Chedid and Stephan ﻿Language Testing in Asia
(2024) 14:25
https://doi.org/10.1186/s40468-024-00294-0

Language Testing in Asia

Open Access

RESEARCH

Adaptation and norm determinationof the Boston Naming Test for healthy Lebanese
adults aged between 50 and 88 years
Georges Chedid1,2*   and Michele Stephan2*Correspondence:
georgeshchedid@gmail.com
1

American University of Kuwait,
Salmiya, Kuwait
2
Holy Spirit University, Kaslik,
Lebanon

Abstract
The Boston Naming Test is a well-known neuropsychological test widely used to evaluate linguistic abilities, encompassing object naming and word retrieval in subjects representing various clinical pathologies. Our study has two main stages: (1) a pilot study
aimed at adapting the BNT to the linguistic and cultural particularities of Lebanese society and (2) norm determination for the Lebanese version of the BNT through the analysis of participants’ responses. The primary goal of this study is to develop a Lebanese version of the BNT comprising 60 images adapted to the Lebanese language
and culture. This version is based on normative data derived from healthy Lebanese
adults aged between 50 and 88 years. The study seeks to assess the influence of age,gender, and education level on the naming performance of participants. In the pilot
study, 103 Lebanese volunteers participated, while the normative study involved 280
healthy volunteers aged between 50 and 88 years. Three screening tests—Montreal
Cognitive Assessment (MOCA), Language Experience and Proficiency Questionnaire(LEAP-Q), and Geriatric Depression Scale 15-item (GDS)—were administered to selectparticipants meeting inclusion criteria. The findings revealed a statistically significant
effect of age and education level on the BNT (Lebanese version) total score. The total
score decreased with age and increased with education. However, the effect of gender
was not significant, a result confirmed by the generalized linear model. This study successfully produced a Lebanese version of the BNT comparable to the original English
version. Additionally, it provided normative data crucial for evaluating naming ability,
word retrieval, and detecting potential disorders associated with aging.
Keywords: Boston Naming Test (BNT), Adaptation, Norm determination,
Neuropsychological tests, Object naming, Word retrieval, Aging

Introduction
The Boston Naming Test (BNT) serves as a widely employed neuropsychological assessment tool specifically designed for evaluating language proficiency, encompassing object
naming, and word retrieval capabilities (Kaplan et al., 1983; Soylu & Cangöz, 2018). Its
widespread application in clinical settings and scientific investigations is attributed to its
simplicity and heightened sensitivity in identifying language impairments across diverse
age groups, including children, adults, and the elderly, who present with various clinical© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permitsuse, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original
author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third
party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or
exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://
creativecommons.org/licenses/by/4.0/.

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conditions such as communication disorders, aphasia, dementia, and brain lesions (Soylu& Cangöz, 2018; Thomas et al., 2019; Vestito et al., 2021).
The BNT was initially designed for the American English-speaking population (Kaplan
et al., 1983). It consists of a set of 60 black and white line drawings of different objects.
These objects vary in difficulty, ranging from easily recognizable objects, such as “house”,“bed,” and “toothbrush”, to more complex and less familiar objects, such as “tripod”, “protractor,” and “abacus” (Kaplan et al., 1983). Then, several adaptations were created inorder to be used in different languages and cultures, such as Italian (Vestito et al., 2021);
Chinese (Li, Y. et al., 2022; Cheung, Cheung,& Chan, 2004); Spanish in Spain (PeñaCasanova et al., 2009); Spanish in Argentina (Allegri et al., 1997; Serrano et al., 2001);
French–Canadian (Roberts & Doucet, 2011); Portuguese (Miotto et al., 2010); Greek(Patricacou, 2007); English in New Zealand (Barker-Collo, 2001); English in Australia(Cruise, Worrall, & Hickson, 2000); Korean (Kim & Na, 1999); and Dutch (Mariën et al.,1998). However, there is currently no version standardized to the Arab world that aligns
with the cultural nuances and semantic intricacies specific to the Lebanese population.
Various countries have employed several methods to translate and adapt the BNT for
use in their respective linguistic and cultural contexts. Some have implemented minor
modifications, such as changing object names to align with the target culture, whileothers have undergone more significant changes (Roberts & Doucet, 2011; Thomas,
2019). In the Swedish version, for instance, the drawings remained unchanged, but thesequence in which they were presented was modified (Tallberg, 2005). Other adaptations involve replacing original test items with culturally relevant alternatives belonging
to the same semantic category; for instance, the substitution of the American-centric“pretzel” with a culturally familiar food in some versions (Patricacou, 2007; Cruise, Worrall, & Hickson, 2000). Notably, the Brazilian adaptation of the BNT involved replacing
20 of the original 60 items with culturally relevant alternatives. These replacements were
carefully chosen based on their frequency, ambiguity, familiarity, and similarity to theoriginal picture. For instance, “pretzel” was replaced with “bolo” (cake), a more familiar
food, while “rhinoceros” became “elefante” (elephant), a more commonly known animal,and “Pão de Açúcar” (Sugarloaf ) replaced the mythical “sphinx” (Miotto et al., 2010).
The Greek adaptation of the BNT replaced four items: “pretzel” with “a kind of cake,”“door knocker” with “mailbox,” “stethoscope” with “blood pressure instrument,” and“scroll” with “ancient Greek column” to better reflect the cultural context (Patricacou,
2007). Finally, the Korean adaptation of the BNT by Kim and Na (1999) involved replacing 49 of the 60 pictures, which can again be categorized as a substantial change.
Demographic variables such as age, gender, and education have been investigated
due to their potential impact on the performance of the BNT, irrespective of neurological conditions (Neil et al., 1995; Grima & Franklin, 2016). Research on the relationshipbetween age and Boston Naming Test (BNT) scores reveals inconsistent findings; while
numerous studies suggest a modest decrease in naming ability with advanced age, particularly in those aged 80 and above, some studies show no significant age effects oreven better performance by older adults (Soylu & Cangöz, 2018; Thomas, 2019; Tallberg, 2005). These discrepancies are attributed to variations in research design andsample characteristics (Grima & Franklin, 2016). Similar inconsistent findings exist
regarding the effect of gender on naming performance. Some studies suggest that men

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perform slightly better than women, while others find no difference between the sexes(Patricacou, 2007; Tallberg, 2005). This discrepancy has been explained in some studies
by suggesting that items presented in the BNT are more familiar to men than women(Thomas, 2019; Olabarrieta-Landa et al., 2015). Education has also been shown to affectnaming performance (Nour et al., 2021). Many studies have found a positive correlation between naming ability and the number of years of education attained. People withfewer years of education tend to have lower scores, especially those with less than 12
years of education (Hawkins & Bender, 2002; Neils et al., 1995).
Naming disorders are prevalent and extend beyond individuals with brain injuries
or advanced age; they manifest in young adults without overt pathological indications.
Anomia, characterized by the inability to name objects and the phenomenon of having
a “word on the tip of the tongue” represent common facets of these disorders (Burke& Shafto, 2004). This cognitive deficit can instigate frustration and discontent among
affected individuals, potentially serving as an early indicator of more severe neurodegenerative conditions, including Alzheimer’s disease, aphasia, and dementia (Burke &Shafto, 2004). Therefore, it is imperative to employ a diagnostic test that assesses objectnaming proficiency in both normative adults and those with pathological disorders.
Lebanon exhibits high dementia rates among individuals aged 60 and above (Phunget al., 2017). The United Nations projects that the Lebanese population aged 65 andolder will constitute 31.2% by 2050 (United Nations, 2017). The prevalence of naming
disorders in Lebanon aligns with global patterns, emphasizing the necessity of employing a validated tool like the BNT, commonly used for identifying such disorders. With
the cultural and linguistic variations, caution is required in the indiscriminate application of such instruments. Given the absence of standardized scoring norms for the BNT
in Lebanon, our focus is on establishing its applicability for the adult Arabic-speaking
Lebanese population.
The aims of the current study were (1) to describe the development of an adapted version of the BNT suitable for Lebanese Arabic speakers using a sample of healthy elderly
Lebanese individuals and (2) to investigate the effects of age, education, and gender on
the scores of the adapted version of the BNT as applied to Lebanese Arabic speakers.

MethodThe adaptation and standardization of the BNT for the Lebanese language and culture
were carried out through a three-phase approach, utilizing methodologies previously
employed in other studies (Grima & Franklin, 2016; Soylu & Cangöz, 2018). It received
approval from the Ethical Committee at the Hospital of Notre Dame de Secours in Byblos, Lebanon, on December 10, 2020. It consists of three main phases:
The first phase: translation

The first phase consists of the translation of the 60 items of the original BNT from English to Arabic by using two standard dictionaries (Ba’labakki, 2004; Reverso Dictionaryn.d.). This translation allowed us to determine the Modern Standard Arabic (MSA) naming for each item. Based on Classical Arabic, MSA is the official written language used ingovernment affairs, news, broadcast media, books, and education (Ibrahim, 2009; Kwaik
et al., 2018). However, Arabic languages are characterized by diglossia: while MSA isPage 3 of 26

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their common means of formal communication, Arabic dialects are the medium of oral
communication within each community (Kwaik et al., 2018). MSA shares with LebaneseArabic a considerable number of lexical, semantic, syntactic, and morphological features, but several differences emerge as well (Boudelaa & Marslen-Wilson, 2013). Therefore, it was essential to check in the second phase that the Lebanese speakers agree on
these translations and use them frequently.
Second phase: pilot study

Different populations may use more than one word to refer to the same object depending on the particular cultural characteristics. Hence, all the possible Lebanese responses
for each item of the BNT were collected even if they differed from the translated ones.
A pilot study was conducted on a sample of volunteers from a Lebanese population to
help determine the name agreement for each image from the original BNT and, from
that, to elaborate an adapted version that takes into consideration the Lebanese dialect
and culture.
Participants of the pilot study

This study was conducted among a sample of Lebanese volunteers of different ages, levels of education, and gender in alignment with previous studies (Patricacou et al., 2007;
Miotto et al., 2010; Grima & Franklin, 2016; Soylu & Cangöz, 2018). All participants
reside in Lebanon and speak Lebanese Arabic as their native language.
A total of 103 volunteers participated in the study, of which there were 63
women (61.2%) and 40 men (38.8%). The range of age was between 18 and 86 years(mean = 35.54; standard deviation = 1.8). The level of education was divided into fourgroups: primary level (12.6%) with basic education, supplementary education till grade
9, secondary level (16.5%) with high school education from grade 10 to grade 12, university level (67%) with a bachelor’s or master’s degree, and doctorate level (3.9%).
Procedure

The pilot study was conducted by asking participants to name each of the 60 picturesof the BNT in Arabic as quickly as possible (with a limit of 20 s) using the word thatmost spontaneously came to their mind. No semantic or phonemic cues were given in
the pilot study as there is no current Lebanese version to base the cueing upon.
Responses for each image of the BNT were entered in Excel to be analyzed. Nameagreements, possible alternative synonyms, and lexical variations were determined foreach image based on the responses given by the participants (see Table 1).
Development of the Lebanese version of the BNTIn order to analyze and adapt the BNT to Lebanese–Arabic, all responses provided by
the participants were subdivided into two categories, and each of these categories was
further subdivided into several more subcategories.
The first category contains all the responses that are accepted based on their alignment with the following:

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Table 1 Analysis of the frequency rate of responses to the 60 items of the original BNT
Correct
responses
Items

No

NA

Bed

103 88

Tree
PencilIncorrect responses

Syn NAR Omi WP VM ICE SOE P

Total
correct
response

Total errors Difficultyindex (p)

15

0

0

0

0

0

0

0

103

0

100

103 103 0

0

0

0

0

0

0

0

103

0

100

103 103 0

0

0

0

0

0

0

0

103

0

100

House

103 86

8

0

0

0

0

7

2

0

94

9

91.26

Whistle103 103 0

0

0

0

0

0

0

0

103

0

100

Scissors

103 103 0

0

0

0

0

0

0

0

103

0

100

Comb

103 97

0

0

0

0

0

6

0

0

97

6

94.17

Flower103 76

26

0

0

0

0

1

0

0

102

1

99.03

Saw

103 103 0

0

0

0

0

0

0

0

103

0

100

Toothbrush

103 103 0

0

0

0

0

0

0

0

103

0

100

Helicopter

103 80

80a

0

0

0

0

7

0

98

7

95.15

Broom

103 103 0

0

0

0

0

0

0

0

103

0

100

Octopus103 94

0

5

1

0

1

2

0

0

99

4

96.12

Mushroom

103 88

0

13

2

0

0

0

0

0

101

2

98.06

Hanger103 101 2

0

0

0

0

0

0

0

103

0

100

Wheelchair

103 41

44

10

0

0

0

7

0

1

95

8

92.23

Camel

103 102 0

1

0

0

0

0

0

0

103

0

100

Mask

103 47

45

47a

0

0

1

4

6

0

92

11

89.32

Pretzel**103 27

8

13

3

0

37

12

3

0

48

55

46.6

Bench

103 71

31

30

0

0

0

1

0

0

102

1

99.03

Racquet103 64

34

64a

0

0

0

2

1

2

98

5

95.15

Snail

103 85

11

7

0

0

0

0

0

0

103

0

100

Volcano103 85

0

14

0

0

2

1

0

1

99

4

96.12

Sea horse**

103 35

10

1

8

0

6

20

19

4

46

57

44.66

Dart

103 68

19

5

7

0

2

1

0

1

92

11

89.32

Canoe

103 65

15

9

0

0

0

14

0

0

89

14

86.41

Globe

103 97

2

2

0

0

0

2

0

0

101

2

98.06

Wreath**103 32

0

2

8

0

2

17

37

3

34

69

37.86

Beaver**

103 8

0

14

8

0

0

69

1

3

22

81

21.36

Harmonica** 103 43

0

43a

10

0

5

16

20

9

43

60

41.74

Rhinoceros

103 88

0

6

3

0

0

6

0

0

94

9

91.26

Acorn

103 93

0

1

0

0

1

8

0

0

94

9

91.26

Igloo**

103 25

0

17

13

0

15

16

0

18 42

61

40.78

Stilts**

103 8

0

5

15

7

2

58

1

7

13

88

12.62

Dominoes**

103 47

0

47a

1

0

0

53

2

0

47

56

45.63

Cactus103 83

0

14

0

0

0

5

0

1

97

6

94.17

Escalator

103 83

14

4

0

0

1

0

1

0

101

2

98.06

Harp**

103 29

0

20

10

0

1

7

35

1

49

54

47.57

Hammock

103 83

3

15

0

1

0

0

0

1

101

2

98.06

Knocker**

103 26

0

0

5

22

1

42

0

7

26

77

25.24

Pelican

103 56

0

8

4

0

0

20

14

1

64

39

62.14

Stethoscope 103 81

0

6

0

0

0

0

0

16 87

16

84.47

Pyramid

103 97

0

1

0

0

2

2

1

0

98

5

95.15

Muzzle**

103 5

0

6

7

21

0

50

0

14 11

92

10.68

Unicorn**

103 10

0

29

1

0

0

44

19

0

39

64

37.86

Funnel

103 96

0

2

0

0

0

3

0

2

98

5

95.15

18

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Table 1 (continued)
Correct
responses
Items

No

NA

Incorrect responses

Syn NAR Omi WP VM ICE SOE P

Total
correct
response

Total errors Difficultyindex (p)Accordion

103 73

73a

5

0

0

4

20

1

73

30

70.87

Noose

103 102 0

0

0

0

1

0

0

0

102

1

99.03

Asparagus

103 75

0

9

4

0

9

4

2

0

84

19

81.55

Compass

103 50

0

40

4

0

1

3

0

5

90

13

87.38

Latch

103 75

21

1

3

0

1

1

0

1

97

6

94.17

Tripod**

103 8

0

20

11

0

12

47

2

3

28

75

27.18

Scroll103 61

27

6

4

0

0

1

3

1

94

9

91.26

Tongs

103 97

0

1

4

0

0

0

0

1

98

5

95.15

Sphinx103 56

0

9

1

0

0

22

9

6

65

38

63.11

Yoke**

103 18

0

0

19

2

1

35

0

28 18

85

17.48

Trellis**

103 0

0

0

12

5

1

82

0

3

0

103

0

Palette**103 15

0

19

1

0

0

47

11

10 34

69

37.86

Protractor**

103 36

7

36a

4

0

0

51

0

5

43

60

41.75

Abacus**

103 4

0

4

19

0

16

41

1

18 8

95

7.77

0

NO number of responses, NA name agreement or target word, Syn synonyms, NAR non-Arabic responses, Omi omission,
WP wrong part, VM visual misperception, ICE intra-categorial errors, SOE superordinated errors, P periphrases, total correct
responses, total errors, p difficulty index**anext to the items designates the words that have been substituted

Target word is Arabized– The name agreement (NA): a picture that prompts a consistent name from the
majority of participants is considered to have high NA, whereas a picture that elicits
multiple different names is considered to have low NA (Boukadi et al., 2016). For
example, more than 80% of the participants agreed on naming « ‫ »تخت‬the image of“bed”.
– Synonyms or alternatives are defined as different correct names given to the sameimage that share the same meaning. For example, the image “bed” received anothervalid common name, which is “‫”سرير‬. The latter is the word found in the dictionary
when translated in its MSA form.
– Answers that were correct according to the image but were named using their foreign origin (Arabicized) can be attributed to the characteristic of bilingualism, which
is prevalent in Lebanese society. For example, the word “helicopter” was named “helicopter” by 78% of the participants (80 out of 103).
The second category contains all responses with errors, where the response was nonconcordant or nonspecific to the target name of the image that had been presented.
The incorrect responses or the responses with errors were divided into five categories. The five categories were inspired by previous studies, particularly the Swedish,Turkish, and Dutch versions of the test (Mariën et al., 1998; Soylu & Cangöz, 2018;
Tallberg, 2005).

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1- Omission: no response or “I don’t know.”
2- Visuo-perspective errors or visual misperception: for example, the picture of a “pretzel” was misperceived as a “rope” (‫ )حبلة‬or “snake” (‫)حية‬.
3- Intra-categorial errors or side-ordinated words: for example, giving the answer of“squirrel” (‫ )سنجاب‬or “rat” (‫ )فارا‬for the image “Beaver.”4- Superordinated word errors: for example, instead of “harp,” they said, “musicalinstrument” (‫)الة موسيقية‬, or for “sea horse,” they said, “animal” (‫)حيوان‬.
5- Periphrases: for example, instead of “muzzle,” participants described the image using
periphrases such as “a thing to prevent the dog from biting” « ‫شي بحطوا للكلب حتى ما‬‫يعض‬.»
The analysis was based on the frequency rate of responses given by the 103 participants to each of the 60 original items of the BNT. This was done by calculating thetotal score of the correct answers for each image (the target word or Name agreement, synonym answers, and responses named using their foreign origin (Arabicizednames)) and the total of answers with errors (visual misperception, intra-category
errors, superordinated errors, periphrases responses, wrong part, no responses, or“don’t know”) (see Table 1).
To perform a careful selection of the items to be included in the Arabic version of
the BNT, the selection was based on the analyses of the difficulty index (p). The difficulty index (p) is equal to the sum of correct responses divided by the total number ofparticipants. It indicates how much each image was successfully recognized, in otherwords, correctly named. It varies from 0 to 1; 1 meaning that the image was named
correctly in 100% of cases and 0.5 meaning it was correctly named in 50% of cases.
If the image took a value smaller than 0.5, it was eliminated and replaced by anotherimage more accessible to the Lebanese population according to previous studies who
used the same criterion for screening (Pedraza et al., 2011; Soylu & Cangöz, 2018)(see Table 1).
The image that had the most visual–perceptual error was the image of “pretzel” which
is a familiar food in the USA, unlike Lebanon. The participants saw this image as a snake
or a rope due to the shape and lack of exposure to this concept. The image that had themost intra-categorical errors was the image of an “abacus”. The participants mistook theobject for a toy. In addition, the word “abacus” does not have an equivalent in Arabic, so
participants had to describe it in order to name it. Also, the “beaver” had a high rate of
intra-categorial error, as the participants mistook this object for a “squirrel” or a “mouse”.
The naming of this item respects the semantic category of the concept presented but
remains far from the correct name. The image that had the most periphrastic responses
was “yoke”. The participants recognized the object and its mode of use, but the majorityof them were unable to find its name. As a result, they had to use periphrases in order toname it. The image that had the most superordinated responses was “wreath”. Participants had difficulty identifying the exact word, and instead referred to the image withgeneral terms such as “decoration,” "‫"زينة‬, or “a decorative object”. Also, for “harp” and“harmonica,” the participants gave these images the generic name of “musical instrument.” This is probably due to the fact that these two instruments are known in the West

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more than in the East where their use is very rare. These two instruments do not haveequivalent common names in Arabic.
In total, 18 pictures were eliminated because they did not receive enough name agreement (NA) from the participants, with a very high error rate. In order to replace thesewords with semantically similar ones with the same level of complexity and frequency, anumber of Lebanese words were selected from books, newspapers, and television, a procedure used before (Heaton et al., 2004; MacKay et al., 2005; Storms, Saerens, &De Deyn
2004; Tsang HL & Lee TM, 2003;). Afterwards, the images were replaced by others fromthe same semantic category ensuring that the word length, number of syllables, and phonemes were as similar as possible to the original item (see Tables 2 and 3). The substitution of images was as follows: pretzel to manouche “‫”منقوشة‬, sea horse to an alligator“‫”تمساح‬, wreath to chandelier “‫”تريا‬, beaver to hedgehog “‫”قنفذ‬, harmonica to flute “‫”مزمار‬,igloo to grotto” ‫”مغارة‬, stilts to clown “‫”مهرج‬, harp to zither “‫”القانون‬, knocker to kebbe pestle“‫”مدقة الكبة‬, muzzle to cage “‫”قفص‬, dominos to chess” ‫”شطرنج‬, unicorn to snowman “‫”رجل ثلج‬,tripod to binocular “‫”ناضور‬, yoke to saddle “‫”سرج‬, trellis to windmill “‫”طاحون‬, palette topaintbrush “‫”ريشة‬, protractor to compass” ‫”بوصلة‬, and abacus to pulley «‫»بكرة‬. To gather
lexical and semantic norms for the new items, we enlisted 37 participants aged between
20 and 35 years. The cohort comprised 19 men and 18 women, all possessing a minimum of 13 years of education. Following the methodology outlined by Patricacou et al.
(2007), these individuals were selected based on their age and educational background,
deemed conducive to proficient task performance. For the familiarity and subjective frequency norms, we followed the same procedure of Chedid et al. (2022) who collected
normative Lebanese Arabic data for 380 pictures. In the familiarity task, participants
were asked to rate the familiarity of the concept depicted by each picture based on how
common an object was in the language speaker’s realm of experience (Bonin et al., 2003;
Boukadi et al., 2016; Chedid et al., 2018). In the subjective frequency task, participants
were asked to estimate the frequency of use of each word in the written or spoken language (Desrochers & Thompson, 2009). The results obtained allowed us to reorganize
the items of the original BNT, as well as the newly replaced images. Adhering to theAmerican Standard order and psycholinguistic variables, items were organized from themost familiar, highest-frequency object to the least familiar, lowest-frequency counterpart. This method mirrors the procedure implemented for the Portuguese version of the
BNT (Patricacou, 2007). Thus, the Lebanese version of the BNT was created (seeTable 4) and was used for the norm determination study to investigate the effects of age,gender, and level of education on naming performance.
Third phase: norm determination of the Lebanese version of the BNT
Participants of this study

The sample of the norm determination study consists of 280 participants, all volunteers,
aged between 50 and 88 years (mean age = 68.57; SD = 10.77). They were recruited fromdifferent Lebanese villages covering different regions of Lebanon. All participants were
informed about the objectives of this study and signed a prior consent form. The sample consists of 138 women (49.3%) and 142 men (50.7%) in total, divided into four age
groups (group 1 = 50 to 59 years, group 2 = 60 to 69 years, group 3 = 70 to 79 years, andgroup 4 = 80 years and over) (Grima & Franklin, 2016; Mariën et al., 1998; Patricacou

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Table 2 Normative data for psycholinguistic variables in Lebanese Arabic for the 60 items of theoriginal BNT
LA intended LA model
name
name

Numberof letters

Number ofsyllables

Number ofphonemesNameagreement(%)

Frequency(mean)

Familiarity(mean)

Bed

‫تخت‬

‫تخت‬

3

1

4

85.43%

6.9

4.77

Tree

‫شجرة‬‫شجرة‬

4

3

6

100%

6.8

4.6

Pencil‫قلم‬‫قلم رصاص‬

3

2

5

100%

6.1

4.66

House

‫بَيْت‬‫بَيْت‬3

1

3

83.49%

5.87

4.61

Whistle‫صوفيرة‬‫صوفيرة‬

6

3

6

100%

3.54

3.6

Scissorsّ‫ْمقَص‬‫ُم ْشط‬

3

2

5

100%

4.9

3.88

Comb

ّ‫ْمقَص‬‫ُم ْشط‬3

1

4

94.17%

5.8

4.34

Flower-‫ زهرة‬-‫َورْ دَة‬‫َورْ دَة‬

4

2

5

73.68%

5.37

4.6

Saw

‫منشار‬‫منشار‬

5

2

6

100%

3.12

3.06

Toothbrush‫فرشاة االسنان‬‫فرشاة االسنان‬

12

5

-

100%

6.13

4.66

Helicopter‫طائرة عامودية‬‫هيليكوبتر‬

9

4

10

86.40%

2.72

3.3

Broom

‫سة‬
َ ‫مِ ْك ْن‬‫سة‬َ ‫مِ ْك ْن‬

5

3

6

100%

5.03

3.68

Octopus‫أخطبوط‬‫أخطبوط‬6

3

7

91.26%

2.01

2.5

Mushroom

‫فطر‬

‫فطر‬

3

2

5

85.43%

3.3

3.16

Hanger‫تَعْليقَة‬‫تَعْليقَة‬

6

3

6

99%

6.22

3.92

Wheelchair‫كرسي متحرك‬‫كرسي متحرك‬

9

6

-

39.80%

2.6

3.2

Camel

‫َج َمل‬‫قناع‬‫َج َمل‬‫ماسك‬

3

2

5

99%

2.14

2.77

4

2

5

45.60%

1.2

1.73

Pretzel‫َك ْعكَة‬2

6

26.20%--‫َم ْقعَ ْد‬‫مضرب‬‫َك ْعكَة‬‫َم ْقعَ ْد‬

5

Bench

4

2

6

68.90%

5.6

3.86‫راكيت‬5

2

6

62.10%

2.78

1.9

Mask

RacquetSnailَّ‫بزيقة‬َّ‫بزيقة‬5

3

7

82.50%

3.5

3.88

Volcano‫بركان‬‫بركان‬5

2

7

82.50%

1.37

1.93

Sea horse‫حصان البحر‬‫حصان البحر‬

9

4

-

33.98%

1.5

1.2

Dart

‫س ِهم‬َ‫س ِهم‬َ

3

2

4

66.00%

1.8

3.21

Canoe

- ‫ زورق‬-‫قارب‬‫شخطورة‬4

2

7

63.20%

2.6

3.44

Globe

‫ال ُك َرة األرْ ضيَّة‬‫ال ُك َرة األرْ ضيَّة‬

13

5

-

94.20%

2.5

2.13

Wreath‫اكليل‬‫اكليل‬5

2

5

31.06%

1.6

1.4

Beaver‫قندس‬‫سمور‬

4

2

6

7.80%

-

-

Harmonica‫هارمونيكا‬‫هارمونيكا‬

9

4

9

41.64%

1.48

2.04

Rhinoceros‫وحيد قرن‬‫وحيد قرن‬

7

4

-

85.40%

1.56

2.66

Acorn

‫بَلّوط‬‫بَلّوط‬4

2

5

90.30%

1.16

3.49

Igloo

‫بيت ثلج‬‫بيت ثلج‬6

3-

24.30%

1.46

1.27

Stilts‫ طويالت‬-‫ساق‬

‫ساق‬

4

1

3

7.70%

-

-

Dominoes‫دومينو‬‫دومينو‬6

3

6

45.63%

1.26

1.83

Cactus‫صبيّر‬‫صبيّر‬4

2

6

80.60%

2.49

2.03

Escalator‫درج كهربائي‬‫درج كهربائي‬

10

-

-

80.60%

3.05

2.51

Harp

‫قيثارة‬‫قيثارة‬6

3

6

28.20%

1.66

2.67

Hammock‫مرجوحة‬‫مرجوحة‬6

3

7

80.60%

3.24

3.12

Knocker‫مطرقة‬‫مقرعة‬5

3

7

25.20%

1.44

3.16

Pelican‫بجعة‬‫بجعة‬

3

2

6

54.40%

2.43

2.07

Stethoscope‫سماعة حكيم‬‫سماعة حكيم‬

8

5

-

78.70%

2.26

2.32

Pyramid

‫هرم‬

‫هرم‬

3

2

5

94.20%

1.01

3.01

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Table 2 (continued)

MuzzleLA intended LA model
name
name

Numberof letters

Number ofsyllables

Number ofphonemesNameagreement(%)

Frequency(mean)

Familiarity(mean)‫ لجم‬-‫لجام‬1.07

Unicorn‫ لجم‬-‫لجام‬

3

1

5

4.90%

1.17

‫حصان خرافي‬

-

-

-

14.60%--

Funnel‫قِمِ ع‬‫قِمِ ع‬3

2

5

93.20%

4.6

3.98

Accordion‫أكورديون‬‫أكورديون‬

8

4

10

74.11%

1.48

2.23

Noose

‫حبل المشنقة‬‫حبل المشنقة‬

10

1

4

99%

2.86

2.35

Asparagus‫ه َْليون‬‫ه َْليون‬

5

2

6

72.80%

3.27

2.37

Compass‫بيكار‬‫بيكار‬

5

2

5

49%

1.85

1.53

Latch

‫قفل‬

‫قفل‬

3

1

4

72.80%

3.96

4.07

Tripod-‫ثالثية االرجل‬

-

-

-

7.76%

-

-

Scroll‫فرمان‬‫رسالة‬5

3

7

59.20%

1.32

1.96

6

94.20%

5.6

3.6

54.36%

1.12

1.27

17.50%

1.24

1.03

Tongs

‫ملقط‬‫ملقط‬

4

2

Sphinx‫أبو الهول‬‫أبو الهول‬

8

3

Yoke

‫نير‬

‫نير‬

3

1

3

Trellis‫تعريشة‬‫سياج‬

42

5

14.60%

2.57

3.34

Palette‫لوحة‬‫صحن تلوين‬

4

2

-

14.56%

2.9

2.57

Protractor ‫منقلة‬Abacus‫طبلية تاج‬‫رابورتور‬

8

3

8

35%

2.38

2.07

‫طبلية تاج‬

-

-

-

3.90%

-

-

LA intended name: Lebanese Arabic intended name from dictionary translation; LA model name: the Lebanese Arabic
model is the actual name given by the majority of participants to the item presented in Lebanese Arabic; Name agreement(%) refers to the consistency with which different people agree on the name of an object depicted in an image indicating
how often a specific name is chosen for the image compared to all responses

et al., 2007; Roberts & Doucet, 2011; Slegers et al., 2018). They were recruited based on
three levels of education (primary, secondary, and university), and all participants had tomeet the inclusion criteria established by prior studies (Soylu & Cangöz, 2018; Slegers
et al., 2018; Grima & Franklin, 2016; Baerecke, 2013; Miotto et al., 2010; Patricacou et al.,2007; Tallberg, 2005; Mariën et al., 1998; Tombaugh & Hubley, 1997Welch et al.,1996):(1) born and residing in Lebanon; (2) speak Lebanese Arabic as their native language;(3) have no particular cognitive impairment, nor any visual, auditory, neurological disorder, or other problem that may disrupt naming abilities; (4) no current antidepressant,antiepileptic, or anxiolytic treatment; (5) no excessive alcohol consumption or history of
withdrawal; and (6) no drug consumption.
Moreover, three screening tests were applied to determine whether the participants were elderly adults with healthy cognitive functions and fit to participate in
the study. The first one was the Language Experience and Proficiency Questionnaire (LEAP-Q) in its standardized Arabic version. It collected data on the knowledge and the degree of mastery of our participants of the Arabic language as wellas other languages and allowed us to divide them into groups (Kaushanskaya et al.,2020). Participants who did not report using Arabic for at least 70% of their daily life
activities were excluded from our study. The second one is the Montreal Cognitive
Assessment (MoCA). This test was to assess mild cognitive dysfunctions: attention,
concentration, executive functions, memory, language, visuo-constructive abilities,
abstraction skills or conceptual thinking, calculation, and orientation (Nasreddine

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Table 3 Normative data for psycholinguistic variables in Lebanese Arabic for the newly replaced
items

PretzelManousheLA intended
name

LA modelname‫َك ْعكَة‬‫منقوشة‬‫َك ْعكَة‬‫منقوشة‬Number Numberof letters ofsyllables

Number of Frequency Familiarity
phonemes (mean)(mean)

5

2

6

-

-

6

3

7

4.83

3.94

Sea horse‫حصان البحر‬‫حصان البحر‬

-

4

-

1.5

1.2

Alligator‫تمساح‬‫تمساح‬

5

2

7

1.73

1.95

Wreath‫اكليل‬‫اكليل‬

5

2

5

1.6

1.4

Chandelier‫تريا‬‫تريا‬

5

2

6

3.34

2.24

Harmonica‫هارمونيكا‬‫هارمونيكا‬

9

4

9

1.48

2.04

Flute

‫مزمار‬‫مزمار‬

5

3

6

1.57

3.06

Igloo

‫بيت ثلج‬‫بيت ثلج‬

6

3

-

1.46

1.27

Cave/grotto‫مغارة‬‫مغارة‬

5

3

7

3.32

2.1

Dominos‫دومينو‬‫دومينو‬

5

3

6

1.26

1.83

Chess

‫شطرنج‬‫شطرنج‬

5

3

7

2.89

3.05

Stilts‫ طويالت‬-‫ساق‬

‫ساق‬

4

1

3

-

-

Clown

‫مهرج‬‫مهرج‬

4

3

6

1.67

2.51

Harp

‫قيثارة‬‫قيثارة‬

6

3

6

1.66

1.37

Zither‫القانون‬‫ قانون‬-‫القانون‬

7

2

6

2.04

1.53

Knocker‫مقرعة‬‫مقرعة‬5

3

7

Kebbe pestle ‫مدقة الكبة‬‫مدقة الكبة‬

-

-

1.75

1.67

Muzzle‫ لجم‬-‫لجام‬

-

3

1

5

1.17

1.07

Cage

‫قفص‬

‫قفص‬

3

2

5

2,27

3.26

Unicorn

-

-

-

-

-

-

-

Snowman‫رجل ثلج‬‫رجل ثلج‬

-

-

-

1.91

2.1

Tripod

-

-

-

-

-

-

-

Binocular‫ناضور‬‫ناضور‬

5

2

6

2.02

2.43

Yoke

‫نير‬

‫نير‬

3

1

3

1.24

1.03

Saddle

‫سرج‬

‫سرج‬

3

2

4

1.86

1.39

Trellis‫تعريشة‬

-

4

2

5

-

-

Windmill‫طاحون‬‫طاحون‬

5

2

7

2.07

1.75

Palette‫لوحة‬‫صحن تلوين‬

4

2

5

2.9

2.57

Paintbrush‫ريشة‬‫ريشة‬

4

2

5

3.27

2.48

3

8

2.38

2.07

5

2

7

2.2

1.4

Protractor‫منقلة‬‫رابورتور‬Compass‫بوصلة‬‫بوصلة‬Abacus‫طبلية تاج‬

-

-

-

-

-

-

Pulley‫بكرة‬‫بكرة‬

4

3

6

1.29

1.7

LA intended name: Lebanese Arabic intended name from dictionary translation; LA model name: the Lebanese Arabic namegiven by most participants in Lebanese Arabic

et al., 2005). The maximum score is 30 points. Participants who scored below 21
were excluded. The third test was the Geriatrics Depression Scale 15-item (GDS).
This scale was designed to screen older adults for depressive feelings and suicidal
intentions (Chaaya et al., 2008). Participants who received scores of 14 and abovefrom GDS were not included in the study. The scores of MOCA (27.16 ± 1.34) andGDS (2.70 ± 1.22) varied between 23 and 30, as well as 0 and 5, respectively. Sociodemographic characteristics along with the mean and standard deviation values forthe screening test scores have been described in Table 5.

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Table 4 The Lebanese version of the BNT with the sum of frequency and familiarity for each item
Items

Name in Arabic

S*

Items

Name in Arabic

S*

1

Bed

‫تخت‬

11.67

31

Racquet‫راكيت‬

5.02

2

Tree

‫شجرة‬

11.4

32

Cage

‫قفص‬

5.01

3

Toothbrush‫فرشاة االسنان‬

10.79

33

Dart

5.01

4

Pencil‫قلم رصاص‬‫س ِهم‬
َ

10.76

34

Camel

5

House

‫بَيْت‬

10.48

35

Globe

4.63

6

Hanger10.14

36

Binocular

Comb

10.14

37

Acorn

‫ناضور‬‫بَلّوط‬4.63

7‫ت َ ْعليقَة‬‫ُم ْشط‬‫ال ُك َرة األرْ ضيَّة‬8

Flower9.97

38

Stethoscope‫سماعة حكيم‬

4.58

9

Bench

‫َورْ دَة‬‫َم ْقعَ ْد‬

9.46

39

Cactus‫صبيّر‬

4.52

10

Tongs

9.2

40

Octopus‫أخطبوط‬4.51

11

Scissors‫ملقط‬
ّ‫ْمقَص‬8.78

41

Pelican‫بجعة‬

4.5

12

Manoushe

8.77

42

Flute

‫مزمار‬

4.4

13

Broom

‫منقوشة‬‫سة‬َ ‫مِ ْك ْن‬

8.71

43

Rhinoceros‫وحيد قرن‬

4.22

14

Funnel‫قِمِ ع‬

8.58

44

Noose

‫حبل المشنقة‬

4.21

15

Latch

8.03

45

Clown

‫مهرج‬

4.18

16

Snail

‫قفل‬
َّ
‫بزيقة‬7.38

46

Pyramid

‫هرم‬

4.02

17

Whistle‫صوفيرة‬7.14

47

Volcano‫بركان‬4.01

18

Mushroom

‫فطر‬

6.46

48

Snowman‫رجل ثلج‬

4.01

19

Hammock‫مرجوحة‬6.36

49

Kebbe pestle‫مدقة الكبة‬

3.94

20

Saw

‫منشار‬6.18

50

Windmill‫طاحون‬3.82

21

Helicopter‫هيليكوبتر‬

6.04

51

Accordion‫أكورديون‬

3.71

22

Wheelchair‫كرسي متحرك‬

6.02

52

Hedgehog‫قنفذ‬

3.7

23

Canoe

‫ شخطورة‬-‫قارب‬

6.1

53

Alligator‫تمساح‬

3.68

24

Chess

‫شطرنج‬5.94

54

Compass‫بوصلة‬3.6

25

Paintbrush

5.75

55

Zither‫القانون‬

3.57

26

Asparagus‫ريشة‬‫ه َْليون‬

5.64

56

Compass‫بيكار‬3.38

27

Chandelier‫تريا‬

5.58

57

Scroll‫فرمان‬-‫رسالة‬

3.28

28

Escalator‫درج كهربائي‬

5.56

58

Saddle

‫سرج‬

3.25

29

Cave

‫مغارة‬5.42

59

Pulley‫بكرة‬

2.99

30

Mask

‫ماسك‬

5.06

60

Sphinx‫أبو الهول‬2.39‫َج َمل‬

4.91

4.62

S* sum of frequency and familiarity

Administration procedure

All participants were tested individually and were administered all 60 items of the BNT
in order of increasing difficulty. Participants were asked to give the names of all theimages presented to them in Lebanese Arabic. Each image was presented for twenty seconds. If an answer is not provided after this time, a semantic cue is given to make iteasier to find the name. A semantic cue provides information related to the meaningof the target word, offering hints like superordinate categories (“vegetable” for “asparagus”), actions associated with the word (“you ring it” for “bell”), or definitions and sentence completions (“stethoscope” a medical instrument to listen to the heart and internalsounds) (Python et al., 2021). If, however, the answer is still not found, another phonemic cue was provided to facilitate word retrieval. A phonemic cue assists word retrieval
by focusing on its sound, offering hints like the first phoneme(s) (it starts with “c” for“cactus”), the first syllable for longer words, or a rhyming word (it rhymes with “nail”
for “snail”) (Python et al., 2021). This process was suspended if the participant was inChedid and Stephan ﻿Language Testing in Asia

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Table 5 Description of sociodemographic characteristics along with mean and standard deviationsof screening test scores of the participants (N = 280)
Mean

Standard deviation

Age (continuous)

68.57(10.77)

MOCA

27.16

(1.34)

GDS

2.70(1.22)

Number of participants

Percentage

Age (categorial)
50–59

75

26.8%

60–69

72

25.7%

70–79

77

27.5%

80 and above

56

20%

GenderFemale138(49.3)

Male

142(50.7)

Education
Primary90(32.1)

Secondary87(31.1)

University

103(36.8)

MOCA Montreal Cognitive Assessment, GDS Geriatrics Depression Scale

distress or refused to continue. The response for each item was recorded via a digitalaudio recorder and transcribed. The total score of the test represents the number of correct spontaneous responses and all correct responses obtained only after a semantic cue(Olabarrieta-Landa, 2015).
All accepted responses of the BNT Lebanese version can be found in the Appendix 1.
We organized participants’ responses using our instruction grid, which covers all possible types of responses (see Appendix 2). This grid was designed based on methods usedin previous studies by Slegers et al. (2018) and Nicholas et al. (1989). This process sorted
responses into two scores: one from responses given without semantic or phonemic cues
and another from those given with cues. The total score combined correct spontaneous responses and correct responses with semantic cues (Cronbach’s alpha = 0.754). Thisscore gauges overall performance on the BNT.

Statistical analysis
Data analysis for the norm determination study was conducted using SPSS software version 26. We used the following information in our study:– The sociodemographic characteristics of the participants– The total score of the BNT (score of spontaneous responses and after a semanticcue)– The four sub-scores (the numbers of the semantic and phonological cues given andthe numbers of the correct responses following the semantic and phonological cues),– error scores (no response, visual misperception, intra-categorical errors, superordinate errors, phonological errors, and periphrastic responses)

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Page 14 of 26– The means, standard deviations (m ± SD), medians, interquartile deviations(me ± IQR), and minimum and maximum were reported for continuous variables,
while frequencies (n) and percentages (%) were reported for categorical variables.
Cronbach’s alpha assessed the total score.
The normality of continuous variables was assessed using the Shapiro–Wilk test. Since
the distribution of scores was skewed, as well as the variance of these scores not being
equal between the groups studied, the generalized linear model (GzLM) was used toquantify the relationship between age (50–59; 60–69; 70–79; and 80 and above), education level (primary, secondary, university, and above), and gender (male; female) with thetotal Lebanese BNT score. Thus, the β coefficient and the 95% confidence interval (95%
CI) were reported. The age × gender × education interaction was tested; in addition to
the Akaike information criterion (AIC), the Bayesian information criterion (BIC) and thecorrected Akaike information criterion (AICC) were used to choose the best model (thesmallest value corresponds to a better model) (Neil et al., 1995). The correlation between
BNT sub-scores and the correlation between sociodemographic variables with BNT subscores and error scores was tested. The Spearman correlation coefficient was reported
when there was a correlation between two continuous variables, the point-biserial correlation coefficient when there was a correlation between a continuous variable and adichotomous variable, and the Kendall correlation coefficient when a correlation between
a continuous variable and an ordinal variable was reported. Finally, a P-value below 0.05
was considered statistically significant (Tallberg, 2005; Tombaugh & Hubley., 1997).

Results
Results of the norm determination study for the Lebanese version of the BNT

The mean (standard deviation), median (interquartile deviation), minimum, and maximum of the total score of the BNT (Lebanese version), as well as its sub-scores andthe scores of errors made by the participants, were all described in (Table 6).
Table 6 Description of the BNT (Lebanese version) scores/sub scores and errors (N = 280)
Mean

Standard
deviationMedianInterquartile
deviations

Min

Max

Total score51(6.09)

52

(8)

31

60

Number of semantic cues given

4.00(5.15)

2

(6)

0

22

Number of the correct responses following the semantic cues

1.53

(1.79)

1

(2)

0

9

Number of phonological cues given

9.16(6.08)

8

(8)

0

28

Numbers of the correct responses following the phonological cues

7.59

(4.77)

7

(7)

0

26

No response after a given cue

0.56(1.29)

0

(1)

0

8

ErrorsVisual misperception errors

1.15(1.70)

0.5

(2)

0

11

Intra-categorical errors

4.16(3.44)

3

(4)

0

16

Superordinate errors

1.59(1.55)

1

(2)

0

8

Phonological errors

0.27(0.60)

0

(0)

0

3

Periphrastic responses

2.18(1.86)

2

(2)

0

9

Chedid and Stephan ﻿Language Testing in Asia

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The results showed that the total score of the BNT (Lebanese version) varied
between 31 and 60, with a mean of 51 ± 6.09 and a median of 52 ± 8. The mean number of phonological cues (phonemic cue) (9.16 ± 6.08) provided was higher than the
average number of semantic cues (4 ± 5.15). The intra-categorical errors had the highest mean (4.16 ± 3.44) among all error types, while the phonological errors had thelowest mean (0.27 ± 0.60). A good internal consistency was found for the Lebaneseversion of the BNT as indicated by Cronbach’s alpha at 0.754 (Pedraza et al., 2011;
Tombaugh & Hubley, 1997).
The generalized linear model (GzLM) was applied to investigate the effect of age,gender, and education on BNT (Lebanese version) performance (Peña-Casanova
et al., 2009; Tsapkini et al., 2011). The results show that the total score of the BNT(Lebanese version) decreases with age and increases with education. It has been
observed that the BNT score decreases by 2.3 in people aged between 60 and 69 years(p = 0.001), by 7.2 in those aged between 70 and 79 years (p < 0.001), and by 11.4 inthose aged over 80 years (p < 0.001) when compared to those aged between 50 and 59
years.
On the other hand, the BNT score increases by 2.12 in people with secondary education (p = 0.001) and by 3.50 in those with a university education (p < 0.001) whencompared to those with primary education.
There were no significant differences found between men and women (p = 0.07).
It is worth noting that the interaction between age × gender × education was tested
and found to be non-significant. Additionally, the model not including interaction(Table 7) has the lowest indices of AIC, BIC, and AICC (1615 vs. 1595; 1621 vs. 1595;
and 1706 vs. 1624 respectively) when compared to the model with interaction.
The norms for sub-scores and errors of the BNT (Lebanese version) by age, gender,and education were also analyzed. The results are presented in Tables 8 and 9.
The study found that the number of semantic and phonological cues provided,
as well as the number of errors, increase with age and decrease with education.
The results showed that there are significant positive correlations between age andTable 7 The results of the generalized linear model (GzLM) for the total score of the BNT (Lebaneseversion)Total score of BNT 60

β(95% IC)P-value(− 3.62; − 0.99)

0.001(− 12.84; − 10.02)< 0.001(− 0.07; 1.83)

0.070

Age
50–59
60–69
70–79
80 and above
Gender1− 2.30− 7.26− 11.43

Male

1

Female0.88(− 8.55; − 5.97)< 0.001

Education
Primary

1

Secondary

2.12(0.92; 3.32)

0.001

University

3.50(2.35; 4.65)< 0.001

β the estimated effect size of age, gender, and education on the BNT performance, IC the range of values

Numbers of the correct responses following the phonological cues

Number of phonological cues given
8.93
14.75
18.25
5.31
6.86
10.58
11.38

60–69
70–79
80 and over
50–59
60–69
70–79
80 and over

3.13

80 and over
6.00

2.50

70–79
50–59

3.29

60–69

10.88

80 and over
0.62

14.58

70–79
50–59

7.29

60–69

Number of the correct responses following the semantic cues

0.69

50–59

Primary

Education

Number of semantic cues given

FemaleGenderAge

The sub-scores of the BNT (Lebanese version)(1.60)(4.46)(3.48)(2.93)(4.40)(6.31)(3.89)(3.08)(2.47)(1.88)(1.94)(0.77)(6.51)(5.63)(3.93)(0.75)

12.82

8.70

6.25

4.44

15.82

11.30

7.50

5.00

2.36

1.60

1.67

1.11

5.27

3.50

2.92

1.33

(4.29)(2.45)(2.49)(1.24)(5.29)(4.50)(2.97)(1.22)(1.63)(1.96)(1.61)(0.60)(2.57)(2.42)(3.29)(0.87)

Secondary

Table 8 Norms for the sub-scores of the BNT (Lebanese version) by age, gender, and education (N = 280)

12.25

8.86

4.54

4.43

13.63

9.57

4.85

4.79

1.13

1.36

0.62

1.14

1.88

2.64

1.23

1.43

(3.37)(4.88)(2.67)(2.31)(3.66)(5.17)(2.70)(2.39)(0.99)(1.45)(1.94)(1.88)(1.64)(2.76)(2.98)(2.87)

University
and more

13.63

10.23

5.90

3.50

19.38

13.46

7.60

3.83

1.75

4.15

1.40

0.50

5.13

15.08

5.20

0.58

PrimaryMale(6.12)(3.30)(2.23)(0.80)(6.72)(3.82)(2.59)(1.19)(1.28)(1.63)(0.70)(0.80)(3.40)(4.39)(2.62)(0.90)

13.55

9.54

5.70

2.45

15.00

11.46

6.30

2.82

2.18

2.08

0.80

0.82

4.00

5.54

1.70

1.18

(5.87)(2.82)(3.68)(1.57)(6.75)(4.94)(3.89)(1.47)(1.54)(2.72)(1.32)(1.08)(2.49)(6.57)(2.71)(1.40)

Secondary

12.00

8.40

4.62

3.13

12.80

9.40

4.85

3.31

1.40

0.87

0.23

0.56

3.20

1.93

0.46

0.63

(6.18)(4.01)(3.04)(2.39)(6.71)(4.55)(3.13)(2.27)(1.58)(1.19)(0.44)(1.31)(3.26)(2.43)(0.66)(1.54)

University
and more

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Periphrastic responses

Phonological errors

Superordinate errors

Intra-categorical errors

0.29
0.75
0.75
1.38
2.71
2.92
3.63

60–69

70–79

80 and over

50–59

60–69

70–79

80 and over

4.63

80 and over
0.08

2.75

70–79

50–59

2.36

60–69

6.75

80 and over
1.38

5.00

70–79

50–59

5.43

60–69

2.13

80 and over
1.69

1.33

70–79

50–59

1.21

60–69

3.13

80 and over
0.31

2.17

70–79

50–59

0.71

60–69

Visual misperception

0.00

50–59

Primary

Education

No response

FemaleGenderAgeError scores of the BNT(Lebanese version)(1.51)(1.62)(1.64)(1.45)(0.89)(0.97)(0.47)(0.28)(1.77)(1.96)(1.22)(1.33)(2.92)(2.17)(3.13)(1.60)(1.25)(1.50)(1.05)(0.63)(3.09)(2.33)(1.07)(0.00)

3.64

3.20

1.83

1.22

0.73

0.00

0.25

0.11

2.64

1.50

1.08

1.33

8.36

4.50

3.83

2.44

2.00

2.50

0.92

0.22

0.73

1.20

0.25

0.00

(1.21)(2.10)(1.90)(0.97)(1.01)(0.00)(0.45)(0.33)(1.03)(1.35)(1.08)(0.71)(3.85)(3.10)(2.66)(1.94)(2.32)(2.01)(1.31)(0.44)(1.79)(1.99)(0.45)(0.00)

Secondary

3.38

3.14

1.08

1.14

0.50

0.43

0.00

0.00

1.88

1.07

0.69

0.93

6.88

4.93

2.46

1.64

1.63

1.36

0.38

0.14

0.63

0.36

0.08

0.07

(2.56)(2.11)(1.32)(1.29)(0.76)(0.65)(0.00)(0.00)(0.99)(1.33)(1.44)(1.38)(1.73)(3.60)(1.56)(1.82)(1.77)(1.45)(0.65)(0.53)(1.06)(0.63)(0.28)(0.27)

University and
more

Table 9 Norms for the error scores of the BNT (Lebanese version) by age, gender, and education (N = 280)

2.88

3.00

2.20

0.58

0.00

0.77

0.20

0.17

2.63

2.92

2.20

0.42

8.63

6.08

2.90

1.50

4.50

2.08

0.10

0.08

0.88

1.62

0.90

0.08

PrimaryMale(2.42)(1.53)(1.40)(0.79)(0.00)(0.93)(0.42)(0.39)(1.51)(1.55)(1.48)(0.51)(4.07)(1.98)(1.66)(0.90)(3.55)(1.55)(0.32)(0.29)(0.83)(1.61)(1.29)(0.29)

2.45

2.62

2.10

0.73

0.55

0.15

0.20

0.00

2.73

2.08

0.70

0.82

8.27

4.38

2.60

1.09

2.00

2.00

1.10

0.09

0.27

0.92

0.00

0.00

(1.29)(1.26)(1.79)(1.19)(0.93)(0.55)(0.42)(0.00)(1.10)(1.26)(0.95)(0.75)(4.61)(3.80)(2.55)(1.04)(2.24)(2.20)(2.02)(0.30)(0.47)(1.66)(0.00)(0.00)

Secondary

3.00

3.33

1.00

0.63

0.10

0.47

0.00

0.06

2.10

0.93

0.15

0.38

6.90

4.40

2.38

1.38

1.80

1.07

0.46

0.19

0.40

0.27

0.00

0.00

(1.76)(2.72)(1.15)(0.81)(0.32)(0.74)(0.00)(0.25)(1.79)(1.10)(0.38)(0.62)(4.38)(2.44)(1.71)(1.67)(1.87)(1.16)(0.66)(0.54)(0.70)(0.46)(0.00)(0.00)

University andmore

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Page 18 of 26

sub-scores, as well as error scores, on the Lebanese version of the BNT. However,a negative correlation was found between education and these scores, as shown in
Table 10.
Additionally, it is worth noting that there was a strong linear correlation between
the number of semantic cues given and the number of correct responses following thesemantic cues (r = 0.834; p < 0.001), as well as between the number of phonologicalcues and the number of correct responses following the phonological cues (r = 0.962;
p < 0.001), as evidenced by the statistically significant correlations (Fig. 1).

Discussion
This research facilitated the development of a Lebanese iteration of the Boston Naming Test (BNT) that aligns comparably with the original American version. Additionally,normative data were collected based on a cohort of healthy Lebanese adults, stratified
according to age, gender, and educational level.
The response analysis results guided the selection of an optimal Lebanese translationaligning with the typical naming tendencies of the Lebanese population. A noteworthy
distinction lies in the fact that the American version of the BNT suggests a single correctname for each image, while Lebanon exhibits linguistic and cultural diversity, allowing
for multiple correct names for the same image due to regional and cultural variations.
For instance, the Arabic term for “dart” (“sahem”; "‫ )"سهم‬can be denoted by diverse names
such as “nablat,” “nashabat,” and “sanka” ("‫ "سنكة‬,"‫ "نشابة‬,"‫)"نبلة‬. To ensure precision, a comprehensive list of accurate responses has been compiled, encompassing the target word
and all its synonyms.
An examination of correct responses within our sample of participants revealed amean score and standard deviation of correct responses (51 ± 6.09), closely alignedwith international norms observed in various studies: 52.76 in Worrall et al. (1995);
49.6 in Mariën et al., 1998; 53.0 in Neils et al. (1995); 53.04 in Tallberg (2005); and 54.5

Table 10 Correlation between sub-scores and errors of the BNT (Lebanese version) with age,gender, and education

Number of semantic cues given

GenderAge

Education(dichotomous)(continuous)(ordinal)− 0.068

0.471**

Number of the correct responses following the − 0.088
semantic cues
Number of phonological cues given
Numbers of the correct responses following
the phonological cues
No response after a given cue
Errors0.741**− 0.101*− 0.103

0.388**− 0.266**

0.022

0.536**− 0.0450.647**− 0.0610.243**

Periphrastic responses
p < 0.05; **p < 0.001− 0.184**0.734**

Intra-categorical errors
Superordinate errors− 0.382**− 0.284**− 0.033

Visual misperception errors

Phonological errors*− 0.066

0.332**− 0.107− 0.097

0.461**
0.456**− 0.105*− 0.106*− 0.325**− 0126*− 0.107*

Chedid and Stephan ﻿Language Testing in Asia

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Fig. 1 Correlation matrix between the given cues and the generated correct responses. 1 semantic cue
given, 2 number of the correct responses following the semantic cues, 3 phonological cue given, 4 numbersof the correct responses following the phonological cuesin Nicholas et al. (1989). Furthermore, the reliability of the Lebanese Boston Naming
Test (BNT) demonstrated acceptability and comparability to the original version. Theinternal consistency, as measured by Cronbach’s alpha, was determined to be 0.75 in ourstudy, closely resembling the reported value of 0.78 in healthy individuals for the original
BNT (Tombaugh & Hubley, 1997).
While it is true that the average age of participants differed between the pilot study
and the normative study, it is important to note that the primary reason for this variation stems from the distinct objectives of each study. The pilot study aimed to assess
initial feasibility and gather preliminary data; hence, participants were recruited with afocus on diversity rather than homogeneity in age (Patricacou et al., 2007; Miotto et al.,2010; Grima & Franklin, 2016; Soylu & Cangöz, 2018). In contrast, the normative study
aimed to establish standardized benchmarks for elderly individuals by recruiting participants aged between 50 and 88 years, thereby ensuring representation of the target
population. Therefore, the difference in participant age reflects the deliberate divergencein study objectives rather than a flaw in methodology (Li et al., 2022; Mariën et al., 1998;
Roberts & Doucet, 2011). The pilot study not only served to devise scoring and administration rules but also provided guidelines tailored to the psycholinguistic and culturalvariables inherent in the Lebanese population for the BNT’s Lebanese version. Accordingly, we restructured the item list maintaining conformity with the original version’sorder. Consequently, certain items underwent repositioning in the Lebanese version

Page 19 of 26

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compared to the American version. Notably, “tongs” was elevated from its original position at number 55 to number 10 due to its heightened frequency in Lebanon, as affirmed
by our pilot study. Conversely, “octopus” was relocated from number 23 in the American
version to number 47 in our version. The reordering also allowed us to demonstrate thatthe difficulty of the new items was similar to those they replaced.
The derived Lebanese version of the Boston Naming Test (BNT) enabled an examination of the impact of age, gender, and educational attainment on the cognitive performance of healthy adult participants within our cohort. Our investigation revealed
significant influences of age and educational level on accurate response rates, aligningwith existing literature (Neils et al., 1995; Tombaugh & Hubley, 1997; Welch et al., 1996).
Specifically, older adults exhibited diminished naming performance compared to their
younger counterparts. Higher error rates among older individuals correlated with anincreased reliance on semantic or phonemic cues to compensate for cognitive deficits.
Conversely, participants with elevated education levels demonstrated superior BNT
scores, reduced dependence on cues, and fewer errors than those with lower educational
levels. Notably, adults aged over 70 with more than 12 years of education outperformed
peers with primary education, indicating a clear association between age, education, anddeclining performance. However, variations in performance decline were evident among
those aged over 70, with individuals possessing higher education levels exhibiting betternaming proficiency. Importantly, all healthy elderly participants aged over 70, regardless of education, retained lexical–semantic knowledge and naming ability with aid cues.
Retrieval following phonemic cues yielded notably high correct response rates. Participants with higher education levels exhibited shorter response times after receiving aid
cues compared to those with lower education levels.
In examining the impact of gender on naming performance, our study found no statistically significant difference between men and women, aligning with findings from previous studies (LaBarge et al., 1986; Ross et al., 1995). However, our results contradict
studies suggesting significant gender effects on naming (Mariën et al., 1998; Welch et al.,1996). A possible explanation for this inconsistency is proposed by certain studies, positing that men and women have divergent interests, particularly concerning images exclusively associated with men. Such images represent specific points of interest for men but
are less engaging for women, given that they fall outside their spheres of occupation orinterest. The lack of statistical significance in the gender effect within the Lebanese version may be attributed to nearly equal familiarity with the replaced images among men
and women in our study.
These findings underscore the significance of conducting normative studies tailoredto specific cultural and linguistic contexts, employing extensive samples that encompass
individuals of diverse ages and educational backgrounds. The present outcomes imply
that the adapted BNT may exhibit enhanced suitability for clinical utilization within the
Lebanese Arabic-speaking population. However, the clinical validity of this adapted version awaits confirmation through future investigations across diverse patient cohorts.
This study aimed to standardize the Boston Naming Test (BNT), a widely utilized neuropsychological assessment for evaluating linguistic capabilities in naming and word
retrieval, especially applicable to various clinical pathologies such as communication
disorders, aphasia, and language impairments resulting from conditions like stroke,

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Page 21 of 26

Alzheimer’s disease, or brain injury. The standardization focused on a diverse, healthy
population across different age groups, providing health professionals with a culturally
adapted Lebanese instrument. The standardized BNT allows clinicians to effectively
test, evaluate, and compare naming performance in individuals with linguistic disorders
against well-defined standards, aiding in the identification and severity assessment ofsuch disorders and facilitating targeted interventions.

Conclusion
It is important to acknowledge the impact of the ongoing technological revolution at
all levels, which is leading to a significant gap between generations. This gap affects not
only the way people think and live but also the social and interpersonal relations, andcultural and sentimental aspects of our society. Therefore, it is necessary to revise thenorms regularly, not only just for the original BNT but also for all the adapted versions,
including the one that we have implemented in this study.
Open practice statement

The raw data supporting the conclusions of this manuscript will be made available uponrequest to the corresponding author. The study research design, methods, and analyses
were pre-specified in the study protocol, which is available upon request. Experimental
materials and data collection instruments used in this study will be made available uponrequest.

Appendix 1

Table 11 All correct responses accepted for the Lebanese version of the BNT
Target word

Synonym‫سرير‬

1

Bed

‫تخت‬

2

Tree

‫شجرة‬

3

Toothbrush‫فرشاة االسنان‬4

Pencil‫قلم رصاص‬

‫قلم‬

5

House

‫بَيْت‬‫منزل‬

6

Hanger‫شنغل‬

7Comb‫ت َ ْعليقَة‬‫ُم ْشط‬8

FlowerBench‫َورْ دَة‬‫َم ْقعَ ْد‬‫زهرة‬

9
10

Tongs

11

Scissors

12

Manoushe

13

Broom

‫منقوشة‬‫سة‬َ ‫مِ ْك ْن‬

14

Funnel‫قِمِ ع‬

15

Latch

16

Snail

‫قفل‬
َّ
‫بزيقة‬17

Whistle‫صوفيرة‬18

Mushroom

‫فطر‬

19

Hammock‫مرجوحة‬‫بانك‬‫ملقط‬
ّ‫ْمقَص‬‫ساقوطة‬‫حلزونة‬‫عنزوقة‬‫مزالج‬Chedid and Stephan ﻿Language Testing in Asia

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Target word

Page 22 of 26

Synonym

20

Saw‫منشار‬21

Helicopter‫هيليكوبتر‬‫طائرة عمودية‬‫طائرة مروحية‬22

Wheelchair‫كرسي متحرك‬‫كرسي للمقعدين‬‫كرسي للمعوق‬

23

Canoe

‫ شخطورة‬-‫قارب‬‫زورق‬

24

Chess‫شطرنج‬25

Paintbrush

26

Asparagus‫ريشة‬‫ه َْليون‬27

Chandelier‫تريا‬

28

Escalator‫درج كهربائي‬

29

Cave

‫مغارة‬30

Mask‫ماسك‬‫قناع‬

31

Raquet‫راكيت‬‫مضرب‬

32

Cage

‫قفص‬

33

Dart

‫س ِهم‬
َ

34

Camel

35

Globe

‫ال ُك َرة األرْ ضيَّة‬36

Binoculor

37

Acorn

‫ناضور‬‫بَلّوط‬38

Stethoscope‫سماعة حكيم‬39

Cactus‫صبيّر‬40

Octopus‫أخطبوط‬41

Pelican‫بجعة‬

42

Flute‫مزمار‬43

Rhinoceros‫وحيد قرن‬

44

Noose

‫حبل المشنقة‬‫حبل او مشنقة‬

45

Clown

‫مهرج‬‫بهلواني‬‫كلون‬

46

Pyramid‫هرم‬

47

Volcano‫بركان‬48

Snowman‫رجل ثلج‬49

Kebbe pestle ‫مدقة الكبة‬50

Windmill‫طاحون‬51

Accordion‫أكورديون‬52

Hedgehog‫قنفذ‬

53

Alligator‫تمساح‬54

Compass‫بوصلة‬55

Zither‫القانون‬56

Compass‫بيكار‬57

Scroll‫فرمان‬‫رسالة‬‫منشور‬58

Saddle‫سرج‬

59

Pulley‫بكرة‬

60

Sphnix‫أبو الهول‬‫كرسي نقال‬‫كرسي للمكرسح‬‫كرسي لزوي‬‫االحتياجات الخاصة‬‫درج متحرك‬‫نبلة‬‫ سنكة‬,‫نشابة‬‫َج َمل‬All alternative responses were validated by cross-checking using a dictionary. Images with poor recognition that were
unfamiliar to the study population were replaced by alternative images from the same semantic category but that was more
relevant to Lebanese culture
These answers helped to evaluate the degree of compatibility of the names attributed to each of the images from the BNTwith the Lebanese Arabic language. In this way, the BNT was adapted to be more compatible with Lebanese culture andlanguage

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Page 23 of 26

Appendix 2

Table 12 The instruction grid of the Lebanese version of the BNT
Possible responses of participants and coding

Examiner response and scoring

Spontaneous response (SR): name agreement orsynonym of the target word such as ‫تخت –سرير‬If the participant adds an adjective to the target word:“It’s a big house” (‫بيت كبير‬.)Accept and move on to the next image by scoring ( +)The answer is also accepted with a score ( +)No response or do not know (NR)

Ask them to give it a try by helping them with a­semantic1 or phonemic c­ ue2*

Wrong part (WP) of the image named

Indicate the exact part of the object to be named

Visual misperception (VM) i.e., “fez” (‫ )طربوش‬for “acorn”(‫)بلوط‬Give them a semantic c­ ue1. If the response is correct
after the cueing we score ( +) if not, give them a phonemic ­cue2* (the first syllable of the target word)

Intra-categorial errors (ICE). i.e., “bull” (‫ )ثور‬for“rhinoceros” (‫)وحيد القرن‬Tell them that this is not the name we are looking for
and we give the them opportunity to self-correct.
If they did not find the exact name, we give them aphonemic ­cue2*

Superordinated word errors (SOE): I.e., “musicalinstrument” (‫ الة موسيقية‬for “flute” (‫)مزمار‬Tell them the answer is true but general, and ask themto specify. If they cannot find the exact name, give thema phonemic c­ ue2*

Phonological error (PHE) i.e., “glove” for “globe or bursa‫ بورصة‬for ‫ بوصلة‬busla

The response is considered correct and we score ( +)Periphrase response (P)We give them a phonemic ­cue2* to help them retrieve
the target name*Note: if a phonemic cue is given, always encode the answer as (-), even if it is correct. This will not count toward the total
score
Total score = sum of SR (spontaneous responses) + sum of correct responses after receiving a semantic cue

Semantic ­cue1: a semantic cue provides information related to the meaning of the target word. offering hints likesuperordinate categories (“vegetable” for “asparagus”), actions associated with the word (“you ring it” for “bell”), or
definitions and sentence completions (“stethoscope” a medical instrument to listen to the heart and internal sounds)(Python et al., 2021)
Phonemic ­cue2: a phonemic cue assists word retrieval by focusing on its sound, offering hints like the first phoneme(s) (itstarts with “c” for “cactus”), the first syllable for longer words, or a rhyming word (it rhymes with “nail” for “snail”) (Python
et al., 2021)

Abbreviations
BNT	Boston Naming Test
LEAP-Q	Language Experience and Proficiency Questionnaire
MOCA	Montreal Cognitive Assessment
GDS	Geriatric Depression Scale 15-item
NA	Name agreement
MSA	Modern Standard Arabic(p)	Difficulty index
LA	Lebanese Arabic
GzLM	Generalized linear model
Acknowledgements
None.
Authors’ contributions
Both authors contributed equally across all aspects of the research and manuscript preparation process, including conceptualization, methodology, data curation, writing, review, and editing.
Funding
This research received no specific grant from any funding agency.
Availability of data and materials
All relevant data and materials are presented within the tables and appendix of this article. Additionally, they are available upon request from the authors.

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Declarations
Competing interests
The authors declare no competing interests.
Received: 11 February 2024 Accepted: 5 June 2024

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