Journal of the International Neuropsychological Society (2005), 11, 408–415.

Copyright © 2005 INS. Published by Cambridge University Press. Printed in the USA.
DOI: 10.10170S1355617705050460

Action (verb) fluency: Test–retest reliability, normative

standards, and construct validity

STEVEN PAUL WOODS,1 J. COBB SCOTT,1,2 DANIELLE A. SIRES,1 IGOR GRANT,1

ROBERT K. HEATON,1 ALEXANDER I. TRÖSTER,3 and THE HIV NEUROBEHAVIORAL
RESEARCH CENTER (HNRC) GROUP
1 Department of Psychiatry, University of California at San Diego, La Jolla, California
2 JointDoctoral Program in Clinical Psychology, San Diego State University and University of California at San Diego,
San Diego, California
3 Department of Neurology, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina

(Received January 7, 2005; Revised February 18, 2005; Accepted February 22, 2005)

Abstract
Action (verb) fluency is a newly developed verbal fluency task that requires the examinee to rapidly generate as
many verbs (i.e., “things that people do”) as possible within 1 min. Existing literature indicates that action fluency
may be more sensitive to frontal–basal ganglia loop pathophysiology than traditional noun fluency tasks (e.g.,
animal fluency), which is consistent with the hypothesized neural dissociation between noun and verb retrieval. In
the current study, a series of analyses were undertaken to examine the psychometric properties of action fluency in a
sample of 174 younger healthy participants. The first set of analyses describes the development of demographically
adjusted normative data for action fluency. Next, a group of hypothesis-driven correlational analyses reveals
significant associations between action fluency and putative tests of executive functions, verbal working memory,
verbal fluency, and information processing speed, but not between action fluency and tests of learning or
constructional praxis. The final set of analyses demonstrates the test–retest stability of the action fluency test and
provides standards for determining statistically reliable changes in performance. In sum, this study enhances the
potential clinical applicability of action fluency by providing demographically adjusted normative data and
demonstrating evidence for its reliability and construct validity. (JINS, 2005, 11, 408–415.)
Keywords: Verbal fluency, Verbs, Test reliability, Test standardization, Test validity, Neuropsychological
assessment

INTRODUCTION frontal–striatal–thalamo–cortical loops (e.g., Buckner et al.,

1995; Cappa et al., 2002), whereas noun generation is more
Action (verb) fluency is a newly developed verbal fluency
dependent on the temporal (e.g., Williamson et al., 1998)
task that requires the examinee to rapidly generate as many
and inferior parietal cortices (e.g., Warburton et al., 1996).
verbs (i.e., “things that people do”) as possible within one For example, Tranel et al. (2001) reported an association
minute. Piatt and colleagues (Piatt et al., 1999a, 1999b)
between deficits in action naming and lesions in the left
were the first to describe the action fluency test, which was
frontal operculum, precentral gyrus (including the underly-
adapted from an extensive literature indicating that the neu- ing white matter), and the anterior insula, whereas deficits
ral systems involved in the generation (e.g., naming) of
in noun (but not action) naming were linked to anterior and
nouns and verbs are dissociable (e.g., Damasio & Tranel,
inferotemporal lesions.
1993). More specifically, prior research indicates that verb
Developed as an extension of the observed noun–verb
generation is primarily associated with the integrity of retrieval dissociation, action fluency is a measure of ver-
bally mediated executive functions that is particularly sen-
Reprint requests to: Steven Paul Woods, Psy.D., HIV Neurobehavioral sitive (and perhaps specific) to frontal systems damage
Research Center, Department of Psychiatry (0603-H), University of Cal-
ifornia, San Diego, 150 W. Washington St., 2nd floor, San Diego, CA relative to traditional verbal fluency tasks in which noun
92103. E-mail: spwoods@ucsd.edu (e.g., animals) or letter cues are used. The construct validity
408
Action (verb) fluency 409

of the action fluency test is supported by several recent METHODS

studies. The convergent validity of action fluency is dem-
onstrated by its correlation with well-validated clinical tests Research Participants
of executive functions (Piatt et al., 1999a; Woods et al., in
press). Evidence of divergent validity is provided by data Participants were 174, English-speaking participants who
showing that action fluency does not correlate with tests of were enrolled in a clinical research protocol at the San Diego
posterior neocortical function (i.e., noun naming and verbal HIV Neurobehavioral Research Center (HNRC). Potential
episodic memory). Data from clinical samples also support study participants were screened for histories of psychosis,
the possible dissociation between noun and verb generation mental retardation, current substance-related disorders (e.g.,
as it extends to generative fluency. For example, Woods alcohol dependence), and neurological and medical condi-
et al. (in press) demonstrated a single dissociation between tions that might adversely impact cognitive functions (e.g.,
noun (i.e., animal) and action fluency in persons with HIV–1 HIV infection, seizure disorders, closed head injury, neo-
infection—a condition associated with a preferential dis- plasms, cerebrovascular disease, etc.). Table 1 displays the
ruption of frontostriatal circuits. Using an empirically derived sample’s demographic characteristics.
cut-point, HIV–1-infected participants with impaired action
fluency scores (,15) were over three times more likely to
demonstrate general neuropsychological impairment on a
Procedure
standard battery than participants who performed within Neuropsychological evaluation
normal limits. Action fluency has also demonstrated supe-
rior sensitivity to dementia in Parkinson’s disease (PDD) as All study participants provided informed, written consent.
compared to letter and animal fluency (Piatt et al., 1999b). Participants were administered action fluency in the con-
Although these early findings are encouraging, the clin- text of a broader neuropsychological, neurological, medi-
ical usefulness of action fluency is hampered by several cal, and psychiatric evaluation. Examiner instructions for
important limitations to the existing literature. For instance, the action fluency test were adapted from Piatt et al. (1999a,
while education-corrected normative data have been pub- 1999b; 2004):
lished for use with older adults (i.e., persons 56–92 years of I’d like you to tell me as many different things as you can
age; Piatt et al., 2004), no normative data exist for use with think of that people do. I do not want you to use the same
younger adults. This is a substantial gap in the literature word with different endings, like eat, eating, and eaten.
because the relationships between demographic factors and Also, just give me single words such as eat, or smell,
test performance, on which normative standards are based, rather than a sentence or phrase. Can you give me an
can vary widely across age groups (Fastenau, 1998). Relat- example of something that people do?
edly, the research supporting the construct validity of action If the response was unacceptable, participants were
fluency has been conducted exclusively with clinical sam- asked to provide another example of an action word (any
ples (Piatt et al., 1999b; Woods et al., in press) and older verb response is acceptable). If the response was accept-
adults (Piatt et al., 1999a), which raises questions regarding able, the examiner stated: “That’s the idea. Now you have
the external validity of these promising findings in younger one minute to tell me as many different things as you can
healthy samples. Finally, the test–retest reliability of think of that people do.”
action fluency is not known. Demonstrating the reliability
of action fluency is an important step toward further estab- The primary variables of interest were the total number
lishing its construct validity; moreover, defining significant of unique verbs generated in 60 s, along with the total num-
and reliable changes in action fluency performance would
potentially enhance the applicability of this measure for
longitudinal assessments in clinical and research settings Table 1. Demographic composition of the study sample
(e.g., measuring treatment efficacy or disease-related cog- (N 5 174)
nitive decline).
Considering these needs, the present study was under- Variable M SD Range
taken to examine the psychometric aspects of action flu- Age (years) 38.8 11.8 18– 66
ency in a sample of younger healthy participants, including Education (years) 13.8 2.5 6–20
(1) the development of demographically-corrected norma- WRAT–3 Reading 103.7 10.3 70–121
tive standards for younger adults; (2) correlational analyses Handedness (% right) 85%
to examine the convergent and divergent validity of action Sex (% male) 68%
fluency, with the hypothesis that action fluency would cor- Ethnicity
White 68%
relate with putative tests of executive functions, verbal work-
Hispanic 16%
ing memory, verbal fluency, and information processing African American 11%
speed, but not with measures of learning, recognition dis- Other 5%
crimination, or constructional praxis; and (3) an evaluation
of the test-retest reliability of action fluency. Note. WRAT–3 5 Wide Rage Achievement Test–Revision 3.
410 S.P. Woods et al.

ber of perseverations (i.e., the repetition or inflection of a Pearson product-moment correlation coefficients (or the
previously generated response, including the participant’s nonparametric Spearman’s rank order correlation coeffi-
self-generated example word) and intrusions (i.e., responses cient) were used to examine the associations between raw
that were not verbs). Verb responses that humans could not scores on action fluency and tests selected on an a priori
plausibly perform (e.g., photosynthesize) and questionable conceptual basis from the larger battery to explore conver-
noun–verb homonyms (e.g., bear) were queried by the exam- gent and divergent validity. For the longitudinal analyses,
iner and coded as intrusions if indicated. paired t tests and Pearson product-moment correlation coef-
The broader neuropsychological test battery was admin- ficients (or their nonparametric counterparts) were used to
istered and scored by research psychometrists in accor- examine the correspondence between the action fluency raw
dance with published, standardized procedures. The battery scores at Time 1 and Time 2. The standard deviations of the
included the following tests: (1) Hopkins Verbal Learning Time 1 and Time 2 difference scores were also generated,
Test–Revised (HVLT–R; Brandt & Benedict, 2001); (2) Brief which allowed for the calculation of reliable change indices
Visuospatial Memory Test–Revised (BVMT–R; Benedict, (RCIs) with 90%, 95%, and 99% confidence intervals (Che-
1997); (3) Controlled Oral Word Association Test (COWAT– lune et al., 1993). The critical alpha level was set at .05 for
FAS; Benton et al., 1994); (4) animal fluency (Benton et al., all analyses, except for the construct validity correlational
1994); (5) Stroop Color-Word Test (Golden, 1978); (6) Trail analyses for which an alpha of .01 was used to reduce the
Making Test, Parts A and B (Reitan & Wolfson, 1985); (7) risk of Type I error due to multiple comparisons.
Wisconsin Card Sorting Test– 64 Card Version (WCST–
64; Kongs et al., 2000); (8) Halstead Category Test (Reitan
& Wolfson, 1985); (9) Paced Auditory Serial Addition Test RESULTS
(PASAT–200; Diehr et al., 1998); (10) Grooved Pegboard
Test (Kløve, 1963); (11) Letter–Number Sequencing, Digit Normative standards
Symbol, and Symbol Search subtests from the Wechsler
The distributions of action fluency total correct, intrusions,
Adult Intelligence Scale–Third Edition (WAIS–III; The Psy-
and perseverations are presented in Figure 1.
chological Corporation, 1997); and (12) the Reading0Word
There was no correspondence between action fluency total
Decoding subtest from the Wide Range Assessment Test–
raw scores and age, sex, or ethnicity (all ps . .05); how-
Revision 3 (WRAT–3; Wilkinson, 1993).
ever, a significant linear relationship emerged between action
fluency and years of education (r 5 .28, p 5 .0002). Thus,
Data Analyses only years of education was entered as a predictor variable
The methodology used to derive the demographically in the fractional polynomial regression equation predicting
adjusted normative standards was adapted from Heaton action fluency total (the distributions of raw scores across
and colleagues (Heaton et al., 2004). First, one-sample three levels of education are presented in Table 2). Action
Kolmogrov-Smirnov tests were conducted to evaluate the fluency raw scores were converted to scaled scores. Table 3
normality of action fluency raw scores. If a normal distri- displays the appropriate conversions for transforming raw
bution was evident (or could be achieved through validated scores to scaled scores. The fractional polynomial regres-
methods of data transformation), raw scores were then con-
verted to scaled scores (M 5 10, SD 5 3) whereby higher
scores reflect better performance. The fractional poly-
nomial regression procedure (Royston & Altman, 1994) was
used to examine possible linear (and nonlinear) associa-
tions between each demographic variable and the action
fluency total raw score. Demographic variables demonstrat-
ing a statistically significant association with action flu-
ency total score were then entered as predictors into the
final fractional polynomial regression procedure (Royston
& Altman, 1994). This procedure uses an iterative algo-
rithm to determine which combination of demographic
predictors (both linear and nonlinear) yields the most advan-
tageous fit of the action fluency scaled score data. The resid-
uals from the fractional polynomial regression were then
used to generate predicted scaled scores from which the
demographically adjusted action fluency T-scores (M 5 50,
SD 5 10) may be derived: Fig. 1. Box and whisker plots displaying the distribution charac-
teristics of Action Fluency Total Correct, Intrusions, and Persev-
T 5 (((Observed Scaled Score 2 Predicted Scaled Score)0 erations. Note that, the dashed lines represent median values, the
circles denote means, and the whiskers indicate the 10th and 90th
Root Mean Square Error) 3 10) 1 50. percentiles.
Action (verb) fluency 411

Table 2. Distribution of raw action fluency total scores Table 4. Distribution of action fluency perseverations by sex
by years of education
Percentile Men (n 5 118) Women (n 5 56)
Education
ⱖ97.5 ⱖ4 ⱖ4
6–12 years 13–15 years 16–20 years 90 3 3
Percentile (n 5 57) (n 5 67) (n 5 50) 75 2 3
50 1.5 2
ⱖ97.5 ⱖ29 ⱖ29 ⱖ32
25 1 1
90 24 24 28
10 0 1
75 21 22 24
ⱕ2.5 0 0
50 16 18 21
25 13 14 16 Note. The formula for calculating T-scores for perseverations is: (((observed
10 10 12 14 perseverations 2 sex M )0sex SD) 3 210) 1 50. “Sex M” and “sex SD”
ⱕ2.5 ⱕ7 ⱕ9 ⱕ13 indicate that separate means and standard deviations should be used for
men (M 51.5; SD 51.2) and women (M 5 2.0; SD 51.0) when generating
Note. The total years of educational attainment variable was operational- T-scores for this variable.
ized using the criteria recommended by Heaton et al. (2004).

Construct Validity
sion procedure revealed education to be a significant pre-
dictor of action fluency total scaled scores @R 2 5 .08; To examine the convergent and divergent validity of action
F(1,173) 5 14.05, p 5 .0002]. The resultant formula for fluency, hypothesis-driven correlational analyses were con-
generating education correct T-scores for the action fluency ducted between action fluency (raw scores) and measures
total variable is displayed in Table 3. selected from the larger neuropsychological battery (see
Results revealed no correspondence between action flu- Table 5). Results revealed significant associations between
ency intrusions and perseverations and demographic fac- the action fluency total score and tests of verbal working
tors of age, education, or ethnicity (all ps . .10). A sex memory, executive functions, fine motor skills, information
effect was evident on perseverations such that men gener- processing speed, and verbal fluency (all ps , .01). In con-
ated significantly fewer perseverative responses than did trast, there was no correspondence between action fluency
women ( p , .01). However, the severely skewed distribu- and measures of praxis, learning, or recognition discrimi-
tion of perseverations ( p , .01) would not permit the use of nation (all ps . .05). Exploratory analyses revealed no sig-
multivariate fractional polynomial regression methods for nificant correlations between action fluency intrusions and
generating sex-corrected normative data. Therefore, descrip- perseverations and the other neuropsychological tests, with
tive statistics and methods for generating sex-corrected the exception of a small, negative association between intru-
T-scores for perseverations are displayed in Table 4. sions and BVMT-R Recognition Discrimination ( p 5 .007).

Test – Retest Reliability

Table 3. Action fluency total raw scores to scaled
scores conversions Eighty-two of the original 174 participants (47%) under-
went repeat testing (see Table 6). Although participants who
Raw scores Scaled scores were followed longitudinally were older (43.5 611.0 years)
ⱕ6 3 than those who did not undergo repeat testing (34.6 6 10.8
7–8 4 years), there were no between-groups differences in educa-
9–10 5 tion, sex, ethnicity, handedness, estimated verbal IQ, or any
11–12 6 action fluency variable (all ps . .05). The test–retest data
13 7 in Table 7 reveals good temporal stability for the action
14–15 8 fluency total score, but slightly poorer reliability for intru-
16–17 9
sions and perseverations. No significant practice effects were
18–19 10
evident for any action fluency variable performance over
20–21 11
22 12 approximately a 1-year test–retest interval. Reliable change
23–24 13 index (RCI) confidence intervals for 90%, 95%, and 99%
25–26 14 are displayed in Table 7 for the total correct, intrusions, and
27–28 15 perseverations variables.
29 16
30 17
ⱖ31 18 DISCUSSION
Results from this study enhance the potential clinical appli-
Note. T-score 5 (((Observed Scaled Score 2 Predicted Scaled Score a )0
2.88) 3 10) 1 50. cability of action fluency by providing education-adjusted
a Predicted Scaled Score 5 10.01 1 (0.33 [ years of education 2 13.81] ) normative data for use with younger adults. Since demo-
412 S.P. Woods et al.

Table 5. Convergent and divergent validity of action fluency

Action fluency
Test variable Total Intrusions Perseverations
Verbal fluency
Action Total — 20.23** 0.03
Action Intrusions — — 20.04
Action Perseverations — — —
COWAT–FAS a 0.53**** 20.01 0.07
Animal Fluency a 0.59**** 20.10 0.02
Learning and memory
HVLT–R Learning 0.07 20.03 0.03
HVLT–R Recognition Discrimination 0.03 20.11 0.13
BVMT–R Learning 20.01 0.05 20.11
BVMT–R Recognition Discrimination 0.12 20.21** 20.02
Constructional praxis
BVMT–R Copy Trial 0.06 20.11 20.04
Verbal working memory
PASAT–200 0.29*** 0.02 0.02
WAIS–III Letter–Number Sequencing 0.33**** 20.04 0.04
Psychomotor
Grooved Pegboard 20.15† 0.18† 0.13
WAIS–III Digit Symbol a 0.30*** 20.17† 0.06
Executive functions
TMT B–A 20.21** 0.12 20.05
Halstead Category Test 20.20** 0.14 20.01
WCST– 64 Perseverative Responses 20.20** 0.10 20.02
Stroop Incongruent Trial a 0.31**** 20.12 20.02

Note. COWAT–FAS 5 Controlled Oral Word Association Test (FAS version); HVLT–R 5 Hopkins
Verbal Learning Test–Revised; BVMT–R 5 Brief Visuospatial Memory Test–Revised; PASAT–200 5
Paced Auditory Serial Addition Test; WAIS–III 5 Wechsler Adult Intelligence Scale–Third Edition;
WCST– 64 5 Wisconsin Card Sorting Test– 64 Card Version; TMT 5 Trail Making Test.
a Pearson product-moment correlation coefficients.

† p ⱕ .05, **p ⱕ .01, ***p , .001, ****p , .0001.

graphic factors are known to influence cognitive test per- observed a positive association between action fluency total
formance, the use of normative standards is critical to ensure score and educational attainment, but not with age, sex, or
accurate interpretation of an individual’s test performance ethnicity. Similar relationships between verbal fluency and
relative to demographically similar others (Heaton et al., education have also been observed with measures of animal
2004). Consistent with the findings of Piatt et al. (2004), we and letter fluency (e.g., Gladsjo et al., 1999). In contrast, no
demographic variable was associated with intrusions or per-
severations, with the exception of a very modest (d 5 0.5)
Table 6. Demographic composition of the test–retest study sex difference in perseverative responses. Thus, it is recom-
sample (N 5 82) mended that standard scores for action fluency persever-
ations be generated separately for men and women (see
Variable M SD Range Table 4).
Test–retest interval (months) 10.5 2.5 4.1–15.5 Extending prior studies of convergent validity in older
Age (years) 43.5 11.0 22– 66 adults (Piatt et al., 1999a) and persons with HIV–1 infec-
Education (years) 13.9 2.5 8–20 tion (Woods et al., in press), we observed significant asso-
WRAT–3 reading score 104.6 9.7 81–120 ciations between action fluency total and putative tests of
Handedness (% right) 90% executive functions, verbal working memory, verbal flu-
Sex (% male) 68% ency, and information processing speed. These findings were
Ethnicity consistent with our a priori hypotheses and indicate that
White 67%
action fluency shares a generally modest proportion of the
Hispanic 17%
African American 11%
variance with tests measuring these related cognitive con-
Other 4% structs. Importantly, evidence of divergent validity was pro-
vided by the lack of significant correlations between action
Note. WRAT–3 5 Wide Rage Achievement Test–Revision 3. fluency and tests of cognitive functions more associated
Action (verb) fluency 413

Table 7. Test–retest reliability and reliable change indices for action fluency

Action fluency Time 1 Time 2 r M Diff SD a 90% CI 95% CI 99% CI

Total 18.2 (5.6) 18.2 (5.8) 0.73** 0.0 4.2 27, 7 28, 8 211, 11
Intrusions 0.2 (0.6) 0.2 (0.5) 0.30* b 0.0 0.7 21, 1 21, 1 22, 2
Perseverations 1.7 (1.3) 1.5 (1.4) 0.24* b 20.2 0.8 22, 1 22, 1 22, 2

Note. Diff 5 difference (Time 2 2 Time 1); CI5 confidence interval; SD 5 standard deviation of the mean difference.
*p , .05. **p , .0001.
a Represents the 68% confidence interval (6 practice effect).
b Data are presented as Spearman’s rank order correlation coefficients.

with the posterior neocortex (i.e., learning, recognition dis- pants had a broad range of demographic characteristics, the
crimination, and constructional praxis). It is unlikely that sample was largely Caucasian, young, and had attained an
these non-significant correlations reflect Type II error as average of 14 years of education. Study sample demo-
the current study was adequately powered to detect small- graphic characteristics are a particularly important consid-
to-medium effect sizes (power 5 .85 to detect r 5 .25 with eration when using regression-based normative standards,
N 5 174 and alpha 5 .01). Exploratory analyses, however, which can be misleading in the event that an individual’s
revealed no discernible pattern of correlations between action particular demographic characteristics are not represented
fluency intrusions and perseverations and the battery of in the normative sample (see Fastenau, 1998; Fastenau &
neuropsychological tests. Such null findings raise ques- Adams, 1996). While the incorporation of the nonlinear
tions regarding the convergent validity of these variables as fractional polynomial regression equations somewhat mit-
indicators of executive functions in healthy populations; in igates the risk of misclassification (Heaton et al., 2004),
other words, errors are so infrequently generated that they prudent use of these normative data require that a given
are not highly informative in nonclinical samples. Error client’s demographic characteristics are compatible with that
analyses on traditional verbal fluency tests have histori- of the standardization sample. To this end, the Piatt et al.
cally yielded fairly inconsistent results (e.g., Suhr & Jones, (2004) normative sample is recommended for use with older
1998; cf. Butters et al., 1986), which may reflect the inher- adults given that the current sample contained only 7 per-
ent difficulty in analyzing variables with low base rates sons age 60 years or older. Moreover, only 10% of the
(Woods et al., 2004). Whether action fluency errors possess present sample reporting having attained less than a high-
predictive or discriminative value in clinical samples remains school education, which indicates that caution regarding
to be determined by future research. possible false positive classification errors is warranted when
Action fluency demonstrated good one-year test-retest applying these normative data to clients with lower levels
reliability. There was no indication of a practice effect in of education. Finally, the normative sample was largely Cau-
action fluency performance at one-year follow-up. The sta- casian, which may have restricted our ability to detect eth-
bility coefficient and standard deviation of change scores nicity differences in action fluency performance if they truly
for action fluency total scores are generally consistent with exist.
published data using letter fluency (e.g., Basso et al., 1999). Although a convergence of research shows that the neu-
The relatively lower reliability of intrusions and presever- ral networks involved in generating nouns and verbs are
ations may be related to the restricted range of observed dissociable, these processes likely overlap to some degree.
scores (i.e., floor effects), which is particularly problematic For example, Tranel et al. (2001) found that left premotor0
in research with younger, healthy adults (Woods et al., 2005). prefrontal lesions were associated with impairments in both
The RCIs provided in Table 7 are intended to assist clini- action and object naming. Moreover, the conceptual knowl-
cians and researchers in more accurately classifying statis- edge of actions is related to frontal, as well as posterior
tically reliable changes in action fluency performance. neocortical areas, including left parietal and posterior mid-
Change scores that fall outside the selected RCI confidence dle temporal regions (Tranel et al., 2003). Cerebellar struc-
interval are considered to represent a statistically reliable tures have also been linked to verb processing (e.g., Sach
improvement or decline in performance. The use of RCIs et al., 2004), although the nature and extent of this link
may reduce the risk of classification errors that can result remains controversial (Richter et al., 2004). As a verb gen-
from attempting to estimate practice effects and normal test- eration task, it is likely that action fluency requires a dis-
retest variability to determine whether a meaningful change tributed neural network that includes the frontal lobes, as
in performance has occurred without the aid of empirical well as more posterior aspects of the neocortex [e.g., pos-
standards. Studies are nevertheless needed to evaluate the terior middle temporal (MT) region] and adjoining white
predictive validity of these RCI data in detecting signifi- matter pathways (Tranel et al., 2003). Accordingly, inter-
cant changes in various clinical samples (i.e., sensitivity). pretation of action fluency as a pure measure of frontal lobe
It is important to highlight the limitations to the external functions is imprudent, despite promising evidence of its
validity of the current study. Although the study partici- divergent validity.
414 S.P. Woods et al.

Future studies may consider examining multiple trials of M.D. (P.I.), Dianne Langford, Ph.D.; Clinical Trials Component:
action fluency that incorporate unique rule-guided search J. Allen McCutchan, M.D., J. Hampton Atkinson, M.D., Ronald J.
strategies. For example, restrictions might be placed on the Ellis, M.D., Ph.D., Scott Letendre, M.D.; Data Management Unit:
generation of inflected verbs (e.g., Sach et al., 2004), noun– Daniel R. Masys, M.D. (P.I.), Michelle Frybarger, B.A. (Data
verb homonyms (e.g., Tranel et al., 2005), or other concep- Systems Manager); Statistics Unit: Ian Abramson, Ph.D. (P.I.),
and Deborah Lazzaretto, M.S.
tual factors, such as actions that require tools or that can
This study was supported by the following grants from the
only be performed by using one’s hands (e.g., Kemmerer & National Institutes of Health: MH62512, DA12065, and MH59745.
Tranel, 2000). Extending the verb generation literature (e.g., The views expressed in this article are those of the authors and do
Buckner et al., 1995) to action fluency, another interesting not reflect the official policy or position of the Department of the
possibility would be to place systematic restrictions on the Navy, Department of Defense, nor the United States Government.
semantic relatedness of dyadic noun–verb switching trials. The authors thank Daniel Tranel, Ph.D., Michael Weinborn, Ph.D.,
The incorporation of additional trials might allow the test and an anonymous reviewer for their helpful comments. We also
user to better delineate the specific nature of the action thank Deborah Lazzaretto and Jennifer Marquie-Beck for their
fluency deficit, as well as perhaps enhance the (already assistance with statistical analyses and figure preparation, respec-
strong) reliability of action fluency. tively. Portions of these data were presented at the 33rd Annual
In sum, findings from this study support the potential Meeting of the International Neuropsychological Society in St.
Louis, MO, USA.
clinical application of action fluency by providing demo-
graphically adjusted normative data in younger adults, actu-
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