The Birthday Party Test (BPT): A new picture description test to support the assessment of simultanagnosia in patients with acquired brain injury

Figures & data

Figure 1. Flow chart regarding participant selection.

Table 1. Characteristics of participants.

	Healthy participants (Total N = 194)		Patients with ABI (Total N = 502)
	N		N		p-Value
Age in years, mean (SD)	194	60.30 (13.76)	502	60.77 (14.32)	.694^h
Gender, N female (%)	194	121 (62.37)	502	232 (46.20)	<.001^i^,*
Handedness, N right (%)	194	168 (86.60)	495	445 (88.60)	.011^i^,*
Education^a, mean (SD)	194	5.61 (0.81)	496	5.12 (1.17)	<.001^j^,*
Etiology, N (%)			502
CVA				329 (65.5)
CVA nos				32 (9.7)
iCVA				250 (76.0)
hCVA				37 (11.2)
i + hCVA				10 (3.0)
Side of lesion^b			329	127/107/34/61
TBI				31 (6.2)
Tumor				27 (5.4)
Parkinson’s disease				20 (4.0)
MS				27 (5.4)
Multiple neurological etiologies				22 (4.4)
Other–single neurological etiology^c				35 (7.0)
Unclassified^d				11 (2.2)
Time since diagnosis in months, median (range)^e			458	6 (0–469)
Visual field defect, N yes (%)^f			386	275 (71.2)
Impaired contrast sensitivity, N (%)^g			395	13 (3.3)

CVA nos: cerebral vascular accident not otherwise specified; iCVA: ischemic cerebral vascular accident; hCVA: hemorrhagic cerebral vascular accident; i + hCVA: ischemic and hemorrhagic cerebral vascular accident; TBI: traumatic brain injury; MS: multiple sclerosis.

^a Highest completed education according to Verhage (1965) ranging from 1 (<6 years of primary education), 4 (less than four years of lower secondary education) to 7 (university degree).

^b Restricted to patients with CVA; right/left/bilateral/unknown.

^c Single etiology other than the ones specified, e.g. posterior cortical atrophy, subarachnoid hemorrhage.

^d Diagnosis unknown at time of referral.

^e In case of multiple neurological disorders, time in months since most recent diagnosis.

^f An absolute binocular visual field defect within 30 degrees from the center.

^g Impaired contrast sensitivity (Log) <1.40.

^h t-Test for comparisons of means.

ⁱ χ²-test for nominal data.

^j Mann-Whitney for ordinal data.

* Significant at p < .05.

Figure 2. The BPT (reduced size).

Figure 3. Distribution of scores on NoA-BPT for healthy individuals (n = 194) and patients with ABI (n = 502).

Table 2. Test performance of patients with ABI and healthy participants.

	N	Min	Max	Median	Mean	SD
Healthy participants (n = 194)
Cookie Theft Picture
Number of persons	194	1	4	4.0	3.48	0.56
Number of spaces	194	0	2	2.0	1.69	0.57
Number of objects	194	3	11	9.0	8.38	2.02
Number of actions/relations	194	2	7	5.0	5.06	0.97
Total score	194	10	24	19.0	18.61	2.82
Time to complete in seconds	193	17.0	369.0	70.0	76.26	39.52
Birthday Party Test
Number of persons/animals	194	3	9	8.0	7.78	1.52
Number of objects	194	2	18	12.0	11.42	3.99
Number of actions/relations	194	1	12	7.0	7.29	1.94
Total score	194	7	37	27.0	26.49	5.71
Time to complete in seconds	193	26.0	272.0	77.0	87.96	43.09
Patients with ABI (n = 502)
Birthday Party Test
Number of persons/animals	502	0	9	9.0	7.69	2.09
Number of objects	502	0	18	12.0	11.17	4.39
Number of actions/relations	502	0	13	7.0	7.02	2.61
Total score	502	6	40	27.0	25.88	7.12
Time to complete in seconds	502	38.0	1192.4	132.0	150.8	83.4

Table 3. Spearman correlation coefficients between the NoA-BPT and various descriptive and clinical characteristics of healthy individuals and patients with ABI.

	NoA-BPT
	N	r	p
Healthy participants
Age	194	–0.127	.077
Gender	194	0.068	.344
Education	194	0.229	.001*
NoA Cookie Theft Picture	194	0.199	.005*
Patients with ABI
Age	502	–0.195	<.001*
Gender	502	0.050	.265
Education	496	0.263	<.001*
Contrast sensitivity^a	395	–0.034	.496
Visual field defects^b	386	–0.147	.004*
Clinical Judgment^c	436	–0.502	<.001*

NoA: Number of actions.

^a Impaired ((Log) <1.40) or not impaired contrast sensitivity.

^b Presence or absence of an absolute binocular visual field defect within 30 degrees from the center.

^c Clinical evaluation of simultanagnosia on a four-point scale.

* Significant at p < .01.

Table 4. Patients with ABI with a NoA score below the cutoff on the BPT and likely having simultanagnosia based on clinical judgment.

	NoA		Clinical judgment		NoA and clinical judgment
Etiology	Total N	N below cutoff (%)^a	Total N	N with likely simultanagnosia (%)^b	Total N	N below cutoff and likely simultanagnosia (%)^c
CVA	329	28 (8.5)	290	15 (5.2)	322	9 (2.8)
TBI	31	1 (3.2)	25	1 (4.0)	31	0 (0.0)
Tumor	27	0 (0.0)	21	1 (4.8)	27	0 (0.0)
Parkinson’s disease	20	2 (10.0)	17	1 (5.9)	20	1 (5.0)
MS	27	0 (0.0)	24	0 (0.0)	27	0 (0.0)
Multiple etiologies	22	4 (18.2)	17	2 (11.8)	21	2 (9.5)
Other	35	5 (14.3)	32	7 (21.9)	35	4 (11.4)
Unclassified	11	2 (18.2)	10	1 (10.0)	11	1 (9.1)
Total group	502	42 (8.4)	436	28 (6.4)	494	17 (3.4)

NoA: Number of actions; CVA: cerebral vascular accident; TBI: traumatic brain injury; MS: multiple sclerosis.

^a Number of patients with a score below the cutoff (≤ 3) on number of actions, representing a score equally or lower than 2 SD below the mean of healthy participants (2th percentile).

^b Number of patients with likely/very likely simultanagnosia according to clinical judgment.

^c Number of patients with both a score below the cutoff (≤ 3) on number of actions and likely/very likely simultanagnosia according to clinical judgment.

Table 5. Characteristics of healthy controls (HC), patients with ABI unlikely having simultanagnosia (NoSim) and patients with ABI likely having simultanagnosia (Sim).

	HC (N = 56)		NoSim (N = 56)		Sim (N = 28)		p-Value
	N		N		N
Age in years, mean (SD)	56	67.5 (9.3)	56	66.4 (10.0)	28	67.3 (9.5)	.820^e
Gender, N female (%)	56	30 (53.6)	56	24 (42.9)	28	13 (46.4)	.518^f
Education^a, mean (SD)	56	5.4 (0.9)	56	5.1 (1.0)	27	5.1 (1.2)	.296^g
Visual field defect, N (%)^b			39	28 (71.8)	21	17 (81.0)	.438^h
Time since diagnosis in months, median (range)^c			52	6.0 (0–285)	26	7.5 (3–67)	.079^e
Cause of ABI^d			56	30/2/2/2/4/14/2	28	15/1/1/1/2/7/1

HC: healthy controls; NoSim: patients with ABI with unlikely/very unlikely simultanagnosia; Sim: patients with ABI with likely/very likely simultanagnosia.

^a Highest completed education according to Verhage (1965) ranging from 1 (less than 6 years of primary education), 4 (less than four years of lower secondary education) to 7 (university degree).

^b Presence of an absolute binocular visual field defect within 30 degrees from the center.

^c In case of multiple neurological disorders, time in months since most recent diagnosis.

^d CVA/TBI/Tumor/Parkinson/Multiple etiologies/Other/Unclassified.

^e ANOVA/t-Test for comparisons of means.

^f χ²-test for nominal data.

^g Kruskal-Wallis for ordinal data.

^h Mann-Whitney for ordinal data.

Table 6. Group comparisons between healthy controls (HC), patients with ABI unlikely having simultanagnosia (NoSim) and patients with ABI likely having simultanagnosia (Sim) with regard to their performance on the BPT.

					Pairwise comparisons^b
	HC (n = 56)	NoSim (n = 56)	Sim (n = 28)	Omnibus test^a	Sim vs. HC		Sim vs. NoSim		HC vs. NoSim
BPT variable	M (SD)	M (SD)	M (SD)	H (df ), p	Z, p	Cohen’s r	Z, p	Cohen’s r	Z, p	Cohen’s r
Number of persons/ animals	7.54 (1.49)	7.84 (1.84)	7.07 (1.76)	8.58 (2), 0.014	–	–	–	–	–	–
Number of objects	10.68 (3.89)	11.16 (4.01)	7.89 (4.27)	10.89 (2), 0.004*	2.75, 0.006**	0.300	3.19, 0.001**	0.348	.54, .586	0.051
Number of actions/ relations	7.30 (1.75)	7.02 (2.15)	2.96 (2.32)	47.68 (2), < 0.001*	6.67, <0.001**	0.728	5.77, <0.001**	0.630	1.10, .270	0.104
Total score	25.52 (5.22)	26.02 (6.00)	17.93 (6.61)	29.20 (2), < 0.001*	4.77, <0.001**	0.520	5.07, <0.001**	0.553	.37, .713	0.035
Time to complete in seconds	87.53 (44.25)	152.95 (68.91)	275.54 (208.73)	65.82 (2), < 0.001*	7.77, <0.001**	0.853	3.41, 0.001**	0.372	5.34, <0.001**	0.507
Impairment on number of actions/relations, N (%)^c	–	2 (3.6)	17 (60.7)	–	–	–	–	–	–	–

HC: healthy controls; NoSim: patients with ABI with unlikely/very unlikely simultanagnosia; Sim: patients with ABI with likely/very likely simultanagnosia.

^a Kruskal-Wallis test.

^b Dunn’s post hoc test.

^c Number of patients with a score below the cutoff (≤3) on number of actions, representing a score equally or lower than 2 SD below the mean of healthy participants (2th percentile).

* Significant at Bonferroni corrected significance level of 0.05/5 = 0.01. **Significant at Bonferroni corrected significance level of 0.05/3 = 0.017.

Figure 4. Receiver operating characteristics curve indicating the correspondence between the BPT number of actions (NoA) and the assessor’s clinical judgment of patients with ABI likely (n = 28) and unlikely (n = 408) suffering from simultanagnosia.

Table 7. Classification statistics for the identification of patients with likely simultanagnosia for various cutoffs of NoA on the BPT.

Cutoff	Sensitivity	Specificity
≤2	46.4	98.8
≤3	60.7	95.8
≤4	78.6	90.4
≤5	85.7	80.1
≤6	92.9	65.9
≤7	96.4	48.3

NoA: Number of actions.

Verhage, F. (1965). Intelligence and age in a dutch sample. Human Development, 8(4), 238–245. https://doi.org/https://doi.org/10.1159/000270308

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