Overview of Studies Assessing the Utility of Screening Batteries in Detecting HIV-Associated

Overview of Studies Assessing the Utility of Screening Batteries in Detecting HIV-Associated Neurocognitive Disorder

Reference / Screening Measure / NP Gold Standard / Exclusion Criteria / Sample size, Population, Country Location / Sample Demographics
Mean years (SD) / HIV+ Sample Characteristics
Mean (SD) / Impairment Classification Criteria and Rate / Design, Analysis, Main Findings / Strengths and Limitations
Chalermchai, Valcour, Sithinamsuwan, Pinyakorn, Clifford, Paul, et al. (2013). Trail making test A improves performance characteristics of the International HIV Dementia Scale to identify symptomatic HAND. / Paper & Pen: IHDS
IHDS + TMTA / Valcour et al. (2007): Grooved Pegboard, Finger Tapping, Timed gait,
TMTA, Colour Trails 1, Colour Trails 2,
Adult
Verbal Learning Test, BVMT, Escala de Inteligencia Wechsler paraAdulto (EIWA) Coding & Block Design, Animal Fluency, First Names Verbal Fluency / History of head injury, neurological or psychiatric conditions, current illicit drug use, acute illness, learning disability / Thailand 75 HIV+ Hospital outpatients / 44% male
Age = 34.75 (7.15) years
Education = 11.15 (4.85) years / 100% cART naïve
CD4 cell count < 350
CD4 cell count = 213 (140.6) cells/mm3
Plasma VL = 4.85 (.62) / 2007 AAN criteria:
overall z score + self-reported or informant functional status via semi-structured interview
Gold Standard impairment rate:
51% overall
27% MND/HAD
Screen impairment rate NR / Cross-sectional
Criterion validity as determined by ROC curves based on 3 criteria:
ANI + MND + HAD vs unimpaired IHDS AUC = .612 34.2% sensitivity 86.5% specificity
MND + HAD vs ANI + unimpaired:
cutoff ≤ 10
IHDS AUC = .774 53.3% sensitivity 89.8% specificity TMTA AUC = .773(cutoff -1SD)
IHDS+TMTA = 86% sensitivity
62% PPP
HAD vs MND + ANI + unimpaired: IHDS AUC = .944 / Application of AAN criteria
No HIV- control group
Limited sample demographics reported
Comorbid conditions NR
HIV duration, AIDS status NR
Incomplete criterion validity indexes

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Reference / Screening Measure / NP Gold Standard / Exclusion Criteria / Sample size, Population, Country Location / Sample Demographics
Mean years (SD) / HIV+ Sample Characteristics
Mean (SD) / Impairment Classification Criteria and Rate / Design, Analysis, Main Findings / Strengths and Limitations
Sakamoto, Thomas, Marcotte, Umlauf, Franlkin, Heaton, et al. (2013) Concurrent classification accuracy of the HIV Dementia Scale for HIV-associated neurocognitive disorders in the CHARTER cohort. / Paper & Pen: HDS / COWAT
Animal Fluency
Codingf
Symbol Searchf
TMTA
TMTB
WCST-64
LNSf
PASAT
Grooved Pegboard,
FMLT
SMLT / NR / CHARTER Study
1580 HIV+
America / Age = 43.1 years (±8.5)
Educ = 12.5 years (±2.6)
77% male
40% Caucasian
48% African American
12% Other
30% HCV positive 51% lifetime depression
38% substance use disorder within last 12 months
74% lifetime substance use disorder / 62% AIDS diagnosis
70% currently on cART
60% detectable HIV RNA plasma VL
Years HIV duration = 9.88 years (±6.4) Years cART duration = 0.92 (IQR: 0.33, 2.25)
Median Nadir CD4 = 179 (IQR: 50, 307)
Median Current CD4 = 423 (IQR: 263, 607) / NP Impairment: 2007 AAN criteria.
Overall Impairment rate = 51%
HDS Impairment Rate:
using raw cutoff score ≤10 = 17%, using T-score <40 = 56% / Cross-sectional ROC curve analyses, criterion validity indexes,
HDS raw score cutoff ≤ 10:
AUC = 0.68 24% sensitivity, 92% specificity, 75% PPP, 54% NPP, 57% Overall accuracy, Odd's Ratio = 3.4
HDS raw score cutoff ≤ 14 (optimal): AUC = 0.68 66% sensitivity, 61% specificty, 64% PPP, 63% NPP, 63% Overall Accuracy, Odd's Ratio = 3.0
HDS T<40: 69% sensivity, 56% specificity, 62% PPP, 64% NPP, 63% Overall accuracy, Odd's Ratio = 2.9 / Did not exclude individuals with comorbid conditions
Used AAN criteria for NP impairment
Comprehensive NP battery
Large HIV+ sample size
No HIV- control group

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Reference / Screening Measure / NP Gold Standard / Exclusion Criteria / Sample size, Population, Country Location / Sample Demographics
Mean years (SD) / HIV+ Sample Characteristics
Mean (SD) / Impairment Classification Criteria and Rate / Design, Analysis, Main Findings / Strengths and Limitations
Moore, Roediger, Eberly, Blackstone, Hale, Weintrob, et al. (2012). Identification of an abbreviated test battery for detection of HIV-associated neurocognitive impairment in an early-managed HIV-infected cohort. / Paper & pen:
2, 3, and 4 test combinations of comprehensive NP battery / Grooved Pegboard, Symbol Searchf, Codingf, TMTA, PASAT, Digit Spanf, BVMT-R, HVLT-R, WCST, TMTB, Stroop CWT, Letter Fluency, Animal Fluency, Action Fluency / NR / 200 HIV+
US military beneficiaries
America / 95.5% male
48.5% White
29% Black
14% Hispanic 8.5% Other
34% with post-secondary degree
Median age = 36.4 years (IQR 28.1-43.6)
3.5% current illicit drug use
1.5% Hepatitis C / Median CD4 count = 546 cells/mm3 (IQR: 417-706)
64% ART treated
Median HIV disease duration = 5 years (IQR: 2-11 years) / Gold standard:
T scores converted to global deficit score (≥ 0.5 = impaired) Overall impairment rate = 19%
Screen Impairment: 2-test combination - 2 tests T < 40 or 1 test T ≤ 35 3-test combination - 3 tests T < 40 or 1 test T < 40 + 1 test T < 35, or 1 test T < 30 4-test combination: 4 tests T < 40, or 2 tests T < 40 + 1 test T < 35, or 2 tests T < 35, or 1 test T < 40 + 1 test T< 30, or 1 test T < 25
Screen impairment NR / Cross-sectional
2 test combination (StroopColor Word Test & HVLT-R learning):
73% sensitivity 83.1% specificity 50% PPP
93% NPP
13.3 Odds ratio
3 test combination (StroopColor Word Test & HVLT-R learning & PASAT): 86.5% sensitivity 75.5% specificity 45.7% PPP
95.9% NPP
19.7% Odds ratio
4 test combination (StroopColor Word Test & HVLT-R learning & PASAT& Action Fluency): 86.5% sensitivity 87.1% specificity 61.5% PPP
96.4% NPP
43.2% Odds ratio / Comprehensive gold standard
Detailed sample characteristics
No HIV- control group
AIDS, VL, nadir CD4 NR
No measure of IADL, did not use AAN criteria

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Reference / Screening Measure / NP Gold Standard / Exclusion Criteria / Sample size, Population, Country Location / Sample Demographics
Mean years (SD) / HIV+ Sample Characteristics
Mean (SD) / Impairment Classification Criteria and Rate / Design, Analysis, Main Findings / Strengths and Limitations
Becker, Dew, Aizenstein, Lopez, Morrow, & Saxton (2011).
Concurrent validity of a computer-based screening tool for use in adults with HIV disease / Computerised
CAMCI: accuracy & RT on
Star Task
Forward Digit Span
Word Recognition
Word Recall
Picture Recognition
Go/No-Go test
Digit Reverse Span
Shopping Trip / Specific NP tests NR
Domains: Memory
Language Visuoconstruction
Psychomotor speed
Motor skills
Executive function / Neurological disease, CNS OI, tumours, or stroke, learning disability, ADHD, active substance abuse or dependence, current major depression / Sample type NR
Americana
29 HIV+
30 HIV- / HIV+
95% male
69.9% Caucasian
Age =51.1 (6.2)
Education =15.1 (1.9)
Wide Range Test of Achievement =11.7 (1.9)
4.3% Diabetes
43.5%Hypertension
21.7% History of Drug Abuse / Dependence
47.8% History of Depression
HIV-
77.8% male
61.1% Caucasian
Age=50.7 (6.3)
Educ =14.6 (2.5)
Wide Range Test of Achievement =11.1 (3.0)
5.6% Diabetes
22.2%Hypertension
44.4% History Drug Abuse / Dependence
61.6% History Depression / NR / NP impairment:
Based on Global Impairment Rating (0-9), where 5-9 = impaired:
30.51% impaired
69.49% normal/ borderline
NOTE: analysis based on assumed Impairment prevalence rate = 30%
Screen impairment rate NR / Longitudinal (12 and 24 weeks follow-up)
Step-wise discriminant function analysis discriminating NP impaired from NP normal/borderline
Criterion validity indexes
Raw scores: 6/14 tasks (Wilks’λ= 0.42, df= 6, p < 0.001)
72% sensitivity
98% specificity
89% NPP
93% PPP
89% classification accuracy
Repeated with T scores: 3/12 tasks(Wilks’λ= 0.62, df= 3, p < 0.001)
56% sensitivity
100% specificity 84% NPP
100% PPP
86% classification accuracy / Specific NP tests, HIV sample characteristics, Screen impairment rate NR
Small sample sizes
Screen criterion validity based on assumed prevalence rate, not actual sample prevalence rate
Criterion validity generated without the inclusion of ‘borderline’ group as impaired
Construct validity of screen NR

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Reference / Screening Measure / NP Gold Standard / Exclusion Criteria / Sample size, Population, Country Location / Sample Demographics
Mean years (SD) / HIV+ Sample Characteristics
Mean (SD) / Impairment Classification Criteria and Rate / Design, Analysis, Main Findings / Strengths and Limitations
Joska, Westgarth-Taylor, Hoare, Thomas, Paul, Myer, et al. (2011).
Validity of the International HIV Dementia Scale in South Africa / Paper & pen:
IHDS / Grooved Pegboard
Finger Tapping
TMTA
CT1
Codingg
HVLT-R
BVMT-R
MAT
MCT
CT2
CWT
WCST
Animal Fluency
Fruit and Vegetable Fluency / Severe psychiatric disorder, recent history of substance abuse, significant neurological disorder, head injury, loss of consciousness >30 min / Primary health care centres
South Africa
96 HIV+
94 HIV- / Ethnicity NR
HIV+
20.8% male
Age = 29.75 (3.67)
Education =10.05 (1.77)
HIV-
37.6% male
Age = 25.16 (5.15)
Education =10.88 (1.28) / AIDS, disease stage, NR
ART naïve
CD4 count=218.09b (150.5)
Years since diagnosis = 3.35 (2.04) / NP impairment rate:
American Academy of Neurology criteria (2007): NP battery + PAOFI + QLESQ
18.75% Normal
13.54% ANI
31.25% MND
36.46% HAD
Screen impairment rate NR / Cross-sectional
HIV+ normed against HIV-
Criterion validity indexes, ROC analyses
Cutoff ≤10
ANI+MND+HAD vs normal:
44.83% sensitivity
78.57% specificity
79% PPP, 100% NPP, 55.81% correct classification
MND+HAD vsANI+normal:
AUC = 0.64
81% sensitivity
54% specificity
Cutoff ≤11
ANI+MND+HAD vs normal:
72.41% sensitivity
46.43% specificity
65% PPP, 100% NPP, 63.95% correct classification
HAD vs normal:
AUC =0.60
74% sensitivity
33% specificity / Ethnicity, AIDS, disease stage, NR
HIV+ & HIV- were sig different in age & education
Screen impairment rate NR

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Reference / Screening Measure / NP Gold Standard / Exclusion Criteria / Sample size, Population, Country Location / Sample Demographics
Mean years (SD) / HIV+ Sample Characteristics
Mean (SD) / Impairment Classification Criteria and Rate / Design, Analysis, Main Findings / Strengths and Limitations
Levine, Palomo, Hinkin, Valdes-Sueiras, Lopez, et al. (2011).
A comparison of screening batteries in the detection of neurocognitive impairment in HIV-infected Spanish speakers / Paper & pen:
HDS
MMSE
NEUROPSI (Reported in Otrosky et al., 1999, Spanish adaptations of English standardised neuropsychological tests: Orientation,
Digits backwards, Visual detection, Serial 3 subtraction, Verbal Memory, Figure Copy, Confrontation naming, Repetition, Comperehension, Verbal and Semantic Fluency, Reading, Writing
Similarities
Calculation
Alternating hand movements) / NP battery translated in Spanish:
Grooved Pegboard
LNSf
PASAT
Codingf
Symbol Searchf
HVLT-R
BVMT-R
WCST
Verbal Fluency
TMTB / < 18 years old
Not raised in Mexico or Central America
Unable to complete NP battery / National Neurology AIDS bank
American (Spanish speakers that migrated from Mexico or Central America)
21 HIV+ / 85.7% male
100% Hispanic
Age = 47.3 (8.2)
Education = 8.7 (4.5)
Comorbidities NR / AIDS, disease stage, years since diagnosis, VL, NR
100% on cART
Median CD4 count =254b(152) / American Academy of Neurology (1996) criteria
NP Impairment rate:
38.09% normal
9.52% ANI
4.76% MND
19.05% HAD
28.57 other
(overall impairment rate = 52.38%)
MMSE impairment:
14.3%
HDS impairment:
61.9%
NEUROPSI impairment:
71.4%
Note: 100% ANI cases misclassified as normal for MMSE, vs 50% for HDS & NEUROPSI / Cross-sectional
Raw scores converted to T-scores, then to Global T-score
ANI+MND+HAD vs normal:
MMSE (cutoff ≤24):
AUC = 0.40
8% sensitivity
88% specificity
HDS (cutoff ≤10):
AUC = 0.63
67% sensitivity
50% specificity
NEUROPSI
AUC = 0.59
75% sensitivity
38% specificity
MND+HAD vsANI+normal:
MMSE (cutoff ≤24):
AUC = 0.57
10% sensitivity
88% specificity
HDS (cutoff ≤10):
AUC = 0.65
70% sensitivity
50% specificity
NEUROPSI
AUC = 0.65
80% sensitivity
38% specificity / No HIV- control group
Comorbidities, AIDS, disease stage, years since diagnosis, VL, NR
Criterion validity indexes based on whole HAND spectrum
Construct validity of screen NR

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Reference / Screening Measure / NP Gold Standard / Exclusion Criteria / Sample size, Population, Country Location / Sample Demographics
Mean years (SD) / HIV+ Sample Characteristics
Mean (SD) / Impairment Classification Criteria and Rate / Design, Analysis, Main Findings / Strengths and Limitations
Simioni, Cavassini, Annoni, Abraham, Bourquin, Schiffer, et al. (2010).
Cognitive dysfunction in HIV patients despite long-standing suppression of viremia / Paper & pen:
HDS / NART
TMTA TMTB Digit Spanf
Alzheimer’s Disease Assessment Scale-cognitive subscale
CANTAB:
Reaction Time
Rapid Visual Information Processing
Spatial Working Memory / Major CNS OI within past 3 years
Other OI not affecting brain in past 2 months
Active drug use
DSM-IV major depression
Pregnant / Hospital outpatients
Swiss
100 HIV+
(50 HIV+ with cognitive complaints, 50 HIV+ no complaints) / Overall sample:
73% ≥ high school
73% Caucasian
72% men
HAND:
65% male
NART = 102 (10.7)
Age = 47.1 (9.6)
14% antidepressant
9% methadone
31% HAD-A ≥ 10
16% HAD-D ≥ 10
NPI = 14.3 (17.7)
No HAND:
92% male
NART = 108.8 (7.6)
Age = 48.5 (9.6)
4% antidepressant
4% methadone
15% HAD-A ≥ 10
4% HAD-D ≥ 10
NPI = 3 (2.1) / 100% on HAART
100% undetectable VL ≥ 3 months
HAND:
Years since diagnosis = 12.4 (6.6)
undetectable VL (years) = 4.2 (2.6)
CD4 count = 586.9b (245.5)
Nadir CD4 = 166.5b (138.8)
8% Toxoplasmosis
No HAND:
Years since diagnosis = 11.2 (5.8)
undetectable VL (years) = 5.1 (3.4)
CD4 count = 627b (307.9)
Nadir CD4 = 182.2b (115)
0% Toxoplasmosis / American Academy of Neurology criteria (Antinori et al., 2007):
NP Impairment rate:
74% overall
42% ANI
28% MND
4% HAD
26% normal
Self-reported cognitive complaints questionnaire:
n = 50
27% general
18% memory related
16% mental slowing
9% attention deficits
n = 50 no self reported cognitive complaints / Cross-sectional
ROC curve analysis, criterion validity indexes
Cutoff ≤ 10
Overall sample
(n = 100)
54.1% sensitivity 96.2% specificity
Optimal cutoff ≤14 (p<0.001)
AUC = 0.83
Self-reported cognitive complaints:
83% sensitivity
63% specificity
92% PPP
No complaints:
88% sensitivity
67% specificity
82% PPP / No HIV- control group
Limited NP battery
Unusually high HAND rate in sample
Did not compute separate criterion validity indexes for computerised and paper and pen NP tests
Included ANI in HAND impairment rate
Construct validity of screen NR

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Reference / Screening Measure / NP Gold Standard / Exclusion Criteria / Sample size, Population, Country Location / Sample Demographics
Mean years (SD) / HIV+ Sample Characteristics
Mean (SD) / Impairment Classification Criteria and Rate / Design, Analysis, Main Findings / Strengths and Limitations
Skinner, Adewale, Gill, & Power. (2009).
Neurocognitive screening tools in HIV/AIDS: Comparative performance among patients exposed to antiretroviral therapy / Paper & pen:
HDS
IHDS
MMSE / Grooved Pegboard
TMTA
SDMT
TMTB / NR / HIV clinic
Canadian
33 HIV+
(13 HIV+ with HAND, 20 HIV+ with other neurological diseases including seizure, stroke, myopathy, neuropathy)
13 HIV- / HIV+ HAND
92.3% male
Age =52.7 (8.9)
Education = 13.4 (2.3)
HIV+ Other neurological disease
85% male
Age =47.1 (7.2)
Education = 13.7 (3.4)
13 HIV-
53.9% male
Age = 49.5 (5.6)
Education =15.1 (SD NR)
Ethnicity, Comorbidities NR / All HIV+ currently receiving or had prior exposure to HAART
HIV+ HAND
CD4 count =348b (253)
VL= 1.9c (2.1)
HIV+ OND
CD4 count =468b (268)
VL = 1.8c (2.3) / NP impairment rate:
American Academy of Neurology criteria (1996)
HAND (n = 13):
n = 7 (21%) MND
n = 6 (18%) HAD
All MSK scores ≤ 2 / Cross-sectional
ROC analyses, criterion validity indexes:
HDS:
Cutoff ≤10
AUC = 0.82
66.7% classification accuracy
46.2% sensitivity 80.0% specificity 60.0% PPP
Cutoff ≤11
61.5% sensitivity 80.0% specificity
IHDS:
cutoff ≤10
AUC = 0.74
69.7% classification accuracy
76.9% sensitivity 65.0% specificity 58.8% PPP
MMSE:
Cutoff ≤27
AUC = 0.48
51.5% classification accuracy
46.2% sensitivity 55.0% specificity
40% PPP / Very limited NP battery
Small sample size
Sample did not include mild cognitive impairment, criterion validity indexes not computed for ANI
Ethnicity, comorbidities, AIDS, disease stage, years since diagnosis, NR
Impairment rates for screens NR
Construct validity of screen NR

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Reference / Screening Measure / NP Gold Standard / Exclusion Criteria / Sample size, Population, Country Location / Sample Demographics
Mean years (SD) / HIV+ Sample Characteristics
Mean (SD) / Impairment Classification Criteria and Rate / Design, Analysis, Main Findings / Strengths and Limitations
Morgan, Woods, Scott, Childers, Beck, Ellis, et al. (2008).
Predictive validity of demographically adjusted normative standards for the HIV Dementia Scale / Paper & pen:
HDS / Outlined in Woods et al. 2004:
Grooved Pegboard
LNSf
PASAT
TMTA
Codingf
Symbol Searchf
HVLT_R
BVMT-R
WCST
Verbal Fluency
TMTB / History of neurological or psychiatric illness, current illicit drug use / Sample obtained from various neuroAIDS studies at the University of California, San Diego
American
135 HIV+
182 HIV- / Normal:
77% male
60% Caucasian
Age=39 (8)
Education =12.8 years (2.6)
ANI
86% male
64% Caucasian
Age= 38.5 years (11)
Education =12.2. (3)
MCMD
96% male
50% Caucasian
Age= 44.3 (7)
Education =14.3 (3)
HAD
93% male
93% Caucasian
Age =40.2 (4)
Education =12.5 (2)
HIV-
68% male
73% Caucasian
Age=36.6 (12)
Education =13.8 (2.5) / HIV+ Normal:
52% AIDS
29% immunosuppressed
59% on cART
HIV+ ANI
46% AIDS
9% immunosuppressed
77% on cART
HIV+ MCMD
77% AIDS
50% immunosuppressed
59% on cART
HIV+ HAD
93% AIDS
43% immunosuppressed
71% on cART
HIV disease stage, VL, CD4 count, nadir CD4 count NR / NP Impairment rate:
Modified American Academy of Neurology criteria (1991):
57% normal
16% ANI
16% MCMD
10% HAD
HDS impairment rate:
42.96% / Cross-sectional
HIV+ scores normed against HIV- controls
Criterion validity indexes
Cutoff ≤10
Overall:
17.2% sensitivity
93.5% specificity
66.7% PPP
60.0 NPP
3.0 OR
ANI
0% sensitivity
93.5% specificity 72.7% PPP
76.7% NPP
3.0 OR
MCMD
22.7% sensitivity 93.5% specificity 50% PPP
80.9% NPP
4.2 OR
HAD
35.7% sensitivity 93.7% specificity 50% PPP
88.9% NPP, 8.0 OR / HIV disease stage, VL, CD4 count, NR
Large sample sizes
Comprehensive reporting of criterion validity indexes that included degrees of HAND severity (ANI, MCMD, HAD), and also for demographically adjusted T-scores in addition to standard raw cut off
Construct validity of screen NR

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Reference / Screening Measure / NP Gold Standard / Exclusion Criteria / Sample size, Population, Country Location / Sample Demographics
Mean years (SD) / HIV+ Sample Characteristics
Mean (SD) / Impairment Classification Criteria and Rate / Design, Analysis, Main Findings / Strengths and Limitations
Bottiggi, Chang, Schmitt, Avison, Mootoor, Nath, et al. (2007).
The HIV dementia scale: Predictive power in mild dementia and HAART / Paper & pen:
HDS / Paper & pen:
NART
WAIS-III Short Form
Grooved Pegboard
Finger Oscillation
Timed Gait
Ruff 2 & 7
TMTA
SDMT
Figure Memory Learning Test
CWT
Verbal Fluency
TMTB
Computerised:
CalCAP
Basic Choice Reaction Time,
Sequential Reaction Time,
Pursuit-Rotor Learning / CNS OI
Space occupying lesions
neurological disorder diabetes,
hepatic and
renal dysfunction substance abuse ≤ 6 months / HIV clinics
American
46 HIV+ / 88% Caucasian
87% male
NART=105 (11)
Age =38.5 (7.4)
Education = 13.5 (2.6)
Comorbidities NR / 46% currently on cART, mean duration =14 months (20.8)
AIDS, disease duration, CD4 cell count, VL, NR / Impairment rate based on MSK classification:
47.8% Normal (MSK=0)
52.2% Subclinical or abnormal (MSK = 0.5-2)
Severe impairment:
Overall z-score ≤-2SD
Moderate impairment:
z-score of ≤-2SD on ≥2 NP tests
Mild impairment:
z-score of ≤-1SD on 1 NP tests, no self-reported functional/emotional decline
NP impairment rate NR / Cross-sectional
Criterion validity indexes
Only NP tests: GP, CODf, TMTA, RAVLT, TMTB, Verbal Fluency were used in analysis
Cutoff ≤ 10
Severe impairment:
36% sensitivity 94% specificity 71% PPP
77% NPP
R = 0.38
kappa =0.34
Moderate impairment:
57% sensitivity 84% specificity 62% PPP
82% NPP
R = 0.42
kappa =0.42
Mild impairment:
93% sensitivity
38% specificity
39% PPP
92% NPP
R = 0.31
kappa=0.22 / Small sample size
No HIV- control group
Comorbiditie, AIDS, disease duration, CD4 cell count, VL, NR
NP impairment rate NR
Criterion validity indexes reported for only a subset of NP tests (n =8)
Reported criterion validity for varying degrees of impairment
Construct validity of screen NR

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