Comparing composite scores for the ANAM4 TBI-MIL for research in mild traumatic brain injury

Grant L. Iverson, Brian J. Ivins, Justin E. Karr, Paul K. Crane, Rael T. Lange, Wesley R. Cole, Noah D. Silverberg

Research output: Contribution to journalArticlepeer-review

8 Scopus citations


Objective: The Automated Neuropsychological Assessment Metrics (Version 4) Traumatic Brain Injury Military (ANAM4 TBI-MIL) is commonly administered among U.S. service members both pre-deployment and following TBI. The current study used the ANAM4 TBI-MIL to develop a cognition summary score for TBI research and clinical trials, comparing eight composite scores based on their distributions and sensitivity/specificity when differentiating between service members with and without mild TBI (MTBI). Method: Male service members with MTBI (n = 56; Mdn = 11 days-since-injury) or no self-reported TBI history (n = 733) completed eight ANAM4 TBI-MIL tests. Their throughput scores (correct responses/minute) were used to calculate eight composite scores: The overall test battery mean (OTBM); global deficit score (GDS); neuropsychological deficit score-weighted (NDS-W); low score composite (LSC); number of scores <50th, ≤16th percentile, or ≤5th percentile; and the ANAM Composite Score (ACS). Results: The OTBM and ACS were normally distributed. Other composites had skewed, zero-inflated distributions (62.9% had GDS = 0). All composites differed significantly between participants with and without MTBI (p <. 001), with deficit scores showing the largest effect sizes (d = 1.32-1.47). The Area Under the Curve (AUC) was lowest for number of scores ≤5th percentile (AUC = 0.653) and highest for the LSC, OTBM, ACS, and NDS-W (AUC = 0.709-0.713). Conclusions: The ANAM4 TBI-MIL has no well-validated composite score. The current study examined multiple candidate composite scores, finding that deficit scores showed larger group differences than the OTBM, but similar AUC values. The deficit scores were highly correlated. Future studies are needed to determine whether these scores show less redundancy among participants with more severe TBIs.

Original languageEnglish
Pages (from-to)56-69
Number of pages14
JournalArchives of Clinical Neuropsychology
Issue number1
StatePublished - Jun 24 2019

Bibliographical note

Funding Information:
This work was funded by the U.S. Department of Defense as part of the TBI Endpoints Development Initiative with a grant entitled Development and Validation of a Cognition Endpoint for Traumatic Brain Injury Clinical Trials (subaward from W81XWH-14-2-0176). Noah Silverberg receives research salary support from a Health Professional Investigator Award from the Michael Smith Foundation for Health Research. Brian Ivins and Rael Lange receive research salary support from the Defense and Veterans Brain Injury Center through a contract with General Dynamics Information Technology (W91YTZ-13-C-0015).

Funding Information:
Grant Iverson has received research support from test publishing companies in the past, including PAR, Inc., ImPACT Applications, Inc., and CNS Vital Signs. He receives royalties for one neuropsychological test (Wisconsin Card Sorting Test- 64 Card Version). He acknowledges unrestricted philanthropic support from the Mooney-Reed Charitable Foundation, ImPACT Applications, Inc., and the Heinz Family Foundation.

Publisher Copyright:
© The Author(s) 2019.


  • Assessment
  • Head injury, Traumatic brain injury
  • Norms/normative studies

ASJC Scopus subject areas

  • Neuropsychology and Physiological Psychology
  • Clinical Psychology
  • Psychiatry and Mental health


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