reading Recognition Test (r=-.19, p<.05).”
Quote in the paperNot a substantial claim - Findingown data
Individuals with lower premorbid cognitive ability, as measured by the NIHTB-CB crystallized composite score, tended to produce more low scores on the NIHTB-CB fluid cognition tests, even when using fully demographically-adjusted scores.
“Individuals with lower premorbid cognitive ability, as measured by NIHTB-CB crystallized composite score, tended to produce more low scores on the NIHTB-CB fluid cognition tests, even when using fully demographically-adjusted scores.”
- Also stated in: § Results · hedged
“Individuals with lower premorbid cognitive ability tended to produce more low scores on the NIHTB-CB fluid subtests.”
Quote in the paperSubstantial claim - Also stated in: § Results · hedged
- Findingown data
Rates of low demographically-adjusted scores on the fluid tests were significantly correlated with the NIHTB-CB Oral Reading Recognition Test (r=-.19, p<.05).
“This relationship was also observed for demographically-adjusted scores: Crystallized composite (r=-.30, p<.001), Picture Vocabulary Test (r=-.35, p<.001), and Oral Reading Recognition Test (r=-.19, p<.05).”
Quote in the paperNot a substantial claim - Findingown data
Rates of low demographically-adjusted scores on the fluid tests were significantly correlated with the NIHTB-CB Crystallized composite (r=-.30, p<.001).
“This relationship was also observed for demographically-adjusted scores: Crystallized composite (r=-.30, p<.001), Picture Vocabulary Test (r=-.35, p<.001), and Oral Reading Recognition Test (r=-.19, p<.05).”
Quote in the paperSubstantial claim - Findingown data
Rates of low age-adjusted scores (≤16th percentile) on the fluid tests were significantly correlated with the NIHTB-CB Picture Vocabulary Test (r=-.46, p<.001).
“Specifically, rates of low age-adjusted scores (i.e., ≤16th percentile) on the fluid tests were significantly correlated with the NIHTB-CB Crystallized composite (r=-.45, p<.001), Picture Vocabulary Test (r=-.46, p<.001), and Oral Reading Recognition Test (r=-.37, p<.001).”
Quote in the paperSubstantial claim - Findingcitation
Individuals with TBI who had lower premorbid ability obtained more low scores.
“individuals with TBI who had lower premorbid ability obtained more low scores.”
Quote in the paperSubstantial claim0 of 2 sources checked- cites Holdnack et al., under review
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- cites Brooks et al., 2011
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Findingown data
Individuals with low crystallized ability (<90) were almost four times more likely to obtain three or more age-adjusted scores at or below the 16th percentile (BR=65.1% vs. 16.7%) than individuals with high crystallized ability (>110).
“For example, individuals with low crystallized ability (<90) were almost four times more likely to obtain three or more age-adjusted scores at or below the 16th percentile (BR=65.1% vs. 16.7%) and almost 10 times more likely to obtain or more+ scores at or below the 9th percentile (BR=51.6% vs. 5.1%) as individuals with high crystallized ability (>110).”
Quote in the paperSubstantial claim - Premisecitation
The NIHTB-CB is sensitive to persistent cognitive impairment following TBI.
“In a validation paper, Tulsky and colleagues illustrate that the NIH-TBCB is sensitive to persistent cognitive impairment following TBI”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Tulsky et al., under review
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Interpretationreasoning
Having three fluid cognition test scores at or below the 16th percentile suggests that a diagnosis of persistent cognitive impairment due to TBI is likely.
“suggesting that a diagnosis of persistent cognitive impairment due to TBI is likely.”
Quote in the paperSubstantial claim - Interpretationreasoning
Crystallized ability stratified base rates provide a more accurate estimate of the likelihood of persistent cognitive impairment in a given person, compared to when crystallized ability is not considered.
“The clinical implication is that crystallized ability stratified base rates provide a more accurate estimate of the likelihood of persistent cognitive impairment in a given person, compared to when crystallized ability is not considered.”
Quote in the paperSubstantial claim - Interpretationown data
Base rates stratified by estimated premorbid ability allow the use of different cut-offs to maximize classification accuracy.
“The base rates stratified by estimated premorbid ability allow the use of different cut-offs to maximize classification accuracy.”
Quote in the paperSubstantial claim - Interpretationown data
Those with TBIs and above average estimated premorbid ability who show two or more scores ≤25th percentile are likely to have acquired cognitive deficits.
“LR+s of 3.46 and 4.08 suggest that those with TBIs and above average estimated premorbid ability who show this pattern of low scores are likely to have acquired cognitive deficits.”
Quote in the paperSubstantial claim - Interpretationreasoning
These algorithms represent a methodology for creating criteria for identifying cognitive difficulties that incorporates knowledge of multivariate base rates that have a relatively low false positive rate (<15%).
“These algorithms are not exhaustive but they represent a methodology for creating criteria for identifying cognitive difficulties that incorporates knowledge of multivariate base rates that have a relatively low false positive rate (i.e., < 15%).”
Quote in the paperSubstantial claim- The authors state this as an assumption: The Crystallized composite score can serve as a proxy for pre-injury Crystallized abilities.
- Interpretationnone given
The present study further supports the validity of the NIHTB-CB for assessing cognition in people with post-acute mild-complicated to severe TBI.
“In conclusion, the present study further supports the validity of the NIHTB-CB for assessing cognition in people with post-acute mild-complicated to severe TBI.”
Quote in the paperSubstantial claim - Interpretationreasoning
For people who were on the border of an ability classification range, applying these criteria likely resulted in an under-estimation of the true rate of cognitive impairment.
“Thus, for people who were on the border of an ability classification range, applying these criteria likely resulted in an under-estimation of the true rate of cognitive impairment.”
Quote in the paperSubstantial claim- Rests on an assumption: Obtained Crystallized scores might be lower than pre-injury scores, especially in people who have sustained severe TBIs.
- The authors state this as an assumption: The Crystallized composite score can serve as a proxy for pre-injury Crystallized abilities.
- Study design and conductnone given
The present study did not include individuals with the mildest forms of TBI, such as those discharged from an Emergency Department without admission to inpatient rehabilitation.
“The present study did not include individuals with the mildest forms of TBI, such as those who are discharged from an Emergency Department, without admission to inpatient rehabilitation.”
Quote in the paperNot a substantial claim - Interpretationreasoning
This study provides validity evidence for the NIHTB-CB in TBI.
“This study provides validity evidence for the NIHTB-CB in TBI.”
Quote in the paperSubstantial claim - Premisecitation
The Crystallized Cognition Composite Score is resistant to the effects of TBI.
“and is resistant to the effects of TBI (Tulsky et al., under review).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Tulsky et al., under review
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Classified as probably not a substantial claim. 18
- May combine two claims. 17
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationThe Crystallized Cognition Composite Score correlates strongly with other known 'hold' tests.
“This composite correlates strongly with other known “hold” tests (Gershon et al., 2014)”
Quote in the paperNot a substantial claim1 of 1 sources checked- cites Gershon et al., 2014 source
The Results (Validity Assessment; page unavailable) report strong correlations between two individual language tests and established vocabulary and reading measures: TPVT with PPVT-4 (0.80) and TORRT with WRAT-4 (0.86). The paper does not report a correlation for the Crystallized Cognition Composite Score itself, so the evidence supports the component tests rather than the stated composite. (LLM, conf=0.87)
Experimental — accuracy not yet measured
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationThe NIHTB-CB measures attention, working memory, language, processing speed, and executive functioning.
“The NIH Toolbox Cognition Battery (NIHTB-CB) measures attention, working memory, language, processing speed, and executive functioning.”
Quote in the paperNot a substantial claim1 of 1 sources checked- cites Weintraub et al., 2013 source
May combine two claims.
Findingown dataThe LR- for complicated mild/moderate TBI for a single score below the 16th percentile is .76, indicating the condition cannot be ruled out.
“The LR- score of .76 for mild complicated/moderate indicates that the condition cannot be ruled out either (i.e., more test information is required).”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataFor above average estimated premorbid ability, the LR+ for the pattern of two or more scores ≤25th percentile is 3.46 for complicated mild/moderate TBI and 4.08 for severe TBI.
“LR+s of 3.46 and 4.08 suggest that those with TBIs and above average estimated premorbid ability who show this pattern of low scores are likely to have acquired cognitive deficits.”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataCorrecting for age, education, gender, race, and ethnicity with demographically-adjusted norms was not sufficient to remove the variance associated with premorbid intellectual ability, and only modestly attenuated the differences between participants with differing levels of crystallized ability.
“Correcting for age, education, gender, race, and ethnicity with demographically-adjusted norms was not sufficient to remove the variance associated with premorbid intellectual ability, and in fact, only modestly attenuated the differences between participants with differing levels of crystallized ability as measured by the NIHTB-CB Crystallized composite.”
Quote in the paperSubstantial claimMay combine two claims.
FindingreasoningThe LR- for severe TBI for a single score below the 16th percentile is .46, providing more evidence for absence of the condition.
“For severe injuries, the LR- of .46 while not completely ruling out the condition provides more evidence for its absence.”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataFor people with above average estimated intellectual ability (Crystallized Composite T=58+), the criterion for screening positively for mild neurocognitive disorder could be having two or more scores ≤25th percentile; this pattern occurs in 13.4% of the normative sample, 45.4% of complicated mild or moderate TBIs, and 53.4% of severe TBIs.
“For people who have above average estimated intellectual ability (Crystallized Composite T=58+), the criterion for screening positively for mild neurocognitive disorder could be having two or more scores ≤25th percentile. This pattern of performance occurs in 13.4% of the normative sample, 45.4% of those with complicated mild or moderate TBIs, and 53.4% of those with severe TBIs.”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataFor those with above average cognitive ability (Crystallized Composite T=58+), having two or more scores ≤16th percentile occurs in 8% of the normative sample, 41% of complicated mild/moderate TBI, and 33% of severe TBI, with LR+s of 5.1 and 4.1.
“For those with above average cognitive ability (Crystallized Composite T=58+), having two or more scores ≤16th percentile occurs in only 8% of the normative sample compared to 41% and 33% of the two TBI groups (LR+s=5.1 and 4.1).”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataAt the 16th percentile cutoff for a low score, 59% of individuals with complicated mild/moderate TBI and 75% of individuals with severe TBI have one or more low scores.
“Considering the 16th percentile (Table 3) as the cutoff for a low score, 59% of individuals with complicated mild/moderate TBI and 75% of individuals with severe TBI have one or more low scores.”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataThe normative base rate of one or more low scores at the 16th percentile is 46%, yielding a specificity of 54%.
“the normative base rate of 46% indicates poor specificity (i.e., 54% or .54).”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataFor people with Crystallized Composite scores between T=50-57, having two or more scores ≤16th percentile occurs in 14.0% of the normative sample, 38.1% of complicated mild or moderate TBIs, and 44.4% of severe TBIs.
“For example, for people with Crystallized Composite scores between T=50-57, having two or more scores ≤16th percentile occurs in 14.0% of the normative sample, 38.1% of those with complicated mild or moderate TBIs, and 44.4% of those with severe TBIs.”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataFor the normative sample with above average cognitive ability (Crystallized Composite T=58+), 13% obtain two or more scores ≤25th percentile, compared to 45% of complicated mild/moderate TBIs and 53% of severe TBIs.
“for people in the normative sample with above average cognitive ability (Crystallized Composite T=58+), only 13% obtain two or more scores ≤25th percentile, compared to 45% of those with complicated mild/moderate TBIs and 53% of those with severe TBIs (Table 2).”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationCognitive impairment after TBI has a negative impact on daily living skills, community reintegration, and return to competitive employment.
“There is a significant body of research showing that cognitive impairment after TBI has a negative impact on daily living skills (Colantonio et al., 2004), community reintegration, and return to competitive employment (Cattelani, Lombardi, & Mazzucchi, 2002).”
Quote in the paperNot a substantial claim0 of 2 sources checkedProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationAnother study involving the same samples reported significant group differences between people with and without TBI, and illustrated that performance on the NIHTB-CB is associated with injury severity.
“Another study involving the same samples reported significant group differences between people with and without TBI, and illustrated that performance on the NIHTB-CB is associated with injury severity (Tulsky et al., under review).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Tulsky et al., under review
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
Probably not a substantial claim: may not pass S4 (based).
Interpretationnone givenBy referencing the tables provided here, researchers and clinicians can apply the diagnostic accuracy properties of NIHTB-CB to identify individual people with persistent cognitive impairment after TBI.
“By referencing the tables provided here, researchers and clinicians can apply the diagnostic accuracy properties of NIHTB-CB to identify individual people with persistent cognitive impairment after TBI.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S2 (checkable).
InterpretationreasoningCriteria for impairment using demographically-adjusted T scores should be different based on a person's estimated level of crystallized intellectual ability.
“then the criteria for impairment using demographically-adjusted T scores should be different based on a person's estimated level of crystallized intellectual ability.”
Quote in the paperNot a substantial claim- The authors state this as an assumption: The Crystallized composite score can serve as a proxy for pre-injury Crystallized abilities.
May combine two claims.
InterpretationreasoningHaving 1+ score below the 16th percentile on the NIHTB-CB fluid tests has LR+ scores below 2.0 and is not significantly associated with TBI.
“Therefore, this test finding (1+ score < 16th percentile on the NIHTB-CB fluid tests) represents LR+ scores below 2.0 which suggests that it is not significantly associated with TBI.”
Quote in the paperSubstantial claimClassified as probably not a substantial claim.
Interpretationown dataResearchers and clinicians can use the data provided in Table 6 to screen patients or research participants with TBI for DSM-5 mild neurocognitive disorder.
“Researchers and clinicians can use the data provided in Table 6 to screen patients or research participants with TBI for DSM-5 mild neurocognitive disorder.”
Quote in the paperSubstantial claim- The authors state this as an assumption: The Crystallized composite score can serve as a proxy for pre-injury Crystallized abilities.
Probably not a substantial claim: may not pass S2 (checkable).
PremisereasoningGroup mean differences between people with vs. without TBI represent an 'averaging' of individuals with diverse neuropsychological profiles.
“Group mean differences between people with vs. without TBI represent an “averaging” of individuals with diverse neuropsychological profiles”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationThe Fluid Composite and Picture Sequence Memory Test have the largest effect sizes.
“and the Fluid Composite and Picture Sequence Memory Test have the largest effect sizes (Tulsky et al., under review).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Tulsky et al., under review
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).
InterpretationreasoningThe findings from this study are relevant to clinicians and researchers working in rehabilitation settings.
“The findings from this study are relevant to clinicians and researchers working in rehabilitation settings.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S4 (based).
Interpretationnone givenThe 5 subtests designed to be sensitive to brain injury allow for a multivariate analysis of results which may improve sensitivity and specificity compared to a single score screening measure.
“Furthermore, the 5 subtests designed to be sensitive to brain injury allow for a multivariate analysis of results which may improve sensitivity and specificity compared to a single score screening measure.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S2 (checkable).
InterpretationreasoningFindings from this study inform rehabilitation psychologists' practice by providing NIHTB-CB score interpretations that put low scores in perspective.
“Findings from this study inform rehabilitation psychologists' practice by providing NIHTB-CB score interpretations that put low scores in perspective.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.
Interpretationnone givenThis finding is consistent with our previous studies with other test batteries and does not reflect any known specific factors (e.g., sampling or norming method) associated with the NIHTB-CB.
“This finding is consistent with our previous studies with other test batteries and does not reflect any known specific factors (e.g., sampling or norming method) associated with the NIHTB-CB.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing), S4 (based).
Study design and conductnone givenStratifying participants on demographic variables and estimated premorbid cognitive ability should have partly accounted for the pre-injury dissimilarities between uninjured controls and people with TBI.
“Stratifying participants on demographic variables and estimated premorbid cognitive ability should have partly accounted for the pre-injury dissimilarities between uninjured controls and people with TBI.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
Interpretationown dataThe cutoff for defining a low score can vary based on the person's Crystallized Composite score.
“The cutoff for defining a low score can vary based on the person's Crystallized Composite score.”
Quote in the paperSubstantial claim- The authors state this as an assumption: The Crystallized composite score can serve as a proxy for pre-injury Crystallized abilities.
Classified as probably not a substantial claim.
PremisecitationGroup-level information cannot be readily applied to address the clinical challenge of determining whether a specific person fulfills criteria for neuropsychological impairment.
“This group-level information cannot be readily applied to address the clinical challenge of determining whether a specific person fulfills criteria for neuropsychological impairment (Chelune, 2010).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Chelune, 2010
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.
InterpretationreasoningThe NIHTB-CB provides a relatively brief screening battery for identifying those at risk for poor functional outcomes and can be used to triage patients for more comprehensive neuropsychological evaluations to assist with rehabilitation planning.
“The NIHTB-CB provides a relatively brief screening battery for identifying those at risk for poor functional outcomes and can also be used to triage patients for more comprehensive neuropsychological evaluations to assist with rehabilitation planning.”
Quote in the paperNot a substantial claimMay combine two claims.
Interpretationnone givenThe NIHTB-CB can be used by clinicians and researchers to quantify cognitive functioning in people with TBIs, and to screen people for DSM-5 mild neurocognitive disorder.
“The NIHTB-CB can be used by clinicians and researchers to quantify cognitive functioning in people with TBIs, and to screen people for DSM-5 mild neurocognitive disorder.”
Quote in the paperSubstantial claimClassified as probably not a substantial claim.
Study design and conductnone givenAll participants were assessed at a single point in time.
“All participants were assessed at a single point in time.”
Quote in the paperSubstantial claim
The paper relies on this without support.
The NIHTB-CB normative sample is representative of adults without TBI for comparison with the TBI samples.
“For these analyses, the TBI subsamples were compared to the normative sample, adults from the general population.”
The paper relies on this without support.
Cognitive impairment can occur following mild, moderate, or severe TBI, and the type and severity of cognitive deficits, recovery trajectory, and risk for permanency can be difficult to predict in individual cases.
“Cognitive impairment can occur following a mild, moderate, or severe TBI, and the type and severity of cognitive deficits, recovery trajectory, and risk for permanency can be difficult to predict in individual cases.”
The paper relies on this without support.
Neuropsychological functioning after TBI is dynamic, with a general trajectory for gradual improvement.
“Neuropsychological functioning after TBI is dynamic, with a general trajectory for gradual improvement.”
The paper relies on this without support.
Obtained Crystallized scores might be lower than pre-injury scores, especially in people who have sustained severe TBIs.
“Of course, obtained scores might be lower than pre-injury scores, especially in people who have sustained severe TBIs.”
The authors state this as an assumption.
The Crystallized composite score can serve as a proxy for pre-injury Crystallized abilities.
“In Table 6, we used the Crystallized composite score as a proxy for pre-injury Crystallized abilities.”
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Severe-TBI rate is reported as both 53.3% and 53.4%
MinorFor the same criterion-two or more scores at or below the 25th percentile among participants with above-average crystallized ability-the severe-TBI rate is reported to one decimal place as both 53.3% and 53.4%.
“High Average Crystallized Composite (T=58+), two or more scores ≤25th percentile, normative BR=13.4%, mild-moderate TBI=45.4%, severe TBI=53.3%”
“This pattern of performance occurs in 13.4% of the normative sample, 45.4% of those with complicated mild or moderate TBIs, and 53.4% of those with severe TBIs.”
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Flagged first, then by citations
Research works printed but not linked: 2
- Iverson GL Brooks BL Holdnack JA 2012 Evidence-based neuropsychological assessment following work-related injury Bush SS Iverson GL Neuropsychological assessment of work-related injuries 360 400 New York Guilford Press
- Lezak MD Howieson DB Loring DW 2004 Neuropsychological Assessment 4th New York Oxford University Press
Cited by
Sorted by citations
Cook, N. E., Iverson, G. L., & Karr, J. E. (2025) · Frontiers in Psychology · doi:10.3389/fpsyg.2025.1473095
Self-citation
- Authors
- Holdnack, J. A., Iverson, G. L., Silverberg, N. D., Tulsky, D. S., & Heinemann, A. W.
- Affiliations
- University of Delaware (US)
- Harvard University (US)
- University of British Columbia (CA)
- Shirley Ryan AbilityLab (US)
- Venue
- Rehabilitation Psychology
- Published
- 2017-11
- Volume
- 62
- Issue
- 4
- Pages
- 474-484
- ISSN
- 0090-5550 (ISSN-L)
- 1939-1544
- PMC
- PMC5745050
- OpenAlex
- W2778986921
- Semantic Scholar
- 605dbd1ecbf18e5bc5b87edd6f18e0cb1edb53be
- Cited by
- 23
- References
- 42
- Citations by year
- 2026: 2 · 2025: 3 · 2024: 2 · 2023: 5 · 2022: 3 · 2021: 2 · 2020: 3 · 2018: 1 · 2017: 2
- FWCI
- 1.29
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- Rehabilitation Psychology (publishedVersion, other-oa)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute on Disability, Independent Living, and Rehabilitation Research
- National Institutes of Health (U54-GM104941)
- Mooney-Reed Charitable Foundation
- Heinz Family Foundation
- ImPACT Applications, Inc.
- Topics
- Health Sciences › Medicine › Epidemiology › Traumatic Brain Injury Research
- Social Sciences › Psychology › Applied Psychology › Psychological Testing and Assessment
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Cognitive Functions and Memory
- Keywords
- traumatic brain injury, NIH Toolbox Cognition Battery, cognitive impairment, fluid cognition, processing speed, memory, executive function, reference values, mild traumatic brain injury, severe traumatic brain injury, diagnostic accuracy
- MeSH terms
- Brain Injuries, Traumatic, Adolescent, Child, Cognition Disorders, Cross-Sectional Studies, Female, Humans, Male, National Institutes of Health (U.S.), Neuropsychological Tests, United States, Reproducibility of Results
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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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