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Sections: Applications Test Administration Individual Versus Group Administration Colored Pencils Delay Times Scoring Criteria Normative Data Research Results Discussion References Normative Addendum Never seen the Rey-Osterreith? The Rey-Osterreith Complex Figure (ROCF) was devised in 1941 by the Swiss psychologist Andre Rey (cited in Lezak, 1983) for the purpose of assessing perceptual organization and visual memory in brain injured subjects. Since that time, wide use of the Rey-Osterreith Complex Figure has been reported, yet little empirical data can be found to support its use. Waber and Holmes (1986) reported that the ROCF "permits assessment of a variety of cognitive processes, including planning and organizational skills and problem-solving strategies, as well as perceptual, motor, and memory functions." (page 563). It is quick, easy, and inexpensive to administer. Standardized procedures for the Rey-Osterreith Complex Figure were published by Osterreith in 1944 (cited in Lezak, 1983). Osterreith standardized the administration procedure, obtained normative data from 230 normal children and 60 adults, and provided interpretative guidance. Aside from Osterreith 's original publication, the ROCF is not available as a test package complete with test materials, administration procedures, detailed scoring criteria, normative data, and reliability analysis. The ROCF is passed from one evaluator to the next as two reproduced sheets of paper, one containing the design, as shown in figure 1, and the other containing an 18-element scoring criteria. The recycling of the ROCF does pose obvious risks. The most obvious is that the integrity of the design may be compromised by repeated reproduction. Waber and Holmes (1986) acknowledged that, after testing over 400 children, an extra line was discovered in the ROCF design, which they used. Sources for this activity were identified through the PsycLIT Database compiled by the PsycINFO Users Services of the American Psychological Association. This database includes over 1300 journals and provides computerized access to international literature in psychology and related disciplines. The database includes publications from 1974 and is updated quarterly. The PsycLIT Database compares article titles and key words of abstracts to a search word entered by the user. For this literature review, the search word was "Osterreith". The search yielded only ten articles. Klicpera (1983) examined problem-solving behavior of reading disabled boys on visuomotor tasks. The ROCF was administered to 33 boys with 10s above 85 and a reading retardation of more than 1 1/2 years on standardized reading tests. A comparison group of 18 boys with no known reading disability and an average IQ of 107.2 was also tested, Klicpera (1983) found that the poor readers showed significantly poorer performance in recall on the ROCF than the control group. Waber and Holmes (1985) formulated a new method for evaluating copy productions of the ROCF and presented normative data for 454 children from middle to lower class district ranging in age from 5 and 14. They also described developmental changes evident in the copy productions that may be of interest in neuropsychological evaluations. Waber and Holmes (1986) provided a continuation of the above study by describing the recall productions from the same test group and prescribing a method for evaluating recall productions of the ROCF. Normative data was also provided. Waber and Bernstein (1989) administered the ROCF to fifth and eighth graders. Within each grade, one group studied the figure visually while another copied it. Each group was tested the same on the recall task, and the results were compared. The eighth graders who studied the figure visually performed better than the group who first copied it. Bennett-Levy (1984) examined the factors involved in performance on the ROCF among 107 adults and derived a regression equation for predicting recall performance from copy performance. Loring, Lee, and Meador (1988) administered the ROCF to 29 patients with partial complex epileptic seizures. The seizures originated in the right temporal lobe in 15 patients and the left temporal lobe in 14 patients. No significant qualitative differences were found when applying Osterreith's scoring criteria. However, after applying a new scoring system to account for qualitative differences, the patients with right temporal lobe seizures were found to perform significantly poorer than the comparison group. Crossen and Wiens (1988) administered the ROCF to 13 adults with moderate to severe head injuries. Recall results were reported to be below normative standards. However, the normative standards were not defined in the research report. Levine, Warach, Benowitz, and Calvanio (1986) studied improvement and recovery factors in patients who had experienced a stroke in the right hemisphere. The ROCF was used, along with other tests, to classify severity. Bigler (1988) administered a battery of psychometric tests including the Rey-Osterreith Complex Figure to patients with verified frontal lobe damage. The patients with left frontal lobe damage performed significantly worse than the patients with right frontal lobe damage did. Bigler, Rosa, Shultz, Hall, and Harris (1989) administered the ROCF to 52 closed head Injury patients ranging from 18 to 55 years old and 42 Alzheimer patients ranging from 55 to 85 years old. Bigler et al. (1989) reported the performance of the Alzheimer patients on both the copy and recall tasks to be poorer than that of the head injury patients. Test administration, when described, was generally consistent with Osterreith's standardized procedure. Lezak (1983) describes the procedure as follows: The subject is first instructed to copy the figure, which has been so set out that its length runs along the subject's horizontal plane. The examiner watches the subject's performance closely. Each time the subject completes a section of the drawing, the examiner hands him a different colored pencil and notes the order of colors.... Time to completion is recorded and both test figure and the subject's drawings are removed. This is usually followed by one or more recall trials. (P.395) This review showed that major differences in test administration with respect to: individual versus group administration, the use of colored pencils, and delay time between copy and recall tasks. None of the researchers indicated placing time restraints on the actual conduct of the copy or recall tasks. The primary determinants to group or individual testing were age, and physical and mental capabilities. Researchers studying head injury (Bigler, 1988; Bigler et al., 1989; Crossen & Wiens, 1988; Levine et al., 1988; Loring et al.,1988), tested subjects individually. Researchers studying only normal children (Waber & Bernstein, 1989; Waber & Holmes, 1986; Waber & Holmes, 1987), tested children as a group with the exception of kindergarten children who were tested individually. All subjects were tested individually in Bennett-Levy's study (1984) of normal adults and Klicpera's study (1983) of older normal children and children with reading problems. In these studies, individual testing was done to enable the examiner to note procedural methods rather than because of limitations of the test group. Colored pencils are used to assess a subject's procedural method and are part of the original procedural method set forth by Osterreith. Changing and controlling the order in which colored pencils are used enables the examiner to determine the sequence with which each element of the drawing is completed. More importantly the examiner can determine if a part-oriented or configurational approach is used. In a configurational approach, the subject completes a framework consisting of the large rectangle and diagonals and then fills in the detail. The use of the colored pencils when administering the ROCF to a group enables the researcher to make this type of determination. For example, if a subject drew a contiguous line for a diagonal within the rectangle, this would be drawn in one color. However, it a diagonal line is completed in two segments, before and after an intersection with the other diagonal line, two colors would probably be evident. Lezak (1983) described the use of colored pencils but also explained that some examiners keep a detailed record of the subject's copying sequence by reproducing the performance and numbering each unit in the order that it is drawn. Bigler et al. (1989) and Loring et al. (1988) reported standard administration of the ROCF was performed according to Lezak (1983). Although this is interpreted as meaning the use of colored pencils, it remains unclear as Lezak (1983) described both methods. As stated, Bennett-Levy (1984) and Klipera (1983) used one pencil and relied on examiner observation to appraise procedural method. Levine et al. (1986), Bigler (1988), and Crossen and Wiens (1988) did not specify this element of the procedure. Waber and Holmes (1985) offered a detailed description of the use of colored pencils: When the tester signaled the children to start, they were to pick up a designated colored pencil and begin to copy the design. When told to switch, they would put down that pencil and continue drawing with the next color designated. This procedure continued until all the colors had been used. The time limit for each color was 60s for kindergarten and first grade children, 45s for second to sixth graders, and 30s for seventh and eighth graders. The red pencil was always used last since red was thought to be a more salient color than the others, and the order of presentation of the other four colors was randomized for each classroom group. (p. 267) Delay time between copy and recall productions varied among examiners. Lezak (1983) reported awareness of examiners who used 20-minute, 30-minute, 40-minute, and 45-minute delay times. However, she also cites research that showed little difference in test results using different delay times as long as the delay is within one hour. The researchers who reported this information used the following delay times. Klicpera (1983): Immediate and 20 minute Scoring criteria used by the researchers reflects the greatest departure from Osterreith's test procedures. A review of Osterreith's scoring criteria is found in Lezak (1983). Osterreith defined 18 units of the drawing and assigned point values of 0 to 2 to each unit depending upon the degree to which the units are correctly drawn and placed. Osterreith evaluated organizational structure in the context of seven different procedural types. Waber and Holmes (1 985) wrote that Osterreith's criteria provides "a basis for comparing a child's performance to that of the normal group, [but] it is insensitive to aspects of the production that may be of considerable theoretical significance. "(p. 265) Specifically, Waber and Holmes (1985) contended that Osterreith's criteria lacks "(1) a valid and reliable method for assessing parameters that are most relevant for neuropsychological diagnosis; and, (2) detailed developmental descriptive data." (p. 265) Waber and Holmes (1985, 1986) and Bennett-Levy (1984) presented details of alternative scoring systems. To analyze detail, Waber and Holmes (1985, 1986) broke the design down into the smallest line sediments possible and objectively evaluated each segment as to accuracy, intersections, alignments, and direction of execution. Using this method, interrater reliability was calculated at 95%. Additionally, the drawings were evaluated for goodness of organization accuracy. The organization rating was based on a 5-point scale ranging from poor (1) to excellent (5). Style rating included four categories: (a) part-oriented, (b) exterior configuration/anterior part-oriented; (c) exterior part-oriented/interior configurational; and (d) configurational. Bennett-Levy (1984) used Osterreith's 18-point scale for detail evaluation. However, a strict application of Osterreith's scale was employed on the copy production, and a lax application was employed on the recall production. Organizational structure was evaluated in terms of symmetry and good continuation rather than Osterreith's seven procedural types. Likewise, Klicpera (1983) used Osterreith's 18-point scale but developed a more detailed analysis process for evaluating organization. Bigler (1988) and Bigler et al. (1989) scored the ROCF according to a method outlined by Denman where a maximum score of 72 may be achieved. Two references were provided in the literature: "Denman, S. B. (1984). Denman Neuropsychology Memory Scale [italics added], Charleston, SC: Privately published" (Bigler. 1988, p. 295), and "Denman S. B. (1984). Manual for the Denman Neuropsychology Memory Scale [italics added], Charleston, SC: Privately published" (Bigler et al., 1989, p. 280). No further direction as to scoring method was offered. Levine et al. (1986) did not specified the scoring criteria used on the ROCF. These researchers combined ratings on the ROCF with ratings on other tests to develop an overall severity rating for stroke victims. Loring et al.(1988) scored the copy production in accordance with Osterreith's 18-point detail rating only for the purpose of excluding patients from the study who did not achieve a certain score. Recall productions were also scored according to Osterreith's 18-point detail rating, but this yielded no significant differences. Loring developed a new qualitative rating focusing on distortion and misplacement errors. With this rating system, significant differences were found between right and left temporal lobe epilepsy patients, with the patients with right temporal epilepsy exhibiting a greater number of errors. Crossen and Wiens (1 988) reported only that head injury subjects scored well below normative standards as reported by Wiens. The cited reference was identified as follows: "Wiens, A.N., McMinn, M.R. & Crossen, J.R. Rey-Osterreith Complex Figure Test: Development of norms for healthy adults. In preparation" (Crossen & Wiens, 1988, p. 399). No further direction as to scoring method was offered. In this section, the use of normative data by the researchers is described. The literature revealed several uniquely different approaches to the use of control or comparison groups. Comparison groups consisted of normal populations, another dysfunctional group, or both. The nature of the studies shed some light on the researchers' approaches, and some approaches seem to require further justification. Osterreith obtained normative data in 1944. This normative data enabled a tester to compare a subject's performance against a comparable normal population. Quantitative copy and recall scores were compared to quantitative norms. Procedural methods were normed as percentiles, or likelihood of occurrence. As reported by Lezak (1983), Osterreith defined the adult's average score on the copy production to be 32 and on the recall production to be 22. Yet Loring et al. (1988), who used Osterreith's 18-point detail scoring criteria, excluded subjects who scored a 34 on the copy trial "so that constructional deficits would not confound examination of memory performance" (p. 241). Without exception, researchers reviewed herein to evaluate organizational processes did not use Osterreith's normative data. Use of Osterreith's normative data for detail analysis was implied in terms of assessing good or poor performances, but no researcher provided specific comparisons within this context. Waber and Holmes (1985, 1986) and Bennett-Levy (1984) studied large normal populations and evaluated subjects in relation to each other. Waber and Holmes (1985, 1986) offered normative data. Loring et al. (1988) compared right and left temporal lobe epilepsy patients to each other. Crossen and Wiens (1988) used unpublished normative data and reported their test group of head injury patients to all be below normal. Levine et al. (1986) studied stroke victims and compared subjects to each other. Klicpera (1983) compared normal children to children with reading problems. Bigler et al. (1989) compared head injured patients aged 18 to 55 to Alzheimer's patients aged 55 to 85. In another study, Bigler (1988) compared two left and two right frontal lobe damaged patients to each other. Waber and Holmes' 1985 study of the ROCF copy task was intended to provide a reliable and valid method of evaluating the ROCF, and to describe cognitive developmental difference among children of different ages. The derived method and resultant normative data is provided in the research report. High interrater statistics were reported for all facets of the evaluation process. Significant developmental features were reported as follows: 1. Nearly total accuracy was achieved by age nine, with little change occurring thereafter. Waber and Holmes' 1986 research report describes the recall performance of the same study group used in their 1985 study. The goals of this study were to devise a reliable and valid evaluation criteria and describe developmental processes. The evaluation criteria and normative data is provided in the research report. Developmental features demonstrated by the recall task were as follows: 1. Accuracy increased with the more configurational versus part-oriented approach. No child achieved total accuracy. Waber and Bernstein's 1989 study provided greater insight into configurational versus part-oriented approaches in cognitive development. Fifth and eighth graders were tested in two groups each. One group performed the copy task of the ROCF while the other group studied the design visually. Then all children performed the recall task in the, same manner. The conclusions presented by the researchers are summarized as follows: 1. Preadolescent children who visually studied the figure produced more configurational recall productions than did those who first copied the figure. This effect was more pronounced among boys. Bennett-Levy (1984) developed a means of predicting recall performance. The derivation of a regression equation is included in the research report. The following observations regarding a normal adult population were offered: 1. Copy strategy, rated in terms of Gestalt concepts of symmetry and good continuation, was the primary determinant of recall score. Loring et al. (1988) reported no significant differences in mean scores on the ROCF between subjects with right temporal lobe epilepsy and left temporal lobe epilepsy when using standard scoring criteria (undefined). However, Loring et al. (1988) developed a qualitative rating that did yield significant differences. Then, right temporal lobe epilepsy subjects exhibited a significantly greater number of errors. Loring et al. (1988) wrote: "The present report illustrated standard CF [Complex Figure] scoring criteria are inadequate to characterize the types of errors observed in patients with right TLE [temporal lobe epilepsy]. .... the type of responses that we observe with right hemisphere seizure focus involve distortion or misplacement. Obviously, a scoring system that scores principally for presence or absence of elements, with little or secondary weight to misplacement, cannot adequately capture the quality of errors..." (p. 244 & 245). Klicpera (1983) reported lower recall scores for the children classified as poor readers as compared to children with no known learning difficulty. This was attributed to poorer planning by the poor readers during the copy phase. The poor readers were less likely than the children in the control group to draw the structure of the design first and then fill in the detail. Rather, they began to reproduce details much sooner than controls. The organizational scheme used when copying was also the scheme used during recall. Recall scores were worse for poor readers even when perfect scores were realized for copy productions. This was attributed to the organizational scheme employed. Klicpera (1983) concluded that the "study suggest[s] that dyslexic children have a developmental delay in an area that is broader than purely verbal skills" (p. 80). It is difficult or impossible to isolate significant ROCF test result data from the research of Crossen and Wiens (1988), Levine et al. (1986), Bigler et al. (1989), and Bigler (1988). Crossen and Wiens (1988) reported ROCF test results "well below normative standards" (p. 395) for subjects with head injury but provided no discrepancy analysis for the ROCF in particular. Levine et al. (1986) offered test results from the study of stroke victims which were based on a composite of psychometric and medical data. Bigler et al. (1989) compared Alzheimer subjects with closed head injury subjects resulting in large age differences between groups. Alzheimer patients performed more poorly on the ROCF, but the analysis explaining this is not very convincing since the age factor is not given adequate attention. Bigler's 1988 test group consisted of only four frontal lobe damaged patients, two with right frontal lobe damage and two with left frontal lobe damage. When reviewed against the other literature, one would expect poorer performance on the ROCF from the right frontal lobe damaged test groups as the right hemisphere enables configurational organizational abilities and the left hemisphere is prominent in part-oriented organizational approaches. However, Bigler (1988) did not support this. In fact, the two left frontal lobe damaged subjects, for whom the right hemisphere was undamaged, demonstrated much poorer performances on the recall portion of the ROCF. The copy portion was poor for just one of the left frontal lobe damaged subjects. Bigler (1988) explained the left frontal lobe damaged subject who had a good copy score and a poor recall score this way: " ...because he did not anticipate that he was going to be required to recall the figure from memory he did not develop any effective strategies for recall while he was copying." (p. 294). This explanation is inadequate, as none of the subjects could have anticipated the recall task. The small number of subjects evaluated makes any conclusions from this study weak. The purpose of this literature review was to define current application of the Rey-Osterreith Complex Figure. Although wide use of the ROCF was reported or implied in the literature, the limited number of published research articles on the subject makes this questionable and prompts the need for a survey across a broad spectrum of test users (i.e. neuropsychologists, clinical psychologists, school psychologists). Test administration, scoring criteria, the use of normative data, and test results were specifically addressed in this review. Examination of these elements showed significant deviation not only from the standardized procedures set forth by Osterreith, but from one researcher to another. This deviation is appropriate with regards to normative data, but it is an area of concern with regards to other aspects of the test. For example, evaluation of test results must include consideration of the copy score derived from the elements of the ROCF design within the context of the organizational approach. Consideration must also be given to the subject's age as the research indicated a correlation between age and score and also implied that it may not be appropriate to administer the ROCF to children under 9 years old. The literature implies a very broad application of the ROCF. Children and adults were tested as well as normal, learning disabled, and brain damaged subjects. The literature also showed application in neuropsychology and education. In neuropsychology, the ROCF may be used to localize and assess the magnitude of brain damage. In education, the ROCF may be used to evaluate input processing of a child suspected of having a learning disability. There is a clear need for users of the ROCF to move towards a standardized method of administering and evaluating performance on the ROCF. Such a movement would also require the development of current normative data from normal, brain-damaged, and learning disabled children and adults. The natural conclusion of such an effort would be to revise Osterreith's standardized procedures and publish the revision in the form of a user's manual for the ROCF. Bennett-Levy, J. (1984). Determinants of performance on the Rey-Osterreith Complex Figure Test: An analysis and a new technique for single case assessment. British Journal of Clinical Psychology, 23, 109-119
Bernstein, J. H. & Waber, D. P. (1996). Developmental scoring system for the Rey-Osterreith Complex Figure: Professional manual. Odessa, FL: Psychological Assessment Resources, Inc. Bernstein & Waber (1996) used a colored-pencil administration system with copy, immediate recall, and 15- to 20-minute delayed recall "without warning" and with "several interpolated verbal tasks" (p. 5). They have complex, meticulously detailed scoring rules for an Organization Score, Style Rating, Accuracy Scores, and Error Scores. Norms, sadly, are based on "454 children. . . . from a middle- to lower-middle-class school district in the northeastern United States. . . . from 5 through 14 years." Kolb, B., & Whishaw, I. Q. (1985). Fundamentals of Human Neuropsychology. New York: W. H. Freeman & Co. Kolb & Whishaw (1985, pp. 734-736) offer norms, apparently using Lezak's (1983) choices of administration procedures and scoring criteria, based on a "randomly selected sample of [2,740] school-aged [6 through 18] subjects collected from the Lethbridge [Alberta] public and separate school systems." The considerable virtue of the large sample is offset by the single location and the lack of precision in rules for administration and scoring. Kolb & Whishaw (1985, p. 738) also offer norms, based on 2,665 people (2,357 children), for the Draw-a-bicycle test. |