Apples Cancellation Test

Background

The Apples (Cancellation) Test is a popular paper-and-pencil diagnostic tool for visual neglect (aka unilateral spatial neglect); a common condition after a stroke or brain injury where a patient fails to pay attention to or process stimuli on one side of their visual field.

Cancellation tests such as the Albert's Test for diagnosing severe visual neglect, Star Cancellation Test and the Bells Test for assessing mild and moderate unilateral spatial neglect have a long tradition for assessing unilateral spatial neglect. The Apples Test, developed in 2011 by Jane Bickerton and colleagues, is considered yet another significant addition to the fleet of cancellation tests: While the Bells Test simply tells a clinician if a patient has visual neglect and on which side, the Apples Test is specifically useful because it can differentiate between two entirely different subtypes of neglect: egocentric neglect and allocentric neglect.

The test consists of an A4 sheet of paper oriented in landscape mode, featuring 150 scattered apples: The Targets apples (50 items) which are fully formed apples represented by complete circles and the distractors (100 items); incomplete apples ('bitten' apples) that have a distinct gap/opening either on their left or their right side. Patients are instructed to cross out (cancel) only the complete apples while ignoring all the incomplete ones.

Egocentric Neglect is characterized by omissions relative to people's own body: in this scenario, only the apples on the left or right side of the screen (relative to own body) would be relevant for selection. Allocentric Neglect, on the other hand, is object-centered and can be unmasked by looking at the selections of 'bitten' apples. A selection of incomplete apples with an opening to the right (but not left) would indicate, for example, that the patient neglects the right side of objects. For such a patient, the bitten apple simply looks whole.

The Millisecond Apples Test adapts the paper and pencil administration of the task to a computerized environment. The original page is presented in the middle of the screen (Note that the script can be set to run the original page size if needed) and participants are asked to select the targets with the mouse or fingers (on touchscreens). Summary variables include several measures suggested by Mauro Manusco and colleagues (2019) that depend on age and level of schooling to varying degrees. To this end the Millisecond Apples Test includes an optional survey of demographic variables. Additionally, the Millisecond Apples Test allows the visualization of the search strategy at task conclusion by highlighting the trail from selected location with a blue line as well as marking each location with a visitation number. Correctly selected locations (complete apples) are referenced in green; incorrect locations are referenced in red. A screenshot of the search path is taken automatically for future analyses.

Alternative cancellation tasks to diagnose visual neglect include the aforementioned Bells Cancellation Test and the Star Cancellation Test.

Task Procedure

Before working on the actual Apples Test, participants work through a short practice test in which they are asked to select all the complete apples from a selection of 7 examples (3 full ones). Participants get two chances. If the first selection contains an error (a missed apple or incorrectly selected incomplete apple), participants receive visual feedback and get the chance to repeat the practice. After a second failure, the test ends prematurely. After the successful completion of the practice, the actual apple search game starts. patients receive the instructions to find all the complete apples that they can within 5 minutes and ignore all the incomplete ones. Once they press the Start button, the test begins and the test page is presented. Anytime participants select an item via mouse click or touch, a blue circle appears around the selected screen location. The test is over if the allotted time is up, or if participants submit their responses via the Submit button.

What it Measures

The Apples Test is a measure of egocentric and allocentric visual neglect.

Psychological domains

• Visuospatial Attention: The ability to consciously direct and shift focus across near-extrapersonal space (the area within arm's reach).
• Selective Attention: The capacity to focus strictly on relevant target stimuli (the complete apples) while actively ignoring irrelevant environmental noise.
• Focused Attention: The mental stamina required to remain locked onto a single, repetitive task over a continuous period without becoming distracted.
• Visual Search and Scanning: The systematic strategy used to look through an environment.

Main Performance Metrics

• Asymmetry Score - Sides: Difference of number of Apples selected on the left vs. right; measure of Egocentric Visual Neglect
• Asymmetry Score - Objects: Difference of number of Left-open/Right-open selected apples; measure of Allocentric Visual Neglect
• Accuracy Score: Analysis of the number of targets not selected; measure of Selective Attention
• Execution Time: Analysis of the execution time of the search; measure of Processing Time

Psychiatric Conditions

The following patient groups are routinely tested with the Apples Test

• Traumatic Brain Injury (TBI)
• Stroke
• Brain Tumors or Infections

References

Search Google Scholar for peer-reviewed, published research using the Inquisit Apples Cancellation Test.

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Bickerton WL, Samson D et al (2011) Separating forms of neglect using the Apples test: validation and functional prediction in chronic and acute stroke. Neuropsychology 25(5):567 https://doi.org/10.1037/a0023501

Mancuso, M., Rosadoni, S., Capitani, D., Bickerton, W. L., Humphreys, G. W., De Tanti, A., Zampolini, M., Galardi, G., Caputo, M., De Pellegrin, S., Angelini, A., Bartalini, B., Bartolo, M., Carboncini, M. C., Gemignani, P., Spaccavento, S., Cantagallo, A., Zoccolotti, P., & Antonucci, G. (2015). Italian standardization of the Apples Cancellation Test. Neurological Sciences, 36(7), 1233–1240. https://doi.org/10.1007/s10072-015-2088-2

Basagni, B., De Tanti, A., Damora, A., Abbruzzese, L., Varalta, V., Antonucci, G., Bickerton, W. L., Smania, N., & Mancuso, M. (2017). The assessment of hemineglect syndrome with cancellation tasks: a comparison between the Bells test and the Apples test. Neurological Sciences, 38(12), 2171–2176. https://doi.org/10.1007/s10072-017-3139-7