Archives of Clinical Neuropsychology, Vol. 14, No. 2, pp.

167177, 1999
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PII S0887-6177(97)00095-4

Normative Data Stratified by Age and

Education for Two Measures of Verbal
Fluency: FAS and Animal Naming

Tom N. Tombaugh

Carleton University

Jean Kozak

Sisters of Charity Health Services

Laura Rees

Carleton University

Normative data stratified by three levels of age (1659, 6079, and 8095 years) and three levels
of education (08, 912, and 1321 years) are presented for phonemic verbal fluency (FAS) and
categorical verbal fluency (Animal Naming). The normative sample, aged 16 to 95 years, con-
sisted of 1,300 cognitively intact individuals who resided in the community. Years of education
ranged from 0 to 21. The total number of words in 1 minute for each of the letters F, A, and S
was correlated r 5 .52 with the number of animal names generated in 1 minute. Regression anal-
yses showed that FAS was more sensitive to the effects of education (18.6% of the variance)
than age (11.0% of the variance). The opposite relationship occurred for Animal Naming,
where age accounted for 23.4% of the variance and education accounted only for 13.6%. Gen-
der accounted for less than 1% of variance for FAS and Animal Naming. The clinical utility of
these norms is discussed. 1999 National Academy of Neuropsychology. Published by Elsevier
Science Ltd

Phonemic and semantic verbal fluency, as measured by an individuals ability to gener-

ate words beginning with a specific letter (e.g., FAS and CFL) and semantic category
(e.g., animals), have played a prominent role in neuropsychological research. Verbal flu-
ency has been demonstrated to be sensitive to lesions in the frontal lobe, temporal lobe,
and caudate nucleus (Benton, 1968; Butters, Granholm, Salmon, Grant, & Wolfe, 1987;
Miceli, Caltagirone, Gainotti, Masullo, & Silveri, 1981; Milner, 1964; Perret, 1974; Ram-
ier & Hecaen, 1970); Alzheimers disease (Appell, Kertesz, & Fisman, 1982; Bayles &

Address correspondence to: Tom N. Tombaugh, Department of Psychology, Carleton University, Ottawa Ontario,
Canada K1S 5B6.

167
168 T. N. Tombaugh, J. Kozak, and L. Rees

Tomoeda, 1983; Butters et al., 1987; Chertkow & Bub, 1990; Cummings, Benson, Hill, &
Read, 1985; Hodges, Salmon, & Butters, 1992; Martin & Fedio, 1983; Ober, Dronkers,
Koss, Delis, & Friedland, 1986; Pachana, Boone, Miller, Cummings, & Berman, 1996;
Rosen, 1980); Huntingtons disease (Butters, Sax, Montgomery, & Tarlow, 1978; Butters
et al., 1987); amnesia (Butters et al., 1987; Weingartner, Grafman, Boutelle, Kaye, &
Martin, 1983), and traumatic brain injury (Raskin & Rearick, 1996).
Current time-limited, verbal fluency tests can be traced to the Thurstones Word Flu-
ency Test, which formed part of the Primary Mental Abilities Test (Thurstone, 1938;
Thurstone & Thurstone, 1949). This test required individuals to write words beginning
with a specific letter over a relatively long period of time (e.g., 5 minutes to write all pos-
sible words that began with the letter S). Benton and colleagues are generally credited
with developing a verbal counterpart for Thurstones procedure (Bechtoldt, Benton, &
Fogel, 1962; Benton, 1968; Fogel, 1962). The letters FAS were used in these experiments
with 1 minute of responding allowed for each letter. The first attempt to develop norms
for letter fluency was by Borkowski, Benton, and Spreen (1967). All letters of the alpha-
bet except X and Z were normed using 1-minute test intervals with 66 maternity pa-
tients. The letters were divided into three difficulty levels: hard (Q, J, V, Y, K, U); mod-
erate (I, O, N, E, G, L, R); and easy (H, D, M, W, A, B F, P, T, C, S). Eventually, this
lead to the verbal fluency test used in the Multilingual Aphasia Examination (MAE;
Benton & Hamsher, 1976; Benton, Hamsher, & Sivan, 1994). Two parallel sets of letter
triads (CFL and PRW) were used rather than FAS. However, according to Ruff, Light,
Parker, and Levin (1996), the name of the test was changed to Controlled Oral Word
Association Test (COWA or COWAT) to avoid confusing the phrase word fluency
with the fluent/nonfluent dimension of aphasia. The letters FAS have continued to be
used as a measure of verbal fluency in the Neurosensory Center Comprehensive Exami-
nation for Aphasia (NCCEA; Benton, 1967; Spreen & Benton, 1969, 1977).
The other popular procedure for assessing verbal fluency is semantic fluency, where
individuals are asked to generate names from a specified category (e.g., animals, fruits,
cities). For example, the Western Aphasia Battery (WAB; Kertesz, 1982) and Boston
Diagnostic Aphasia Examination (BDAE; Goodglass & Kaplan, 1983) uses Animal
Naming as its word fluency test, the Mattis Dementia Rating Scale (Mattis, 1988) uses
the Supermarket Test, where the person names items found in a supermarket, and the
Set Test (Issacs & Kennie, 1973) uses color, animals, towns, and fruits. A review of the
literature shows that the category of animals is most frequently employed. Recently,
comparison of performance on phonemic and semantic measures of verbal fluency has
been used to investigate language deficits in Alzheimers patients, with mixed results
(for reviews see Hart, 1988; Lezak, 1995; Zec, 1993).
In spite of the widespread use and clinical utility of verbal fluency tests, few norms
are available across the entire adult age range. Those that are available are for the
COWAT. This is largely because two recent studies have produced a reasonably com-
prehensive set of norms (Ivnik, Malec, & Smith, 1996; Ruff et al., 1996). Unfortunately,
a similar state of affairs does not exist for FAS. The original normative data for FAS in
NCCEA were from a rural sample that was poorly educated with lower levels of intelli-
gence (Spreen & Strauss, 1991). The normative data produced subsequently suffer from
restricted age samples or limited number of individuals (Bolla, Lindgren, Bonaccorsy, &
Bleecker, 1990; Cauthen, 1978; Geiser & Vanderploeg, 1993; Kozora & Cullum, 1995;
Read, 1987; Yeudall, Fromm, Reddon, & Stefanyk, 1986). Norms for animal naming
with an adequate range for age and education are lacking also. Consequently, the pur-
pose of the present study is to provide age (1695 years) and education (021 years) ap-
propriate normative data for FAS and Animal Naming.
 Verbal Fluency 169

METHOD

Participants and Materials

The normative sample consisted of 1,300 individuals who participated in two different
experiments. The first experiment investigated the effects of aging on the acquisition
and retention of visual and verbal information with 895 community-dwelling volunteers
(Hubley, 1995; McIntyre, 1996). Participants were recruited through booths at shopping
centers, social organizations, places of employment, psychology classes, and by word-
of-mouth. They did not receive any financial remuneration for participating. A self-
reported history of medical and psychiatric problems, including a list of all currently
prescribed medications, was obtained from each participant. Any person with a known
history of neurological disease, psychiatric illness, head injury, or stroke was excluded.
All participants were living independently in the community, and ranged in age from
16 to 85 years (M 5 52.3, SD 5 18.1). The average education level varied from 4 to 21
years (M 5 12.9, SD 5 2.6). The male to female ratio was 397 to 498. All persons scored
higher than 23 on the Mini-Mental State Examination (MMSE; Folstein, Folstein, &
McHugh, 1975) and lower than 12 on the Geriatric Depression Scale (GDS; Brink et al.,
1982). English was the first language for all individuals. Scores from the Vocabulary sub-
test of the Wechsler Adult Intelligence Test-Revised (WAIS-R; Wechsler, 1981) were
available for a subset of 364 participants.
The remaining 405 participants represent a subset of individuals drawn from the Ca-
nadian Study of Health and Aging (CSHA) (Canadian Study of Health and Aging
Working Group, 1994). All participants received a consensus diagnosis of no cognitive
impairment regardless of 3MS scores (n 5 283 for 3MS .77; n 5 122 for 3MS ,78) by
physicians and clinical neuropsychologists on the basis of history, clinical and neurologi-
cal examination, and an extensive battery of neuropsychological tests (see Tuokko,
Kristjannson, & Miller, 1995; Tuokko & Woodward, 1996 for additional details about
neuropsychological protocol and results). Ages ranged from 65 to 95 years (M 5 79.2,
SD 5 6.5). Number of years of education varied from 0 to 21 years (M 5 10.5, SD 5 3.8).
The male to female ratio was 162 to 243. All persons stated that English was their first
language.

Procedure
The total number of words generated in 1 minute for the letters F, A, and S (phone-
mic fluency) was obtained from all 1,300 participants. The number of words generated
for each individual letter was available only from the 895 participants from the first ex-
periment. The instructions were identical to those used by Spreen and Benton (1977)
and described in detail by Spreen and Strauss (1991). Participants were instructed that
proper nouns and multiple words using the same stem with a different suffix (e.g., friend,
friends, friendly) were not acceptable. The ages for the FAS sample ranged from 16 to
95 years (M 5 60.7, SD 5 19.9). Years of education ranged from 0 to 21 (M 5 12.1, SD 5
3.2). The male to female ratio was 559 to 741.
The number of animal names generated in 1 minute (semantic fluency) was obtained
from a subset of 735 individuals (331 from the first study and 404 from the second study).
Instructions followed those of Rosen (1980) and required individuals to say the names
of as many animals that they could think of in a 1-minute period. The ages for the Ani-
mal Naming sample ranged from 16 to 95 years (M 5 67.0, SD 5 19.8). Years of educa-
tion ranged from 0 to 21 (M 5 11.4, SD 5 3.4). The male to female ratio was 310 to 425.
170 T. N. Tombaugh, J. Kozak, and L. Rees

TABLE 1
Means (M) and Standard Deviations (SD) for
Number of Words Generated to the letters F, A,
and S for Education, Age, and Gender

FAS

Category n M (SD)

Education (years)
08 163 24.9 (10.7)
912 664 36.7 (12.2)
1316 392 42.6 (11.6)
1721 81 43.9 (12.3)
Age (years)
1619 19 39.3 (12.0)
2029 106 41.2 (09.2)
3039 132 43.1 (11.4)
4049 121 43.5 (12.2)
5059 144 42.1 (11.1)
6069 220 38.5 (13.7)
7079 334 34.8 (12.8)
8089 200 28.9 (11.7)
9095 24 28.2 (11.0)
Gender
Male 559 37.0 (13.0)
Female 741 37.8 (13.1)
Total 1300 37.5 (13.1)

RESULTS

Phonemic Fluency (FAS)

For descriptive purposes, years of education was divided into four groups, and ages
were divided into nine age ranges. Table 1 shows the mean number of words generated
for each of these two variables as well as for gender. Inspection of Table 1 shows that
FAS scores tended to increase with increasing education, with the least amount of
change occurring between the last two categories (1316 years and 1721 years). FAS
scores decreased with advancing age with the least amount of change occurring from
ages 16 to 59 years. Females generated slightly more words than males. Simultaneous re-
gression analyses further explored the effects of these three variables. Education ac-
counted for 18.6% of the variance, while age accounted for only 11.0% Gender was not
significant and therefore did not enter the equation. Comparable values were obtained
from a subset of individuals who were administered both verbal fluency tests. Education
accounted for 21.7% and age accounted for 11.8%. Vocabulary scores (WAIS-R) corre-
lated r 5 .25 (p , .001) with overall FAS scores.
On the basis of these analyses and visual inspection of the data, it was decided to
stratify the norms on the basis of age (1659, 6079, and 8095 years) and years of educa-
tion (08, 912, and 1321). Normative data for total FAS scores are provided in Table 2.
Table 2 shows that within each age level FAS scores increase with increased education.
When education is used as the major variable of interest, FAS scores decrease within
any given educational category as age increased. An analysis of variance (ANOVA) ap-
propriate for a 3 (education) 3 3 (age) factorial design showed that both age and educa-
tion were statistically significant with a small but statistically significant interaction, Age:
F(2, 1291) 5 50.6, p , .001; Education: F(2, 1291) 5 87.2, p , .001; Age 3 Education:
F(4, 1291) 5 2.6, p , .05.
 TABLE 2
Norms for FAS Stratified for Age (1659, 6079, and 8095 Years) and Years of Education (08, 912, and 1321)

Age 1659 Years Age 6079 Years Age 8095 Years

Education (Years) Education (Years) Education (Years)

08 912 1321 08 912 1321 08 912 1321

(n 5 12) (n 5 268) (n 5 242) (n 5 76) (n 5 292) (n 5 185) (n 5 75) (n 5 102) (n 5 46)

Percentile Score
90 48 56 61 39 54 59 33 42 56
80 45 50 55 36 47 53 29 38 47
70 42 47 51 31 43 49 26 34 43
60 39 43 49 27 39 45 24 31 39
Verbal Fluency

50 36 40 45 25 35 41 22 29 36
40 35 38 42 22 32 38 21 27 33
30 34 35 38 20 28 36 19 24 30
20 30 32 35 17 24 34 17 22 28
10 27 28 30 13 21 27 13 18 23
M 38.5 40.5 44.7 25.3 35.6 42.0 22.4 29.8 37.0
(SD) (12.0) (10.7) (11.2) (11.1) (12.5) (12.1) (8.2) (11.4) (11.2)

Note. M 5 mean; SD 5 standard deviation.

171
172 T. N. Tombaugh, J. Kozak, and L. Rees

Two measures of reliability were obtained. The first measure assessed the degree of
internal consistency that existed among the three letters. A coefficient alpha (Cronbach
alpha) was computed using the total number of words generated for each letter as indi-
vidual items (Letter F: M 5 14.4, SD 5 4.5; Letter A: M 5 11.9, SD 5 4.4; Letter S: M 5
15.0, SD 5 4.7). The coefficient alpha of r 5 .83 was sufficiently high to insure high item
homogeneity even though t-tests showed the number of words was significantly different
(a 5 .001) among the three letters (F vs. A: t(1,893) 5 19.0; F vs. S: t(1,893) 5 5.2; A vs.
S: t(1,893) 5 23.0).
The second measure of reliability was obtained from 38 older participants who had
taken the FAS on two occasions separated by 5.6 years (SD 5 .76). The mean ages at the
first and second administration were 65.6 years (SD 5 9.7) and 71.2 years (SD 5 9.9), re-
spectively. The small decrease in scores that occurred for the second administration
(38.7 vs. 36.3) was not statistically significant (t 5 1.97, p . .05). A correlational analysis
showed the test-retest reliability was within acceptable limits (r 5 .74, p , .001).

Semantic Fluency (Animal Naming)

Table 3 shows the number of animal names generated in 1 minute for each of four
levels of education, nine age ranges, and gender. Inspection of the table shows that the
number of animals named increased as years of education increased. The greatest in-
crease occurred between 0 to 8 and 9 to 12 years, and between 9 to 12 and 13 to 16 years.
The opposite trend occurred for age, where the number of animals named remains rela-
tively constant until age 60, when it began to decrease with advancing age. Males gener-
ated more animals names than females. When the effects of age, education, and gender
on animal naming were analyzed by regression analayses, age accounted for 23.4% of
variance, education for 13.6%, and gender for less than 1%. It should be noted that all

TABLE 3
Means (M) and Standard Deviations (SD) Numbers
of Animals Named in 1 Minute for Education,
Age, and Gender

Animal Naming

Category n M (SD)

Education (years)
08 140 13.9 (3.9)
912 377 16.7 (4.6)
1316 173 19.0 (5.2)
1721 44 19.5 (5.2)
Age (years)
1619 19 21.5 (4.4)
2029 41 19.9 (5.0)
3039 43 21.5 (5.5)
4049 45 20.7 (4.2)
5059 43 20.1 (4.9)
6069 92 17.6 (4.7)
7079 228 16.1 (4.0)
8089 200 14.3 (3.9)
9095 24 13.0 (3.8)
Gender
Male 310 17.4 (5.1)
Female 425 16.5 (5.0)
Total 735 16.9 (5.0)
 Verbal Fluency 173

these individuals also had been administered the FAS. Vocabulary scores (WAIS-R)
correlated r 5 .17 (p , .001) with total number of animals named.
Table 4 presents normative data stratified using the same three levels of education
and age as employed previously with FAS scores. As with FAS, number of animals
named within a specific age level progressively increased with increasing amounts of ed-
ucation, and scores within any given educational level progressively decreased with in-
creasing age. An ANOVA appropriate for a 3 (education) 3 3 (age) factorial design
showed that both age and education were statistically significant, Age: F(2, 726) 5 88.1,
p , .001; Education: F(2, 726) 5 28.1, p , .001; Age 3 Education: F(4, 726) 5 .65, p . .05).
Finally, a correlational analysis showed that number of animals named correlated r 5
.52 (p , .01) with FAS scores. Correlations of the number of animals named with indi-
vidual letters were as follows: Letter F 5 .31, Letter A 5 .36, and Letter S 5 .39.

DISCUSSION

The results from the present study provide norms for two verbal fluency tests that
have enjoyed widespread experimental and clinical usage but have not been adequately
normed. Previous norms for FAS and animal naming have used a restricted age or edu-
cational range (Bolla et al., 1990; Geiser & Vanderploeg, 1993; Read, 1987; Selnes et al.,
1991; Spreen & Benton, 1977; Yeudall et al., 1986). By recruiting individuals having a
wide range of ages (1695 years) and years of education (021), the present set of norms
represent a substantial improvement over those previously available.
Evidence from a variety of sources shows that verbal fluency measures are sensitive
to the effect of years of education and age, but are relatively insensitive to gender (Bolla
et al., 1990; Borod, Goodglass, & Kaplan, 1980; Geiser & Vanderploeg, 1993; Hamsher
& Benton, 1978; Ivnik et al., 1996; Ruff et al., 1996; Sarno, Bounaguro, & Levita, 1985).
The present study confirms and extends these findings by showing that measures of pho-
nemic and semantic verbal fluency are differentially sensitive to age and education. Re-
gression analyses performed on scores from individuals who had completed both verbal
fluency tests demonstrated that for FAS education accounted for more variance than

TABLE 4
Norms for Animal Stratified for Age (1659, 6079, and 8095 Years)
and Years of Education (08, 912, and 1321)

Age 1659 Years Age 6079 Years Age 8095 Years

Education (Years) Education (Years) Education (Years)

08 912 1321 08 912 1321 08 912 1321

(n 5 4) (n 5 109) (n 5 78) (n 5 61) (n 5 165) (n 5 94) (n 5 75) (n 5 103) (n 5 46)

Percentile Score
90 26 30 20 22 25 18 19 24
75 23 25 17 19 22 16 17 20
50 20 23 14 17 19 13 14 16
25 17 18 12 14 16 11 12 14
10 15 16 11 12 13 9 11 12
M 19.8 21.9 14.4 16.4 18.2 13.1 13.9 16.3
(SD) (4.2) (5.4) (3.4) (4.3) (4.2) (3.8) (3.4) (4.3)

Note. M 5 mean; SD 5 standard deviation.

174 T. N. Tombaugh, J. Kozak, and L. Rees

age (education 5 21.7% vs. age 5 11.8%) while for Animal Naming the opposite rela-
tionship existed (education 5 13.6% vs. age 5 23.4%). In both analyses, gender was
found to account for less than 1% of the variance. Consequently, the current set of
norms were stratified over age (1659, 6079, and 8095 years) and years of education
(08, 912, and 1321) and percentile equivalents were determined.
The results from our sample may differ from other normative data based exclusively
on the CSHA sample, but contained only participants with 3MS scores greater than 77
(e.g., Tuokko & Woodward, 1996). We felt that using only the final consensus diagnosis
would produce a more representative sample than combining it with a criterion 3MS
score. This decision was based on two factors. First, the final consensus diagnosis was
based on an extensive series of clinical, neurologic, and neuropsychologic tests. Conse-
quently, we felt that using scores from a brief mental status examination was unwar-
ranted and unnecessary. Second, results from prior research (Tombaugh, McDowell,
Kristjansson, & Hubley, 1996) demonstrated that scores on the 3MS are sensitive to the
effects of age and education, and using a 3MS criterion score might restrict the represen-
tativeness of our sample. Subsequent data analyses on the CSHA sample confirmed this
suspicion. Participants scoring below a 3MS score of 78 were significantly (F 1,403), p ,
.01) older (81.8 vs. 79.8 years), had fewer years of education (8.7 vs. 11.9) and scored
lower on FAS (23.8 vs. 33.4) and Animal Naming (11.5 vs. 12.9).
The major clinical utility of these norms is that they will increase the ability of neu-
ropsychologists to determine more precisely the degree to which verbal fluency is im-
paired in patients of varying ages and educational level. Moreover, the provision of
norms for both phonemic and semantic fluency offers the additional advantage of allow-
ing the neuropsychologist to determine if one type of verbal fluency is affected more
than the other. Such a determination has been shown to be useful in making differential
diagnoses. For example, Steenhuis and Ostbye (1995) reported that phonemic fluency
had greater clinical utility in identifying cognitive loss in nondemented individuals and
the generation of animal names contributed more to the diagnosis of dementia. Consis-
tent with this are reports that semantic fluency declines more in Alzheimers patients
than does letter fluency (Crossley, DArcy, & Rawson, 1997; Kozora & Cullum, 1995),
and the inclusion of an animal naming test significantly increases the sensitivity of the
MMSE to identify Alzheimers disease (Tombaugh et al., 1996). Finally, Zec (1993), in
his review of the literature on Alzheimers disease (AD), concluded that semantic flu-
ency may be considerably more useful than phonemic word fluency in the differential
diagnosis of patients with AD at all stages of dementia from normal elderly persons (p. 43).
Two major factors should be kept in mind when using the current norms. First, the
norms are applicable only when the letters F, A, and S or the category of animals are
used. A large degree of variety exists among the number of names generated to different
letters of the alphabet. For example, in the present study, significant differences were
found in number of words generated with the letters F, A, and S. This is consistent with
Thorndike-Lorges frequency count (Thorndike & Lorge, 1944); with the data contained
in the original report by Borkowski et al. (1967); and with results from other research us-
ing cognitively intact and cognitively impaired persons (Hart, Smith, & Swash, 1988;
Yeudall et al., 1986). Similarly, different types of semantic categories yield different
number of exemplars (Hart, Smith, & Swash, 1988; Hodges et al., 1992; Monsch et al.,
1992). The lack of comparability in number of exemplars between different types of flu-
ency tasks provides ample evidence that the present norms should be used exclusively
with the letters F, A, and S and the semantic category of animals. Ruff et al. (1996), in
their normative article on Bentons Controlled Oral Word Association Test, expressed a
similar caution that despite the fact that the FAS and COWA (e.g., CFL or PRW) are
 Verbal Fluency 175

two versions of the same procedures, the raw scores on the two versions are not compa-
rable (p. 337).
Second, the current norms are only applicable when the person is fluent in English.
The current norms should not be used when the exemplars to the same letters or animals
category were generated in a different language. This is clearly illustrated by Steenhuis
and Ostbye (1995), who reported a significant difference in verbal fluency between
French and English for FAS (English 5 22.7, French 5 15.01) and Animal Naming (En-
glish 5 12.3, French 5 10.9) in an older population that contained individuals diagnosed
as demented, cognitively impaired, and cognitively intact.

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