Columbia International Publishing

American Journal of Alzheimers Disease

(2013) 1: 72-79
doi:10.7726/ajad.2013.1005

Research Article

Characterization of Verbal Operants in Patients with

Alzheimer's Disease
Juliana Francisca Cecato1*, Luana Luz Bartholomeu2, Daniel Bartholomeu3, Jos Maria Montiel4, Jos
Eduardo Martinelli5
Received 28 May 2013; Published online 20 July 2013
The author(s) 2013. Published with open access at www.uscip.org

Abstract
Language is an important cognitive function and its decline may represent demential syndrome in
evolution. Verbal behavior theory, proposed by Skinner, analyzes language in terms of verbal
operants.
Objective: to compare the verbal behavior (verbal operants) in subjects with Alzheimers disease
(AD) and elderly without any cognitive impairment.
Methods: The cross-sectional study included 69 subjects aged over 60 years old, and with above 4
years of educational level. All participants undergone detailed medical history and
neuropsychological assessment. Forty-three patients received AD diagnostic and 26 comprised the
control group.
Results: There were significant differences between the two groups in intraverbal (p<0,0001), copy
(p<0,0001), dictation (p<0,0001), tact (p<0,0001) and autoclitics measures (p<0,0001). Regarding
echoic behavior, the results showed no significant differences (p=0,268).
Conclusion: verbal operant analysis may be another aspect to be considered in the differential
diagnosis of AD patients.
Keywords: Elderly; Verbal operants; Diagnosis; Neuropsychology; Psychological Assessment

______________________________________________________________________________________________________________________________
*Corresponding e-mail: cecatojuliana@hotmail.com; montieljm@hotmail.com
1* Rua Ch de Frade, 131 Mooca, So Paulo-SP, Brazil
2 Faculdade Anhanguera de Jundia
3 Centro Universitario Salesiano de So Paulo
72
4 UNIFIEO Jundiai IPADE
5 Jundiai Medical School

Juliana Francisca Cecato, Luana Luz Bartholomeu, Daniel Bartholomeu, JosMaria Montiel, JosEduardo
Martinelli / American Journal of Alzheimers Disease (2013) 1: 72-79

1. Introduction
Language assessment in elderly with suspect of Alzheimers disease (AD) is considered a challenge
for many researchers, because their changes are correlated with many other functions (Mansur et
al., 2005), such as working memory, that is related to the understanding of sentences, repetition,
reading and writing, for example (Yassuda, 2002; Mansur et al., 2005; Corra, 2008). Some studies
suggests that in AD advanced stages the patient finds great difficulty in constructing sentences and
naming objects, loses the ability to take initiative in conversations and presents a limited verbal
repertoire (Mac-Kay, 2003; Mansur et al., 2005; vila and Bottino, 2008; Corra, 2008;). In later
stages of AD, the language disorder can cause aphasia and mutism (Mac-Kay, 2003; vila & Bottino,
2008). However, even in advanced stages of dementia, patients can participate in conversations
which evidence preserved aspects of social skills (Mansur et al., 2005) and the repetition of phrases
(Mac-Kay, 2003; Teixeira and Caramelli, 2008).
Analyze the language through responses of people to different stimuli may help to better
understand this behavior. To the behavior analysis, language can be interpreted as a specific
operant behavior characterized to be able to directly change the behavior of another person (Matos,
1991; Barros, 2003; Srio et al., 2008; Martin & Pear, 2009). Language can be seen as a behavior in
which the individual directs his speech voice and/or writing for the environment (Catania, 1999).
Consider the language behavior as intrinsically linked to environmental causes implies that verbal
responses occur in effect of the reinforcement of the response that was followed (Andery, 2010).
Hence, the verbal behavior also makes possible new relationships between individuals and their
environment, which makes it interesting to identify the issues involved in this relationship (Srio
et. al., 2008). Taking into account the importance of verbal behavior for psychology and the
relevance of analyze this behavior in elderly subjects, specially in the AD diagnoses, this study
aimed to compare the verbal behavior in AD patients and a control group of elderly without
cognitive impairment.

2. Methods/Participants
The patients received AD diagnosis by DSM-IV (APA, 1994) and NINDS-ADRDA (Mckhann et al.,
1984) criteria that was made by a Gerontologist. The exclusion criteria for the study were: patients
with Clinical Dementia Rating (CDR) of 0.5 and 3, major depression, severe visual and hearing
impairments, history of stroke, and educational level more than 5 years. The inclusion criteria for
the normal controls (NC) were scores above the cutoff on neuropsychological tests, have no
problem to perform the basic activities of daily living, have more than five years of study and do not
meet the criteria for AD.
The cross-sectional study included 69 subjects aged over 60 years old (range 60-91 years old).
Forty three patients received AD diagnosis, 30 were female (69.77%) and the mean age of the AD
group was 77.83 (SD= 6.64, range, 61-91). 26 subjects were normal controls (NC) aged from 60 to
86 years old (mean age of 72.46 SD = 7.35) and 69.23% were female. The educational level of the
two groups were very similar. The experimental group (AD group) had 5-8 years of education and
65.12% of the subjects had more than eight years of study. In the NC group, participants with 5-8
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Juliana Francisca Cecato, Luana Luz Bartholomeu, Daniel Bartholomeu, JosMaria Montiel, JosEduardo
Martinelli / American Journal of Alzheimers Disease (2013) 1: 72-79

years of education were observed in 34.61% of this group and 65.29% had more than eight years of
schooling.

3. Instruments and Procedures

All participants undergone a structured interview for mental illness by means of Cambrigde
Examination for Mental Disorders of the Elderly (CAMDEX) and the cognitive assessment
Cambrigde Cognitive Examination (CAMCOG) (Roth et al., 1986), the Mini-Mental State Examination
(MMSE) (Folstein et al., 1975), the Clock Drawing Test (CDT) (Mendez et al., 1992), Pfeffer
Functional Activity Questionnaire (PFAQ) (Pfeffer et al., 1982) and Geriatrics Depression Scale
(GDS) (Yesavage et al., 1986). All evaluations were performed individually at the consultory of the
gerontologist.
All participants who met the inclusion criteria undergone the test batery through verbal behavior.
We selected the following verbal operants: intraverbal, copy, echoic, dictation, tact and autoclitic.
Each task sought for a verbal operant. Table 1 describes the categories of verbal operants and their
relationship between stimulus (S) and responses (R). A total score was given for the correct
performance on each task. If the patient could not perform the task, points were deducted from the
score of the corresponding verbal operant.
To the analysis of verbal operants (Table 2) we used CAMCOG (Roth et al., 1986) which is the
cognitive part of the CAMDEX structured interview. The CAMCOG assesses various cognitive
functions such as attention, concentration, spatial and temporal orientation, abstract, language,
calculation, praxis and memory. In these tests, the CAMCOG also adds the MMSE as part of their
evaluation. The CAMCOG consists of 19 items and the maximum score reaches 107, and the cutoff
for dementia is 80 points. The equivalences between CAMCOG and verbal operants were defined
from a previous stimulus (S) and response (R) expected for that stimulus, that is, according to the
CAMCOG test responses were established in each verbal operant category (Table 2).
All data were analyzed using the SPSS system 15.0 (2007). We employed the Mann-Whitney test to
verify differences of verbal operants between groups and Kruskal-Wallis test to verify differences
between educational levels.
Table 1 Categories of verbal operants and the relations between stimulus (S) and response (R).
Source: MATOS (1991)
Category
SD
R
SR
Intraverbal
Sets of verbal
Vocal/motor
Social
associations issuer
Copy
Visual
Motor (copy a draw)
Social
Echoic

Auditory (words)

Vocal (repet words)

Social

Autoclitic

Auditory/visual covert

Vocal/motor

Social

Dictation

Auditory

Motor

Social

Tact

Object

Vocal/motor (object)

Social
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Juliana Francisca Cecato, Luana Luz Bartholomeu, Daniel Bartholomeu, JosMaria Montiel, JosEduardo
Martinelli / American Journal of Alzheimers Disease (2013) 1: 72-79

Table 2 Categories of verbal operants established between items of CAMCOG

Category
CAMCOG Test
Total Score
Autoclitic
Spatial and temporal orientation, verbal fluency,
49
memory recall, recognition memory, remote
memory, recent memory, memory fixing, praxis and
sum of money
Intraverbal
Comprehension, attention and concentration,
24
calculate the change for a certain amount of money
and abstract thought
Tact
Object naming, picture naming, definitions and
25
perceptions
Echoic
Repetition of a phrase and repetition of words
4
Copy

Drawing pentagon, spiral and home

Transcription

Write a sentence

Dictation

Write an address

4. Results
Regarding the evidence of verbal operants, the AD group showed lower mean scores compared to
normal controls. After statistical analysis we observed significant differences between AD group
and NC in intraverbal (p <0.0001), copy (p <0.0001), dictation (p <0.0001), tact (p <0,0001) and
autoclitic (p <0.0001). Regarding the echoic verbal operant, the results showed no significant
differences (p = 0.268), as shown in Table 3. The greatest differences were found in intraverbal and
autoclitic means between groups.
Table 3 Comparison between groups in verbal operants. * Statistical analysis by Mann-Whitney. N=
number of cases
Verbal operants
Groups
N
Means
*p
NC
26
54,08
Intraverbal
0,0001
AD
43
23,47
Copy

NC
AD

26
43

46,50
28,05

0,0001

Echoic

NC
AD

26
43

36,00
34,40

0,268

Autoclitic

NC
AD

26
43

56,19
22,19

0,0001

Dictation

NC
AD

26
43

42,29
30,59

0,0001

Tact

NC
AD

26
43

46,48
28,06

0,0001
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Juliana Francisca Cecato, Luana Luz Bartholomeu, Daniel Bartholomeu, JosMaria Montiel, JosEduardo
Martinelli / American Journal of Alzheimers Disease (2013) 1: 72-79

We also observed age effects on verbal operating variables in both groups. Participants were
organized into three groups regarding educational level as follows, 5-8 years, 9-11 years and> 11
years of study.Without the division of the diagnostic group (i.e. AD and NC) no verbal operants
showed significant differences between educational levels groups. However, splliting the sample by
diagnostic groups, the experimental group (AD subjects) showed to be affected by schooling,
instead of controls. No verbal operants have any significant difference to NC, but for AD group,
intraverbal and copy verbal operants were significantly differentiated between educational levels
(Table 4). The intraverbal showed an average of 14.17 in the group with 5-8 years, 23.42 for 9-11
years and 28.60 for elderly over 11 years of schooling. The copy operant presented mean of 14.87
in the 5-8 years group, 21.92 to AD patients with 9-11 years of educations, and 29.20 for elderly
over 11 years of schooling (Table 4).
Table 4 Educational level effects on verbal operants to AD patients
Mean Rank
Verbal Operant
5 to 8 years
9 to 11 years
> 11 years
14,17
23,42
28,60
Intraverbal

*p
0,006

Copy

14,87

21,92

29,20

0,001

Echoic

20,13

23,00

23,00

0,148

Autoclitic

22,70

22,62

20,77

0,892

Dictation

19,13

24,58

22,63

0,369

Tact

16,80

20,50

28,50

0,019

*Statistical analysis by Kruskall-Wallis test.

5. Discussion
In AD the literature, many answers are found for language impairment (Mansur et al., 2005; vila &
Bottino, 2008), but little is known about what happens to verbal behavior in elderly and less when
these are affected by dementia (Dixon et al., 2011). In normal aging, the decline of the words rate of
acquisition and organization of discourse is expected, but nothing that interferes with elderly
communication (vila & Bottino, 2008). Learning disabilities can be evidenced in AD when the
patient attempts to verbalize everyday situations (Dixon et al.,, 2011) and it is noted difficulties in
the understandig of information, for example, during the processes of data storage, manipulation of
this information, organization and issuing verbal responses (Mansur et al., 2005). This fact is
confirmed by the data obtained in our research when biggest differences between the means of
verbal operants in intraverbal and autoclitic were observed. Therefore the results show these two
verbal operants are the most affected in cases of dementia. Srio et al. (2008) refers that intraverbal
operant is related to our formal knowledge, or information acquired with historical facts that are
evoked by the presentation of discriminative stimuli. However, the autoclitic are responses that
depend on other verbal operants to happen, including the combination and arrangement of the
verbal repertoire (Catania, 1999). Clearly these verbal operants have a direct relationship between
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Juliana Francisca Cecato, Luana Luz Bartholomeu, Daniel Bartholomeu, JosMaria Montiel, JosEduardo
Martinelli / American Journal of Alzheimers Disease (2013) 1: 72-79

speaker and listener interactions built during the life (especially in childhood) and their repertoires
are developed according to the stimuli that subjects received in their community (Andery, 2010).
We evidenced differences between AD patients and normal controls regarding verbal behavior.
Only echoic behavior was not able to differentiate these two groups. Echoic behavior is of great
importance for learning especially for children, which mimic the speech of their parents (Catania,
1999; Srio et al., 2008; Ossher et al., 2013). However, this verbal operant do not assesses the
dementia in elderly. The vocal responses do not differ between controls and AD by the fact that the
echoic behavior does not require understanding of the speaker on the word or phrase that just echo
(Catania, 1999). This means that patients with dementia will be able to mimic or echo phrases
and/or words equal to the examiner. It is not required of an individual mental processing or
understanding the meaning of what is being said (Catania, 1999; Srio et al., 2008; Ossher et al.,
2013).
Another point that deserves attention is related to educational level. Although there was no
difference between these levels in the normal elderly, differences were observed in operating
intraverbal and copy when analyzing the educational level of the dementia group. Mathuranath et
al. (2003) and Diaz et al. (2004) describe the importance of considering the educational level when
assessing language in elderly. A hypothesis which explains the higher average operating intraverbal
in the group with more than 11 years of study is that over the history of life, elderly people with
more years of schooling were more stimulated to develop and shape this functioning (Matos, 1991;
Srio et al., 2008).
The verbal operant copy was required from a visual motor task as copying a drawing, which can
explain the better performance of patients with more years of education. In this sense we can say
that patients with lower education levels did not perform well this kind of task because do not
properly pay attention to all information contained in the drawing, and this can be a good screening
test in these cases (Rossini & Galera, 2006). Perhaps the training provided by years of study can
favor neuronal plasticity (Prestes, 1998; Ossher et al., 2013;) where some brain regions can
establish synaptic communication that is central to the execution of some tasks (Andrade, 2008).
This research proposes the analysis of language from a new perspective, to evaluate the
possibilities of verbal behavior in aging and elderly patients with probable AD. The results showed
significant differences with respect to the verbal operants and normal elderly with dementia. If the
verbal behavior occurs through the mediation of others, through an indirect relationship, nonmechanical, and have been built during the life requires further analysis of the stimuli that cause
the elderly with dementia shows the impairment of some functions and preservation of others.
Also, this research contributes in clearing verbal aspects of AD diagnosis that can be employed to
facilitate comprehension of such characteristics in this disease and suggests points of intervention
considering educational level. New researches could be done in differentiating such verbal operants
in CDR levels to helps the discrimination of verbal aspects in AD severity.

6. Conclusion
The verbal behavior has been little studied in elderly patients with dementia. There was a
significant difference in relation to intraverbal, copy, autoclitic, dictation and tact between AD
patients and normal controls. However, the echoic analysis showed no significant differences,
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Juliana Francisca Cecato, Luana Luz Bartholomeu, Daniel Bartholomeu, JosMaria Montiel, JosEduardo
Martinelli / American Journal of Alzheimers Disease (2013) 1: 72-79

which may indicate that the verbal operant can remain preserved in cases of mild to moderate
dementia. It can be concluded that the analysis of verbal operants may be another aspect to be
considered in the differential diagnosis of elderly with cognitive impairment and patients with
Alzheimer's disease.

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