How To Assess Visual Neglect: Which Visual Neglect Test Is Best?

Visual neglect is when someone loses the ability to pay attention to half (the left or right side) of the visual field. It’s caused by brain damage, most commonly a stroke.

It’s very disruptive to patients’ lives, but luckily you can help! The first step to rehabilitating visual neglect is a good assessment. 

In this article, you’ll learn:

• Evidence-based visual neglect tests
• Which screen to prioritize if you’re short on time 
• A step-by-step guide to the Catherine Begego Scale

To make your life easier, you’ll find direct links to the assessments and PDFs.

And to save even more time, check out the 5-star-rated Adult Speech Therapy Starter Pack!

What Is Visual Neglect?

Visual neglect is a cognitive impairment caused by damage to the left or right hemisphere of the brain, typically after a stroke or brain injury. 

With this disorder, the patient doesn’t pay attention to visual information coming from the opposite side of the brain injury.

For example, if a patient has a stroke in the right hemisphere of their brain, they won’t pay attention to the left side of their visual field. This is called “left neglect” (Ting et al., 2011). Left neglect is more common than right neglect.

Visual neglect is an attention issue, not a visual issue. Although most patient can still see both halves of their visual field, their brain isn’t paying attention to half of it. 

Many people with visual neglect aren’t aware they have it. They must learn habits to remind themselves to pay attention to their affected side. 

If you suspect another vision disorder, like a visual field cut, or if you aren’t comfortable treating visual neglect, refer out:

• An OT that works with visual-perceptual disorders 
• An optometrist or ophthalmologist who works with neurological disorders

How Do You Screen For Visual Neglect?

When possible, it’s best to do multiple visual neglect tests and then compare how your patient performs on each. Research suggests that a single screening test isn’t enough to rule out visual neglect (Moore et al., 2022). 

But what do you do if you only have time for one quick bedside screen? 

Members of the European Academy of Neurology Scientific Panel on Higher Cortical Functions recommend the following order of operations when screening for spatial neglect after a stroke:

1. Cancellation Task. If you only have time to do one screen, do a cancellation test
2. Figure copying, line bisection, or baking tray task. If possible, do a secondary screener
3. Functional scale. And if feasible for you and your patient, do a functional scale like the Catherine Bergego Scale (Moore et al., 2022)

Let’s dive into specific recommendations for each of these categories.

1. Start With A Cancellation Test

If you can only do one visual neglect screen, then do a cancellation task.

Here are 4 evidence-based recommendations:

Bells Cancellation Test

The Bells Cancellation Test was developed in 1989 and takes only 5 minutes to administer.

It doesn’t require any subtests or props. Your patient finds and circles 35 bells on a page with 280 distractors.

Here’s how to do it:

1. Use the demonstration page to explain the tasks
2. Ask your patient to find and circle all of the bells on the test page
3. Use the answer page to assess for signs of visual neglect

Bells Cancellation Test PDF

Behavioral Inattention Test (BIT) 

The BIT is a cancellation test developed by Barbara Wilson, a clinical psychologist, and colleagues. It has excellent interrater reliability, test-retest reliability, and criterion validity (Halligan et al., 1991; Jehkonen et al., 2000).

You can buy the BIT assessment on Pearson’s website.

The BIT takes about 40 minutes to complete. Its target population is adults aged 19–83 years old.

This visual neglect test has two subtests. One is a conventional paper and pen assessment, while the other is a functional assessment.

• The BIT Conventional Subtest has 6 items: line crossing, letter cancellation, star cancellation, figure and shape copying, representational drawing, and line bisection. 
• The BIT Behavioral Subtest has 9 items: pre-scanning, menu reading, article reading, phone dialing, telling and setting the time, map navigation, coin sorting, address and sentence copying, and card sorting.

Oxford Cognitive Screen (OCS) – Hearts Cancellation Test

The OCS is a cognitive screen published in 2015 by the University of Oxford. It was developed for patients post-stroke, so it’s aphasia friendly!

You can get the screen for free as long as you register on Oxford’s website. There is also a digital version called the OCS Plus.

The OCS assesses Language, Praxis, Number, Memory, and Spatial and Controlled Attention.

The Hearts Cancellation subtest specifically tests visual neglect and attention abilities. Learn more about the test, including an introduction video, on the Oxford Cognitive Screening website.

The Birmingham Cognitive Screen (BCoS) Apple Cancellation Task 

_{Image from Separating Forms of Neglect Using the Apples Test: Validation and Functional Prediction in Chronic and Acute Stroke by Bickerton et al, 2011}

The BCoS was developed by Birmingham University for patients post stroke. It tests 5 cognitive areas: controlled and spatial attention, language, memory, number processing, and praxis.

The apple cancellation task is in the ‘controlled and spatial attention’ subtest and assesses for 2 types of neglect (egocentric and allocentric).

2. Do A Secondary Visual Neglect Test

If you have the time, do a secondary screening test.

Compare your patient’s performance on this test to their performance on the cancellation test for a more accurate result. 

Keep in mind that, alone, these secondary tests may not accurately screen for visual neglect.

A failed bisection test, for example, may be caused by a fine motor impairment, hemianopia, or optic ataxia. Failing a copying task might be caused by a motor deficit (Moore et al., 2022).

The European Academy of Neurology Scientific Panel on Higher Cortical Functions recommended the following secondary visual neglect screens:

Figure Copying. A pencil and paper task where ask your patient to copy a figure. It’s best to choose a figure with multiple images on a horizontal plane (e.g. a mountain scene). Figure copying is included in the Behavioral Inattention Test described above.

Line Bisection Task. This is a quick screen where you ask a patient to draw a line through the middle of all the lines on a page. Stroke Engine offers a free Line Bisection PDF. It’s also part of the Behavioral Inattention Test.

Baking Tray Tasks. Ask your patient to arrange items evenly across a baking tray. This screen is highly sensitive to visual neglect.

3. Add A Functional Scale

Some patients with visual neglect do well on pen-and-paper visual screens. A functional scale, like the Catherine Bergego Scale, can assess if and how visual neglect is impacting their daily lives.

Below is an example of how to do a functional scale for visual neglect.

Catherine Bergego Scale (using KF-NAP™)

The Catherine Bergego Scale (CBS) is an evidence-based visual neglect test in which the clinician observes a patient doing activities of daily living (Azouvi et al, 2003).

It has excellent internal consistency, interrater reliability, and validity (Bergego et al. 1995, Azouvi et al 1996, Azouvi et al 2003, Luukkainen-Markkula et al. 2011)

Although well-regarded, the CBS is hard to track down! It lives in a decades-old journal article and lacks detail on how to administer it.

Enter the Kessler Foundation!

With support from the NIH and Department of Education, they created the Kessler Foundation Neglect Assessment Process (KF-NAP) which is essentially a protocol for how to administer the CBS.

Their manual and scoring sheet are both available on the Kessler Foundation website.

The Catherine Bergego Scale also includes an anosognosia screen, although it’s not covered in this post.

See How to Improve Awareness for a free worksheet.

Catherine Bergego Scale PDF

Visit the Kessler Foundation’s website to download the most recent KD-NAP materials for free. 

How Long Does It Take?

The Catherine Bergego Scale takes approximately 30 minutes.

Who Should I Use It With?

The CBS is appropriate for patients with right or left hemisphere damage after a stroke or brain injury who can do the activities (put on a shirt, navigate their environment, etc.)

How do I Administer the Catherine Bergego Scale?

Gather Materials

Here’s a materials list from the KF-NAP Examiner’s Kit:

• Empty garbage can or plastic bin
• Lab coat/large button-down shirt
• Plastic basin filled with water
• Mirror with stand
• Grooming supplies (hairbrush, soap, washcloth, paper towel, disposable face wipes, etc.)
• Food tray or placemat
• Eating utensils
• Water and food
• Napkins

Observe and score the patient on the following 10 items. See the KF-NAP Manual for details.

Throughout this screen, don’t cue the patient to attend to the left or right! Avoid giving orientation cues and instructions. 

1. Gaze orientation. Observe how they visually explore the environment. Do they gaze to both the left and right?
2. Limb awareness. Observe if your patient spontaneously attends to the limbs on their affected side. 
3. Auditory attention. Without warning, make a loud noise on their not affected side (drop a trash can or clap loudly). Later, repeat this on their affected side. Compare their reactions.
4. Personal belongings. Ask patients to locate their personal belongings in the room (for example, a bag)
5. Dressing. Observe the patient as they put on an open-front shirt or coat.
6. Grooming. Observe the patient perform 3 grooming tasks (comb hair, wash face, dry face).
7. Navigation. Observe the patient navigating to a familiar place (bathroom, cafeteria). It should have an equal number of right turns and left turns.
8. Collisions. Observe if the patient collides or runs into objects or people as they navigate their environment. Again, there should be an equal number of right turns and left turns.
9. Meals. Observe the patient eating and drinking consumables you placed on a food tray or placemat. 
10. Cleaning after meals. Observe if the patient cleans both sides of their mouth during and after a meal.

How do I Score the Catherine Bergego Scale?

The CBS uses a 4-point scale:

0 = no neglect
1 = mild neglect
2 = moderate neglect
3 = severe neglect

Rate the patient on each of the 10 items on the scale. Record the patient’s total score out of 30. The higher the score, the more severe the visual neglect.

For specific scoring instructions for each item on the scale, see the KF-NAP Manual.

Visual Neglect Speech Therapy Materials

Visit our shop for printable Visual Neglect worksheets and patient handouts.

For a step-by-step guide to assessing and treating visual neglect, take The Adult Speech Therapy Roadmap Course (eligible for 1.55 ASHA CEUs).

References

• Azouvi, P., Olivier, S., de Montety, G., Samuel, C., Louis-Dreyfus, A., & Tesio, L. (2003). Behavioral assessment of unilateral neglect: study of the psychometric properties of the Catherine Bergego Scale. Archives of physical medicine and rehabilitation, 84(1), 51–57. https://doi.org/10.1053/apmr.2003.50062
• Azouvi, P., Marchal, F., Samuel, C., Morin, L., Renard, C., Louis-Dreyfus, A., Jokie, C., Wiart, L., Pradat-Diehl, P., Deloche, G., & Bergego, C. (1996). Functional consequences and awareness of unilateral neglect: Study of an evaluation scale. Neuropsychological Rehabilitation, 6(2), 133-150.
• Bergego, C., Azouvi, P., Samuel, C., Marchal, F., Louis-Dreyfus, A., Jokie, C., Morin, L., Renard, C., Pradat-Diehl, P., & Deloche, G. (1995). Validation d’une échelle d’évaluation fonctionnelle de l’héminegligence dans la vie quotidienne: l’échelle CB. Annales de Readaptation et de Medecine Physique, 38, 183-9.
• Bickerton, W. L., Demeyere, N., Francis, D., Kumar, V., Remoundou, M., Balani, A., Harris, L., Williamson, J., Lau, J. K., Samson, D., Riddoch, M. J., & Humphreys, G. W. (2015). The BCoS cognitive profile screen: Utility and predictive value for stroke. Neuropsychology, 29(4), 638–648. https://doi.org/10.1037/neu0000160
• Bickerton, W. L., Samson, D., Williamson, J., & Humphreys, G. W. (2011). Separating forms of neglect using the Apples Test: validation and functional prediction in chronic and acute stroke. Neuropsychology, 25(5), 567–580. https://doi.org/10.1037/a0023501
• Deloche, G., Azouvi, P., Bergego, C., Marchal, F., Samuel, C., Morin, L., Renard, C., Louis-Dreyfus, A., Jokic, C., Wiart, L., Pradat-Diehl, P. (1996). Functional consequences and awareness of unilateral neglect: Study of an evaluation scale. Neuropsychol Rehabil, 6, 133-150.
• Fullerton, K. J., McSherry, D., Stout, R. W. (1986). Albert’s Test: A neglected test of perceptual neglect. The Lancet,1(8478), 430-432.
• Halligan, P., Cockburn, J., et al. (1991). “The behavioural assessment of visual neglect.” Neuropsychological Rehabilitation 1(1): 5-32.
• Jehkonen, M., Ahonen, J. P., et al. (2000). “Visual neglect as a predictor of functional outcome one year after stroke.” Acta Neurol Scand 101: 195-201. Find it on PubMed
• Luukkainen-Markkula, R., Tarkka, I.M., Pitkänen, K., Sivenius, J., & Hämäläinen, H. (2011). Comparison of the Behavioral Inattention Test and the Catherine Bergego Scale in assessment of hemispatial neglect. Neuropsychological Rehabilitation, 21(1), 103-116.
• McDermott, A. Catherine Bergego Scale (CBS). Stroke Engine. Retrieved from https://strokengine.ca/en/assessments/catherine-bergego-scale-cbs/on Sept, 2024.
• Moore, M., Milosevich, E., Beisteiner, R., Bowen, A., Checketts, M., Demeyere, N., Fordell, H., Godefroy, O., Laczó, J., Rich, T., Williams, L., Woodward-Nutt, K., & Husain, M. (2022). Rapid screening for neglect following stroke: A systematic search and European Academy of Neurology recommendations. European journal of neurology, 29(9), 2596–2606. https://doi.org/10.1111/ene.15381
• Samuel, C., Louis-Dreyfus, A., Kaschel, R., Makiela, E., Troubat, M., Anselmi, N., Cannizzo, V., & Azouvi, P. (2000). Rehabilitation of very severe unilateral neglect by visuo-spatio-motor cueing: Two single case studies. Neuropsychological Rehabilitation, 10(4), 385-99.
• Ting DS, Pollock A, Dutton GN, Doubal FN, Ting DS, Thompson M, Dhillon B. Visual neglect following stroke: current concepts and future focus. Surv Ophthalmol. 2011 Mar-Apr;56(2):114-34. doi: 10.1016/j.survophthal.2010.08.001. PMID: 21335145.